ODP ACADEMY For Administrative Entities

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ODP ACADEMY For Administrative Entities Changing
Practices, Unchanged Values

• Administrative Entity Oversight Monitoring Process

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ODP Academy

• Overview of the new AE Oversight Monitoring
  Process
• Development Implementation
• Structure of the Tool
• Elements of the Tool

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Why Develop a New Administrative Entity Oversight
Monitoring Process?

• In order to meet CMS assurances, ODP needs to
• Retain ultimate authority and responsibility for
  the operation of the waivers
• Exercise oversight over the performance of waiver
  functions by other agencies

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How Did ODP Develop the Process?

• A core group of ODP staff detailed the process
  using input received from AEs, the Regions, and
  Central Office staff.
• ODP Academy sessions are then used to relay
  information

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How Did ODP Develop the Process?

• ODP developed the AE Monitoring tool using
  requirements found in
• The Operating Agreement
• CMS Assurances
• Bulletins
• ODP Monitoring of Counties (OMOC)
• ODP Initiatives

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How Did ODP Develop the Process?

• Considering the AEs capacity to meet the new
  business practices, the AE Monitoring tool was
  reduced to the following items
• Operating Agreement (OA) requirements
• CMS Assurances (CMS-A)
• ODP Initiatives
• Data Integrity

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Whats Different

• The OMOC Process was valid from 2002 until
  3/31/07.
• With the approval of the Consolidated Waiver the
  AE Oversight Monitoring Process begins 4/1/07.
• Continuous systemic review
• Greater focus on quality
• Accessibility to and utilization of a wider
  variety of data sources

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Continuous Evidence Based Oversight

• Monthly reports sent to Administrative Entity
• Reports due to Regional Office every three months
• Regional and AE risk management activities
• Quarterly reports due to CMS regarding the CMS
  assurances

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How Will ODP Implement the New AE Oversight
Process?

• The Regions will develop monitoring schedules
• Regional Teams will share oversight
  responsibilities

Teamwork
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AE OVERSIGHT MONITORING LEAD

• Each region has identified an AE Oversight
  Monitoring Process lead.
• The Regional Lead will
• Serve as the Regional contact for the AE
  Oversight Monitoring Process
• Coordinate the AE Oversight Monitoring Process to
  ensure consistency with the Statewide standards.
• Provide technical assistance to Regional and AE
  staff
• Four regional leads and the central office point
  person will be the keepers of the process

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Where and How Will Monitoring be Completed?

• Regional reports reviews
• Home and Community Services Information System
  (HCSIS)
• Onsite
• Reviews
• Interviews

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How Will Monitoring be Conducted?

• 90 days prior to onsite review, Regional Teams
  will
• Pull all reports and samples
• Share reports with AEs
• 60 days prior to onsite review, Regional Teams
  will review samples and reports using information
  from
• Regional Offices
• HCSIS

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How Will Monitoring be Conducted?

• Two weeks prior to onsite reviews, Regional
  Teams will provide AEs with names of individuals
  in the sample
• In order to initiate the new AE Oversight
  Process, these time frames will be shortened
  during the first year (9 month vs. 12 month).

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How Will Monitoring be Conducted?

• At first, ODP Regional Teams will record and
  tally their findings off-line
• Once the process becomes finalized, HCSIS will be
  used to record findings

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How Will Scores be Determined?

• 100 compliance will be required for some items
• A Compliance Scale will be used for other items
• 90 to 100 Fully Compliant
• 80 to 89 Mostly Compliant
• 70 to 79 Somewhat Compliant
• Below 70 Noncompliant
• Any score below 90 will require a Corrective
  Action Plan

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What Will Happen After Onsite Reviews are
Completed?

• Regional team members will collaborate to
  complete summary reports
• Summary reports will be
• Shared with Regional and Central Office staff
• within 45 days of review
• Approved by Regional Program Manager
• Sent to the AEs

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What Will Happen After Onsite Reviews are
Completed?

• The AE will develop a Corrective Action Plan if
  needed, based on the findings in the summary
  reports.
• The Corrective Action Plan must be submitted to
  the Regional Office within 45 calendar days of
  the receipt of the finding report
• Each Regional team will review the AEs
  Corrective Action Plan and develop a validation
  plan

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Structure of the AE Oversight Monitoring Tools

• Review of the guidelines, worksheets and scoring
  tool

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SIX OVERALL ELEMENTS

• Quality of Life
• Administrative Entity Capacity
• Provider Qualifications/Monitoring
• Rights
• Eligibility/Level of Care
• Other Administrative Functions

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Elements of the Oversight Monitoring Process

• Requirements are not new
• Regions County/AEs have been responsible for
  these items for some time

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Quality of Life Issues Individual Support Plan
(ISP) Reviews

• Implemented according to time frames in Operating
  Agreement (OA CMS-A)
• Address all assessed individual needs (OA
  CMS-A)
• Document Services
• Frequency
• Amount
• Duration
• Provider type for each service (OA CMS-A)
• Outcomes relate to preferences and needs (OA
  CMS-A)

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Quality of Life Issues Individual Support Plan
(ISP) Reviews

• Timeliness of ISP Process (OA CMS-A)
• Updated/revised at least annually or if there is
  a change in the service need
• Team members invited to ISP meetings (OA)
• Services authorized prior to receipt of services
  (OA CMS-A)

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Quality of Life Issues Supports Coordination
(SC)

• Monitoring of individuals according to schedule
  (OA CMS-A)
• PUNS
• Reviewed annually (OA)
• Updated accordingly (OA)
• Completed for those with unmet need (OA)
• Signed and distributed (OA)

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Quality of Life Issues SC Review - Data
Integrity

• Mandatory fields completed in HCSIS
• Demographics
• Eligibility
• Enrollment information.
• Data integrity is crucial to the process.

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Quality of Life Issues - Quality Management (QM)
Requirements

• Quality Management/ Quality Implementation
  (QM/QI) plan written (OA)
• QI actions (OA)

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Quality of Life Issues Incident Management (IM)

• These items are all in relation to the
  implementation of the Incident Management
  bulletin.
• Corrective action is implemented (CMS-A)
• AE investigates incidents according to Certified
  Investigation manual (CMS-A)

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Quality of Life Issues Incident Management
(IM) (contd)

• Appropriate actions are taken within 24 hours of
  incidents (CMS-A)
• Local policies and procedures are in place to
  implement IM Bulletin (CMS-A)
• Semi-annual qualitative reports are issued (CMS-A)

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Quality of Life Issues Independent Monitoring
for Quality (IM4Q)

• AE assures providers address considerations (OA)
• AE informs IM4Q when action is taken on a
  consideration (OA)
• AE uses sharing process (OA)
• AE, with IM4Q, addresses major health and safety
  concerns (OA)
• AE uses IM4Q reports for evaluation and quality
  improvement (OA)

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ODP Initiatives - Employment

• AE documents OVR funding availability (OA)
• Initial referral is in individuals file
• HCSIS Functional Level Employment screen is
  completed
• AE follows ODP expected employment practices
• Each region has an employment point person

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ODP Initiatives

• Lifesharing
• AE follows ODP expected Lifesharing practices
• Restraint Reduction
• AE achieves annual statewide restraint reduction
  goal

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AE Capacity

• ISP completed in HCSIS for everyone receiving ODP
  services (OA CMS-A)
• AE has a designated PUNS Point Person (OA)
• AE has a designated IM4Q Point Person (OA)

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AE Capacity

• Bureau of Hearings Appeals orders are
  implemented within 30 calendar days (OA
  CMS-A)
• Provider dispute findings are implemented within
  calendar 30 days (OA CMS-A)

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AE Capacity

• Designated AE staff register for and participate
  in ODP Academy (OA)

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AE Capacity

• AE has a designated Employment Point Person
• AE has a designated Lifesharing Point Person

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Provider Monitoring

• All licensed/certified and non-licensed providers
  meet waiver qualification standards (OA CMS-A)

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Provider Monitoring

• All Waiver providers, except unlicensed
  individuals working through Vender
  Fiscal/Employment Agent, Intermediary Service
  Organization (VF/EA ISO), have a signed MA
  Agreement (OA)
• AE Waiver Provider contract is signed by all
  providers, except unlicensed individuals working
  through VF/EA ISO (OA)

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Provider Monitoring

• Provider training is conducted according to state
  and waiver requirements (CMS-A)
• All providers meet licensing and certification
  standards (OA CMS-A)

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Rights Due Process

• Individuals/families are notified of waiver
  eligibility appeal rights (OA)
• Notice of due process and appeal rights is
  provided as required (OA)
• Individuals receive required written notice of
  changes in waiver services (OA)
• Denials
• Reductions
• Terminations

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Rights Due Process

• AE assists individuals/families to file appeals
  as needed (OA)
• Waiver services under appeal continue as required
  (OA)

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Rights Choice

• Individuals/families have choice of services (OA
  CMS-A)
• Individuals/families have choice of providers (OA
  CMS-A)

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Rights Service Review

• Service Review findings are implemented within 30
  days (OA)

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Eligibility/Level of Care (LOC)

• LOC determinations are completed for everyone
  likely to receive services (OA CMS-A)
• Persons determined to be not qualified for ICF/MR
  LOC are provided due process as required (OA)
• All waiver participants are eligible for ICF/MR
  LOC (OA)

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Eligibility/Level of Care (LOC)

• Qualified Mental Retardation Professionals (QMRP)
  complete the certification of need consisting of
• Individual/family interview
• Social/psychological review
• Current medical evaluation (OA CMS-A)

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Eligibility/Level of Care (LOC)

• QMRPs certification of need is based on
  standardized adaptive behavior assessment that
  shows significant limitations in
• Age standards
• Three or more areas of major life activity (OA
  CMS-A)

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Eligibility/Level of Care (LOC)

• LOC re-determinations are completed annually (OA
  CMS-A)
• County Assistance Office is notified of changes
  in assets affecting eligibility within 10 days of
  the change or as required (OA)
• Eligibility information is maintained in files
  (CMS-A)

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Financial Management - General

• Waiver funds are used only for eligible services
  (OA CMS-A)
• Waiver funds are used only for eligible
  recipients (OA CMS-A)
• Claims are verified for eligibility and
  authorization (OA CMS-A)
• Payments for waiver services are made only to
  qualified providers and vendors (OA CMS-A)

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Financial Management - General

• Ineligible services are excluded from Federal
  Financial Participation (FFP) (OA)
• Clean claims are paid within 30 days (OA)
• DPW is notified within 10 days of overpayments
  (OA)
• Paid claims do not exceed limits or caps (OA)
• Audits are completed as required (OA)

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Financial Management Rate Setting

• Rates are established by DPWs Rate Setting
  Methodology and/or approved by DPW

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Financial Management Reports

• Quarterly expenditure reports are submitted to
  ODP within 14 days of the end of the quarter. (OA
  CMS-A)
• Annual waiver reports submitted by September 15th
  for the previous Fiscal Year. (OA CMS-A)
• Annual income and expenditure reports submitted
  by September 15th for the previous Fiscal Year
  unless otherwise directed by ODP. (OA CMS-A)

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Financial Management Individual Emergency
Services Form (IESF)

• IESFs are submitted as required (OA)

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Other Administrative Functions Record Retention

• Records are retained according to specified time
  requirements (OA)
• Waiver records are safeguarded per HIPPA
  regulations (OA)

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Other Administrative Functions Self-Assessments

• Self-assessments are completed annually (OA)
• Corrective actions are submitted to ODP within 30
  days of completion of the Self-Assessment. (OA)
• Corrective activities are completed and validated
  by the AE. (OA)
• Self-assessment records are maintained for three
  years (OA)

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Other Administrative Functions Fully Served

• All Consolidated Waiver participants are fully
  served (OA CMS-A)
• All Person/Family Directed Support (P/FDS) Waiver
  participants are fully served.
  (OA CMS-A)

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Other Administrative Functions Personal Funds

• Individuals personal funds are managed as
  required by the current bulletin (CMS-A)
• Administration and Management of Client Funds,
  bulletin number 6000-88-08, issued October 5,
  1988

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Other Administrative Functions Departmental
Monitoring

• Corrective Action Plans to the Departments AE
  Oversight Monitoring Process are completed by the
  AE within 45 calendar days (OA)

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Next Steps

• Assure all necessary data reports are available
  to support the AE Oversight Monitoring Process
• Determine the sample size
• Monitor and evaluate the AE Oversight Monitoring
  Process to make changes and improvements as
  needed.

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AE Oversight Monitoring Mailbox

• All questions go to the mailbox
• Regional AE Leads and Central Office Point person
  develop answers
• Answers sent out to list serve members
• Mailbox address is
• ra-aeoversight_at_state.pa.us