Provider Applicant Orientation for the Office of Developmental - - PowerPoint PPT Presentation

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Provider Applicant Orientation for the Office of Developmental - - PowerPoint PPT Presentation

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Provider Applicant Orientation for the Office of Developmental Programs OFFICE OF DEVELOPMENTAL PROGRAMS www.dpw.state.pa.us > > 1 www.dhs.state.pa.us TABLE OF CONTENTS Monitoring of Providers Slide 67 ODP Service System Slide 3

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OFFICE OF DEVELOPMENTAL PROGRAMS

Provider Applicant Orientation for the Office of Developmental Programs

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TABLE OF CONTENTS

ODP Service System Slide 3 ODP Mission and Values Slide 13 Person Centered Planning Slide 21 Rules & Regulation Slide 30 ODP Waivers Slide 35 Becoming a Provider Slide 51

Glossary [Attachment 1] Resources [Attachment 2]

Monitoring of Providers Slide 67 Incident & Risk Slide 74 Management Financial Management Slide 92 Quality Management Slide 100 Provider Training Slide 105 Wrap Up Slide 111 Post Test Slide 114

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THE ODP SYSTEM IN PA

The Office of Developmental Programs intends that all applicants to provide waiver services for individuals with an intellectual disability and/or Autism understand the ODP system prior to starting services

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  • The ODP system is committed to providing opportunities to

individuals for quality, integrated and community based supports

  • Supports include:

– Home and Community Based Services [HCBS] in an individual’s

home or local community

– Non-residential supports including employment, job support and

facility based day services

– Residential supports in group homes and Life Sharing settings

where an individual lives with others in a family setting.

– Transportation – Therapies

  • Services are available through the Consolidated and

Person/Family Direct Support [PFDS] Waivers, base funding, and Intermediate Care Facilities for people with ID [ICFs/ID].

ODP SYSTEM

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WHOM DO WE SERVE ?

Individuals with an intellectual disability or autism who have been determined programmatically and financially eligible and are registered with a county program

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STRUCTURE OF THE ODP SYSTEM IN PA

Supports Coordination Organizations Advocates CMS AE’s Individual & Family Providers ODP Licensing

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WHO ARE WE?

  • The Office of Developmental Programs [ODP] is the

state office designated to administer and oversee supports and services to individuals with Intellectual Disability [ID] and Autism

  • ODP delegates authority to County/Administrative

Entities [AE]. AE’s are ODP’s delegates for assuring that federal and state requirements are met within their jurisdiction.

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WHO ARE WE - DHS ORGANIZATIONAL STRUCTURE

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WHO ARE WE - ODP ORGANIZATIONAL STRUCTURE

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WHAT WE DO?

ODP is responsible for:

– Managing Waivers – Allocating waiver capacity – Registering Providers – Maintaining Online Web- Based Applications – Overseeing Monitoring of Providers – Establishing rates – Writing Policy – Monitor AE’s – Qualify SCO’s – Monitor Supports Coordination Organizations [SCO’s]

County/AE’s are responsible for:

– Providing technical assistance and support to providers – Qualifying providers – Determining individual eligibility – Authorizing services – Monitoring providers – IM4Q – Managing waiver capacity – Reporting and investigating incidents – Maintaining and safeguarding waiver records

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Provider information

  • ISP’s
  • Service & Support Directory
  • Service Authorizations
  • Incident Management
  • Provider Qualifications
  • User Training Resources
  • Claims Management
  • Learning Management

System [LMS]

Individuals’ information

– Individual Support Plans (ISPs) – Assessment data – Medical history – Financial data – Services and supports – Service notes – Other data related to individuals

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HCSIS, PROMISe™ & EIM

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HOW TO STAY CONNECTED

  • ODP communicates regularly with its

stakeholders through:

  • Listservs
  • PA Bulletin
  • Announcements
  • Information Packets and Memos
  • MyODP Website
  • Provider Associations
  • Meetings and Conferences
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ODP Mission, Vision & Values

to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and

  • pportunity in

their lives.

Mission

to continuously improve an effective system

  • f accessible services

and supports that are flexible, innovative and person‐centered.

Vision

based on the Everyday Lives: Values in Action, ODP’s vision promotes the belief that, with the support of family and friends, people with disabilities can and should decide how to live their lives.

Values Scope

ODP serves individuals with an intellectual disability and/or Autism Spectrum Disorders.

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Everyday Lives - VALUES IN ACTION

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Everyday Lives - VALUES IN ACTION

Responsibility Control

My Life, My Way

Choice Freedom Stability Health and Safety Employment, Meaningful Contribution Individuality Connected Relationships Partnership Communication Quality Success Advocacy

What Families Value

The Unique Role of Family Supporting Families Throughout the Lifespan Mentoring Choice and Control Health and Safety Knowledge and Resources Simplicity and Flexibility Quality and Stability Communication Collaboration Respect and Trust Opportunity for Innovation

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  • 1. Assure Effective Communication
  • 2. Promote Self-Direction, Choice and Control
  • 3. Increase Employment
  • 5. Support Families Throughout the Lifespan
  • 4. Promote Health, Wellness, and Safety
  • 6. Support People with Complex Needs
  • 7. Develop and Support Qualified Staff

Everyday Lives, Values in Action

RECOMMENDATIONS

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Everyday Lives, Values in Action

RECOMMENDATIONS

  • 8. Simplify the System
  • 9. Improve Quality
  • 10. Expand Options for Community Living
  • 11. Increase Community Participation
  • 12. Provide Community Services to Everyone
  • 13. Evaluate Future Innovations based on

Everyday Lives Principles

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SELF DETERMINATION

  • Self-determination is for everyone.
  • Everyone can make choices.
  • Everyone should have control over his
  • r her life.
  • Everyone is different and there is value in

difference; therefore supports need to be individualized.

  • Everyday Lives are for everyone.
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POSITIVE APPROACHES

Positive Approaches is a worldview, a movement, in which all individuals are treated with dignity and respect, in which all are entitled to Everyday Lives.

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THE ODP SYSTEM

What does this mean for you as a prospective provider?

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PERSON CENTERED PLANNING

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PERSON CENTERED PLANNING

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Person Centered Planning is about an individual’s strengths, interests and preferences to achieve a balance of what is important TO the person and FOR the person.

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THE ISP

The ISP is the standardized planning document for individuals that follows the principles of Everyday Lives and Person Centered Planning. It addresses individual’s assessed needs; and designs services and supports that are meaningful in an individual’s life.

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THE ISP

Understanding Communication

Medical

Information Individual Preferences Functional

Information

Personalized Outcomes

Health and

Safety

Services and Supports

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ISP TEAM

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The ISP team consists of:

  • The individual.
  • The individual’s family, guardian, surrogate or

advocate.

  • The Supports Coordinator [SC].
  • Providers of service.
  • The common law employer or managing employer if

the individual has chosen to self-direct.

  • Other people who are important in the individual’s life

and who the individual chooses to include.

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PROVIDER ROLES IN ISP DEVELOPMENT

  • Complete assessments, evaluations, and progress

reports

  • Direct Support Professionals [DSP] participate in the

team meeting

  • Provide updates to the ISP
  • Train staff on the individual’s ISP
  • Implement the authorized ISP

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SCENARIO 1

Shawn lives with her mother, but her Mom is getting too frail to lift or hold her. Shawn uses a wheelchair and her bedroom and bathroom are on the 2nd floor. Despite her physical challenges, Shawn is a very strong-willed person and refuses to move away from her Mom. The possibilities of Shawn having an everyday life is at risk. Shawn is enrolled in the PFDS Waiver and receives job supports and transportation from ABC, Inc. Shawn’s ISP stated that she needed a safer environment and staff supports due to her mobility issues. Her preferences were clearly stated that she wants to continue to live with her mother. Her ISP addressed her desire to move due to the physical challenges and the inability to assure her health and

  • safety. However, in the Individual Preference section, it states that living with her mother is very

important to her. Referrals were sent to providers with Shawn’s plan. Shawn, with her team including her Mom and the SC chose XYC, Inc. While the cost for purchase or lease of a home are not allowable expenses (ODP will not participate in the cost of occupancy for private homes), the new provider and SC assisted Shawn and her mom with referrals to a public agency to sell their home and develop a trust for Shawn to pay future rent. Shawn and her Mom both found an apartment that was accessible, and Shawn now receives job supports; transportation; home modifications and in-home supports under the PFDS Waiver.

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BACK-UP PLAN

55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMS HOME AND COMMUNITY-BASED SERVICES Subchapter A. GENERAL PROVISIONS § 51.3. Definitions

Back-up plan—

(i) A strategy developed by a provider to ensure the HCBS the provider is authorized to provide is delivered in the amount, frequency and duration as specified in the participant’s ISP.

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ISPs

What does this mean for you as a prospective provider?

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RULES & REGULATIONS

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RULES & REGULATIONS

The Mental Health & Intellectual Disability Act of 1966 Chapter 1101 MA Regulations & Policy 55 PA Code Chapter 51 Waiver Program Regulations 55 PA Code Chapter 2380 Adult Training Facility Licensing Regulations 1915(c) Home and Community-Based Services Waiver Consolidated Waiver 55 PA Code Chapter 2390 Vocational Facilities Licensing Regulations 1915(c) Home and Community-Based Services Waiver Person/Family Directed Support Waiver 55 PA Code Chapter 6400 Community Homes Licensing Regulations 55 PA Code Chapter 6500 Family Living Homes Licensing Regulations 55 PA Code Chapter 3800 Child Residential and Day Treatment Facilities 55 PA Code Chapter 5310 Community Residential Rehabilitation Services for the Mentally Ill ODP Waiver Provider Agreement

RULES & REGULATIONS

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55 PA Code Chapter 51

All Consolidated and P/FDS waiver services are regulated by 55 PA Code Chapter 51.

There are 4 subchapters to 55 PA Code Chapter 51:

  • A. General provisions: 51.1
  • B. Provider qualifications and participation: 51.11
  • C. Payments for services: 51.41
  • D. Closures and termination: 51.151
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CERTIFICATE OF COMPLIANCE

The following must be included with an Application for Certificate of Compliance/Licensure:

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  • Articles of Incorporation (if appropriate);
  • Pennsylvania Department of State Fictitious Name

Approval (if appropriate);

  • Certificate of Occupancy (UCC permit);
  • Civil Rights Compliance Questionnaire must be

completed and mailed to the appropriate Bureau of Equal Opportunity office

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HIPAA

The Health Insurance Portability and Accountability Act (HIPAA)

  • The Privacy Rule requires actions including:
  • Notifying participants about their rights
  • Adopting and implementing privacy procedures
  • Training employees
  • Privacy Officer
  • Securing records
  • Protected Health Information (PHI]
  • Information that a provider receives or creates about the

participant that relates to a past, present or future physical or mental health condition, or treatment or payment for the treatment that can be used to identify the participant.

  • Must be kept confidential

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative- Simplification/HIPAAGenInfo/AreYouaCoveredEntity.html

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ODP WAIVERS

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ODP WAIVERS

ODP’s Home and Community-Based Waivers

  • Two of ODP’s approved waivers are:
  • Consolidated
  • Person/Family Directed Support [P/FDS]
  • Each waiver specifies the types of services that may be provided in home

and community settings

  • Each waiver caps the number of people who may receive services under

the waiver

  • Each waiver limits the services to people with specific eligibility
  • The need for services must be established through an assessment

process, reviewed and discussed with the planning team and documented in an ISP.

  • Each waiver includes standards to meet the required waiver assurances
  • Individuals can only be in one waiver at a time
  • Not every individual supported by ODP is enrolled in the Waiver.
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WAIVER ASSURANCES

The Federal HCBS Waiver Assurances are:

  • Level of Care
  • Service Plan
  • Qualified Providers
  • Health and Welfare
  • Financial Accountability
  • Administrative Authority
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The purpose of the CMS HCBS rule is to make sure individuals receive services in settings that are integrated in the community and individuals receiving services have access to community resources equal to that of those who do not receive services. Individuals receiving services should be able to:

  • Have opportunities to seek employment and work in

competitive and integrated settings.

  • Engage in community life.
  • Control personal resources.
  • Obtain services in the community.

CMS FINAL RULE

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WAIVER SERVICES

  • Assistive Technology
  • Advanced Supported Employment
  • Behavioral Support
  • Benefit Counselling
  • Communication Specialist
  • Community Participation Support*
  • Companion
  • Consultative Nutrition Services
  • Education Support
  • Family/Caregiver Training
  • Home and Vehicle Adaptations
  • Housing Transition and Tenancy
  • Homemaker/Chore
  • Lifesharing*
  • Residential Habilitation*
  • Respite
  • Shift Nursing
  • Supports Broker
  • Supports Coordination
  • Specialized Supplies
  • Supported Living
  • Therapy Services
  • Transportation
  • Financial Management Services

–

Agency with Choice (AWC)

–

Vendor Fiscal/Employer Agency (VF/EA)

  • Vendor Services

–

Public Transportation

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WAIVER SERVICE DEFINITIONS

Elements of a Waiver Service Definition

  • Description of the service
  • Frequency (how often) duration (how long) and intensity (the

levels of support that may be offered)

  • Information on where and how the service may be provided
  • Applicable regulation and licensing requirements
  • Qualifications of providers and staff
  • Qualifications of staff that provide specialized supports and therapy
  • Limits to service provision (amount, location, duration, or services

which are exclusionary of each other)

  • Billing codes (in ISP Manual)
  • Definition of the service unit (in ISP Manual)
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SUPPORTS COORDINATION

Supports Coordination is a critical service that involves the primary functions

  • f locating, coordinating and monitoring needed services and supports for

waiver participants. Locating services and supports consists of assistance to the participant and his or her family in linking, arranging for, and obtaining services specified in an Individual Support Plan [ISP], including needed medical, social, habilitation, education or other needed community services. Activities included under the locating function include all of the following in addition to the documentation of activities.

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WAIVER CAPACITY

Waiver Capacity is the number of individuals that may be enrolled in the Consolidated and P/FDS Waivers at any given time. Currently, there are over 30,000 individuals enrolled in the waiver.

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PUNS

Waiver enrollment is prioritized based on the PUNS:

Prioritization of Urgency of Need for Services

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REFERRAL & PROVIDER SELECTION

  • The Individual Support Plan is the primary source of

information for referrals to providers

  • Waiver participants have the right to choose from any

willing and qualified provider

  • Providers shall respond to referrals with information to

the individual, family and SC of whether they are able to

  • ffer the services in the plan or if not, why not.
  • Providers must have a reasonable basis for rejecting a

referral

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  • Services for individuals accepted by the Provider

must begin within 45 days of waiver enrollment.

  • If an individual selects another willing and qualified

provider to replace the current provider, both providers shall cooperate during the transition between providers.

  • A provider that is no longer willing to provide an

HCBS to a participant shall provide written notice at least 30 days prior to the date of discharge.

PROVIDER ADMISSION & DISCHARGE POLICIES

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CHOICE & CONTROL

  • Federal policy encourages states to increase the

level of choice and control to individuals.

  • The Commonwealth has implemented programs for

individuals and their families to self-direct services.

  • Person Centered Planning enhances the choice and

control that waiver recipients have in selecting services and providers

  • Individuals and their families are encouraged and

supported with making more decisions

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HOME AND COMMUNITY SERVICES INFORMATION SYSTEM

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Melissa has lived in a group home for a few years. She decided she will move to an apartment to be more independent. Her team plans to support her during and beyond this move. The group home she left at Provider Z, now has an opening or a vacancy. Since Melissa is still using her waiver ‘slot’ for the new place, the group home opening can only be filled by a person who is waiver eligible and has been approved by the AE and an individual who has selected Provider Z. Some vacancies can remain vacant for a long time and cannot be billed. Therefore, a strong understanding and careful management of a provider’s capacity is essential.

SCENARIO 2

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WAIVER SERVICES

What does this mean for you as a prospective provider?

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BECOMING A PROVIDER

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BECOMING A PROVIDER – PROCESS FLOW

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GETTING STARTED

These are the steps you’ve already taken as a provider applicant:

  • Expressed interest in rendering Consolidated and/or

P/FDS Waiver services within ODP

  • Received the Provider Applicant [aka ‘Getting Started’] e-

mail from ODP or AE

  • Registered to attend this session on MyODP
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Provider registers for Applicant Orientation, attends session and takes test.

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PROVIDER APPLICANT ORIENTATION

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PROVIDER APPLICANT ORIENTATION

If the provider applicant passes the test … … ODP will forward Applicant Orientation certificate along with Applicant Orientation & Next Steps e-mail to Provider

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PROVIDER APPLICANT ORIENTATION

The Certificate expires 120 days from the date it is issued.

If the provider does not become qualified within 120 days, they will need to attend a second Provider Applicant Orientation session and take the test again.

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  • ODP Licensed Providers will be required to self register, to obtain a

user id that will allow them access to the Provider Self Service portal for Certification and Licensing.

Provider Registration

Cr eat e Pr ovi der Sel f Cr eat e Pr ovi der Sel f Ser vi ce Account Ser vi ce Account

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LICENSING

Licensed Providers (2380, 2390, 6400, 6500) must email the ODP Regional Waiver Capacity Manager for site clearance and receive an approval letter.

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Provider to complete ODP Provider Agreement

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PROVIDER AGREEMENT

ODP Waiver Instructions and Agreement

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Quality Assessment & Improvement Contact Information

  • Complete the Quality

Assessment & Improvement Contact Information questionnaire

  • Send the confirmation

to the AE in which you intend to provide the majority of services

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PROVIDER QUALIFICATION

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Provider applies for services for which they are qualified.

  • License (if required)
  • ODP agreement
  • Approved APC letter
  • Approved DP FORM 1059

ODP Provider Enrollment unit will review application and if approved, enroll in PROMISeTM.

MEDICAL ASSISTANCE (MA) PROGRAM ENROLLMENT

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Notification is received from the HCSIS Help Desk that the provider may add services for which they are qualified in HCSIS. Provider logs into HCSIS to adds services.

PROVIDER ADDS SERVICE

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Rates loaded into PROMISeTM and contracts created in HCSIS within 5-7 business days.

If participants choose the provider’s services, the Supports Coordinator can add the services to the ISP. The Supports Coordinator submits the ISP to the Administrative Entity for review.

MEDICAL ASSISTANCE (MA) PROGRAM ENROLLMENT

The Administrative Entity authorizes services and the provider may begin to provide services.

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Scenario 3

Phil owns a empty house. He is considering using this home to support people with disabilities. He has asked how he may get paid. The answer to this is not easy.

  • Phil could simply lease or sell the home to an individual or a provider. In

this case, he is a landlord and does not need to be enrolled in the system.

  • If Phil wants to ‘rent rooms’ but not provide any waiver services, this is not

eligible for ODP funding.

  • Phil can establish a community home for people with an intellectual
  • disability. He must complete the registration and enrollment process,

become qualified for Residential Habilitation services, complete the Provider Applicant Orientation.

  • Get licensed, obtain ODP approval for site size, enroll in PROMISe™ and if

Phil’s agency is the provider of choice for an individual enrolled in the Consolidated Waiver, begin services.

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BECOMING A PROVIDER

What does this mean for you as a prospective provider?

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MONITORING OF PROVIDERS

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MONITORING OF PROVIDERS

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Licensing

  • DHS determines compliance with applicable regulations

QA&I Self-Assessment

  • Annual
  • Provider assesses their own performance with regulations and waiver assurances

QA&I On-Site

  • Triennial
  • AE’s determine provider’s performance with regulations and waiver

assurances ISP Monitoring by Supports Coordinators

  • Frequency determined by which waiver, ISP and special circumstances
  • Health, Welfare and Safety
  • Service Provision as specified in the ISP

IM4Q

  • Independent monitors measure quality of life and level of individual and families’

satisfaction with services

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  • Requirement per Consolidated and P/FDS Waivers and

applicable regulations

  • Must be completed and approved prior to qualification

and before a PROMISe™ enrollment application is approved by ODP

  • Required for providers both initially and on an ongoing

basis

MONITORING OF PROVIDERS

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MONITORING OF PROVIDERS

I N I T I A L LY ANNUALLY T R I E N N I A L LY A S NEEDED

NEW PROVIDER SELF ASSESSMENT AE ONSITE REVIEW CORRECTIVE ACTIONS PROVIDER SELF ASSESSMENT

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  • Mission/vision statement
  • Staff Qualification requirements
  • Checking if staff or sub-contractors

are eligible to provide waiver services

  • Restraint policy
  • Record Management
  • Emergency disaster response plan
  • Grievance procedures
  • Policies/procedures for checking

staff on LEIE, SAM and Medicheck

  • Accessibility for Individuals who

are deaf Protocol

  • Response to individual health

and behavioral emergencies/crises

  • Ensure implementation of back-

up plans

  • Conflict of interest
  • Ensure replacement of lost and

damaged property

  • Appropriate transition of

individuals

  • Incident Management
  • Annual training curriculum, as

per regulations

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MONITORING OF PROVIDERS

Agency Policies and Procedures shall include:

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NEW PROVIDER SELF-ASSESSMENT

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INDEPENDENT MONITORING for QUALITY

72

Essential Data Elements (EDE) Survey Satisfaction Choice and Control Dignity Relationships Respect and Rights Inclusion

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INCIDENT MANAGEMENT

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INCIDENT MANAGEMENT

ODP Incident Management Bulletin # 6000-04-01

Title 55, Human Services Subpart A. Statement of Policy Chapter 6000 Subchapter Q Incident Management

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INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALL PROVIDERS WITHIN 24 HOURS

Abuse Law Enforcement Activity Death Missing Person Emergency Closure Misuse of Funds Emergency Room Visits Neglect Fire Psychiatric Hospitalization Hospitalization Rights Violation Individual to Individual Abuse Suicide Attempt Injury Requiring Treatment Beyond First Aid

INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALL PROVIDERS WITHIN 72 HOURS

Medication Error Restraints

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INCIDENT MANAGEMENT

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INCIDENT MANAGEMENT – CERTIFIED INVESTIGATIONS

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LIFECYCLE OF AN INCIDENT

Incident is recognized or discovered Incident is recognized or discovered Immediately, actions are taken to protect health and safety Immediately, actions are taken to protect health and safety

Within 24 hours of

  • ccurrence,

reportable incident report entered into system Within 24 hours of

  • ccurrence,

reportable incident report entered into system Development and implementation of Corrective Action Plans Development and implementation of Corrective Action Plans

Final incident report entered into system Final incident report entered into system

Within 30 days of the report, determine

  • utcome of

investigation – if applicable Within 30 days of the report, determine

  • utcome of

investigation – if applicable Within 24 hours of entry in EIM, Oversight Entities review initial reportable incident report Within 24 hours of entry in EIM, Oversight Entities review initial reportable incident report Within 30 days of the final report submission, Final incident report is reviewed and closed by Oversight entities Within 30 days of the final report submission, Final incident report is reviewed and closed by Oversight entities Within 24 hours of the report, Investigation initiated – if applicable Within 24 hours of the report, Investigation initiated – if applicable

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INCIDENT MANAGEMENT

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Provider roles and responsibilities:

1. Assign an individual with overall responsibility for incident management. 2. Develop a policy for incident management. 3. Ensure that staff, individuals and families are trained on incident management policies and procedures. 4. Assign roles within their organization for reporting and investigation of incidents. 5. Assure corrective action to individual incidents. 6. Conduct analysis of data on incidents and the quality of investigations. 7. Identify and implement individual and systemic changes based

  • n risk management analysis.
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PROVIDER IM ROLES

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Point Person Incident Management Representative Certified Investigator

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PROVIDER IM ROLES

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  • Receive verbal or other reports of allegations or

suspicion of incident

  • Safeguard the individual
  • Ensure Incident Report is submitted
  • Communicate with others involved in investigation
  • Follow up
  • Review of Incidents

Point Person

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PROVIDER IM ROLES

81

Incident Management Representative

  • Overall agency responsibility
  • Ensure activities of initial reporter and point person are

completed

  • Finalization of Incident report within 30 days
  • Peer Review
  • Evaluate the quality of incident investigations
  • Maintain an investigation file within the agency
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PROVIDER IM ROLES

82

  • Receive training and certificate
  • Maintain certification
  • Conduct prompt investigations
  • Enter investigation summary in EIM

Certified Investigator

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PROVIDER IM RESPONSIBILITIES

  • Promote the health, safety, rights and enhance the dignity of

individuals receiving services.

  • Ensure that staff and others associated with the individual have

proper orientation and training to respond to, report and prevent incidents.

  • Develop provider-specific policy/procedures for incident

management. – Includes the possible immediate and long-term effects to the individual from an incident or multiple incidents”.

  • Provide ongoing training to individuals and families on the

recognition of abuse and neglect.

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OVERSIGHT ENTITY’S ROLES

  • Review actions to protect health, safety and rights that

were taken by the provider

  • Request additional information from providers regarding

the incident, actions taken and recommend additional actions to protect health, safety and rights as appropriate

  • Communicate with individual, their family, guardian or
  • ther designee as appropriate about the incident
  • Assist with securing supports or services that are

needed as a result of the incident

  • Determine if an investigation needs to be completed in

addition to the requirement placed upon the provider

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CHILDREN AND ADULT PROTECTIVE SERVICES

85

Adult Protective Services Act [APS] Act 70 Older Adults Protective Services Act [OAPSA] Act 79-1987 Child Protective Services Act [CPS] Act 3490

SUSPECT ELDER ABUSE OR ABUSE OF AN ADULT WITH A DISABILITY? CALL: 1-800-490-8505 REPORTING CHILD ABUSE, CALL 800-932-0313 (TDD: 866-872-1677)

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INCIDENT MANAGEMENT

What does this mean for you as a prospective provider?

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Incident Management is reactive, Risk Management is proactive.

87

INCIDENT MANAGEMENT AND RISK MANAGEMENT

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RISK MANAGEMENT

  • Risk management promotes a positive quality of life

for individuals with intellectual disability and/or autism by ensuring their health, safety and well-being.

  • A risk management system identifies factors that

increase risk to individuals and to develop practices that reduce risk.

  • A risk management system uses data to track

incidents and plan preventative measures for the future

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RISK MANAGEMENT

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Provider risk management process needs to include, but not limited to:

  • The review and analysis of incident management data, certified

investigation findings and other information such as complaints, service reviews, etc.;

  • Discovery of root cause and contributing factors directly related to
  • ccurrence; and
  • Individual-specific and systemic actions to manage and/or mitigate

risk.

  • Providers must relate preventive measures directly to the cause of

the incident for them to have an impact on occurrence or recurrence.

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.

SCENARIO 4

Matthew, age 23, lives at home with his mother and brother. His brother is paid by a provider to provide Home and Community Habilitation services to him 3x a week.

.

During a monitoring visit, Matthew tells the Supports Coordinator that his brother has been leaving him home alone so his brother can go out when he was supposed to be working with him. Matthew’s ISP states that he needs supervision when in his home. The Supports Coordinator [SC] discusses this with Matthew’s mother and identifies this as a concern in the service notes. No incident was reported. On the next monitoring visit by the SC, Matthew doesn’t say anything, and the SC didn’t bring it up either.

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FINANCIAL MANAGEMENT

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RATE SETTING

  • Cost-based Rates
  • Cost Report Rates
  • Area Average Rates
  • Lowest Rates
  • Department-established fee rates
  • Market-based approach
  • Determination of cost components
  • Geographical areas
  • Vendor
  • Good or services offered to the general public

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How Rates are Assigned to Providers

  • Once a provider has their account(s) established in HCSIS

and PROMISe™ and have been qualified they can begin to add the services in HCSIS to each AE that will be authorizing services

  • Services are added by procedure code, by AE
  • Once the rate is added to PROMISe™, the rate will be

loaded to HCSIS and will be available for inclusion in an ISP

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RATE SETTING

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When Providers can bill for services

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  • The provider’s Service and Supports Directory (SSD) is updated

appropriately

  • The provider’s service or services have already been attached to an

Individual’s Support Plan (ISP) and authorized by the Administrative Entity

  • The provider has viewed the Service Authorization Notice(s) found in

HCSIS > Provider Self Service prior to rendering and billing for an ODP service and has confirmed that the data elements contained in it are accurate

  • The provider has already rendered the service per the frequency

indicated in each individual’s ISP, and that the service or services rendered are documented in your organization’s file notes or record keeping system

CLAIMS

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  • Every time a claim is billed, there must be supporting

documentation which shows that the service that was billed matches the authorized service from the ISP.

  • Providers are responsible to ensure that the amount,

frequency, duration, staffing ratio, and types of services that are billed to PROMISe™ correctly match the authorizations from individual’s ISPs, and providers must maintain supporting documentation to substantiate each claim.

CLAIM AND SERVICE DOCUMENTATION

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Claims must be supported by documentation that the services is:

  • Provided to a Medicaid-eligible

individual

  • Provided by a qualified provider
  • Authorized based on accessed need
  • Rendered as authorized in an ISP
  • Includes:

– Date the service was rendered – Name of the recipient – Medicaid identification number – Name of provider and person providing the service – Nature, extent or units of service – The place the service was

rendered.

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CLAIM AND SERVICE DOCUMENTATION

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  • Progress notes are to be completed during the

calendar month the service is provided.

  • Progress notes must be written every time a

service is delivered if the service is occurring

  • n a less than monthly basis, (for example the

service is provided every 6 weeks or every 90 days). PROGRESS NOTES

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FINANCIAL MANAGEMENT

What does this mean for you as a prospective provider?

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QUALITY MANAGEMENT

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Quality Management is a methodology by which organizational performance is continuously measured, evaluated, and improved. Individuals and other stakeholders are engaged in designing and improving services.

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QUALITY MANAGEMENT

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PDCA Model for Improvement

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CHAPTER 51. Subchapter A. § 51.25. QUALITY MANAGEMENT PLAN

55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMS HOME AND COMMUNITY-BASED SERVICES

Subchapter A. GENERAL PROVISIONS § 51.25. Quality Management Plan (a) A provider shall meet the QM plan criteria developed by the Department. (b) The provider shall create and implement a QM plan. (c) The provider shall evaluate the following when developing a QM plan: (1) The manner in which the provider will meet the Department’s QM plan criteria. (2) The provider’s quarterly performance review data and available reports in HCSIS and EIM. (3) The results from provider monitoring and SCO monitoring. (4) Compliance with the requirements in 42 CFR 441.302 (relating to state assurances). (5) Incident management data, including data on the incident target under § 51.17 (relating to incident management). (6) Results of satisfaction surveys and reviews of grievances.

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QUALITY MANAGEMENT - ODP’S PRIORITIES

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PROVIDER TRAINING

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PROVIDER TRAINING

55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMS HOME AND COMMUNITY-BASED SERVICES Subchapter A. GENERAL PROVISIONS § 51.23. Provider training

(a) A provider shall implement a standard annual training for the provider and staff. (b) Before providing an HCBS to a participant, a provider shall ensure that its staff have met any additional pre- and in-service training requirements as detailed in a participant’s ISP. (c) A provider shall retain documentation of completion of training for each staff. (d) A provider shall update annual training to reflect the Department’s current policies and procedures and emerging practices.

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PROVIDER TRAINING

  • 55 PA Code Chapter 51 regulations specifically require training for

all staff in the following areas: (1) Department policy on intellectual disability principles and values. (2) Training to meet the needs of a participant as identified in the ISP. (3) QM plan. (4) Identification and prevention of abuse, neglect and exploitation of a participant. (5) Recognizing, reporting and investigating an incident. (6) Participant grievance resolution. (7) Department-issued policies or procedures. (8) Accurate billing and documentation of HCBS delivery.

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PROVIDER TRAINING

The PA Code: www.pacode.com Chapter 2380, Section 2380.36 Chapter 6400, Section 6400.46 Chapter 2390, Section 2390.40 Chapter 6500, Section 6500.45

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TRAINING RESOURCES

TIU CDS TEMPLE HCQU ASERT COLUMBUS

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Provider Applicant Orientation for the Office of Developmental Programs

What does this mean for a prospective provider?

– Stay Informed! – Read very carefully – Provide quality services – Search websites to learn updates on provider related information. – Promote person centered practices – Assure individual’s health & safety – Adhere to federal and state requirements – Always cooperate with local, state or federal investigators – Meet critical deadlines – Be accountable

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Q & A’s

110

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WHAT’S NEXT

  • 1. Download the presentation online
  • 2. Complete the Post-Test online and submit
  • 3. Receive Certification of Successful

Completion

  • 4. Proceed with Provider Enrollment process
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POST TEST

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POST-TEST

PATH: Training > Intellectual Disability > All Intellectual Disability Training

Your Name

MyODP: https://www.myodp.org/

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POST-TEST

1 2

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POST-TEST

This is the same course where you registered. Scroll down to find the post-test

  • block. Look for

the link with the session and date you attended.

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Your trainer will give you a sheet like this before you leave today. Be ready to enter the “enrollment key” when you click the post-test link.

POST-TEST

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POST-TEST

Post-test Provider Applicant Orientation (ID): August 25, 2017 BUCKS

The post-test will be visible in the block below on August 28, 2017 at 8:00 A.M.. The test will close on September 5 at 5:00 P.M. All attempts must be completed between those dates.

Note the dates the test will be available. PowerPoint with notes and other materials: available the day of the session at 4PM.

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POST-TEST

Post-test Provider Applicant Orientation (ID): August 25, 2017 BUCKS

Bucks 8/25/17: Post Test Attempt 1 – Available from August 28 8:00 A.M. to September 5 5:00 P.M. Bucks 8/25/17: Post Test Attempt 2 – Available UNTIL September 5 5:00 P.M.

Links to the post test will be available on the day noted on the instruction sheet. Attempt 2 will only become available if the first test is not passed.

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POST-TEST

After answering all questions and pressing the

button

You will be asked TWICE if you are ready to submit and finish the attempt

And then you will receive feedback on your attempt and information on what to do next.

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POST-TEST and NEXT STEPS

The CEO/Director will be notified immediately after submitting the test attempt if the test was passed. If the test is not passed on the first attempt, it is strongly recommended that you review materials again before the second attempt. For those who pass (first or second attempt) and meet requirements, a Certificate will be issued within two week. “Next Steps” are included in the email with the Certificate. The email with Certificate begins the 120 day clock to complete the qualification process.

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POST-TEST and NEXT STEPS

You will need to attend this Orientation session again if: You do not pass the post-test OR You do not complete the qualification process within 120 days. Applicants are limited to attending two (2) Orientation sessions within a calendar year. Note that registering for a Provider Applicant Orientation session but not attending counts toward one of the two sessions per calendar year. Applicants that cancel in advance will not be penalized.