Region III/Division of Medicaid and Children's Health Operations

Transcription

1 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania Region III/Division of Medicaid and Children's Health Operations Gary D. Alexander, Secretary Department of Public Welfare Room 333, Health and Welfare Building P.O. Box 2675 Harrisburg, PA Re: Final Quality Assessment Report- Pennsylvania's Person/Family Directed Support Home and Community Based Waiver, CMS Control #0354 Dear Mr. Alexander: Enclosed is the final report of the Centers for Medicare & Medicaid Services' (CMS) quality review of Pennsylvania's Person/Family Directed Support Home and Community Based Waiver, CMS control number This waiver serves individuals with intellectual disabilities aged three and older who require the level of care provided by an intermediate care facility (ICF) for the intellectually disabled. Thank you for your assistance throughout this process, and for sending comments on the draft report. The State's response has been incorporated into the report. Specifically, we found insufficient evidence to demonstrate compliance with the level of care, service plans, qualified providers, health and welfare, administrative authority, or financial accountability assurances. However, we recognize the State's efforts of including a detailed plan for addressing compliance with the assurances. CMS requests that the State continue to work with the National Quality Enterprise, the current CMS quality grantee, to develop a quality improvement strategy for this waiver that will be in place at the time of the renewal. This technical assistance is available to the State at no cost. Finally, we would like to remind you to submit a renewal package on this waiver to CMS Central and Regional Offices at least 90 days prior to the June 30, 2012 expiration of the waiver. Your waiver renewal application should address any issues identified in the final report as necessary for renewal and should incorporate the State's commitments in response to the report. Please note the State must provide CMS with 90 days to review the submitted application. If we do not receive your renewal request ninety days prior to the waiver expiration date, we will contact you to discuss termination plans. Should the State choose to abbreviate the 90 day timeline, 42 CFR and 42 CFR requires the State to notify recipients of service thirty days before expiration of the waiver and termination of services. In this instance, we also request that you send CMS the draft beneficiary notification letter sixty days prior to the expiration of the waiver. Do you know someone who has been denied medical insurance because of a pre-existing condition? If so, they may be eligible for the new Pre-Existing Condition Insurance Plan. Call toll free (TTY ) or visit and click on "Find Your State" to learn more.

2 Page 2- Gary D. Alexander We want to extend our sincere appreciation to the Office of Developmental Programs staff who assisted in the process and provided information for this review. If you have any questions, please contact Harry Mirach at (215) Sincerely, Enclosure Ted Gallagher Associate Regional Administrator cc: Kevin Friel, ODP Nancy Kirchner, CMCS

3 U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services Region III FINAL REPORT Home and Community-Based Services Waiver Review Pennsylvania Person/Family Directed Support Waiver CMS Control #0354 June 30, 2011

4 EXECUTIVE SUMMARY Pennsylvania's Person/Family Directed Support (P/FDS) Home and Community-Based Services Waiver for individuals with intellectual disabilities provides home and community-based services (HCBS) targeted to individuals with intellectual disabilities aged three and older who require the level of care provided by an intermediate care facility (ICF) for the intellectually disabled. The latest CMS 372 Report, for the waiver year ending June 30, 2008, indicated that the Waiver served 9,560 individuals at an average annual per capita cost of$1 0,860. The Office of Developmental Programs (ODP), within the Pennsylvania Department of Public Welfare (DPW), is the State Medicaid Agency responsible for the administration and operation of the Pennsylvania's P/FDS Waiver. The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program. The Centers for Medicare & Medicaid Services (CMS) conducted the current review of the waiver program in accordance with 42 CFR and instructions in the May 28, 2004 (and February 6, 2007 update) Interim Procedural Guidance. We requested that the State provide evidence to CMS to substantiate that the waiver is being administered in accordance with the terms of the approved Section 1915( c) waiver and that the specified assurances are met. The review was completed via a desk review of the materials submitted and ongoing communication with the State's ODP. The CMS completed the review of information provided by the State. While the State presented evidence of discovery for all of assurances, specific issues arose in more than one assurance that the State should consider. First, the State should consider applying its comprehensive quality strategy to the newer processes and systems; specifically, with regard to the Service Plan and Financial Accountability assurances. For example, the State did not present discussion or evidence addressing the statewide standardized needs assessment, Supports Intensity Scale (SIS), implemented in year Further, the State did not present evidence of discovery addressing its recent changes to the P/FDS Waiver's reimbursement methodology. Also, the State did not consistently offer evidence of remediation, which examines both the performance of and outcome of such remediation activities where less than 100 percent compliance with any performance measure existed. Moreover, the State did not consistently offer evidence of implementation of system improvements for all assurances. Further, while the State presented a sampling strategy that discusses using a statistically significant, randomized sample, the State has not fully implemented the strategy. Finally, the evidence demonstrated elements of discovery for the all assurances within more recent timeframes (i.e. CY 2009-CY 2010), but for certain subassurances, the State provided no historical data reflecting previous years' data. The report findings for each assurance are as follows: I. State Conducts Level of Care Determinations Consistent with the Need for Institutionalization The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed.

5 II. Service Plans are Responsive to Waiver Participant Needs The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. Ill. Qualified Providers Serve Waiver Participants The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. IV. Health and Welfare of Waiver Participants The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. V. State Medicaid Agency Retains Administrative Authority over the Waiver Program The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. VI. State Provides Financial Accountability for the Waiver The State does not demonstrate this assurance.

6 Home and Community-Based Services Final Waiver Review Report Person/Family Directed Support Waiver for Individuals with Intellectual Disabilities CMS Control # 0354 Introduction: Pursuant to 1915( c) of the Social Security Act, the Secretary of the Department of Health and Human Services has the authority to waive certain Medicaid statutory requirements to enable a State to provide a broad array of HCBS as an alternative to institutionalization. CMS has been delegated the responsibility and authority to approve State HCBS waiver programs. The CMS must assess each home and community-based waiver program in order to determine that State assurances are met. This assessment also serves to inform CMS in its review of the State's request to renew the waiver. State's Waiver Name: Operating Agency: State Waiver Contact: Target Population: Level of Care: Person/Family Directed Support (PFDS) Waiver Pennsylvania Department of Public Welfare, Office ofdevelopmental Programs (ODP) Jeanne Meikrantz, Policy Supervisor, ODP Department of Public Welfare (DPW) (610) Individuals with intellectual disabilities aged three and over Intermediate care facility for the intellectually disabled Number of Waiver Participants: 9,560 reported served for the year ending June 30, 2008 Average Annual Per Capita Costs: $10,860 reported for waiver year ending June 30, 2008 Effective Dates of Waiver: From July 1, 2007 to June 30, 2012 Approved Waiver Services: Education Support Services Home and Community Habilitation Horne Accessibility Adaptations Licensed Day Habilitation Prevocational Services Supported Employment Job Finding and Job Support

7 Supported Coordination Unlicensed Residential Habilitation Therapy Services Supports Broker Services Assistive Technology Behavioral Support Companion Home Finding Specialized Supplies Transitional Work Services Vehicle Accessibility Adaptations Homemaker/Chore Personal Support Services Respite Transportation Nursing Services Review conducted by: Melanie T. Benning Program Management Branch CMS Contact: Harry A. Mirach, Manager Program Management Branch DMCHO/CMS (215)

8 I. State Conducts Level of Care Determinations Consistent with the Need for Institutionalization The State must demonstrate that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with care provided in a hospital, NF, or ICF/MR. Authority: 42 CFR ; 42 CFR ; 42 CFR : SMM The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. Process: This waiver uses an Intermediate Care Facility (ICF) level of care (LOC). Qualified Mental Retardation Professionals (QMRP) conduct and certify both initial LOC evaluations and LOC reevaluations. QMRPs are employed by Administrative Entities (AE), Supports Coordination Organizations (SCO), qualified agencies or independent professionals with whom the AE has a contract. Based on the certified LOC evaluation or reevaluation, the AE finalizes the LOC determination. If the AE determines that an individual does not meet eligibility criteria for an ICF LOC, the AE provides the individual or surrogate a standardized letter that includes information about the reason for the decision and the individual's appeal rights. The LOC evaluation process begins with the application of three criteria to a waiver applicant to determine eligibility for an ICF level of care. Specifically, the applicant must have a diagnosis of mental retardation, require active treatment and be recommended for an ICF LOC. The AE determines LOC eligibility based on a review of the individual's medical evaluation, psychological evaluation, a signed and dated Standardized Adaptive Assessment completed by the QMRP, and a signed and dated "Certification of Need for ICF/MR" form. With regard to recertification of need for an ICF LOC, the AE uses an evaluation by a physician, and evaluation and certification by a QMRP to determine such need. The latter certification is based on an assessment ofthe individual's current social, psychological, and physical condition and the individual's continuing need for home and community based services. The QMRP completes this assessment in conjunction with the individual's team and a current medical evaluation by a physician, physician's assistant or nurse practitioner. Then, the QMRP completes the required "Annual Recertification of Need for ICF/MR" form, which serves to document the results of the recertification process. The Office of Developmental Programs (ODP) monitors completion of LOC initial evaluations, annual reevaluations and appropriate use of processes and instruments for LOC determination. ODP uses the Home and Community Services Information System (HCSIS) and Administrative Entity Oversight Monitoring Process (AEOMP) to conduct such monitoring. Evidence: With regard to the subassurance that an evaluation of the LOC is provided for all applicants for whom there is a reasonable indication services may be needed in the future, the State reviewed data from 100 percent of new enrollees; therefore, no sampling was conducted. The State provided a summary report of data measuring the percentage of new P/FDS Waiver enrollees who received a LOC evaluation prior to waiver enrollment. The State further distinguished such data by region and by Fiscal Years (FY). During Fiscal Years , 99 percent of new waiver enrollees had a LOC determination date on or before the first day of their

9 enrollment in the waiver. Specifically, 100 percent of enrollees in the Southeast region had a LOC determination date on or before the first day of enrollment in the waiver and for the Central, Northeast, and West Regions, 99.5 percent, 97.5 percent, and 98.8 percent of enrollees respectively. During Fiscal Years , 98.7 percent of new waiver enrollees had a LOC determination date on or before the first day of their enrollment in the waiver. Specifically, 98.3 percent of enrollees in the Southeast region had a LOC determination date on or before the first day of enrollment in the waiver and for the Central, Northeast, and West Regions, 98.6 percent, 97.5 percent, and 99.8 percent of enrollees respectively. During Fiscal Years , 99.4 percent of new waiver enrollees had a LOC determination date on or before the first day of their enrollment in the waiver. Specifically, 100 percent of enrollees in the Southeast region had a LOC determination date on or before the first day of enrollment in the waiver and for the Central, Northeast, and West Regions, 98.8 percent, 99.2 percent, and 99.5 percent of enrollees respectively. The data source used is HCSIS. Regarding remediation for non-compliance with the above-referenced performance measures, the State offered a summary of a remediation activity where an AE identified a problem when a record of a waiver participant who transferred to another County was found not to include a Certification of Need for ICF/MR Level of Care form. However, the State did not discuss a plan to correct the problem or any outcome of such correction. With regard to evidence of system improvement, the State offered an example that is pending implementation. The State developed an exception report listing individual waiver participants and their respective AEs for which the initial LOC detennination requirement was not met. The State proposes sharing this report with the relevant AEs to assist them in addressing remediation of non-compliance and developing system improvements. With regard to evidence demonstrating that the LOC of enrolled participants is reevaluated at least annually, or as specified in the approved waiver, the State derived data from the data source, AEOMP, for CY Out of 300 enrollee records (derived from 26 out of the 48 AEs) sampled, 73 percent of enrollees received a recertification of need for an ICF LOC within 365 days of the prior review. While the State did not offer evidence of remediation for the 27 percent non-compliance with the above-referenced performance measure, the State did present a system improvement. Specifically, the State developed a plan that outlines the State's specific remediation and system improvement strategies to address the Level of Care assurance. At this time, the State has not fully implemented the plan. With regard to the LOC evaluation, determination, re-determination and review processes and instruments, the State derived data from the data source, AEOMP, for CY Out of the 322 enrollee records sampled, a signed and dated form used to document whether choice was ofiered between waiver services and institutional care service ("Delivery Preference Form") was present for 93 percent of enrollees. Next, the State examined whether a medical evaluation with an ICF LOC diagnosis was present; the State found, out of the 322 enrollee records sampled, a medical evaluation form with an ICF diagnosis for 40 percent of enrollees. Also, the State examined whether a psychological evaluation was present; the State found, out of the 322 enrollee records sampled, a psychological evaluation form for 76 percent of enrollees. Further, the State examined whether a standardized adaptive assessment was present; the State found, out of the 322 enrollee records sampled, a standardized adaptive assessment for 63 percent of

10 enrollees. Additionally, the State examined whether a signed and dated certification of need for ICF LOC was present. The State found, out of the 322 enrollee records sampled, a certification of need for ICF LOC for 83 percent of enrollees. Finally, the State examined whether a signed and dated annual recertification of need for ICF LOC was present. The State found, out of 300 enrollee records sampled, a completed annual recertification of need for ICF LOC for 79 percent of enrollees. The State provided evidence of remediation with regard to the above-referenced subassurance. The State identified a problem with an AE where 20 percent of cases did not include a signed and dated service delivery preference form at the time of registration for waiver services. As a result of identification of this issue, the AE agreed to develop a form for both counties to use when they register or open a new case in the MR system that will inquire whether an individual is offered Service Delivery Preference at registration. Also, whether Service Delivery Preference was offered will be documented into the HCSIS. The outcome of such remediation activities with an AE were not documented as the State left the section identifying "Date Compliance Validated" blank. With regard to system improvement, the State addresses the AE's non-compliance with LOC requirements through the AEOMP by requiring the AEs to develop corrective action plans. Also, ODP published a bulletin entitled "Individual Eligibility for Medicaid Waiver Services" to inform AEs about the procedures for the initial determination and annual redetermination of an individual's eligibility for services and supports provided under the P/FDS Waiver. This bulletin states the ICF/MR level of care requirements, the process for determining whether an individual meets such requirements and the appropriate forms and instruments to use for LOC determinations and to request a fair hearing. The State also developed a plan that outlines the State's specific remediation and system improvement strategies to address the Level of Care assurance; to date, the plan has not been implemented in its entirety. CMS Findings: The State has demonstrated that it has mechanisms in place to perform discovery, remediation and system improvement related to the Level of Care assurance. However, while the State presented a sampling strategy that discusses using a statistically significant, randomized sample, the State has not fully implemented the strategy. Further, the State did not provide evidence of remediating all findings where compliance was less than I 00 percent. Required Recommendations: The evidence demonstrated the element of discovery for all subassurances. However, where discovery efforts reveal compliance with an assurance at less than 100%, the State should address the element of remediation by including data reflecting both the performance of and outcome of remediation activities. This change should be in place at the time of renewal of this waiver. With regard to system improvement, the State should fully implement system improvement activities for the Level of Care assurance, prior to renewal of the P/FDS Waiver. The State should implement a sampling strategy that ensures the State's uses an adequate random sample that is representative of the population of waiver participants. The State should examine its sampling strategy to ensure that it is using an adequate random sample that is representative of the population of waiver participants. For more information, the State is referred to the waiver Application for a l915(c) Home and Community-Based Waiver [Version 3.5] Instructions,

11 Technical Guide and Review Criteria, Release Date: January 2008 (referred to here as the Technical Guide) and Sampling: A Practical Guide for Quality Management in Home & Community-Based Waiver Programs (referred to here as the Sampling Guide), both of which are available on the website that houses the waiver web-based application. In addition, technical assistance with sampling strategies for Medicaid waiver compliance is available to the State at no-cost from the National Quality Enterprise. Pennsylvania Response: During the past four years, ODP conducted two cycles of the AEOMP. Each cycle was completed over two calendar years-cycle 1 during calendar years 2007 and 2008 and Cycle 2 during calendar years 2009 and At the time ODP submitted its Quality Review of the 1915(c) P/FDS Home and Community Based (HCBS) Waiver to CMS in September 2010, Cycle 1 had been completed as scheduled by December 2008 and Cycle 2 data were available from the review of the sample of participant records associated with 26 AEs. As of December 2010, ODP completed scheduled reviews of all participant records for all 48 AEs in Cycle 2 AEOMP. At the time of this report, all data from Cycle 2 AEOMP questions are available upon request. ODP is currently working with National Quality Enterprise contractors to ensure its sampling methodology and strategy is consistent with CMS expectations at the time of waiver renewal. Level of Care Subassurance A requires that an evaluation of Level of Care is provided for all applicants for whom there is reasonable indication that services may be needed in the future. Compliance with this Subassurance has been 100% for FY From July 2009 through July 2010, ODP identified and remediated all cases of noncompliance through a 100% review of cases using HCSIS data. ODP will continue to review 100% of cases of initial level of care determinations for compliance with Subassurance A every month. In cases where noncompliance is found, ODP will generate a list of individual waiver participants involved and disseminate the list to the appropriate AE. The relevant AE will be expected to remediate any problems and return evidence of remediation to ODP within 30 days. ODP's initial approach to the evaluation of data results obtained through the AEOMP was to require AEs to design and implement Corrective Action Plans containing improvement strategies rather than documenting remediation of each individual case of noncompliance. In the future, AEs will be required to document remediation of each individual case of noncompliance in their Corrective Action Plans. ODP will aggregate and report statewide remediation data. These processes will be in place at the time of waiver renewal. As indicated in the CMS Draft Report, ODP provided an example of a remediation activity involving missing documentation. The Certification of Need for ICF/MR Level of Care form (DP 250) was not in the record of a waiver participant who transferred to another county. ODP required correction of this problem. The DP 250 form was obtained by Chester County and placed in the person's waiver record. In an example provided with ODP's Quality Review of the 1915(c) P/FDS Home and Community Based (HCBS) Waiver, ODP identified a problem where 20 percent of the AE's cases were missing a signed and dated Service Delivery Preference form. As of February 10, 2011, ODP confirmed that individuals in this example have been offered Service Delivery Preference.

12 To minimize the possibility of future occurrences, the AE developed a form for both counties to use when registering or opening a new case to verify that an individual is offered Service Delivery Preference at the time of registration when the individual is currently receiving Medical Assistance and that the offer is documented in HCSIS. ODP distributed Level of Care Remediation and Improvement Strategies to AEs on January 28, ODP asked AEs for feedback on these strategies in order to develop a standardized list of remediation actions to be used across the State. ODP is also developing an AE dashboard that will include information about Level of Care redeterminations due within 30 days and 60 days to assist AEs in minimizing future noncompliance. ODP expects to complete both activities by July II. Service Plans are Responsive to Waiver Participant Needs The State must demonstrate that it has designed and implemented an adequate system for reviewing the adequacy of service plans for waiver participants. Authority: 42 CFR ; 42 CFR ; 42 CFR ; SM.\ ; SMM Section 1915(c) Waiver Format. Item Number 13 The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. Process: A team of individuals meets to address each beneficiary's specific needs and potential services. The team includes family members and/or other individuals selected by the beneficiary, a Supports Coordinator (SC) and service providers. Using information gathered from assessment of the beneficiary, recommendations of team members and ODP service definitions, the SC develops an Individual Service Plan (ISP) in the HCSIS. The ISP addresses the following: possible natural supports in the participant's community, desired outcomes and appropriate types of services, and service providers. Prior to a participant's receipt of services, the State requires AEs to approve ISPs and authorize services consistent with assessed needs up to the P/FDS cap using criteria described in the Administrative Entity Operating Agreement. Such service authorization is necessary for providers to be paid for submission of a claim. The ISP is reviewed at least annually or within 365 days of the prior annual ISP. Where changes are identified in the participant's needs and/or choices, the ISP is revised more frequently up to the individual cost limits. The ODP monitors ISP development through the AEOMP. Specifically, ODP uses the system to periodically review random samples of ISPs of P/FDS Waiver participants in order to ensure consistent ISP development, service authorization and implementation. In September 2007, ODP began implementation of the Supports Intensity Scale (SIS) as the statewide standardized needs assessment. SIS is completed for each waiver participant to consistently identify the level of support need. The results of the SIS are provided to the participant and their planning team. As part of the planning process, the team reviews that level

13 of support indicated by the SIS and determines the specific services and number of units that are needed to meet the support need. Evidence: With regard to the subassurance that the service plans address all participants' assessed needs and personal goals, either by waiver services or other means, the State provided a summary report of data measuring the percentage of participants that had all assessed needs addressed in the ISP, but did not include any performance measures examining whether the service plans address all participants' personal goals. During CY , the data indicates all assessed needs addressed in the ISP of 93 percent of waiver participants, out of 300 P/FDS waiver participants sampled. During the same timeframe, the data indicates the outcomes listed on the ISP relate to the waiver participant's identified service preferences for 98 percent of waiver participants, with 322 P/FDS participants sampled. Also, the State presented data indicating the outcomes listed on the ISP relate to an identified need for 98 percent of waiver participants, with 322 P/FDS participants sampled. The data source used is AEOMP. While the State did not present evidence of remediation and the outcome of such remediation for the respective 7 percent, 2 percent, and 2 percent of non-compliance with the above-referenced performance measures, the State does identify system improvements aimed at increasing compliance with this subassurance. The State presented a "Statewide Supports Coordination Training'' schedule, from January 1, 2010 to July 30, 2010, which includes identification of the types of attendees from the waiver program. This schedule includes topics such as "ISP Outcome Development and Implementing Outcomes," "Personal Preferences Section and Outcome Development in the ISP", and "ISP Review." The State demonstrated that a total of 1102 Supports Coordinators and 15 AEs attended at least one of the training sessions. With regard to the second subassurance that the State monitors service plan development in accordance with its policies and procedures, the State's performance measures do not examine the State's monitoring of entities engaged in service plan development to ensure such entities are in accordance with policies and procedures. Rather, the measures examine other aspects of waiver participants' service plan development. First, the State provided a summary report of data measuring the percentage of participants who attend their own ISP meeting. During CY , the data demonstrated 98 percent of waiver participants attended their own ISP meeting, with 203 P/FDS waiver participants sampled. During CY , the State presented data from enrollees demonstrating that required members of the team were invited to the ISP meeting for 78 percent of the 322 waiver participants sampled. The data source used is AEOMP. With regard to remediation for both of the above-referenced performance measures, the State demonstrated evidence of identification of a problem where inconsistent documentation influenced participation in ISP meeting attendance. To remediate non-compliance with ISP meeting attendance, the State developed an "Individual Support Plan Signature Page," that the waiver enrollee and ISP team participants are required to complete and sign when they attend ISP meetings. While the State does not provide a summary of the outcome of this remediation, the State did develop a plan to use documentation of these pages to validate participant and team member attendance at ISP meetings in the future. The State also provided evidence of remediation with a plan of correction for an AE with a 23 percent non-compliance rate for inviting team members to ISP meetings. The AE submitted a corrective action plan, which the

14 State included in its evidence, resulting in a I 00 percent compliance rate for that AE during the following calendar year. Also, with regard to system improvements for the second performance measure, the ODP revised regulations for licensed services that specify who must attend ISP meetings. The State presented additional performance measures for the second subassurance. Specifically, the State provided a summary report of data demonstrating whether service frequency is indicated in the ISP. During CY IO, service frequency was included in the ISP of 83 percent of the 322 P/FDS waiver participants sampled. Also, the State provided data demonstrating whether all services and supports were included in the ISP. During CY , services and supports were included in the ISP of96 percent of the 322 waiver participants sampled. Moreover, the State provided data demonstrating whether the AE authorized services consistent with the service definitions during CY I 0. The data demonstrates that AEs authorized services consistent with the service definitions for 94 percent of the 299 P/FDS waiver participants sampled. Finally, the State provided data demonstrating whether the AEs authorized qualified providers(s) to deliver all services authorized in the ISP. During CY I 0, AEs authorized qualified provider(s) to deliver all services authorized in the ISP for 98 percent of the 322 waiver participants sampled. With regard to remediation, the State provided evidence of remediation generally applicable, but not specific to, the above-reference performance measures. Specifically, the State provided a plan of correction for an AE with a 20 percent non-compliance rate for ISPs documenting the frequency, amount and duration of services and provider type for each service. The State included the plan of correction in its evidence, resulting in improved compliance rate of 96 percent for the AE during the following calendar year. With regard to system improvement, the State offered evidence of this for the third abovereferenced performance measure. Specifically, if ODP determines that an AE has not authorized all services in an ISP according to the service definitions, the AE is notified. The State requires the AE to initiate corrective actions by working with the SCO to update the ISP to ensure consistency with the service definitions and ensure fair hearing rights are issued as necessary. With regard to the third subassurance that service plans are updated or revised at least annually or when warranted by changes in the participant's needs, the State evaluated 322 waiver participants using the data source, AEOMP, for CY The State found that 68 percent of 322 participants' ISPs were revised and approved within 365 days of the prior ISP update. The State also measured whether the ISP was changed as a result of identification of a change in need. The data demonstrated that 90 percent of the 322 waiver participants' ISPs were changed as a result of an identification of a change in need. The State initiated remediation of non-compliance that addresses whether ISPs are updated or revised on at least an annual basis. Specifically, when an AE had 10 percent non-compliance with this subassurance, the State oversaw the development and implementation of a corrective action plan for the AE. The AE submitted a corrective action plan, which the State included in its evidence, resulting in a I 00 percent compliance rate for that AE during the following data cycle. The State did not provide evidence of remediation that addresses the 10 percent non-compliance with whether waiver participants' ISPs were changed as a result of an identification of a change in need.

15 With regard to system improvement, the State identified a problem with discrepancy among the AEs with their determination of annual ISP review dates. To ensure future consistency among the AEs, the State revised annual review date terminology in HCSIS. AE reviewers were also retrained on this issue during an AE Oversight Regional Reviewer Meeting in September In the future, ODP plans to revise reports to track whether annual ISPs are completed in a timely manner and distribute them to AEs to support the remediation strategy for the Service Plan assurance. The State did not provide evidence of system improvement that addresses whether waiver participants' ISPs were changed as a result of an identification of a change in need. With regard to the fourth subassurance that services are delivered in accordance with the service plan, including in the type, scope, amount and frequency specified in the service plan, the State submitted evidence from the data source of AEOMP. The State provided a summary report of data demonstrating whether services were initiated within 45 calendar days of the waiver enrollment date of new enrollees. During CY , the State demonstrated that services were initiated within 45 calendar days of the waiver enrollment date for 96 percent of the 35 enrollees sampled. Further, the State examined whether, based on review of records, all services and supports in the approved ISP were received. The State found that all services and supports in the approved ISP were received by 91 percent of the 322 participants sampled. Finally, the State surveyed the percent of waiver participants who indicated they received the services they needed. The State found that 70 percent out of the 855 waiver participants surveyed indicated receiving the services they needed. The State does not present remediation or system improvements for this subassurance. The State discusses that this subassurance is monitored and non-compliance corrected through the AEOMP. By July 2011, the State agrees to track compliance with the performance measures and distribute reports of such tracking to the AEs to support remediation strategies for this subassurance. With regard to the fifth subassurance that participants are afforded choice between waiver services and institutional care and between or among waiver services and providers, the State submitted evidence from the data source, HCSIS, examining 100 percent of new enrollees. The State provided a summary report of data demonstrating the percentage of new enrollees with a service preference choice indicated or a Service Delivery Preference form (Form 457) with an effective date on or before the "waiver begin" date. For FY , 99.9 percent of all new enrollees had a service preference choice indicated or a Service Delivery Preference form with an effective date on or before the "waiver begin" date. The State presented similar findings for FY and FY With regard to remediation for the 0.1 percent non-compliance with the above-referenced performance measure, the State did not offer a specific example of a remediation activity with a corresponding outcome for this subassurance. With regard to evidence of system improvement, the State offered an example of such improvement, while not fully implemented. First, it developed an exception report listing individual waiver participants and their respective AEs for which the Service Delivery Preference requirement was not met. Beginning in CY , the State commits to share this report with the relevant AEs to assist them in addressing remediation of non-compliance and

16 developing system improvements. The State will expect AEs to review this data monthly to determine if a systematic issue exists, and if so, the AE would develop and submit a corrective action plan to ODP. The State examined additional performance measures for the fifth subassurance using the data source, AEOMP, for CY First, out of 318 waiver participants sampled, the State found documentation for 47 percent indicating choice was offered to the individual and/or family between and among services. Also, out of 187 waiver participants sampled, the State found documentation for 93 percent indicating the Supports Coordinator (SC) discussed with them the different types of services that may be available. Additionally, out of 316 waiver participants sampled, the State found documentation for 66 percent indicating a choice of willing and qualified service providers was offered to the individual and/or family. Finally, out of 184 waiver participants sampled, the State found documentation for 91 percent indicating the SC discussed different providers that may be available to provide services to them. With regard to remediation for non-compliance, the State identified a problem where AE Oversight reviewers were not consistently applying the same guidelines regarding where in the client record choice was recorded. The State changed the guidelines for CY and retrained AE reviewers to reflect the expectation that reviewers could search anywhere in the waiver participant's record for documentation of choice. The State noted a decline in the compliance rate for whether choice among and between services was offered to the individual and/or family for Cycle 2, following implementation of the remediation. Additionally, the State presented a corrective action plan for an AE that was non-compliant with the above-referenced performance measure and the performance measure addressing whether the Supports Coordinator discussed different types of services that may be available. While the State did not verify that it validated the AE's compliance, data indicated that compliance improved for the first performance measure (from 0 percent to 50 percent compliance) and remained the same for the second performance measure (75 percent). With regard to system improvements, the State identified a problem of SCs not documenting the offering of choice to individuals. To address this problem, the ODP implemented an ISP signature page that documents whether choice of services and choice of providers is offered. This signature page will be maintained in the individual's record. Also, ODP issued an ISP Bulletin that includes an ISP Manual outlining the process for development of ISPs. Moreover, ODP issued an updated, annotated ISP that provides a description of information to be included in each section of the ISP. Finally, ODP has developed remediation strategies AEs are expected to implement when non-compliances are measured and contends these measures will be implemented in the future. CMS Finding: The State has demonstrated that it has mechanisms in place to perform discovery, remediation, and system improvement related to the Service Plan assurance. However, while the State presented a sampling strategy that discusses using a statistically significant, randomized sample, the State has not fully implemented the strategy. Further, the evidence demonstrated elements of discovery for the all of the subassurances within more recent timeframes (i.e. CY 2009-CY 2010), but for certain performance measures, the State provided no historical data reflecting previous years' data. Also, the State did not provide evidence of remediating all findings where compliance was less than 100 percent. Moreover, the State did not utilize performance measures that examine the State's oversight of entities engaged in

17 service plan development to ensure such entities are in accordance with policies and procedures. Finally, the State did not provide evidence addressing the statewide standardized needs assessment, Supports Intensity Scale (SIS), implemented in year Required Recommendations: The State should provide evidence that demonstrates elements of discovery tor all performance measures using both historical and recent data. Also, it is unclear whether the State's sample was statistically significant based on the information the State provides. The State should examine its sampling strategy to ensure that it is using an adequate random sample that is representative of the population of waiver participants. For more information, the State is referred to the waiver Application for a 1915( c) Home and Community-Based Waiver [Version 3.5] Instructions, Technical Guide and Review Criteria, Release Date: January 2008 (referred to here as the Technical Guide) and Sampling: A Practical Guide for Quality Management in Home & Community-Based Waiver Programs (referred to here as the Sampling Guide), both of which are available on the website that houses the waiver web-based application. In addition, technical assistance with sampling strategies for Medicaid waiver compliance is available to the State at no-cost from the National Quality Enterprise. The State should utilize performance measures that examine the State's oversight of entities engaged in service plan development to ensure such entities are in accordance with policies and procedures. The State is commended for its system improvements to address this assurance. However, where discovery efforts reveal compliance with an assurance at less than 100%, the State should address the element of remediation. Specifically, the State should examine whether its remediation methods support improved compliance with the assurance. The State should also measure and demonstrate both the performance of and outcome of remediation activities. These changes should be in place at the time of renewal of this waiver. Finally, the State should present evidence addressing the statewide standardized needs assessment, Supports Intensity Scale (SIS), implemented in year This should include oversight and monitoring of entities operating the SIS. Pennsylvania Response: During the past four years, ODP conducted two cycles of the AEOMP. Each cycle was completed over two calendar years-cycle 1 during calendar years 2007 and 2008 and Cycle 2 during calendar years 2009 and At the time ODP submitted its Quality Review of the 1915(c) P/FDS Home and Community Based (HCBS) Waiver to CMS in September 20 I 0, Cycle 1 had been completed as scheduled by December 2008 and Cycle 2 data were available from the review of the sample of participant records associated with 26 AEs. As ofdecember 2010, ODP completed scheduled reviews of all participant records for all48 AEs in Cycle 2 AEOMP. At the time of this report, all data from Cycle 2 AEOMP are available upon request. After Cycle 1 AEOMP was completed, all AEOMP questions were reviewed and revised where appropriate. As a result, the same questions were not included in both Cycle 1 and Cycle 2 AEOMP in all cases. Where historical data for the same questions are available, these data were included in the Quality Review of the 1915(c) P/FDS Home and Community Based (HCBS) Waiver submitted to CMS in September 2010.

18 ODP is currently working with National Quality Enterprise contractors to ensure its sampling methodology and strategy is consistent with CMS expectations at the time of waiver renewal. ODP's initial approach to the evaluation of data results obtained through the AEOMP was to require AEs to design and implement Corrective Action Plans containing improvement strategies rather than documenting remediation of each individual case of noncompliance. In the future, AEs will be required to document remediation of each individual case of noncompliance in their Corrective Action Plans. ODP will aggregate and report statewide remediation data. These processes will be in place at the time of waiver renewal. ODP's initial approach to the evaluation of data results obtained through the AEOMP was to require AEs to design and implement Corrective Action Plans containing improvement strategies rather than documenting remediation of each individual case of noncompliance. In the future, AEs will be required to document remediation of each individual case of noncompliance in their Corrective Action Plans. ODP will aggregate and report statewide remediation data. These processes will be in place at the time of waiver renewal. ODP distributed Service Plans Remediation and Improvement Strategies to AEs on January 28, ODP asked AEs for feedback on these strategies in order to develop a standardized list of remediation actions to be used across the State. Additionally, ODP plans to revise reports that will track whether annual ISPs are completed in a timely manner and distribute them to AEs to support Service Plans remediation strategy in the same way as described for Level of Care reports. ODP expects to complete both activities by July ODP is reviewing and where needed revising all Service Plans performance measures in conjunction with National Quality Enterprise contractors. These performance measures will be submitted in the waiver renewal. For Subassurance B, the State monitors service plan development in accordance with its policies and procedures, ODP will analyze data down to the level of the entities involved. In addition to assessing AE performance with respect to plan development, ODP will monitor service plan development in accordance with its policies and procedures through use of a newly developed Supports Coordination Organization (SCO) monitoring process scheduled for implementation in July 20 ll. The SCO Monitoring process will include performance measures specific to whether SCOs develop service plans in accordance with ODP's policies and procedures. The ISP Signature Page form, implemented in July 2010, will be used to measure compliance with attendance at ISP meetings during the monitoring cycle that will begin July Through the AEOMP, ODP included the performance measure, "Q4.A". The outcomes listed on the ISP relate to an identified preference." ODP regards the term "identified preferences" as "identified personal goals." ODP is reviewing and where needed revising all Service Plans performance measures in conjunction with National Quality Enterprise contractors. These performance measures will be submitted in the waiver renewal. For Subassurance E, choice between waiver services and institutional care, all cases of noncompliance with Service Delivery Preference were reviewed to ensure all necessary data has been entered in HCSIS and that data previously entered into HCSIS is accurate. During FY 09-10, one instance of noncompliance was noted through a 100% review of data in HCSIS. The individual involved was offered Service Delivery Preference. Thus far in FY 20 l ,

19 compliance in this area has been 100%. ODP will review I 00% of cases of Service Delivery Preference for compliance with Subassurance E, choice between waiver services and institutional care every month as of July In any case where noncompliance is found, ODP will communicate the information to the AE. The AE will be expected to remediate the problem and return evidence of remediation to ODP within 30 days. In the future AEs will be required to document remediation of each individual case of noncompliance in their Corrective Action Plans, including individual problems found pertaining to the offering of choice between and among services and providers. ODP will aggregate and report statewide remediation data. These processes will be in place at the time of waiver renewal. ODP's contracted entity, Ascend, began to complete Supports Intensity Scale (SIS) assessments in Initially, delays were found to occur due to start~up issues such as underestimating the time involved in conducting initial training, organizing participation of respondents in the assessment process, and scheduling conflicts. After clarifying expectations through communications with SCOs and providers, Ascend was able to increase the number of assessments completed each month. Data on the number of assessments completed are maintained monthly and available upon request. Ascend is also developing a web-based scheduling system in order to streamline the scheduling process by allowing for the collection and viewing of information online rather than through multiple telephone calls. The system will also support the electronic collection and validation of demographic information. The results of the SIS are accessible in HCSIS for use by the planning team during ISP development and revision. An alert is available in HCSIS that advises the Supports Coordinator the SIS summary is complete and available for use. ODP is currently working with National Quality Enterprise contractors to refine performance measures regarding ODP's oversight and monitoring of the contractor administering the SIS. III. Qualified Providers Serve Waiver Participants The State must demonstrate that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers. Authority: 42 CFR ; S,MA The State does not fully or substantially demonstrate the assurance, though there is evidence that may be clarified or readily addressed. Process: The ODP is responsible for establishing and monitoring P/FDS Waiver provider qualifications. The ODP requires providers to submit a completed qualification application and copies of required documentation to the AE in order for provider payments to occur for the provision of waiver-eligible services. When a provider fails to meet initial or annual qualification standards, AEs are required to recommend adverse actions, which are reviewed by ODP. With regard to the Supports Coordination Organization (SCO) providers, they submit initial and annual qualification applications and supplemental information to ODP, which in turn directly deems them qualified if requirements are met.

20 The ODP requires AEs to complete the waiver provider qualification process as outlined in written policies and procedures. In June 2008, the ODP implemented a standardized provider qualification methodology and process in HCSIS. Using this system, the ODP and AEs monitor provider qualification activities by accessing real-time data and information from the HCSIS. In July of 2009, ODP and waiver providers began to utilize a standard ODP Waiver Medical Assistance Agreement and discontinued local waiver contracts between AEs and providers. Further, ODP implemented a process to prevent the creation of a new contract in HCSIS with providers for services that are not qualified. This process is aimed at preventing authorization of that provider's unqualified services in new ISPs. ODP's provider enrollment staff are responsible for verifying providers are qualified prior to processing PROMISe enrollment application requests. With regard to new and ex1stmg providers of licensed services, such providers are issued licensure on an annual basis based on onsite inspections conducted by the State. Also, the PROMISe provider enrollment team collects and verifies licenses for home health, nursing, therapist and psychologist providers. The National Plan and Provider Enumeration System assigns the providers a unique National Provider Identifier (NPI), which is entered into PROMISe with other identifying license information. Each PROMISe billing validates against the NPis to ensure that the required professional licenses are held by staff prior to providing waiver services. With regard to non-licensed and non-certified providers, new providers must be qualified prior to creation of a contract in HCSIS. Such contract creation allows services to be attached and authorized in individual plans. With regard to providers of the Supports Coordination services, ODP initially validated Supports Coordination Organizations (SCOs) based on receipt and review of written materials when this service was added to the waiver. However, in 2009, the ODP staff began validating the qualifications of all SCOs through an onsite review process that included utilization of a standardized evaluation tool. The provider training requirements vary by service in the approved waiver. However, hourly specifications exist for the SCOs, which have an annual requirement of a minimum of 40 hours per calendar year, including annual GOP-sponsored training and local training. Evidence: With regard to the subassurance that the State verifies whether providers initially and continually meet required licensure and/or certification standards and adhere to other state standards prior to their furnishing waiver services, the State provided three performance measures, with data for one performance measure. The State developed but did not present data for the following two measures: the number and percent of new providers, by provider type, that meet licensure and/or certification standards and/or other state standards prior to the provider furnishing waiver services and the number and percent of providers offering a new service that meet required licensure and/or certification standards and/or other state standards prior to their furnishing waiver services. The ODP provided an action plan with timelines for implementing such data collection for the above-referenced performance measures. The State also presented a performance measure for which data was collected. Specifical1y, it examined the number and percent of licensed providers, by provider type, that continue to meet required licensure and/or certification standards and/or other state standards within 365 days. The data source used is