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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
7/17/2017 2
AE and SCO Annual Sample
7/17/2017 3
• 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
7/17/2017 4
• 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.
7/17/2017 5
QA&I Annual Timeline
7/17/2017 6
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
7/17/2017 7
Annual Timeline – AEs (continued)
7/17/2017 8
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
7/17/2017 10
QA&I Individual Interviews – Administrative Entities
7/17/2017 11
• 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
7/17/2017 12
• 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)
7/17/2017 13
• 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
7/17/2017 14
• 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)
7/17/2017 15
• 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
7/17/2017 16
• 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
7/17/2017 17
• 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
7/17/2017 22
• 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
How QA&I Process enhances ODP’s Quality Strategy
• 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
How QA&I Process enhances ODP’s Quality Strategy
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
QM Planning: What’s the same?
MyODP @ https://www.myodp.org/course/index.php?categoryid=264
Click on: Quality Management Planning and Implementation Documents
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
QM Planning: What’s the same?
MyODP @ https://www.myodp.org/course/index.php?categoryid=264
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 the same?
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
QM Planning: What’s new?
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
QM Planning: What’s new?
• 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
QM Planning: What’s new?
• 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
QM Planning: What’s new?
• 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
QM Planning: What’s new?
• 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
QM Planning: What’s new?
MyODP @ https://www.myodp.org/course/index.php?categoryid=214
QM Planning: What’s new?
7/17/2017 46
QM Planning: What’s new?
7/17/2017 47
7/17/2017 48
QUESTIONS
ODP Contact Information
7/17/2017 49
ODP QA&I Process Mailbox:
7/17/2017 50
THANK YOU!