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Office of Developmental Programs

QA&I for HCBS Services

AMDINISTRATIVE ENTITY SESSION

July 19, 2017

Farm Show Complex, Harrisburg PA

7/17/2017 1

Self Assessment

• Opportunity for entities to evaluate their own

performance each year

• The focus is “Everyday Lives: Values in Action”

• The self-assessment tool will mirror the QA&I

tool

• Self-assessment will be used to inform and

build quality improvement activities for the

remainder of the QA&I cycle

• All entities are expected to remediate issues

discovered during the self assessment process

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AE and SCO Annual Sample

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• Selected alphabetically with representation from each region

• Separate number of individuals selected to capture Level of Care performance

AE

• Identified based on individuals selected in the core sample

• The SCO that is authorized in the individual’s ISP

SCO

QA&I Sampling – Provider Selection

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• For onsite review, Providers selected using last digit of MPI #

• New providers will be assigned onsite review

• AEs conduct the review using their own selection of individuals

• Provider qualification is aligned with onsite year

Provider

Annual Sample Exceptions

• Any SCO that has not been included in the 1st or 2nd year

QA&I review will be automatically included the third year of the

QA&I cycle for review.

• If an SCO is selected in more than one year of the QA&I

cycle, the records from the core sample will be reviewed from

that SCO but ODP may or may not elect to do an additional

onsite review of that SCO.

• New Providers may be included in ODP’s distribution more

than once in a three-year period.

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QA&I Annual Timeline

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Onsite

Selections

Announced

June 15

June 30

ODP Issues

Statewide

QA&I Report

• Self

Assessments

Begin

• AE& SCO

Desk Reviews

Begin

July 1

July 15• ODP Notifies

AEs of

Provider Pool;

• Provider Desk

Reviews

Begin

Self

Assessments

Deadline

August 1*(8/31 for 2017)

August 31*(9/30 for 2017)

ODP Issues Self

Assessment

Statewide

Aggregate

Report

All Onsite

Reviews Begin

September 1

November 30Finalize All

Desk Reviews

All Onsite

Reviews

Completed

December 31

January 31All

Comprehensive

Reports Issued

Comp Report

Responses

Complete

including

Corrective Action

& Quality

Improvement

February 28

April 30All

Updated

QM Plans are

Submitted

Annual Timeline – Administrative Entities

• All self-assessments begin July 1 and are due on

August 1 each year

– EXCEPTION! Self-assessments are due August 31 for

2017

• Dates in timeline are targets for entire process

– Each AE will have specific deadlines depending on:

1. Scheduling of the onsite review, and

2. Completion and closure of the QA&I Comprehensive Report

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Annual Timeline – AEs (continued)

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Comprehensive Report Issued Electronically

[30 Days Following Onsite Visit]

Entity Responds with Proof of Remediation

and PPRs

[30 Days Following Comprehensive Report]

Closure of Comprehensive

Report with Approval of Remediation & PPR

[20 Days Following Entity Response]

QM Plan Submission & PPR Update

[30 Days After

Comprehensive Report Closure]

QA&I Team Review & Informal Feedback of

QM Plan and PPR Update

[30 Days of QM Plan Submission]

Submission of Evidence for Extended

Timeline PPRs

ODP Communication that All Improvement is Completed/Acceptable

Self Assessment Document of

Improvement Impact; QM Plan Adjustment

7/17/2017 9

QUESTIONS

Desk Review Process – Administrative Entities

• A review of available documentation prior to the

onsite review to:

– inform the overall QA&I process

– determine focus areas for the onsite review

• The desk review will use all available data sources

• Findings from the QA&I desk review may identify

areas that will require additional follow-up before or

during the onsite review

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QA&I Individual Interviews – Administrative Entities

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• Individual interviews are considered a critical component of the

QA&I process.

• ODP or designee will conduct interviews for the sample prior to,

during, or after the onsite review

• Where appropriate, a person familiar with the individual will be

asked to assist in the interview. The individual may choose who

is present during the interview.

• In keeping with person-centered practices, the individual may

choose not to participate in the interview or can opt to discuss

their experience by phone.

• Any person conducting an interview must ensure follow-up and

reporting, as appropriate, of any issue related to health and

safety or service quality.

Onsite Review Process – Administrative Entities

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• Onsite visits begin September 1 and are completed

by December 31.

• Two ODP staff will comprise onsite team, including

team member completing desk review.

• Visits will occur over a 2-day period.

• A confirmation letter of the onsite review will be sent

to AEs two weeks prior to the visit.

Onsite Review Process – AE (continued)

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• Entrance Conference

– Overview of QA&I Process & Timelines

– Opportunity for AE to Provide Organizational Overview

and highlight quality improvement priorities, successes

and challenges

– Onsite Visit Expectations

• Onsite visit will consist of record reviews, individual

interviews and discussions with AE staff

• Exit Conference

– Onsite Review Overall Experience & Impressions

– Highlights of Best or Promising Practices

– Highlights of Remediation and Improvement Identified

– Expectations for Corrective Action, Final QA&I

Comprehensive Report, and Quality Improvement

QA&I Comprehensive Report – Administrative Entities

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• A written report issued for each reviewed entity in no

more than 30 calendar days of the onsite review

completion.

• The compilation of official findings from:

– Desk review

– Onsite review

– Face-to-face interviews ~ individuals and staff

– Self-assessments

• Overall contains positive performance points and

recommendations for improvement, not just presentation

of raw results

QA&I Comprehensive Report – AEs (continued)

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• AEs will have 30 calendar days to review and respond,

including:

– Evidence of remediation completed within 30 days of

discovery, and Plans to Prevent Recurrence

– Any points of disagreement with the report findings

including appropriate evidence justifying the disagreement

• ODP will close or request further clarification within 20

calendar days of receipt of the AE’s response

• AEs will have 30 calendar days from the date of closure

to submit the QM Plan and/or Action Plan, updated as a

result of the QA&I review.

• Main body of the reports will be posted on MyODP.org

QA&I Questions – Administrative Entities

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• Focused more on Everyday Lives: Values in Action

• Emphasis on gathering information about the

individual’s experience

• Questions are more consistent across Providers,

SCOs and AEs

• AE Database is the platform for data entry

• Questions include both scored and non-scored

questions. Non-scored questions are identified on

the tools.

QA&I Exploratory Questions – Administrative Entities

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• Series of questions related to ODP selected

priorities for improvement

• Opportunity for AEs to prepare for expectations

related to the new regulations or priorities for

improvement

• Opportunity for ODP to learn where service

community is in need of technical assistance or

growth

• Promote the adoption of promising practices

• Information gathered from exploratory questions will

be used to promote quality and form the basis for

QM planning

Brief Review of AE QA&I Tool

• Individual’s experience of the system through

interviews

• AE Tool– 59 Questions

– Focus areas: Quality Improvement; Person Centered Planning,

Service Delivery & Outcomes; Health & Safety

• Example Questions

– The AE provides notification of Due Process Rights at

waiver enrollment (during the last FY).

– The AE measures progress towards achieving identified

QMP goals and objectives.

7/17/2017 18

QA&I Guidelines – Administrative Entities

• Questions tools all contain guidelines for how the

question is to be interpreted

• Guidelines also:

– point to source documents pertaining to each question

– specify those questions that are considered exploratory

7/17/2017 19

QA&I Guidelines Example – AEs

• The AE pays for communication assistance for the

performance of Support Coordination Services.

• Guidance:

– The reviewer determines if the AE has identified a need and paid

for necessary communication assistance for the performance of

Supports Coordination services. Acceptable evidence includes:

paid invoices, billing statements, etc. Mark YES if the AE paid for

necessary communication assistance for Supports Coordination

services. Mark NO if the AE did not pay for necessary

communication assistance for Supports Coordination services.

Mark NA if there were no identified needs or the SCO did not

request communication assistance. (Source: ODP Bulletin #00-

14-04, “Accessibility of ID Services for Individuals Who Are Deaf

ODP Bulletin #00-04-13 "Limited English Proficiency. )

7/17/2017 20

Corrective Action Plan – Administrative Entities

• A catalog of those instances requiring remediation, as

well as a PPR including a QM Plan and/or Action Plan,

where necessary.

• An attachment to the QA&I Comprehensive Report, on

an ODP approved template.

• If the QA&I Comprehensive Report includes instances of

not meeting the standard, the entity must remediate

each one and develop a PPR, if applicable.

– Proof of remediation and a Plan to Prevent Recurrence,

including where QM Plans and/or Action Plans will be

developed, must be submitted within 30 calendar days of

receipt of the QA&I Comprehensive Report.

7/17/2017 21

Remediation – Administrative Entities

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• Instances in which an entity has not met the standard of

a particular QA&I question or series of questions

• These instances must be corrected, either upon

discovery or within 30 days of discovery

– There will be occasions when remediation must occur

immediately due to concerns for health and safety.

– Otherwise, remediation must occur within 30 days

following electronic issuance of the Comprehensive Report

by ODP.

• The instances for remediation will be:

– Summarized within the QA&I Comprehensive Report

– Specified in the accompanying Corrective Action Plan

Remediation – Administrative Entities (continued)

7/17/2017 23

• Each entity is required to include in its response to the

QA&I Comprehensive Report

– Proof of remediation already completed, including the date

of completion - and/or -

– A Plan to Prevent Recurrence (PPR) for each instance

noted in the Corrective Action Plan

– Identification of areas in which a QM Plan and/or Action

Plan will be developed

• Any exceptions to completion of remediation within 30

days of discovery must be negotiated with ODP

Plans to Prevent Recurrence (PPR) - AEs

• PPR outlines actions that will be taken to ensure

future instances of non-compliance do not occur.

• A PPR is required when

– the compliance score for the requirement falls below 86%

OR

– 9 or fewer records were reviewed and there are 2 or more

instances of non-compliance.

• For any PPR activity requiring longer than 3 months

to implement, the entity is responsible to provide an

update on the progress of such activity(s) within 30

days of the QA&I Comprehensive Report to the

QA&I Lead.

7/17/2017 24

Validation – Administrative Entities

• AEs are responsible for submitting evidence of

remediation and implementation of PPRs.

• ODP will review and approve all remediation and

PPR activities in order to close the QA&I

Comprehensive Report.

• Each year in the self-assessment process, AEs are

expected to address the impact of PPR activities

completed within the past year.

7/17/2017 25

Directed Corrective Action Plan (DCAP) - AEs

• May be required for ongoing engagement with ODP

until such issues identified in the DCAP are

resolved to the satisfaction of the QA&I Review

Team.

• A DCAP through mandatory technical assistance

may be required, at a minimum, when:

– The entity fails to respond to imminent risk for one or more

individuals;

– The entity demonstrates repeated non-compliance in one

or more areas;

– The entity’s performance is below 86% for 5 or more

designated questions, if the sample is greater than 10; or

– Performance for one or more designated questions is

below 50% performance.

7/17/2017 26

7/17/2017 27

BREAK

7/17/2017 28

Quality Improvement & QM Plans

Quality Improvement & QM Plans - Key Points

• How QA&I Process enhances and supports ODP’s

system-wide Quality Strategy – Everyday Lives:

Values in Action

• Using QA&I Process and Results to develop QM

Plans and Action Plans

– What’s the same?

– What’s new?

7/17/2017 29

ODP Goals for QA&I

7/17/2017 30

• Measure progress toward systems

improvement based on Everyday

Lives: Values in Action ISAC

recommendations

• Gather timely & useable data to

manage the ODP system performance

• Use data to manage the service

delivery system with a continuous

quality approach

• Demonstrate AE outcomes with

operating agreement

• Collect data for Waiver performance

measures

• Verify that SCOs and Providers comply

with 6100 regulations

Purpose of Revised QA&I Process

7/17/2017 31

• Eliminate multi-layered

process and unnecessary

duplication

• Create more time to focus on

quality improvement and the

experience of individuals

• Desire to move away from

hierarchical compliance and

remediation toward

collaborative partnerships that

foster technical assistance and

shared learning

• Improve methods for collecting

and using data in a timely way

Quality of

the

Individual’s

Experience

Compliance

How QA&I Process enhances ODP’s Quality Strategy

• QA&I Questions will inform QM Planning:

– Tied to Everyday Lives: Values in Action

• Assuring Effective Communication

• Promoting Self-Direction, Choice and Control

• Increasing Employment

• Supporting Families

• Promoting Health, Wellness, and Safety

• Supporting People with Complex Needs

• Increasing Community Participation

– Focus on determining the individual’s experience with

services and supports

– Emphasize:

• Person-centered practices

• Service delivery

• Health & safety

7/17/2017 32


• QA&I Questions will inform QM Planning:

– Tied to Everyday Lives: Values in Action

• Develop and Support Qualified Staff

• Improve Quality

• Performance results will assist ODP, AEs, SCOs, and

Providers:

– Determine priorities for improvement

– Develop baselines and target objectives for QM Plans

7/17/2017 33


7/17/2017 34

• At least one ODP team member will possess QM

Certification

• By December 31, 2018, at least one member of the AE

onsite review team will possess ODP QM Certification

• Entrance Conference offers:

– Opportunity for entity leadership to share mission, vision,

successful and in-process quality improvement projects,

discuss challenges and identify areas for technical assistance

• Exit Conference offers:

– Highlights of best or promising practices

– Highlights of remediation and improvement identified

– Expectations for corrective action, quality improvement, and

Final QA&I Comprehensive Report

Program

Design..Discovery..Remediation..Improvement

(DDRI)

DESIGN

Plan for and set stage for

achieving positive outcomes

DISCOVERY

Find positive and negative

outcomes in a systematic,

timely manner

REMEDIATION

Address negative outcomes

in a timely manner

IMPROVEMENT

Improve quality via systemic

changes

CONTINUOUS CYCLE

This is

where

data

analysis

comes in

35

QM Planning: What’s the same?

7/17/2017 36

QM Plan Template Year:

Entity Name: Focus Area:

Goal Outcome Target Objective Performance Measure/

Data Source/Responsible

Person


MyODP @ https://www.myodp.org/course/index.php?categoryid=264

Click on: Quality Management Planning and Implementation Documents

https://www.myodp.org/course/index.php?categoryid=264

7/17/2017 37

Action Plan Template

Entity Name: Focus Area:

Desired Outcome:

Target Objective:

Performance Measure (s):

Data Source (s):

Responsible Person:

Action Item Responsible

Person (Name)

Target

Date

Status Completion Date



Click on: Quality Management Planning and Implementation Documents


Recommended QM Plan Components:

– Goals

– Desired Outcomes

– Target Objectives and Baselines

– Performance Measures

– Data sources used to measure performance

– Person Responsible for the QM Plan

Recommended QM Action Plan Components:

– Action Item

– Responsible Person

– Target Date

– Status

– Completion Date

7/17/2017 38


QM Planning: What’s new?

Identifying Opportunities for Improvement

• Choose Focus Areas and Goals considering:

– ODP’s Everyday Lives priorities

– your mission, role, and the services and

supports you offer in light of Everyday Lives

priorities

– input and feedback offered by ODP and/or

the AE in identifying systemic opportunities

for improvement

• Everyday Lives Publications support the QM

Planning process:

– Everyday Lives: Values in Action

– Recommendations, Strategies, and

Performance Measures

7/17/2017 39

MyODP @ https://www.myodp.org/mod/page/view.php?id=7775

https://www.myodp.org/mod/page/view.php?id=7775


Identifying Opportunities for Improvement

• QA&I Results will be available to each entity

– Performance data in areas supported by exploratory

questions will support QM Planning

– Plans to Prevent Recurrence (PPRs) will foster prioritization of

focus areas

• When performance falls below the threshold of 86%, evaluate

whether the cause for poor performance represents a systemic

problem in need of a quality improvement project supported by a QM

Plan and Action Plan

– Review of QA&I data will allow for development of baselines and

realistic target objectives

7/17/2017 40

• QM Plans will be submitted and reviewed as part of the QA&I Process.

• If you have a QM Plan and accompanying QM Action Plan already in place and findings from the QA&I Process prompt you to update these documents,

– Update your existing Action Plan until it’s time to develop your new Fiscal Year QM Plan and Action Plan

– Update your QM Plan and Action Plan to begin July 1

• If you discover an area where you need to develop a new QM Plan and accompanying Action Plan,

– Add a new Focus Area, Goal and Target Objective to the existing QM Plan that will carry you to June 30th of the following fiscal year

– Add Action Plan steps to achieve the Target Objective– Implement the new work immediately with continuation in the following

fiscal year

7/17/2017 41


• Using the QA&I tool, AEs, SCOs and Providers are expected

to conduct a self-assessment of their performance annually to

inform and build quality improvement activities, evaluate

progress on implementing the QM Plan and determine the

effectiveness and impact of action steps.

• Organizations not slated for onsite QA&I review until years 2

and 3 are expected to use their self-assessment results to

prioritize and engage in improvement activities while awaiting

the onsite review.

• It is the intention that AEs, SCOs and Providers will continue

to engage in quality improvement activities during the two-

year period between formal QA&I onsite reviews.

7/17/2017 42


• ODP and AEs will follow up with the entity on progress

in implementing QM Plans and provide technical

assistance as needed during the course of the QA&I

Cycle.

• Technical assistance by either ODP or AEs will focus on

quality improvement.

7/17/2017 43


• Statewide Reports

– Self-Assessments

• Annually, at the completion of the self-assessment

process for all entities, ODP will issue an aggregate

report of self-assessment results and analysis

statewide. This report will be used to inform the QA&I

process throughout the year and technical assistance

targeted to AEs, SCOs and Providers.

– Annual QA&I Report

• Annually, ODP will compile all data collected from the

QA&I process into a report that represents statewide

performance of AEs, SCOs and Providers and the

overall system as it relates to quality of services and

supports and person-centered best practices.

7/17/2017 44


• Requirements for ODP QM Certification

– At least one ODP team member will possess QM

Certification

– By December 31, 2018, at least one member of the AE

onsite review team will possess ODP QM Certification

• ODP QM Certification

– Complete prerequisites

– Application and registration process

– In-person class:

• September 13 and 14, 2017 in Ebensburg

• October 11 and 12, 2017 in Chester County

• October 31 and November 1, 2017 in Mechanicsburg

7/17/2017 45





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7/17/2017 48

QUESTIONS

ODP Contact Information

7/17/2017 49

ODP QA&I Process Mailbox:

[email protected]

mailto:[email protected]

7/17/2017 50

THANK YOU!