2/1/2013 TIMELINES TODAY S GOALS

Transcription

1 ICF REVIEW STREAMLINING TABLETOP EXERCISE January 16, 2013 TIMELINES January 16 Tabletop Exercise January 23 Exercise Outcomes shared with Participants February 5 Exercise Outcomes shared with Streamlining Group February 15 Questions presented to CMS March 15 Tentative timeline for CMS Meeting/Discussion June 1 New Review Process Finalized July 1 New Review Process Pilot Begins January 1, 2014 New Review Process Initiated TODAY S GOALS Identify process revisions that this group has the ability to immediately initiate Identify process revisions that will require state level system changes Identify process revisions that will be presented to CMS Identify parking lot items 1

2 STATE OPERATING REQUIREMENTS Task 1 Sample Selection (See Section XIII for additional requirements) Task 2 Review of Facility Systems to Prevent Abuse, Neglect and Mistreatment and to Resolve Complaints Task 3 Individual Observations Task 4 Required Interviews with Individuals and/or Family/Advocate and Direct Care Staff Task 5 Drug Pass Observation Task 6 Visit to Each Area of Facility Serving Certified Individuals Task 7 Record Review of Individuals in the Sample Task 8 Team Assessment of Compliance and Formation of the Report of ICF Deficiencies TASK 1 SAMPLE SELECTION Purpose to reflect a proportionate representation of individuals served by functional levels (mild, moderate, severe and profound) Not required to be statistically valid Focus not only on the individual, but the individual s interaction with staff and peers in all environments, which means that other individuals may likely be added to the sample during the review. Once on-site, additional information may be obtained regarding the facility s services and special needs may be identified that are not represented in the sample (ie; facility serves a number of individuals who are non-ambulatory, but the sample does not reflect an individual with this need). Additional individuals may be added to the sample if this occurs. You may not allow the facility to select the sample. TASK 1 SAMPLE SELECTION Sample Size - Team to use ODH Sample Size Alternative Sampling Procedure allowed in SOM Add to CMS questions list to see if we can develop and Alternative Sampling Procedure to be used in all settings utilizing existing date from IAF, Perseus, etc. 2

3 TASK 1 SAMPLE SELECTION Things that Must stay the same Reviews must be unannounced Sample Size Proportionate by functional levels Ability to add individuals to the sample Changes we can Make Combined team to use ODH Sample Size grid/dodd sample size goes away DODD no longer provides ICF s with a 90 day notice of reviews Add functional levels to information provided by ICFs to DODD Approval to use an Alternative Sampling Procedure TASK 2 SYSTEMS TO PREVENT ABUSE, NEGLECT AND MISTREATMENT Assure facility has a system for reporting incidents in accordance with State law Assure facility has a system for reporting incidents to the administrator Review completed incidents as well as those in process Conduct this review early in the review process TASK 2 SYSTEMS TO PREVENT ABUSE, NEGLECT AND MISTREATMENT Things that Must Stay the Same Incident reporting system must be evaluated as part of the review process Changes We Can Make Review MUIs prior to on-site review through ITS Add Administrator notification date to ITS data Review Team members look at UIs on-site Review Team members look at incident policy on-site Ability of all reviewers to telework to allow pre-survey work to occur off-site Add Outcome of 5 day investigation to ITS system for ICFs only 3

4 TASK 2 SYSTEMS TO PREVENT ABUSE, NEGLECT AND MISTREATMENT CMS Questions Does the ITS system and the MUI process required by DODD rules meet the requirements of the Standard of Staff Treatment of Clients and could ODH rely on data from DODD to determine compliance? Can MUI data (ie; individual patterns and trends) be used to assist in sample selection in addition to functional ability? Can we develop an Alternative Sampling Selection. SOM allows for this. PRE-SURVEY PROCESS Parking Lot Items How to determine team size? How to determine on-site review time? Put on parking lot for pilot project? Cross walk between ODH Task 2 Tags and DODD Process Set up training for ODH Reviewers on ITS Surveys are scheduled based on end date of Medicaid Provider Agreement DODD to revise term license dates to coincide with this date If we use LOC info for functional level, how do we ensure it is current? Ask ODH reviewers for feedback on any drawbacks that would result by providing sample names prior to exit. ON-SITE REVIEW PROCESS Entrance Conference Sample Presentation Documents that Providers should have available - Facility Map/Day Program Locations - Names/Contact Numbers for Staff (Qs, DON, HR, Finances, etc) - UI log - MUI process - Discharge list (since last review) - Any individuals who are out on leave today 4

5 LUNCH BREAK Go down the hill to stop sign, go straight through stop sign and go under freeway. At traffic light, turn left, at next traffic light, turn left and you will find: Wendy s Burger King White Castle Chinese Arby s McDonalds Subway Taco Bell TEAM MAKE-UP & DUTIES ODH Focus - Individual Interviews - Individual Observations - Drug Pass - Day Programming - Record Review - Physical Environment (LSC) DODD Focus - Personnel - Individual Funds - MUI/UI - Behavior Support - Administration TASK 3 INDIVIDUAL OBSERVATIONS Purpose to determine if the necessary relationship between the individual s needs and preferences and what staff know and do in all settings throughout the day is made. Observe sample individual in all environments in which services are provided if possible Observations throughout the day (morning, afternoon, and evening) are essential. Services should reflect a consistent pattern of interaction with the individual at all times and in all locations Validate discrepancies to identify a systemic deficiency rather than an isolated occurrence. Individual observation worksheet (HCFAA-30701) MAY be used. 5

6 TASK 3 INDIVIDUAL OBSERVATIONS Things that Must Stay the Same Changes We Can Make - All members of team will share observations Can a DODD reviewer identify a deficiency that is an ODH Tag only, do the investigation and share outcome with ODH reviewer and have ODH add to the certification review without having the ODH reviewer re-do the survey investigation? With an MOU? With appropriate training? TASK 4 - INTERVIEWS Purpose to determine how the individual perceives the services delivered by the facility and to clarify information gathered during observations. Hierarchy - Individual - Family/Guardian - Direct Service Staff - QMRP/Professional Staff - Administrator/Management Staff Must conduct a set number of individual interviews Use questions as identified in SOM Observations notes MAY be documented on HCFA TASK 4 - INTERVIEWS Things that Must Stay the Same Changes We Can Make - All members of team will conduct interviews - Can staff from both agencies conduct interviews that count towards required number of interviews? 6

7 TASK 5 DRUG PASS OBSERVATION Procedures found in W368 Guidelines No change process to be conducted by ODH review team member TASK 6 - AREA VISITS Visit each area of the facility in which services are provided in order to ensure; - services are being provided in a manner required by rules and regulations - the general physical safety of the environment (not LSC) - that individual rights are asserted and protected TASK 6 AREA VISITS Things that Must Stay the Same Changes We Can Make - All members of team will share observations 7

8 TASK 7 RECORD REVIEW Purpose to verify info obtained during observations and interviews, review plan revisions, and verify that health and safety supports are in place. Not an in-depth review of the record unless inconsistencies are identified TASK 7 RECORD REVIEW Things that Must Stay the Same - Record review is conducted last to verify Changes We Can Make - DODD review team will look at DODD focus areas TASK 8 TEAM ASSESSMENT, EXIT & REPORT The combined ODH/DODD review team will meet prior to the exit conference to determine areas of non-compliance with either federal tags or state licensure rules. Determination is made on whether an area of non-compliance will be cited as part of the certification review or the licensure review (no duplicate citations) Exit Conference conducted to share citations with provider. Parking Lot Items - Review Timelines (number of days on-site) DODD comes on last day - Report process for getting both reports to provider - POC process for provider submission of POC - POC verification can ODH do verification if on-site required and DODD continue to accept documents for verification of licensure cites? - Licensure Award Term (scoring) 8

9 NEXT STEPS? Where do we go from here? Suggestions: 9