CHAP Provider Education and Training

1
CHAP ProviderEducation and Training

• Plan of Correction

2
Todays Agenda

• Welcome
• Background
• Performance improvement
• Plan of Correction
• Process
• Components
• Timing
• FAQs
• Summary and Next Steps
• Q A

3
Todays Objectives

• Describe rationale for CHAPs new requirement for
  a Plan of Correction
• Name key content elements of a Plan of Correction
• List steps and time frames of Plan of Correction
  process

4
Housekeeping

• Webinar tools
• We have muted your phones
• Raise your hand
• Type a question
• Questions
• Jot a note
• Plenty of time at end for Q A
• Email questions to POCquestions_at_chapinc.org

5
Background

• Why Change?

6
Background

• 2 Kinds of Citations
• CHAP Required Actions
• Evidence indicates not in compliance with
  standard
• Improvement expected by next visit
• Former required actions not met
• Deficiencies continuing since last visit
• CMS deficiencies
• Deemed home health and hospice
• 2567 form
• 10 days

7
Background

• CHAP BOR required Progress Reports
• Status of correction of deficiencies cited
• After the fact
• Minimal guidance
• Issues
• Lack of guidance for organizations on performance
  improvement process until after the fact
• Requests from organizations
• Many new providers
• Process variation inefficient, error prone

8
CHAP Facts

• Examining our role as the accrediting
  organization
• Adequate guidance?
• Adequate structure?
• Support for continuous improvement?

9
CHAP Facts

• LOT of need/emphasis on structure
• QAPI
• Requirement for accreditation
• Public scrutiny
• Input from CMS
• Home Health
• Hospice
• DMEPOS
• Concerns on National Front
• Fraud and abuse
• Medicare trust fund
• Health care reform

10
CHAP Facts

• MANY new providers
• Quality improvement is our mission
• Duty
• CHAP accredited organizations
• Industry
• Community at large

11
Why Change?

• Performance improvement is Continuous
• CHAP PI Standard-details
• CHAP accredited organizations request/demonstrate
  needs/DESERVE stronger framework
• Meets requirements CHAP must meet to offer deemed
  status

12
CHAP Performance Improvement

• Opportunity

13
Accreditation Process
14
Accreditation Process Variation
Process Variation
15
CHAP Process Change
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Plan of Correction

• Process

17
CHAP Process Change
Add
Delete
18
New Process Step by Step

• Conclusion of Site Visit
• Exit Conference
• Verbal report of deficiencies
• Site Visitor recommendation to Board of Review
• Administrative Review/Creation of POC
• Email to Organization
• 10 business days after end of site visit
• Provider defines/documents Plan of Correction

19
New Process Step by Step

• Emails POC to CHAP
• 10 calendar days after receipt
• Review
• Accept/return for further work

20
Plan of Correction

• Getting Started

21
Plan of Correction Getting Started

• Deficiency
• Review Standard
• What is performance expected?
• What was evidence of deficiency cited?
• Clarify with Site Visitor during visit
• Make notes at exit
• Think about
• What is wrong?
• What is root cause of problem?

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POC Getting Started Sample

• Citation

• Analysis

• It is required that pre-employment and subsequent
  periodic TB screening of employees in accordance
  with written policy. This requirement was not met
  as evidenced by review of 4 personnel files of
  clinical staff which did not contain
  documentation of pre-employment TB screening in
  accordance with written policy.
• Pre-employ TB Screening 4 of 10 (40) Records
  missing.
• LPN--Record 87845
• RN--Record 77358
• RN--Record 55277
• RN--Record 22194

• Expected performance
• 100 pre-employment TB screens
• What we did wrong
• Records missing data
• Screened?
• Paper or process problem?
• Monitoring?
• BIG R?

23
Plan of Correction

• Written
• RECOMMEND review with PAC, GB
• Defines elements
• WHAT
• WHO
• WHEN
• HOW

24
Plan of Correction

• Components

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Elements of POC

• WHAT?
• What action will we take to correct the
  deficiency cited?
• Multiple actions may be needed
• Examples of action items
• Provide training/education/inservice
• Test competency
• Redesign a process
• Improve/reinforce communication

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Elements of POC

• WHO?
• Who is responsible to implement the corrective
  action?
• Job role, not name
• Examples of roles
• Administrator
• Governing Body
• Director of Nursing
• General Manager
• Distribution Supervisor
• Production Pharmacist

27
Elements of POC

• WHEN?
• What is the latest date on which all elements of
  the action item will be completed?
• Time frame should be
• Reasonable to complete action
• Generally not in excess of 60 days

28
Elements of POC

• HOW?
• What actions will the organization take to ensure
  the effectiveness of the action and the ongoing
  correction of the deficient practice?
• Monitoring
• Define frequency and volume
• Generally intense (100) at beginning then
  incorporated into routine monitoring (quarterly
  audit)
• Define indicator
• Examples-MD orders, supervisory visits, annual
  competencies

29
Elements of POC

• HOW continued
• This is critical to successful Performance
  Improvement
• Did the change take?
• Is it correcting the deficient practice?
• Examples of monitoring
• Audit
• Field supervision
• Testing

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POC Accept/Reject

• Elements of review
• All elements present?
• Reasonableness
• Action plan?
• Time frame?
• Action will correct deficient practice?
• Specific?
• Senior management/oversight?
• Monitoring effective insight/oversight?

31
Plan of Correction

• Timing

32
Process and Timing
33
New Accreditation Process
3 months
34
Plan of Correction

• Examples and Tips

35
POC Examples

• WHAT-provide mandatory inservice for all staff
  including policy review, CHAP standard and
  company expectations and documentation
  requirements
• OR
• Revise policy/tool/other document to include
  missing element and educate all staff

36
POC Examples

• WHO
• The Director of Nursing will provide the
  inservice
• OR
• The Administrator will be responsible for this
  change

37
POC Examples

• WHEN
• The inservices will be completed by August 31,
  2009
• OR
• The new forms will be provided to all new
  patients starting August 31, 2009 and to all
  currently active patients by September 15, 2009

38
POC Examples

• HOW
• The Nursing Supervisor will monitor 100 of HHA
  notes for documentation according to the care
  plan. This will occur daily until 95 compliance
  achieved, then be included with quarterly record
  review.
• OR
• The Distribution Manager will contact 10 new set
  ups per week by phone to affirm that they
  received and are aware of their co-payment.

39
POC Examples to Avoid

• We will hold an inservice
• Weaknesses
• What is topic?
• Who will learn?
• Not specific enough

40
POC Examples to Avoid

• We will revise our form and send it to all 300
  patients in one week
• Weaknesses
• Not reasonable workload and time frame
• Does not include staff education

41
POC Examples to Avoid

• We will monitor 100
• Joan Smith will oversee
• Weaknesses
• What is the indicator?
• What is the frequency of the monitoring?
• Name of staff member need title

42
POC Tips

• Be as specific as possible
• Be as detailed as needed
• Be clear-WHO, WHAT, WHEN, HOW
• Ensure the action matches the problem
• The larger the organization and the more
  extensive the problem, the more actions and time
  and monitoring are needed

43
POC Tips

• Ensure Site Visitor/CHAP have correct name and
  email address for POC
• Watch for delivery!
• Complete each element for each deficiency
• Review and print your copy
• Electronically sign and submit to CHAP

44
Plan of Correction

• CHAPs Tool Set

45
POC Toolset
46
POC Toolset
47
POC Toolset
48
Frequently Asked Questions

• Plan of Correction

49
Frequently Asked Questions

• Which organizations are required to do Plans of
  Correction?
• All organizations seeking CHAP accreditation for
  all of our accredited service lines

50
Frequently Asked Questions

• I am new to community based health care and I
  have never done this! How am I supposed to
  figure this out?
• Many CHAP accredited providers are new to quality
  and performance improvement strategies. However,
  using CHAPs common sense approach and guided
  electronic POC toolset, with our coaching as
  needed, any motivated provider will be able to
  develop a realistic effective Plan of Correction.
  We are committed to your success!

51
Frequently Asked Questions

• What charges/fees will CHAP be adding for the
  Plan of Correction process?
• None.
• What value does the Plan of Correction add for my
  accredited organization?
• A stronger framework and incentive to understand
  WHY problems exist, and SET A ROADMAP to the
  correction of that problem. BETTER PLANNING
  leads to BETTER RESULTS.

52
Frequently Asked Questions

• Does the time to develop and return a Plan of
  Correction affect my accreditation status if I am
  seeking continuing accreditation?
• No. Accredited organizations maintain their
  accredited status until it is withdrawn or
  terminated.

53
Frequently Asked Questions

• Do I need to send copies of policies or forms
  that I change, or other evidence with my POC?
• No. If there is something specific we need to see
  in order to accept your POC, we will contact you
  and ask for it.

54
Frequently Asked Questions

• I corrected the deficiency on site. Why did you
  cite it anyway?
• The Site Visitor identified an issue during your
  site visit. The report will acknowledge that you
  corrected it, but it must be included in your
  report to ensure that it is in the forefront of
  your mind. You corrected it, but you still need
  to monitor it to ensure it stays corrected.

55
Frequently Asked Questions

• If the 10th calendar day is on a Saturday or a
  holiday, can I send my POC on Monday?
• That would be late. Using email date stamps the
  received date. Any delays in receiving your POC
  will delay your final accreditation.

56
Frequently Asked Questions

• How will I know if you accept my POC?
• We will email you our response

57
Frequently Asked Questions

• Does the time to develop and return a Plan of
  Correction affect when CHAP recommends me to CMS
  as a new provider?
• Returning your POC timely will assist CHAP in
  recommending deemed status for home health and
  hospice organizations. An acceptable POC is
  necessary for all organizations to achieve
  accreditation.

58
Frequently Asked Questions

• What if no deficiencies are cited during my site
  visit?
• Congratulations for excellent performance! No
  Plan of Correction will be required.

59
Frequently Asked Questions

• When does this new requirement for a Plan of
  Correction start?
• For home health and hospice organizations
• Site Visits ending September 1, 2009 and later
• For all other organizations
• By the end of 2009
• Specific dates will be communicated

60
Frequently Asked Questions

• Will we continue to also have to complete the
  2567?
• No, the CMS 2567 will be replaced by CHAPs
  electronic POC, which will contain CHAP citations
  as well as CMS citations for deemed home health
  and hospice organizations.

61
Frequently Asked Questions

• Who are the people who will review our POC for
  acceptance and how are they qualified to do so?
• Our Regional Directors of Professional Service
  will be reviewing your POCs. These are
  professional staff members who have education at
  the Masters Level and at least 8 years of
  experience at a management level in community
  based health care

62
Frequently Asked Questions

• What if we disagree with the citations?
• If a disagreement arises during the visit, please
  have a telephone meeting with one of our
  Directors which includes the Site Visitor. Any
  citation that is cited will need to be responded
  to in a POC. If you disagree with an
  accreditation decision, you may request a
  reconsideration in writing.

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Summary and Next Steps

• Plan of Correction

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Summary

• NEW POC Process
• Begins for site visits ending Sept 1 and after
• Home Health and Hospice organizations begin first
• Other types timing TBA
• CHAP electronic tool provides guidance
• Process and tool support performance improvement
• POC must be accepted to move forward with
  accreditation

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I LIKE CHANGE!
Only a Wet Baby Likes Change
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Next Steps

• Monitor website for announcements, FAQs
• www.chapinc.org
• Make sure CHAP has the correct email address for
  the person who will receive the POC and other
  announcements
• Send questions to POCquestions_at_chapinc.org

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Questions and Answers

• Plan of Correction POCquestions_at_chapinc.org

68
THANK YOU

• CHAP appreciates the opportunity to work with you
  and applauds your commitment to quality
  improvement!