Habilitation Supports Waiver(HSW) Focus on Quality and Compliance

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1 Habilitation Supports Waiver(HSW) Focus on Quality and Compliance Home and Community Based Waiver Conference November 2017 Belinda Hawks Yingxu Zhang

2 Agenda Welcome & Introductions Target Audience: HSW Coordinators, QI Coordinators Status Updates on the 1115 Waiver Quality Improvement Strategy (QIS) and Performance Measures (PMs) Service-related Issues Waiver Support Application (WSA) Residential Living Arrangement Reminders

3 Status Updates on the 1115 Waiver

4 HSW and 1115 Waiver Current 5 year application for HSW expired on 9/30/2015. MDHHS requested extension and the request was approved by CMS through 12/2017. The 1115 Waiver application is under review of the Centers for Medicare and Medicaid Services (CMS). Expected effective date of the 1115 Waiver: TBD Interim Payments change with the 1115 Waiver. State to implement a change in payment methodology to a traditional capitation payment, which includes eliminating recoupment and repayment. State to work on the monitoring process to assure at least one HSW service is received per month.

5 Quality Improvement Strategy (QIS) & Performance Measures

6 QIS & Performance Measures CMS approved the HSW 372 narrative report for FY16 This was the sixth report using the current Performance Measures and sampling methodology Approval by CMS was the culmination of a lot of hard work by PIHP staff, the HSW Coordinators, and the BHDDA team.

7 Historical HSW Data FY15 HSW Initial Certification: 404 Recertifications: 395 Site Review: 5 PIHPs, 138 Records FY16 HSW Initial Certification: 327 Recertifications: 389 Site Review: 5 PIHPs, 253 Records

8 2017 HSW Enrollment vs Disenrollment PIHP 2017 Enrollment 2017 Disenrollment Net growth on HSW Enrollment Region 1 - NorthCare Region 2 Northern MI Region 3 - Lakeshore Region 4 Southwest MI Region 5 - Mid-State Region 6 - Southeast Region 7 - Detroit-Wayne Region 8 - Oakland Region 9 - Macomb Region Total

9 QIS Discovery Phase CMS requires that the State comply with all conditions of the approved waiver. Currently, the approved waiver identifies the Site Review process as the method for discovery for nearly ½ of the PMs Other Data Sources of the PMs: WSA, Medicaid Fair Hearing Requests, EQR Technical Report, CIRS, initial app & recertification, CHAMPS. Any change in the sampling or discovery methodology would require that DHHS submit an amendment to CMS and the changes must be approved before implementing any new processes.

10 Site Reviews The site review is the data source for 14 of the 35 PMs in the HSW. The site reviews include: clinical record reviews an administrative review focused on policies, procedures, and initiatives that are not otherwise reviewed by the EQR Provider Qualifications grievance and appeals tracking sentinel event and critical incident reporting health and welfare consumer interviews visits to consumers homes and other programs where services are delivered New HCBS rules

11 QIS Discovery Phase During the Site Review Evidence needed for PMs Freedom of Choice Preplanning meeting (or IPOS) should document explanation of - Freedom of choice of providers - Freedom of choice of waiver services Qualified Providers PIHP records must demonstrate credentialing, training (including training on the IPOS), and each provider of waiver services meets the MPM provider qualifications initially and on-going. Timeliness of PCP Meeting If record includes documentation that meeting was convened after 365 days at request of the person or guardian, that is not considered out-of-compliance. Service Provision - PIHP records must demonstrate that services and supports are provide as specified in the plan.

12 QIS Discovery Phase for Other Data Sources Evidence needed for PMs Timeliness of Recertification must be within 365 days of previous certification date on WSA. Steps for Recertification must include: Monitor coming due report (30,60,90 etc days) Recertification assessment to be paired with IPOS date Once completed and signed, dates are entered into WSA Level of Care must meet the requirements for ICF/IID LOC for either initial certification or recertification: PIHPs have been completing the review worksheets for re-certifications and new applications as a quality check for accuracy (Pink sheets & Blue sheets).

13 372 Findings from Site Review Data from FY16 Site Reviews Percent of C-1:... applicants for provision of HSW services that meet initial credentialing standards prior to provider enrollment. 94.9% C-2: providers of HSW services that continue to meet credentialing standards. 98.4% C-3:...non-licensed, non-certified waiver service providers that meet provider qualifications as stated in the Michigan Medicaid Provider Manual. C-4:... waiver providers that meet staff training requirements. D-1:...enrolled participants whose IPOS include services and supports that align with the individual's assessed needs. 98.8% D-2:... enrolled participants whose IPOS had adequate strategies to address their assessed health and safety risks. 96.0% D-3: percent of enrolled participants whose IPOS reflect their goals and preferences. 98.8% D-4: IPOS for enrolled participants that are developed in accordance with policies and procedures established by MDHHS. 96.8% D-5:... enrolled participants whose IPOS are updated within 365 days of their last plan of service % D-6: enrolled participants whose IPOS changed if the individual's needs changed. 99.2% % D-7: IPOS for enrolled participants in which services and supports are provided as specified in the plan, including type, amount, scope, duration and frequency. 94.5% D-10: enrolled participants who are informed of their right to choose among the various waiver services. 98.4% D-11: enrolled participants who are informed of their right to choose among the various waiver providers. 98.8%

14 372 Findings from Site Review C-3: 83.8% of non-licensed, non-certified waiver service providers met provider qualifications as stated in the Michigan Medicaid Provider Manual. Issue: 1) lack of evidence on criminal background checks completed prior to date of hire for staff who were hired before the criminal background check policy was implemented. Issue: 2) lack of clarification on regarding the frequency of ongoing criminal background check. Issue: 3) date of service vs. date of hire on evidence of training (IPOS, prevention of transmission of communicable disease,etc Remediation: 1) MDHHS provided clarification on the review standard 2) MDHHS revised contract to provide clarification on frequency 3) PIHP - Ongoing monitoring

15 372 Findings from Site Review C-4: 82.6% of the waiver providers meet staff training requirements. The issue identified during the site review was a lack of training in the IPOS. Two causes were identified related to this performance measure: 1) PIHPs did not have polices in place to assure staff were trained in the participant s IPOS, and 2) PIHPs or providers lack the process of documenting the IPOS training even though the training indeed occurred. Since the compliance rate was below 86%, MDHHS-BHDDA submitted Quality Improvement Project to CMS.

16 Critical Incidents Reporting System (CIRS) PIHP Contract: PIHPs will report the following events, except suicide within 60 days after the end of the month in which the event occurred for individuals actively receiving services, with individual level data. Non-suicide death Emergency Medical treatment due to Injury or Medication Error Hospitalization due to Injury or Medication Error Arrest of Consumer Statewide average on reporting an incident into the system: 43 days (range from 0 day to 178 days)

17 Critical Incidents Reporting System (CIRS) FY17 HSW Data as of 10/25/2017 # of HSW Type of Incident Individuals Arrest 6 Emergency Medical Treatment - Injury 18 Emergency Medical Treatment - Injury - Not during physical management 582 Emergency Medical Treatment - Injury - Unknown if during physical management 5 Emergency Medical Treatment - Injury - During physical management 0 Emergency Medical Treatment - Medication Error 11 Emergency Medical Treatment due to Injury or Medication Error 1 Hospitalization - Injury 1 Hospitalization - Injury - Not during physical management 50 Hospitalization - Injury - Unknown if during physical management 1 Hospitalization - Injury - During physical management 0 Hospitalization - Medication Error 2 Non-Suicide Death - Accidental 3 Non-Suicide Death - Homicide 1 Non-Suicide Death - Natural Causes 189 Total 870 Remediate Remediate More information

18 Critical Incidents Reporting System (CIRS) The death of a HSW individual is reported in two systems: WSA and the CIRS FY17 total number of deaths from two different data sources: HSW: 264 deaths CIRS: 191 Deaths 73 unreported deaths in CIRS as required by contract. State average reporting rate (use death as an example): 72.3%

19 Critical Incidents Reporting System (CIRS) 90.0% Issues Identified: 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 85.0% 75.5% 76.3% 72.3% 61.8% 59.9% FY11 FY12 FY13 FY14 FY15 FY16 FY Underreporting Duplicate reporting on same incident Incidents were not reported to the level of detail as required MDHHS is planning on revising the CIRS: more incident categories, remediation, etc. Reporting Rate (use Death as an example) Average Days

20 QIS Remediation Phase Most of the PMs require individual-level remediation, including LOC, IPOS, Qualified Providers, and Health & Welfare. Timeframes for remediation must be followed PIHPs did very well on remediating issues in timely manner Site review team is now looking for remediation within 90 days as part of the follow-up reviews Injuries due to medication error Type of medication error: wrong dose, wrong medication, wrong time, wrong person, etc. Remediation: staff training is a required remediation if the staff is not terminated.

21 QIS Remediation Phase In FY16, MDHHS started to note repeat citations in the site review reports to the PIHPs. Per PIHP Contract: 9.0 CONTRACT REMEDIES AND SANCTIONS The state will utilize a variety of means to assure compliance with contract requirements and with the provisions of Section b of Michigan's Mental Health Code, regarding Specialty Prepaid Inpatient Health Plans. The state will pursue remedial actions and possibly sanctions as needed to resolve outstanding contract violations and performance concerns. The application of remedies and sanctions shall be a matter of public record. If action is taken under the provisions of Section b of the Mental Health Code, an opportunity for a hearing will be afforded the PIHP, consistent with the provisions of Section b.(6). The MDHHS will utilize actions in the following order: A. Notice of the contract violation and conditions will be issued to the PIHP with copies to the Board. B. Require a plan of correction and specified status reports that becomes a contract performance objective. C. If previous items above have not worked, impose a direct dollar penalty and make it a non-matchable PIHP administrative expense and reduce earned savings from that fiscal year by the same dollar amount. D. For sanctions related to reporting compliance issues, MDHHS may delay up to 25% of scheduled payment amount to the PIHP until after compliance is achieved. MDHHS may add time to the delay on subsequent uses of this provision. (Note: MDHHS may apply this sanction in a subsequent payment cycle and will give prior written notice to the PIHP) E. Initiate contract termination.

22 QIS Improvement Phase Continuous improvement as issues are identified may be improvement at the individual, local, regional, and/or state level. Example of individual & system improvement: Noting that freedom of choice of providers and waiver services is now being incorporated into pre-planning meetings and some PIHPs are documenting this for all recipients of services, not just HSW enrollees. Example of new system improvement focus: As we identify areas for improvement, we will modify performance measures.

23 Service-Related Issues

24 Service Utilization in FY17 HSW Services Number of HSW Individuals Using HSW Services Percent of HSW Individual Using HSW Services Supports Coordination % Community Living Supports % Out of Home Non Vocational Habilitation % Respite Care % Enhanced Pharmacy % Supported Employment Services % Enhanced Medical Equipment & Supplies % Prevocational Service % Family Training % Personal Emergency Response System % Private Duty Nursing (age 21 and over) % Environmental Modifications % Goods and Services % Total HSW Population in FY % 94 HSW Individuals received supports coordination as their only HSW service in FY of the 94 HSW individuals are under the age of 18. Encounters as of 10/25/2017

Private Duty Nursing (PDN) Under age 21 on HSW: Effective October 1, 2016 Authorized Medicaid Private Duty Nursing Providers will submit all requests for initial of PDN

25 Private Duty Nursing (PDN) Under age 21 on HSW: Effective October 1, 2016 Authorized Medicaid Private Duty Nursing Providers will submit all requests for initial of PDN services to the Program Review Division (PRD) in the Medical Services Administration within MDHHS Private Duty Nursing Providers will then submit all requests for PDN services to the PRD. If PDN is an approved service by PRD, the PDN agency will receive the Prior Authorization(PA) determination/decision from PRD If PDN is an approved service by PRD, PRD will enter the determination/decision into CHAMPS The PDN agency will notify the CMH of approval or denial this information must be included in the IPOS

26 Private Duty Nursing Age 21 and over on HSW: Effective May 1, 2017 Currently three options exist for PDN over age 21 and over: HSW, MI Choice Waiver, and MI HealthLink. Confirmed HSW enrollment must precede a request for Private Duty Nursing eligibility approval To be determined eligible for PDN services, the PIHP must find that the beneficiary meets Medical Criteria I (one) and III (three), or meets Medical Criteria II (two) and III (three) The CMHSP/PIHP RN will assess all new requests for approval and all yearly renewals according to current HSW Medicaid PDN Policy. Medicaid Policy will be followed for each case reviewed All supporting medical documentation requirements remain the same. Documentation from Medical Specialists, etc. See HSW Section of the Medicaid Provider Manual

27 Short Break for Some Fun & Exercise

28 Waiver Support Application (WSA)

29 WSA/Slot Counter Michigan has a specific number of HSW slots approved by the Centers for Medicare and Medicaid Services (CMS) per fiscal year. 7,902 at any given point in time 8,268 cumulative unduplicated count in the fiscal year The assignment of slots is managed by DHHS. Each PIHP has an annual allocation of active enrollments that cannot be exceeded. Priority for filling slots (in no particular order): Children aging off the Children s Waiver People who are determined to be at a high risk of institutional placement People at age 21 and older who need PDN and meet HSW eligibility

30 WSA/Slot Counter The PIHP HSW Coordinator monitors its slot allocations closely to determine when to submit applications to DHHS. When someone disenrolls, the vacancy opens on the first day of the following month, whether the person left the HSW on the 1st or last day of the month, they fill that slot for the entire month. MDHHS-BHDDA is obligated to manage the HSW slot utilization for the State of Michigan. The 95% slot utilization threshold is the evidence that a Pre-Paid Inpatient Health Plan (PIHP) is in compliance with this requirement. If someone is waiting for an opening, he or she can receive b-3 services so there should be no delay in services.

31 FY17 HSW Slots Utilization Rate by Region 100.0% 99.0% 98.0% 97.6% 97.0% 96.0% 95.0% 95% 94.0% 93.0% 92.0% 91.0% 90.0% 99.3% 99.9% 99.7% 100.0% 96.5% 96.7% 93.7% 98.1% 96.5% 95.9% Region Average %Utilization Statewide Average = 97.6% 95% Requirement

32 WSA - Inactive Status Purpose: to keep someone enrolled in the HSW but to temporarily suspend active services when the person will be ineligible for the HSW longer than a full month. This is generally for a limited-term stay in a hospital or nursing facility for rehabilitation. Action: The HSW payment is suppressed for month(s) of inactivity FY2017 Inactive Cases: A total of 103 HSW individuals had at least one inactive segment in the WSA Average days of inactive: 109 days

33 Inactive in WSA When to use Inactive Status: Only when you know the person will be ineligible for HSW for at least the full month. Do not use for short-term (less than a full month) stays. Example 1: someone goes into the hospital on 11/9/2017 and then on to a rehab facility for a eight-week stay (1/4/2018). Enter inactive segment 11/9/2017 Indefinite end date When the person comes home on 1/5/2018, end the indefinite inactive date on 1/4/2018 and then add a new row to make active again. Example 2: someone goes into the hospital on 11/9/2017 and then on to a rehab facility for 4 weeks (12/7/2017). Don t enter any inactive segment into the WSA.

34 HCBS Tab and Reports in WSA The WSA now includes HCBS information: HCBS Tab HCBS reports Trainings on how to navigate the HCBS Tab and HCBS reports are available at: WSA >> go to Training >> select HAB >> select HAB Training Documents Please start to enter HCBS provider information into the HCBS Tab when you open a new HSW case if the new case meets the following criteria: living in a provider owned or controlled settings, AND/OR receiving supported employment, out of home non-vocational habilitation, or prevocational services. Please update the HCBS provider information at least annually for all cases that meet the above criteria to make sure WSA has the most current provider information. Run the HCBS reports to monitor the HCBS compliance status of the providers.

35 Residential Living Arrangement

36 Residential Living Arrangement (RLA) RLA code in WSA is updated when a person is first enrolled and when it is time for the RLA validation project (usually around August). Initial enrollment: BH-TEDS records must be submitted prior to HSW enrollment. MDHHS will have to send the packets back to PIHP if no BH-TEDS record is in the system. RLA Validation project: Each year, BHDDA will compare the RLA information reported in BH-TEDS to the information in the WSA. If you need to update the BH-TEDS data for this comparison, remember all fields must be collected and reported prior to 8/15. If the individual s annual assessment is due in September, another update in September will not be required. Please be certain that the information in BH-TEDS is correct for the time that BHDDA does this annual validation. REMEMBER: MDHHS expects that HSW services are monitored on a ongoing basis which should include a verification of the living arrangement against the RLA code in the system.

37 Reminders Can't be on both MI choice and HSW Transfers are initiated by the PIHP HSW coordinators in each region. PIHP HSW Coordinator needs to update the WSA when a beneficiary transfers from one CMH to another CMH within your region. Check eligibility every year and disenroll those individuals who no longer meet eligibility Check your PIHP s WSA approved users list and notify MDHHS immediately if a user is no longer authorized access. When making a change on the enrollment tab ie: changing the CMH name due to a move, please add a line rather than overriding the information already in the system. Use the WSA generated Case Number when communicating with MDHHS. This number is a random number so you don t need to encrypt the .

38 Questions?

39 Contact Information Belinda Hawks Federal Compliance Section Manager HSW, CWP, SEDW, Site Reviews or Yingxu Zhang Analyst, or Lori Caputo Waiver Program Technician, or

40 Thank you for all you do to keep us moving forward!!!

The Children s Waiver Program

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