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ODP ACADEMY For Administrative Entities …Changing Practices, Unchanged Values Administrative Entity Oversight Monitoring Process Pennsylvania Department.

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Presentation on theme: "ODP ACADEMY For Administrative Entities …Changing Practices, Unchanged Values Administrative Entity Oversight Monitoring Process Pennsylvania Department."— Presentation transcript:

1 ODP ACADEMY For Administrative Entities …Changing Practices, Unchanged Values Administrative Entity Oversight Monitoring Process Pennsylvania Department of Public Welfare Office of Mental Retardation

2 2 ODP Academy: AE Oversight March 2007 ODP Academy Overview of the new AE Oversight Monitoring Process – Development & Implementation – Structure of the Tool – Elements of the Tool

3 3 ODP Academy: AE Oversight March 2007 Why Develop a New Administrative Entity Oversight Monitoring Process? In order to meet CMS assurances, ODP needs to: – Retain ultimate authority and responsibility for the operation of the waivers – Exercise oversight over the performance of waiver functions by other agencies

4 4 ODP Academy: AE Oversight March 2007 How Did ODP Develop the Process? A core group of ODP staff detailed the process using input received from AEs, the Regions, and Central Office staff. ODP Academy sessions are then used to relay information

5 5 ODP Academy: AE Oversight March 2007 How Did ODP Develop the Process? ODP developed the AE Monitoring tool using requirements found in: – The Operating Agreement – CMS Assurances – Bulletins – ODP Monitoring of Counties (OMOC) – ODP Initiatives

6 6 ODP Academy: AE Oversight March 2007 Considering the AE’s capacity to meet the new business practices, the AE Monitoring tool was reduced to the following items: – Operating Agreement (OA) requirements – CMS Assurances (CMS-A) – ODP Initiatives – Data Integrity How Did ODP Develop the Process?

7 7 ODP Academy: AE Oversight March 2007 What’s Different The OMOC Process was valid from 2002 until 3/31/07. With the approval of the Consolidated Waiver the AE Oversight Monitoring Process begins 4/1/07. – Continuous systemic review – Greater focus on quality – Accessibility to and utilization of a wider variety of data sources

8 8 ODP Academy: AE Oversight March 2007 Continuous Evidence Based Oversight Monthly reports sent to Administrative Entity Reports due to Regional Office every three months Regional and AE risk management activities Quarterly reports due to CMS regarding the CMS assurances

9 9 ODP Academy: AE Oversight March 2007 How Will ODP Implement the New AE Oversight Process? The Regions will develop monitoring schedules Regional Teams will share oversight responsibilities Teamwork

10 10 ODP Academy: AE Oversight March 2007 AE OVERSIGHT MONITORING LEAD Each region has identified an AE Oversight Monitoring Process lead. The Regional Lead will: – Serve as the Regional contact for the AE Oversight Monitoring Process – Coordinate the AE Oversight Monitoring Process to ensure consistency with the Statewide standards. – Provide technical assistance to Regional and AE staff – Four regional leads and the central office point person will be the keepers of the process

11 11 ODP Academy: AE Oversight March 2007 Where and How Will Monitoring be Completed? Regional reports reviews Home and Community Services Information System (HCSIS) Onsite – Reviews – Interviews

12 12 ODP Academy: AE Oversight March 2007 How Will Monitoring be Conducted? 90 days prior to onsite review, Regional Teams will: – Pull all reports and samples – Share reports with AEs 60 days prior to onsite review, Regional Teams will review samples and reports using information from: – Regional Offices – HCSIS

13 13 ODP Academy: AE Oversight March 2007 How Will Monitoring be Conducted? Two weeks prior to onsite reviews, Regional Teams will provide AEs with names of individuals in the sample In order to initiate the new AE Oversight Process, these time frames will be shortened during the first year (9 month vs. 12 month).

14 14 ODP Academy: AE Oversight March 2007 How Will Monitoring be Conducted? At first, ODP Regional Teams will record and tally their findings off-line Once the process becomes finalized, HCSIS will be used to record findings

15 15 ODP Academy: AE Oversight March 2007 How Will Scores be Determined? 100% compliance will be required for some items A Compliance Scale will be used for other items 90 to 100% = Fully Compliant 80 to 89% = Mostly Compliant 70 to 79% = Somewhat Compliant Below 70% = Noncompliant Any score below 90% will require a Corrective Action Plan

16 16 ODP Academy: AE Oversight March 2007 What Will Happen After Onsite Reviews are Completed? Regional team members will collaborate to complete summary reports Summary reports will be: – Shared with Regional and Central Office staff within 45 days of review – Approved by Regional Program Manager – Sent to the AEs

17 17 ODP Academy: AE Oversight March 2007 What Will Happen After Onsite Reviews are Completed? The AE will develop a Corrective Action Plan if needed, based on the findings in the summary reports. The Corrective Action Plan must be submitted to the Regional Office within 45 calendar days of the receipt of the finding report Each Regional team will review the AE’s Corrective Action Plan and develop a validation plan

18 18 ODP Academy: AE Oversight March 2007 Structure of the AE Oversight Monitoring Tools Review of the guidelines, worksheets and scoring tool

19 19 ODP Academy: AE Oversight March 2007

20 20 ODP Academy: AE Oversight March 2007

21 21 ODP Academy: AE Oversight March 2007

22 22 ODP Academy: AE Oversight March 2007 SIX OVERALL ELEMENTS Quality of Life Administrative Entity Capacity Provider Qualifications/Monitoring Rights Eligibility/Level of Care Other Administrative Functions

23 23 ODP Academy: AE Oversight March 2007 Elements of the Oversight Monitoring Process Requirements are not new Regions & County/AEs have been responsible for these items for some time

24 24 ODP Academy: AE Oversight March 2007 Quality of Life Issues – Individual Support Plan (ISP) Reviews Implemented according to time frames in Operating Agreement (OA & CMS-A) Address all assessed individual needs (OA & CMS-A) Document Services – Frequency – Amount – Duration – Provider type for each service (OA & CMS-A) Outcomes relate to preferences and needs (OA & CMS-A)

25 25 ODP Academy: AE Oversight March 2007 Timeliness of ISP Process (OA & CMS-A) – Updated/revised at least annually or if there is a change in the service need Team members invited to ISP meetings (OA) Services authorized prior to receipt of services (OA & CMS-A) Quality of Life Issues – Individual Support Plan (ISP) Reviews

26 26 ODP Academy: AE Oversight March 2007 Quality of Life Issues – Supports Coordination (SC) Monitoring of individuals according to schedule (OA & CMS-A) PUNS – Reviewed annually (OA) – Updated accordingly (OA) – Completed for those with unmet need (OA) – Signed and distributed (OA)

27 27 ODP Academy: AE Oversight March 2007 Quality of Life Issues – SC Review - Data Integrity Mandatory fields completed in HCSIS – Demographics – Eligibility – Enrollment information. Data integrity is crucial to the process.

28 28 ODP Academy: AE Oversight March 2007 Quality of Life Issues - Quality Management (QM) Requirements Quality Management/ Quality Implementation (QM/QI) plan written (OA) QI actions (OA)

29 29 ODP Academy: AE Oversight March 2007 Quality of Life Issues – Incident Management (IM) These items are all in relation to the implementation of the Incident Management bulletin. Corrective action is implemented (CMS-A) AE investigates incidents according to Certified Investigation manual (CMS-A)

30 30 ODP Academy: AE Oversight March 2007 Quality of Life Issues – Incident Management (IM) (cont’d) Appropriate actions are taken within 24 hours of incidents (CMS-A) Local policies and procedures are in place to implement IM Bulletin (CMS-A) Semi-annual qualitative reports are issued (CMS-A)

31 31 ODP Academy: AE Oversight March 2007 Quality of Life Issues – Independent Monitoring for Quality (IM4Q) AE assures providers address considerations (OA) AE informs IM4Q when action is taken on a consideration (OA) AE uses sharing process (OA) AE, with IM4Q, addresses major health and safety concerns (OA) AE uses IM4Q reports for evaluation and quality improvement (OA)

32 32 ODP Academy: AE Oversight March 2007 ODP Initiatives - Employment AE documents OVR funding availability (OA) – Initial referral is in individual’s file HCSIS Functional Level Employment screen is completed AE follows ODP expected employment practices – Each region has an employment point person

33 33 ODP Academy: AE Oversight March 2007 ODP Initiatives Lifesharing – AE follows ODP expected Lifesharing practices Restraint Reduction – AE achieves annual statewide restraint reduction goal

34 34 ODP Academy: AE Oversight March 2007 AE Capacity ISP completed in HCSIS for everyone receiving ODP services (OA & CMS-A) AE has a designated PUNS Point Person (OA) AE has a designated IM4Q Point Person (OA)

35 35 ODP Academy: AE Oversight March 2007 AE Capacity Bureau of Hearings & Appeals orders are implemented within 30 calendar days (OA & CMS-A) Provider dispute findings are implemented within calendar 30 days (OA & CMS-A)

36 36 ODP Academy: AE Oversight March 2007 AE Capacity Designated AE staff register for and participate in ODP Academy (OA)

37 37 ODP Academy: AE Oversight March 2007 AE Capacity AE has a designated Employment Point Person AE has a designated Lifesharing Point Person

38 38 ODP Academy: AE Oversight March 2007 Provider Monitoring All licensed/certified and non-licensed providers meet waiver qualification standards (OA & CMS-A)

39 39 ODP Academy: AE Oversight March 2007 Provider Monitoring All Waiver providers, except unlicensed individuals working through Vender Fiscal/Employment Agent, Intermediary Service Organization (VF/EA ISO), have a signed MA Agreement (OA) AE Waiver Provider contract is signed by all providers, except unlicensed individuals working through VF/EA ISO (OA)

40 40 ODP Academy: AE Oversight March 2007 Provider Monitoring Provider training is conducted according to state and waiver requirements (CMS-A) All providers meet licensing and certification standards (OA & CMS-A)

41 41 ODP Academy: AE Oversight March 2007 Rights – Due Process Individuals/families are notified of waiver eligibility appeal rights (OA) Notice of due process and appeal rights is provided as required (OA) Individuals receive required written notice of changes in waiver services (OA) – Denials – Reductions – Terminations

42 42 ODP Academy: AE Oversight March 2007 Rights – Due Process AE assists individuals/families to file appeals as needed (OA) Waiver services under appeal continue as required (OA)

43 43 ODP Academy: AE Oversight March 2007 Rights – Choice Individuals/families have choice of services (OA & CMS-A) Individuals/families have choice of providers (OA & CMS-A)

44 44 ODP Academy: AE Oversight March 2007 Rights – Service Review Service Review findings are implemented within 30 days (OA)

45 45 ODP Academy: AE Oversight March 2007 Eligibility/Level of Care (LOC) LOC determinations are completed for everyone likely to receive services (OA & CMS-A) Persons determined to be not qualified for ICF/MR LOC are provided due process as required (OA) All waiver participants are eligible for ICF/MR LOC (OA)

46 46 ODP Academy: AE Oversight March 2007 Eligibility/Level of Care (LOC) Qualified Mental Retardation Professionals (QMRP) complete the certification of need consisting of: – Individual/family interview – Social/psychological review – Current medical evaluation (OA & CMS-A)

47 47 ODP Academy: AE Oversight March 2007 Eligibility/Level of Care (LOC) QMRP’s certification of need is based on standardized adaptive behavior assessment that shows significant limitations in: – Age standards – Three or more areas of major life activity (OA & CMS-A)

48 48 ODP Academy: AE Oversight March 2007 Eligibility/Level of Care (LOC) LOC re-determinations are completed annually (OA & CMS-A) County Assistance Office is notified of changes in assets affecting eligibility within 10 days of the change or as required (OA) Eligibility information is maintained in files (CMS-A)

49 49 ODP Academy: AE Oversight March 2007 Financial Management - General Waiver funds are used only for eligible services (OA & CMS-A) Waiver funds are used only for eligible recipients (OA & CMS-A) Claims are verified for eligibility and authorization (OA & CMS-A) Payments for waiver services are made only to qualified providers and vendors (OA & CMS-A)

50 50 ODP Academy: AE Oversight March 2007 Financial Management - General Ineligible services are excluded from Federal Financial Participation (FFP) (OA) Clean claims are paid within 30 days (OA) DPW is notified within 10 days of overpayments (OA) Paid claims do not exceed limits or caps (OA) Audits are completed as required (OA)

51 51 ODP Academy: AE Oversight March 2007 Rates are established by DPWs Rate Setting Methodology and/or approved by DPW Financial Management – Rate Setting

52 52 ODP Academy: AE Oversight March 2007 Financial Management – Reports Quarterly expenditure reports are submitted to ODP within 14 days of the end of the quarter. (OA & CMS-A) Annual waiver reports submitted by September 15 th for the previous Fiscal Year. (OA & CMS-A) Annual income and expenditure reports submitted by September 15 th for the previous Fiscal Year unless otherwise directed by ODP. (OA & CMS-A)

53 53 ODP Academy: AE Oversight March 2007 Financial Management – Individual Emergency Services Form (IESF) IESFs are submitted as required (OA)

54 54 ODP Academy: AE Oversight March 2007 Other Administrative Functions – Record Retention Records are retained according to specified time requirements (OA) Waiver records are safeguarded per HIPPA regulations (OA)

55 55 ODP Academy: AE Oversight March 2007 Other Administrative Functions – Self-Assessments Self-assessments are completed annually (OA) – Corrective actions are submitted to ODP within 30 days of completion of the Self-Assessment. (OA) – Corrective activities are completed and validated by the AE. (OA) – Self-assessment records are maintained for three years (OA)

56 56 ODP Academy: AE Oversight March 2007 Other Administrative Functions – Fully Served All Consolidated Waiver participants are fully served (OA & CMS-A) All Person/Family Directed Support (P/FDS) Waiver participants are fully served. (OA & CMS-A)

57 57 ODP Academy: AE Oversight March 2007 Other Administrative Functions – Personal Funds Individual’s personal funds are managed as required by the current bulletin (CMS-A) – “Administration and Management of Client Funds”, bulletin number , issued October 5, 1988

58 58 ODP Academy: AE Oversight March 2007 Other Administrative Functions – Departmental Monitoring Corrective Action Plans to the Department’s AE Oversight Monitoring Process are completed by the AE within 45 calendar days (OA)

59 59 ODP Academy: AE Oversight March 2007 Next Steps Assure all necessary data reports are available to support the AE Oversight Monitoring Process Determine the sample size Monitor and evaluate the AE Oversight Monitoring Process to make changes and improvements as needed.

60 60 ODP Academy: AE Oversight March 2007 AE Oversight Monitoring Mailbox All questions go to the mailbox Regional AE Leads and Central Office Point person develop answers Answers sent out to list serve members Mailbox address is:


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