ARTICLE
Presentation (PDF) Open in new window The Indiana Family and Social Services Administration (FSSA) Division of Disability and Rehabilitative Services (DDRS) Bureau of Quality Improvement Services (BQIS) Shelly Thomas, Assistant Director Provider Re-Approvals • CERT Citations • Complaint Allegations • Revised Data Assessment/Remediation Plan • Meeting with BQIS • Summary Letter following meeting • Appeals CERT Citations Revised approach to reviews: • Providers will continue to be held accountable to 460 IAC Article 6 requirements as well as requirements outlined in the approved CMS Waiver Applications and corrective action plans (CAPs) will be required for standards not met. • If the provider’s policies do not align with DDRS policies, then the item will be cited in the review; however, a formal CAP will not be required. • CAPs are only required when 460 IAC Article 6 standards are not met. • Providers will be given two validation attempts instead of one. • The risk area in the Provider Re-Approval Profile will be based on CAPs required instead of the number of citations (effective 11/1/2013). Complaint Allegations Complaints will have three categories of citations: • Substantiated, CAP Required (these would be cases that require formal corrective action through the complaint investigation process). • Substantiated, CAP NOT Required (these would be cases that may not be directly tied to consumer outcomes, e.g., documentation, etc., or cases where the provider implements corrective action during the information gathering stage of the review). • Unsubstantiated (allegation not supported). Revised approach to investigations: • Citations will be based on 460 IAC Article 6, Indiana Code, requirements outlined in the approved CMS Waiver Applications, DDRS Waiver Manual, DDRS Provider Agreement and/or Federal Regulations and supported with any applicable DDRS policy. • Identifying a lack of files or documents in the home, may or may not be captured as a negative finding: 1. If the documents pertain to program implementation (e.g., risk plans, behavior plans, tracking sheets for ISP goals and objectives, or behavioral documentation), AND are required to be in the home, and are not, then we would cite as a finding. We would still request that the provider place these documents in the home ASAP. • If the provider can produce this information from the office within 24 hours, then no CAP is required. • If the provider cannot produce this information, then a CAP is required. 2. If the documents do not pertain to program implementation, even if required to be in the home, (e.g., monitoring in the home, policies, training, etc.) AND are not in the home, we will request the documents from the office. – If the provider can produce this information from the office, then it will not be cited and a CAP will not be required. – If the provider cannot produce this information within 24 hours, then it will be cited but a CAP will not be required. • If a provider has repeated minor issues where a CAP was not required, BQIS will elevate the specific issue and require a formal CAP. • If an issue is corrected during an investigation, it will be cited, but would not require a CAP since the issue had been corrected. • If not directly related to program implementation or consumer health and welfare, additional findings will not be cited (e.g., documentation issues such as title of the trainer, etc.). • To encourage collaboration, surveyors will communicate with the provider throughout the CAP process. This may include having conversations about the best approach to address the situation and providing recommendations when requested. • The risk area in the Provider Re-Approval Profile will be based on CAPs required instead of the number of issues substantiated (effective 11/1/2013). Data Assessment/Remediation Plan Revised Directions What does BQIS really want? Data Assessment/Remediation Plan ANALYSIS OF DATA Please briefly describe reason(s) you believe your organization’s rates fell above or below the expected range. This may include information on things such as: • Confirmation of the data • Individual specific data if this appears to be driving your rates (e.g., a lot of incidents attributed to a few participants) • Evidence to suggest data is trending in the right direction (i.e., showing improvement) QUALITY ASSURANCE/QUALITY IMPROVEMENT SYSTEM Please describe, in a succinct manner, your agency’s quality assurance/quality improvement systems and explain how these activities are used to monitor the identified risk area. This should include: • A description of the activities your agency uses to prevent problems from occurring and to assess that services are being delivered according to consumers’ support, behavior, and risk plans. • What information your agency collects, aggregates, and analyzes to identify areas of concern. (It is unnecessary to provide copies of checklists and other monitoring tools, please just summarize what these collect). • Whom is collecting this information and how often. • How is this information being assessed, by whom, and how frequently. • What actions your agency takes to address the areas of concern and reduce risk to consumers. • How your agency assesses the effectiveness of remediation actions. • What your agency does when remediation actions have not resulted in positive outcomes for the consumer. • New practices your agency has implemented as a result of monitoring findings. • Data supporting suggested improvement in response to implementing new practices. REMEDIATION PLANS/PLANS FOR IMPROVEMENT Based on this information, what steps (if any) will be taken in the next 6-months to facilitate improvement? Providers should include specific information to explain the actions that will be taken, such as: • Who within your agency will implement? • When will the step(s) or activities be implemented? • How will effects of any change(s) be evaluated? Re-Approval Meeting with BQIS Meetings occur when: • BQIS has additional questions regarding the Plan; • Information in the Plan is not clear; and/or • When essential elements are missing from the Plan. Meeting Follow-up Letter BQIS will send a letter following the meeting that: • Reiterates the topics discussed during the meeting; • Reiterates what to include in the Addendum; and/or • Reiterates the timeframe for submission of the Addendum. BQIS REVIEW APPEAL PROCESS Appeal of Citations • Appeals must be submitted in writing to the BQIS Director within 7 business days of the date the Findings Report was issued. • The appeal must include: 1. Basis for the citation appeal; and 2. Supporting documentation or evidence. • Supporting documentation must be submitted with the appeal request or the appeal will not be considered. • BQIS will issue appeal decisions to the provider within 10 business days of receipt. • If the appeal is disallowed, the provider must submit a Corrective Action Plan (CAP) for the appealed citation within 5 business days from BQIS notification of such. • If the appeal is allowed, the citation will be removed and a revised report issued along with the appeal decision. Appeal of Corrective Action Plan (CAP) Denials • Appeals must be submitted in writing to the BQIS Director within 7 business days of the date the CAP Denial was issued. • The appeal must include: 1. Basis for the CAP Denial appeal; and 2. Supporting documentation or evidence. • Supporting documentation must be submitted with the appeal request or the appeal will not be considered. • BQIS will issue appeal decisions to the provider within 10 business days of receipt. • If the appeal is disallowed, the provider must re-submit a CAP for the appealed CAP within 5 business days from BQIS notification of such. • If the appeal is allowed, the CAP will be accepted and a revised report issued along with the appeal decision. WHAT PROVIDERS NEED TO KNOW ABOUT RE-APPROVALS BQIS must ensure providers are: • Compliant with regulations; • Understand their consumers; • Understand their staff; • Can demonstrate sufficient systems are in place to effectively support consumers; • Can identify ineffective systems and work toward continual improvement. WHAT ELSE SHOULD PROVIDERS KNOW? • BQIS will provide technical assistance when possible; • BQIS is available for phone consults. RESOURCES BQIS Helpline: BQIS.Help@FSSA.IN.gov BQIS Webpage: www.IN.gov/FSSA/DDRS/2635 Complaint Line: 1-866-296-8322 Shelly Thomas, Assistant Director, (317) 234-2764 Janice Gross, Compliance Director, (317) 233-1645