Qualified Provider Assurances: How Pennsylvania Reports on the Quality of Home and Community Based Service Providers to CMS

Qualified Provider Assurances: How Pennsylvania Reports on the Quality of Home and Community Based Service Providers to CMS

Session Objectives Review the Qualified Provider Assurance, Sub-Assurances, and Performance Measures. Review the Role of the QMET in meeting the Qualified Provider Assurance

The Qualified Provider Assurance the Qualified Provider Assurance is located in Appendix C of the listed in the 3.5 HCBS waiver application 3 Qualified Provider Sub-Assurances 5 Performance Measures

Meeting the Assurances Review of OLTL s performance under the Qualified Waiver assurances is a dual effort conducted by both the Bureau of Provider Supports and the Quality Management Efficiency Teams.

Qualified Provider Assurance 1 The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

Qualified Provider Performance Measure 1 Number and percent of newly enrolled waiver providers, by provider type, who meet required licensure/ certification and initial Qualified Provider standards prior to service provision.

Qualified Provider Performance Measure 2 Number and percent of providers, by provider type, continuing to meet applicable licensure/ certification and applicable waiver standards following initial enrollment.

Qualified Provider Assurance 2 The State monitors non-licensed/ noncertified providers to assure adherence to waiver requirements.

Qualified Provider Performance Measure 3 Number and percent of newly enrolled nonlicensed/ non-certified waiver providers, by provider type, who meet initial Qualified Provider standards prior to service provision.

Qualified Provider Performance Measure 4 Number and percent of non-licensed/ noncertified providers, by provider type, who continue to meet waiver provider qualifications.

Qualified Provider Assurance 3 The State implements its policies and procedures verifying that provider training is conducted in accordance with state requirements and the approved waiver.

Qualified Provider Performance Measure 5 Number and percent of providers, by provider type, meeting provider training requirements.

What is the Quality Management Efficiency Team (QMET) that is doing all this measuring?

Reason for QMET The Quality Management Efficiency Teams were developed as a response to Centers for Medicaid and Medicare Services (CMS) requirements for quality assurance.

Purpose of QMET The QMET monitoring of the waiver standards is meant To provide agencies with baseline information and identify areas of quality improvement To provide CMS with evidence of the Commonwealth s compliance with the Qualified Provider Assurances

Responsibility of QMET: Work collaboratively to monitor the OLTL providers using an objective set of standards Work with Providers, Stakeholders and other OLTL Bureaus to ensure compliance with CMS waiver assurances

Where does QMET fit into the BIG PICTURE?

QMMA Organizational Chart Office of Quality Management, Metrics, and Analytics (QMMA) Quality Management Division Metrics and Analytics Division Quality Management Unit Quality and Compliance Unit Quality Management Efficiency Unit (QMEU)

Organizational Chart of the QMET Statewide QMEU Coordinator Southwest Quality Management Efficiency Team Southeast Quality Management Efficiency Team Northeast Quality Management Efficiency Team Northwest Quality Management Efficiency Team Central Quality Management Efficiency Team Regional QMET Structure QMET Program Specialist Financial Representative Registered Nurse Social Worker

QMET as a Whole All QMET regional teams work together to accomplish overall and regional objectives The QMEU Statewide Coordinator provides the core leadership for cross-regional issues and ensuring consistency in QMET operations across the Commonwealth

Individual QMET Members: Each QMET staff member participates and contributes to various aspects of monitoring visits Every team member is crosstrained

Where do the QMETs Operate?

Where QMETs Operate Although the QMETs are assigned specific regional locations, any QMET member or team can conduct a monitoring at any provider location because of the consistency of QMET operations.

Southwest Region includes the following 16 counties: LAWRENCE BEAVER BUTLER ALLEGHENY WASHINGTON ARMSTRONG WESTMORELAND INDIANA CAMBRIA BLAIR GREENE FAYETTE SOMERSET BEDFORD HUN TIN GD ON FULTON Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Indiana, Fayette, Fulton, Greene, Huntington, Lawrence, Somerset, Washington, and Westmoreland

Southeast Region includes the following 10 counties: SCHUYLKILL LEHIGH NORTHAMPTON BERKS BUCKS LANCASTER CHESTER MONTGOMERY DELAWARE PHILADELPHIA Berks, Bucks, Chester, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia, and Schuylkill

Northeast Region includes the following 13 counties: TIOGA BRADFORD WAYNE SUSQUEHANNA SULLIVAN PIKE LUZERNE COLUMBIA MONROE MONTOUR WYOMING LACKAWANNA CARBON Bradford, Carbon, Columbia, Tioga, Pike, Sullivan, Lackawanna, Luzerne, Monroe, Montour, Wayne, Susquehanna, and Wyoming

Central Region includes the following 15 counties: CLINTON LYCOMING UNION CENTRE SNYDER MIFFLIN JUNIATA PERRY CUMBERLAND NORTHUMBERLAND DAUPHIN LEBANON FRANKLIN ADAMS YORK Adams, Centre, Clinton, Cumberland, Dauphin, Franklin, Juniata, Lebanon, Lycoming, Mifflin, Northumberland, Perry, Snyder, Union, and York

Northwest Region includes the following 13 counties: ERIE WARREN CRAWFORD MERCER CLARION VENANGO FOREST JEFFERSON MCKEAN POTTER ELK CAMERON CLEARFIELD Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, and Warren

Multiple Office Monitoring: Providers who have offices in more than one QMET region If a provider has offices in more than one QMET region, monitoring will take place at the corporate office

Multiple Office Monitoring All information to verify provider adherence to established standards will be reviewed at the Provider s Corporate Headquarters The QMET Provider information may be pulled from any office within the provider s organization

Multiple Office Monitoring Example: If an OLTL provider has offices in the Central and Northeast regions, and the provider s corporate headquarters are located in the Northeast region, then this will be the location for the On-Site monitoring Sample files and information may be requested for any regional office and expected to be on site at the Provider s corporate headquarters

The QMET Monitoring Process

QMET Monitoring The QMET monitors standards as they are established in the current, approved waiver. The QMET does not write or change the standards. They monitor what is.

Qualified Provider Waiver Standards Reference Guide

Qualified Provider Waiver Standards Reference Guide Objective Criteria Sorted by service Cross reference against each waiver Transparency Lists all areas that will be monitoring by the QMET are listed No requirements are listed in the Waiver Standards Reference guide that are not listed in the waiver; review what is

Qualified Provider Waiver Standards Reference Guide Available on-line at http://www.dpw.state.pa.us/partnersproviders /PMQ/QMMA/QMET/QMETResources/ Aging and Attendant Care Approved Waivers: http://www.dpw.state.pa.us/servicesprogram s/medicalassistance/suppservwaivers/

Qualified Provider Waiver Standards Reference Guide As the waivers are renewed our policies effecting the waivers are adjusted, the Qualified Provider Waiver Standards Reference Guide and Monitoring tool will be updated Providers will be notified via email that the reference guide was updated to reflect any changes Changes are made only after OLTL has FINALIZED the change as a matter of policy

QMET Monitoring The QMET reviews information from a provider to determine their compliance with all the qualified provider standards QMET conducts on-site monitorings at least every two years for every provider in each OLTL waiver.

QMET Monitoring The QMET also conducts follow-up reviews of Standards Implementation Plans created by providers Ensures providers are working towards meeting all qualified provider waiver standards Assures CMS that we are fully implementing the remediation plan as required in Appendix C

The QMET Monitoring Tool

The Monitoring Tool The QMET monitoring tool is based on the Waiver Standards or F/EA The Waiver Standards are pulled directly from the language found in the current, approved waivers

The Monitoring Tool The Monitoring Tool is web based It is structured with Headings, Measurements, and Sub- Measurements Standards met are a YES, and standards not met are a NO in the monitoring tool

The Monitoring Tool The Standard Heading is a specific topic which groups waiver standards by subject Example: Limited English Proficiency Under the Heading are Measurements related to the topic A measurement is a Waiver standard Example: Verify that language assistance is provided to consumers without charge

The Monitoring Tool If a measurement requires the review of a sample (such as participant files or direct care worker files), the tool will have additional fields available to populate that data Example: Heading: Fiscal/ Employer Agent Measurement: The F/EA FMS must maintain copies of time sheets in the direct care workers file Enough fields will appear to answer the question for each sample file

The Monitoring Tool

The Monitoring Tool

The Monitoring Tool

The Monitoring Tool

QMET Contact Information The QMET Contact Information has been included in your packet

Review of Presentation Objectives What are the Qualified Provider Assurances? How many are there? What is the QMET? What is there part in looking at the Qualified Provider Assurances?

Conclusion & Questions To learn more about the QMET, please feel free to watch the e-learning webinar on Qualified Providers. It is being posted at http://www.dpw.state.pa.us/partnersprovider s/pmq/qmma/qmet/qmetresources