Division of Quality Improvement Updates

< New Review Protocols

< Update HCBS Settings Regulations & Related Activities

Barbara Van VechtenEllie Smith

Alicia MatulewiczDQI - Continuous Quality

Improvement 1

New Regulatory Survey Protocols

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INCIDENT MANAGEMENT

Part 624 and Part 625

Two Parts1. Agency Level Central

Review2. Site/Service Level

Review

Agency LevelCentral Review

Incident Management Protocol

Overview: Central Review - BPC Verification

• Required Notifications occurring• Jonathan’s Law activities implemented• IRC membership and activities appropriate• IRMA Compliance • Integrity of information in IRMA• Agency analyzes and documents events,

trends, and root causes • Agency identifies needed systemic changes• Agency implements needed systemic changes

Agency/Central Review

Key Agency/Central Review Activities

Before Agency Visit:• Internal Communication with IMU• Review of IRMA InformationDuring Agency Visit:• Sampling of incidents, occurrences,

events• Documentation review• Interview

Scheduled Review (in most cases*)

Ensure access to the documentation needed

Ensure people who can provide information regarding agency processes and implementation available

Facilitate access to IRC members

Central Agency Sampling

CLASSIFICATION Sample Size

Reportable Incidents 20%

Minimum all or 5, whichever is smaller Maximum 25

Serious Notable Occurrences

20% Minimum all or 5, whichever is smaller

Maximum 25

Minor Notable Occurrences

10% Minimum all or 5, whichever is smaller

Maximum 15

Part 625 Events 10%

Minimum all or 5, whichever is smaller Maximum 10

Agency Events Agency Reportables

Minor Events (events by agency policy required to be reported and documented that do

not require reporting per 624 and 625)

Medication Errors: 10% Minimum all or 10 whichever is smaller

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"Other" Minor Events: 5% Minimum: 5

Maximum: 10

Documentation NeededHard copy or electronic format. Not meant to mean IRMA. • OPWDD 147 - Reportable incident and Notable Occurrence reports• OPWDD 148 - Report on Actions Taken in Response to an Incident• OPWDD 149 – Investigative Reports• OPWDD 150 – Report of Event Situations (or PA doc. for Part 625 events)

• “Non-reportable“ events reported per agency policy• All related attachments and supporting documentation• Documentation of required notifications• Documentation demonstrating compliance with Jonathan's Law• Incident Review Committee (& subcommittee) review minutes• Evidence of implementation of actions re: recommendations • Actions w/ employees implicated in substantiated cases of abuse• Governing Body meeting minutes: 12 months or since last review• Trend review and analysis reports

Agency/Central:Requirements Reviewed:

Effective agency communication of P & P as requested to:• individuals• family/guardian/advocate prn• agency employees, interns,

volunteers, consultants, contractors, & family care providers

Agency Level: Reporting Requirements

• Incidents, occurrences, events were identified and reported

• Incidents, occurrences, deaths and events were reported to CEO, OPWDD, Justice Center

• Reporting within time frames• Reporting documented in IMRA • Reporting as required to VPCR – agency has

process to ensure• IRMA Entry and Updates• Assurances that reporting occurred as

entered into IRMA- IRMA integrity

Agency Level: Notifications

• MHLS, BOV, Coroner, Law Enforcement• Verbal and document communications

per Jonathan’s Law• Resignations and Terminations to the JC• Service Coordinator notifications and

provision of additional info assist in assurance of necessary actions

• IRMA closure and final reports

Agency Level:Incident Review Committee

• Membership• No Conflict of Interest• Training and Ethics• Meetings• Review and monitoring• Recommendations and follow-up• Minutes

Agency Level: Trending

• Trending conducted

• Analysis of trends

• Recommendations to address

• Recommendations implemented

Agency Level: Part 625

• Reporting as required

• IRMA entry

• Interventions and actions taken by agency as needed are appropriate and accurate based on IRMA information

PROTOCOL: INCIDENT

MANAGEMENT PROTECTIONS

SITE/SERVICE REVIEW

Focus of Protocol

Review Requirement

s most closely

related to ensuring the protection of individuals

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Requirements Reviewed

• All events are reported (RI, NO, Events)

• Needed immediate care and protection is provided and documented

• Investigations thorough, timely, documented

• Recommendations & preventive measures implemented at person-site-service level

When implemented

INCIDENT SAMPLE SELECTION

Activities

1. Communication with IMU

2. Review of IRMA Documentation:Events reportedReview Investigations for sampledIdentify items to verify/validate:

Immediate care & protections Corrective & preventive measure

On-Site ActivitiesVERIFY Events meeting 624 or 625 definitions were

reported Initial actions documented as implemented

were implemented Items recommended & agreed upon were

implemented (as they relate to the site/service)– Plan revisions & resultant changes to services &

supports – Staff changes, training, supervision– Equipment and renovations– Monitoring actions– Recommendations from OPWDD: OIIA investigation

(IRMA); IMU (as informed)– Justice Center Corrective Action Plans (CAPs)

Behavior ServicesPart 633.16

3 Tools for Behavior Services Review

1. “Routine Review” Protocol

2. “Agency Level” Review Protocol

3. Time Out Rooms supplement as part of Physical Plant review

Behavior Services “Routine Review”

•Reviews the practical application of the regulations.• Evidenced in the planning and implementation of Behavior Services for individuals

•Review implemented in conjunction with reviews of sites and services

Behavior Supports“Routine Review” Application• All residential facilities certified or operated

by OPWDD, (including family care homes); for this protocol, only staff are referenced.

• All facilities certified by OPWDD: (Day Programs) except: free standing respite; clinic treatment facilities; and diagnostic and research clinics

• Day habilitation services (whether or not provided in a certified facility);

• Prevocational services (whether or not provided in a certified facility); and

• Community habilitation (low frequency)

When Used• Recertification Visits/Full reviews– At applicable certified programs–where Behavior Services are provided

• Review of services to WBCMs in IRAs

• Review of services for the individuals in the DOH Sample receiving applicable services

Sampling• All WBCMs in IRAs• All DOH sample individuals

receiving applicable services• Sub-Sample of individuals in

Certified residences and day programs

Section 1-General Requirements

• Applies to all Behavior Support Plans regardless of the specific strategies

• Functional Behavioral Analysis

• BSP Development: Who involved

• BSP Content

Section 2: Plans w/ Restrictive, Intrusive or Rights Limiting

Strategies• Ensure development by Licensed

Psychologist or CSW or BIS supervised by same

• Written Informed Consent

• HRC approval

Section 2: Plans with Restrictions/Limitations

Plans describe:– Necessity of restriction–Previously attempted but unsuccessful

strategies–Guidance for postponement of activity–Plan for fading or elimination of

restrictions–How to document intervention use–Plan to review/analyze use of interventions

Section 3: Mechanical Restraints

• Justification• Staff Actions• Use Criteria: application, removal

&duration• Monitoring the person’s needs,

comfort, and safety• Reduction/elimination of use• Physician's order• Full documentation of implementation• Device Modification

Section 4: Medications4a. General Medication

Requirements

4b. PRN Medications

4c. Medications for Symptoms of co-occurring diagnosed psychiatric disorder

4a. Medication General Requirements

• Documented hx of the behavior or symptom for the past 12 months

• Conditions for use per Dr. orders

• Results/effectiveness

• Adverse and Side Effects reported

Section 4c: Meds for symptoms of diagnosed co-occurring psychiatric

disorder

• Documentation of connecting symptom to psychiatric diagnosis to medication

• Plan clearly identifies target symptoms to be addressed by medication

• Plan clearly identifies how to evaluate and document symptoms and absence of same to measure improvement

• Plan includes strategies in addition to medication

• Plan developed by qualified person

BSP Implementation & SafeguardRequirements

Organized by Behavioral Interventions/Strategies:5a Physical Interventions 5b Mechanical Restraints 5c Medication use and review 5d Rights Limitations 5e Time-Out Rooms

Section 5 a-e Monitoring & Safeguards for Use of Intrusive

Strategies• Staff trained in the Plan• Trained in each specific intervention technique• Strategies implemented correctly per the plan• Strategies were terminated per the plan • Strategies were interrupted when necessary

for safety and/or comfort• Assessment of persons condition, oversight,

monitoring• Documentation of implementation• Required notifications

Behavior Services-Agency Level

Behavior ServicesAgency Annual Review

7 Standards Related to:• Staff Qualifications• Staff Training provided and

monitored• Human Rights Committee aka Behavior Review Committee–Has required membership– completes it review activities

Behavior ServicesAd Hoc Agency Review

• Policy and procedure review• At this time will only be conducted :– if routine reviews indicate systemic

problems– Complaints– Other indicators, such a RIA or Incident

Management raise concern– Consult with Area Director as needed

TIME OUT ROOMS

• Standards added to Safety/Physical Plant Proto

• Review during walk through at sites with T.O. room

• ONLY APPLIES TO: – New or significantly modified T.O. rooms

since April 01, 2013– However may assist in identify hazards

that should not be present whether or not the room is new.

Protocols can be found on OPWDD website:

http://www.opwdd.ny.gov/opwdd_services_supports/service_providers/division_of_quality_improvement_protocols

QUESTIONS

HCBS Settings Requirements

•An Overview for Day Services Providers

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HCBS Rules in a Nutshell Enhancement/Expansion of

Rights—Same as everyone else

Requirements for demonstrated/evidence based individualized and person-directed service delivery

People must be supported to have maximum control over their lives and day-to-day decision making

Feds are raising the bar; not just CMS, Justice Dept. too, i.e., Olmstead enforcement

• Over time, this means DQI will be holding

providers to a higher degree/expectations

for true person-centeredness in our future compliance/

enforcement activities • OPWDD regulations to come

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Key ElementsFinal rule - effective March 17th (up to five

year transition plan)Consistent definition of ‘community

settings’ across all HCBS Medicaid authorities

Defines person centered planning requirements and process (effective now)

Applies to all settings (includes day settings); CMS guidance for non-residential settings pending… yet they say don’t wait….. 50

General HCBS Settings RequirementsAllowable HCBS Setting: is integrated in & supports full access to the

greater community; is selected by the Person from among options; ensures individual rights: privacy; dignity &

respect; freedom from coercion & restraint; optimizes autonomy & independence in

making life choices;facilitates choice among types of services &

who provides them.

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Home and Community-Based Setting Requirements

ALLOWABLE Home and Community-Based Settings:

Integrated in & support access to greater community; Opportunities: to seek employment & work in

competitive integrated settings; engage in community life; control personal resources;

Ensure same degree of access for to the community for HCBS Persons compared with non-Medicaid persons;

Enable choices by the Individual from among setting options, (including non-disability specific settings);

Person-centered service plans document the options based on the Individual’s needs & preferences.

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New HCBS Settings Requirements Ensures RIGHTS of ALL people receiving HCBS = same

RIGHTS of All Citizens

Modification to the additional requirements (RIGHTS) must be:

Supported by specific assessed need; Justified and documented in the Person- Centered Service Plan; Meet the additional specific criteria outlined in the regulations 53

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Revised HCBS Settings ADM Sets Stage For:

Implementation of HCBS Settings Assessment Tool (residences);

Interpretation and Understanding of the HCBS Settings Standards; and

OPWDD’s promulgation of Future Regulations on this topic

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• Challenges: Interpretation of CMS

regulations in order to “assess” the standards

Practical realities of the service system vs. need to “push the envelope” We are pushing the envelope for the assessment

The person’s experience in the setting is a major determining factor according to structure of CMS exploratory questions

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HCBS Settings ADM

The ADM describes the quality principles and standards that OPWDD will be assessing beginning November 2014

It is expected that providers will use the following to actively plan and develop approaches to work towards maintaining full compliance with the HCBS Settings federal requirements: ADM #2014-04 OPWDD’s HCBS Setting Assessment Tools CMS guidance and Exploratory Questions.

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HCBS Settings ADM

The standards in the ADM specifically address:

the person-centered habilitation planning process;

delivery of person-centered HCBS funded supports and services in integrated settings;

promotion and support of informed choice and rights; and,

standards applicable to the nature and experience of each person’s living situation.

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HCBS Settings ADM: A. Guidance on Hab Planning Process and Service

Delivery Federal PCP regulations are weaved in where

applicable; PCP Process not end goal—designed to result in

outcomes to ensure the person has more choice and control in his/her life;

Habilitation Plans are a required attachment to the Person-centered Plan (i.e., ISP) and must be coordinated with the ISP. As such the Habilitation Plan is encompassed in the person’s service plan;

Habilitation Plans are person-centered/person-directed, individualized, and include activities and interactions that are meaningful to the person;

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A. Guidance on Hab Planning Habilitation supports/services should focus on developing skills that

are needed in order to facilitate greater degrees of choice, independence, autonomy and full participation in community life;

Exploration of new experiences is an acceptable component of the Habilitation Plan.o Learning about the community and forming relationships often require a

person to try new experiences to determine life directions. o This trial-and-error process eventually enables the person to make informed

choiceso To identify new valued outcomes that then become part of the ISP and Hab

Plan; The Habilitation Plan (or alternative documentation that becomes part of

the habilitation/service plan) should reflect:o the personally meaningful community inclusion/integration activities,o the timing and desired frequency/duration of these activities, ando the supports needed for the person to fully participate

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A. Guidance on Hab Planning

Whenever possible, supports are provided in a way that maximizes use of natural and peer supports in the community, not just paid staff and providers;

The Habilitation Plan must be updated in accordance with ADM #2012-01, when the individual’s circumstances or needs change, or at the request of the individual.

Residential providers should ensure that individuals are

aware of their right to request a Habilitation Plan change. Residential providers are expected to take timely action to honor these requests.

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HCBS ADM: B. HCBS Waiver Service Provision Is Required to Support Full Access to the Greater Community to

the Same Degree of Access as Individuals Not Receiving HCBS:

HCB services, supports, and settings must be designed to: facilitate full access to engage in community life; seek employment and work in competitive integrated settings;

engage in meaningful activities; explore meaningful relationships and social roles; reside in the home of choice; share in other hallmarks of community living in accordance with

individualized needs and preferences identified in the person’s habilitation/service plan and to the same degree of access as individuals without disabilities.

HCBS settings (and services and supports) must seek to optimize and not regiment individual initiative, autonomy, and independence in making life choices 61

B. HCBS Waiver Service Provision Is Required to Support Full Access to the Greater Community to

the Same Degree of Access as Individuals Not Receiving HCBS, (Cont.)

• For “same degree of access” to life in the community, we need to ensure that people with disabilities are not segregated or isolated from people without disabilities and ensure that support and service delivery practices are not “institutional” in nature.  62

HCBS Waiver Service Provision Is Required to Support Full Access to the Greater Community to

the Same Degree of Access as Individuals Not Receiving HCBS, (Cont.)

Facilitate Informed Choice and Protect Rights:Encourage and support individuals to choose and control their own schedules and activities including both scheduled and unscheduled activities The provider/site must ensure that sufficient support is

available based upon peoples’ priorities in their Plans for scheduling and activity preferences.

Spontaneity in choice of activities encouraged and supported whenever possible, no different than non-disabled

May need to consider use of natural supports and creative resources

a person may not be able to participate in a regularly scheduled/planned activity due to illness or other reason—this must also be supported by the provider. 63

HCBS Waiver Service Provision Is Required to Support Full Access to the Greater Community to

the Same Degree of Access as Individuals Not Receiving HCBS, (Cont.)

Facilitate Informed Choice and Protect Rights: Support informed choice by exploring with the person the

potential consequences and responsibilities of decision making Employ positive approaches w/ safeguards and honor “dignity

of risk” Protect individuals from coercion, and unnecessary use of

restrictive interventions Provide mechanisms for people to file anonymous complaints Encourage, respect and support peoples’ observance of

cultural, religious/spiritual, and other preferences Ensure that individual freedom and independence is not

abridged through administrative operations Use plain language and accessible communication

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What about circumstances where a person’s needs may dictate that he/she cannot

safely access the HCBS Settings Rights?

Rights must not be modified outside of the person centered planning process or without the informed

consent of the person or authorized surrogate unless there is an

immediate, serious and credible threat (this is a high bar).

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Federal Requirements if Rights Modification is Necessary

• Must be supported in the Plan as follows: • 1. ID of specific assessed need• 2. Documentation of positive interventions and supports used

prior to modification • 3. Documentation of less intrusive methods tried• 4. clear description of condition in direct proportion to the

assessed need • 5. Inclusion of regular collection/review of data to measure

effectiveness of modification • 6. Established timeframes for periodic review• 7. Informed Consent of the person • 8. Assurance that interventions/supports will cause no harm to

the person 66

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Why is DQI doing an HCBS Settings “Assessment” for Certified Residential

Settings? Part of OPWDD’s HCBS Settings Transition Plan To Collect Baseline Information To Identify Major Challenges that OPWDD Must Address

Systemically to Work Towards Full Compliance After the Assessment, the OPWDD Transition Plan will need to

be revised to include the specific activities to ensure full compliance (i.e., programmatic changes, reinvestment strategies, etc.)

An opportunity for providers to learn, grow, and enhance person centered practices during the transition period

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General Implementation Information about DQI’s Assessment

The HCBS Assessment for IRAs and CRs will begin in November 2014 and run through September 2015 (the end of DQI’s survey cycle)

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General Implementation Information

“No’s/Not Mets” are not a bad thing for the Assessment—rather, they will help OPWDD to identify where to focus in transition planning

It is an opportunity for the provider to grow, learn, make enhancements and changes for the better.

OPWDD will use a conservative approach to selecting Yes for any assessment standard i.e., in most cases evidence of a Yes is necessary, otherwise, standard is “Not Met/No”

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General Information

For the Assessment, a YES means that THIS PERSON IS TRULY RECEIVING SUPPORTS IN A PERSON CENTERED MANNER AND ENVIRONMENT

• Assessment Tool is designed for use with the Guidance Document to help determine the criteria that leads to whether a standard is a “Yes” or a “No”.

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Implementation Methodology and Guidance Document

YES

NO

Select No if any of the following

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General Implementation Information—Key Themes of

the Assessment The final rules establishes an outcome

oriented definition that focuses on the nature and quality of individuals’ experiences

The new standards are “experiential” and about “qualities” of the setting

The regulations focus on whether individuals supported have the “same degree of access” as others in the community 73

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Will aggregate results by domain area/section: Percentage of sites that have achieved standards Percentage moving towards standards achievement Percentage likely to achieve during transition period Percentage unlikely to achieve standards during

transition Actual results will help OPWDD Target areas/action

plan for training and quality improvements at systems level to finalize the OPWDD Transition Plan.

Data aggregation over time will help target quality improvement strategies and identify successes

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Next Steps and What You Can Do to Prepare:

Agency Survey

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So what to do….

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? Does the individual chooses from whom they receive services and supports? Were options regarding provider agencies

provided? Can the individual identify other providers who

render the services s/he receives? Does the individual express satisfaction with the

provider selected ? Does the individual know how and to whom to

make a request for a new provider?

? Does the setting/service reflect the Individual’s needs & preferences? A Person Centered Planning methodology used to

identify needs/preferences reveals ideal service settings 78

? Is the individual is employed or active in the community outside of the setting? Does the individual work in an integrated community

setting? If the individual would like to work, is there activity that

ensures the option is pursued? Does the individual participate regularly in meaningful

non-work activities in integrated community settings?

The setting does not isolate individuals supported from individuals in the broader community (those not receiving HCBS). Is the setting in the community? Is there sufficient transportation available to access the

community? Is there sufficient support to access the community? 79

? Are individual choices incorporated into the services and supports received? Do staff ask the individual about needs and preferences? Does the individual express satisfaction with the services? Are individuals aware of how to make a service request? Is individual choice facilitated in a manner that leaves the

individual feeling empowered to make decisions?

? Is/are the Individual/chosen representative(s) actively involved in Person-Centered Planning meetings? Person is part of or directs meeting time, location,

invitation process and frequency Was the Individual present during the planning meeting? Did/does the planning meeting occur at a time and place

convenient for the individual to attend?

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Agency Survey

Provider agencies and DDROs will be asked to complete a survey through survey monkey

The purpose of the agency survey is to gather contextual information on organizational systems and provider preparations for HCBS Settings Transition and Compliance

The survey will also ask for information on homes that may trigger “heightened scrutiny” so that OPWDD can begin an inventory for transition planning activities

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Involve your Stakeholders: Engage the Board of Directors in the direction,

oversight, and approval of transition strategies/activities, review of data/surveys, and quality improvement approaches

Actively communicate with staff and people supported and their family members and advocates on these standards, compliance strategies and changes necessary and involve them in the improvement process

Solicit feedback from individuals served and their advocates on how to do better through satisfaction surveys, focus groups, residence meetings, and other applicable forums.

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Review All Organizational and Site/Program Policies, Procedures,

Practices, Training Materials, Forms, etc.

Ensure consistency with HCBS Settings requirements;

Ensure no blanket rules/restrictions/practices that limit individual choice, autonomy or rights;

Ensure that materials for people are written in plain language and are accessible

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Enhance Training & Communication Approaches

to Integrate HCBS Settings Principles Training, orientation, etc. should

reflect these expectations Reinforce with staff how to support

individuals to exercise control and choice in their lives

Cultural competency training Adopt and implement Direct Support

Professional Competencies 84

Implement Organizational Self-Assessment Practices for HCBS

Settings and Person Centered/Directed Service provision

Use the OPWDD HCBS Settings Assessment Tools and Guidance Document and the CMS Exploratory Questions to assess the homes that you operate

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Enhance Person Centered/Directed Planning and Service Delivery

Practices Systemically Throughout the Organization and its Services and

Support Delivery infrastructure

Use OPWDD’s optional Strengths and Risks Inventory

when planning with peoplehttp://www.opwdd.ny.gov/node/5521

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The HCBS federal regulations specify:“the written plan must reflect risk factors and measures in place to

minimize them, including individualized back-up plans and

strategies”. [CFR 441.l301 (C)(2)(vi)]

•

Some of NYS OPWDD’s Major System Challenges

OPWDD’s Infrastructure/service delivery dollars heavily invested in facility based service delivery

‘Bundled’ rate setting methodologies Large residences (many former ICFs) vs CMS’s 2008

NPRM re homes of 4 beds or less Balancing ‘Protection’ vs. Individual Choice and

Autonomy i.e., Justice Center/ provider/staff fear of liability

Staffing/Resource/Transportation Unmet training needs re truly person centered planning

& supporting people to maximize their control over their lives

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The Bottom Line

• “The new rule seeks to improve quality of life for people with disabilities by ensuring

• that HCBS funding is used only for services in settings that are truly integrated, as opposed to those that replicate institutional environments in all but name.”

• ASAN Policy Brief, “Defining Community: Implementing the new Medicaid HCBS Rules”, 9/2014 89

OPWDD Transition Plan materials and response to public comments

Link to NYS Transition Plan and materials Link to CMS Resource Materials and Tool

Box OPWDD HCBS Settings Tool Box Materials from Stakeholder Work Group

Meetings • Feedback and suggestions are welcome

and appreciated!90

QUESTIONS?

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