May 20, Quality Assurance Overview

May 20, Quality Assurance System Overview FY 04/05- new Quality Assurance tools implemented, taking into consideration CMS Quality Framework and expectations FY 05/06- various revisions to Quality Assurance tools, including deletion / addition of some QA Indicators and reorganization of some Outcomes, scoring revision, modification of performance levels FYs 06/07, 07/08, 08/09, 2010 & minimal changes to the Quality Assurance tools, contributing to the ability to further compare data / performance across extended periods of time

May 20, Inter-Rater Reliability Overview Reliability: measurement between 2 or more raters using the same tool, to establish the extent of consensus on use of the tool The expected outcomes of the Inter-Rater Reliability studies are: Provide a wide-range of sampling opportunities across regions and surveyors Measure the extent of agreement in regard to compliance with QA Indicators Identify Indicators where there are trends in differences of scoring across numerous IRR studies Provide opportunities to increase consensus through such mechanisms as refining surveyor guidance, modification of tools, education of those entities being surveyed

May 20, IRR- Summary of the Data FY 08/09 The table below shows reliability data for the FY 08/09 fiscal year, representing degree of agreement among Quality Assurance reviewers.

May 20, Quality Assurance System Overview Quality Assurance Survey Process: Consultative Reviews Annual Review except for some clinical providers and those providers achieving 3 or 4 Star status Sample Selection Notification / document request On-site review Conciliation process Report of findings Quality Improvement Planning Reporting through Regional and Statewide Quality Management Committees

May 20, Quality Assurance System Overview Quality Assurance Tools: Organizational: Day-Residential / Personal Assistance / Clinical Independent Support Coordination (organizational practices & utilizing data from waiver Individual Record Reviews) Individual: Day-Residential Personal Assistance Behavioral Nursing Therapy

May 20, Quality Assurance System Overview Quality Assurance Tool Structure: Domains 1. Access and Eligibility 2. Individual Planning and Implementation 3. Safety and Security 4. Rights, Respect and Dignity 5. Health 6. Choice and Decision Making 7. Relationships and Community Membership 8. Opportunities for Work 9. Provider Capabilities and Qualifications 10. Administrative Authority and Financial Accountability Outcomes Indicators Guidance and Provider Manual References

May 20, Quality Assurance System Overview Quality Assurance Scoring & Domain Applicability: Domains Applicable by Provider Type: Day-Residential: 2, 3, 4, 5, 6, 7, 8, 9, 10 Personal Assistance: 2, 3, 4, 5, 6, 9, 10 Support Coordination: 1, 2, 3, 9, 10 Behavioral: 2, 3, 4, 6, 9, 10 Nursing: 2, 3, 4, 5, 6, 9, 10 Therapy: 2, 3, 4, 6, 9, 10 On the web: QA and Waiver Review Tools Report Card Listing

May 20, Quality Assurance System Overview Quality Assurance Tool Scoring: Domains: 6- Substantial Compliance 4- Partial Compliance 2- Minimal Compliance 0- Noncompliance Outcomes: SC- Substantial Compliance PC- Partial Compliance MC- Minimal Compliance NC- Noncompliance Indicators: Yes- Substantial Compliance No- Noncompliance Performance Levels: Exceptional Performance Proficient Fair Significant Concerns Serious Deficiencies Special Scoring Criteria: Exceptional: A score of Substantial Compliance is required in Domains 2, 3, 5 and 9, if applicable. Proficient: For each applicable Domain, the performance score must be at least Partial Compliance. Fair: For each applicable Domain, the performance score must be at least Minimal Compliance.

May 20, Star Providers- 3 & 4 Star Status 4-Star Status: 96% or above compliance on QA surveys for 2 years; No Domain below Partial Compliance Must achieve Substantial Compliance in Domain 3 ISC agencies must achieve Substantial Compliance in Domain 2 No preventable egregious events resulting in death of individual for one year; Annualized substantiated investigation rate of 10 substantiations per 100 persons supported (10:100) or less for one year; Quality Tier designation from Court Monitor, if applicable. Approval for four-star status is by the Regional Quality Management Committee, followed by submission to State-wide Quality Management Committee for final approval.

May 20, Star Providers- 3 & 4 Star Status 3-Star Status: 85% or above compliance on QA surveys for 2 years; No Domain below Partial Compliance Must achieve Substantial Compliance in Domain 3 ISC agencies must achieve Substantial Compliance in Domain 2 No preventable egregious events resulting in death of individual for one year; Annualized substantiated investigation rate of 10 substantiations per 100 persons supported (10:100) or less for one year; Quality Tier designation from Court Monitor, if applicable. Approval for four-star status is by the Regional Quality Management Committee, followed by submission to State-wide Quality Management Committee for final approval.

May 20, Impact of Quality Assurance Data Provides an overview of system performance Viewed and utilized by a wide audience Data utilized by DIDD Central Office, Agency Teams, Regional Offices, Quality Management Committees, court monitors Facilitates change throughout the service delivery system and decision making Data is used in assessing progress and to identify areas needing corrective intervention Special Reporting Focused review of Domains, Outcomes and Indicators Focused analysis with provider detail Review of provider performance by provider- type and regionally Comparison of performance across years

May 20, Sample Data:

May 20, Sample Data:

May 20, Sample Data: Day-Res.FY 06/07FY 07/08FY 08/097/1/09 – 12/31/10 Domains 221%24%41%53% 323%40%42%45% 465%71%75%83% 537%35%42% 55% 674%87%93%96% 794%96% 99% 873%84%82%93% 918%33%41%35% 1048%45%59%

May 20, Waiver Monitoring Overview DIDD implements three HCBS Waivers under the administrative oversight of TennCare: Self-Determination Waiver State-wide Waiver Arlington Waiver Each waiver entails annual monitoring as performed by Quality Assurance, with follow-up remediation and validation activities as coordinated by regional Operations and Case Management staff Monitoring for each waiver consists of administration of two review tools Qualified Provider Individual Review (involves identification of a state-wide sample which is selected at the beginning of each waiver-year) All findings / issues are expected to be remediated with provider and systemic trends identified and addressed as data is analyzed. Findings / issues are reviewed and discussed by both the Regional Quality Management Committees and the State-wide Quality Management Committee