PROVIDER MONITORING TOOL FOR NEW PROVIDERS

Transcription

1 OFFICE OF DEVELOPMENTAL PROGRAMS PROVIDER MONITORING TOOL FOR NEW PROVIDERS (FY ) Note: This tool is intended for use by new Providers enrolled after 7/01/2011 1

2 Provider Monitoring Tool Instructions I. Overview of Provider Monitoring Tool This Provider Monitoring Tool is designed to assess a Provider s structure and practices across a number of measures to ensure compliance with regulations, waiver requirements, Provider Agreement terms and policies and procedures. This tool consists of 26 questions addressing compliance standards divided broadly into 8 Oversight Areas. The compliance standards are policy statements taken from the waivers, regulations, Provider Agreement, and policies and procedures that this monitoring process will use to measure compliance. II. Tool Users The tool is intended for use by waiver providers excluding Supports Coordination Organizations (SCO), as follows: 1. New Providers: New Providers, enrolled after July 1, 2011, need to complete and submit this tool before being authorized to provide services. Note 1: Please note that New Providers who provide only transportation services to waiver individuals ( Transportation-only Providers ) should complete a separate tool which can be found on the Provider Information Center (PIC) at Providers who provide Transportation services in addition to other traditional services should use this tool. Note 2: Once a new Provider completes the New Provider tool, the Provider will be enrolled in the Annual Provider Monitoring process and will complete the full Provider Monitoring tool during the next monitoring cycle. For more information about the Provider Monitoring process, please visit the PIC ( or Doing Business with ODP/Developmental Programs homepage ( ams/index.htm). III. Tool Completion Instructions The following guidelines are intended to help a user complete and submit this tool successfully. 1. All questions applicable to the Provider have to be answered before the tool can be submitted. 2. There are two question formats in this tool: a. Yes/No: These questions are to be answered by selecting 'yes' or 'no' based on the guidelines provided. N/A can only be chosen where indicated. If there is a circumstance where N/A applies but is not an option, please choose No and explain the reason in the Section Comments box at the end of the section. b. Section Comments boxes: Every section in the tool has a comment box at the end of the section. This comment box can be used to provide clarifications, explanations and relevant details related to the questions in that section. For example, as explained above, if there is a circumstance 2

3 where N/A applies but is not an option, the reason can be explained in the Section Comments box at the end of the section. If adding a comment, please reference the question number[s]. 3. Instructions for Providers: When responding to questions in this tool, providers must retain all related documentation, including policy & procedure documentation. This file with supportive or documentary evidence (referred to as relevant documentation throughout this tool) must be retained and made available to the AE reviewers or ODP upon request. ODP suggests each Provider print the PDF version of the tool, or download the Word version of the tool and mark answers on one of those documents before transferring final answers to the Zoomerang tool. Zoomerang does not allow a user to print a submission once complete, so the modified PDF or Word document would serve as the Provider s submission record. IV. Tool Sections There are 2 sections in this tool: 1. Introductory Questions: These questions relate to basic organizational information related to the responding Provider. 2. Policy/Procedure Questions: These questions relate to written policies, procedures, and other documentation that ODP requires the Provider to maintain. V. General instructions 1. In case of questions, issues or concerns related to the questions on this tool, please contact [email protected]. 2. In case of technical difficulties, please contact the Zoomerang helpline at If providers or reviewers encounter any issues related to the Provider s data on external systems, or an inability to access necessary information, please reach out to your Regional ODP. 3

4 Section I: Introductory Questions Question 1 What is your legal IRS Provider organization name (the name used in the enrollment process)? Provider Name: Question 2 What is your organization's nine digit MPI number? MPI Number: Question 3 Which AEs does your organization intend to provide services in? Please enter each AE name on a separate line. Question 4 Which regions does your organization intend to provide services in? Please enter each region name on a separate line. Question 5 What is your Provider contact information (for the person entering this report)? Contact Name (first and last name): Contact Phone Number (no space or dash): Contact Address: Question 6 Please reference the list of waiver services provided on the PIC: Identify and copy all of the waiver services your organization provides into the text box below. Please enter each service on a separate line. 4

5 Section II. Policy and Procedure Questions Overview: The following questions relate to the policies and procedures employed by the provider while providing waiver services to individuals. In order to answer these questions, providers need to be able to identify specific sections within their policy documentation that address the questions. Methodology: When responding to these questions in the tool, providers must retain all related documentation, including policy & procedure documentation, training curriculum, training records, etc. Question 7 Oversight Area: Organizational Structure Compliance Standard: There is a written organizational structure outlining key administrative functions. Source Document: Waiver Assurance on Administrative Authority Reviewers will review relevant documentation and job descriptions. Is a clearly defined organizational structure available? If an organizational structure is available, mark 'Yes' If an organizational structure is not available, mark 'No' Question 8 Oversight Area: Organizational Structure Compliance Standard: There is a written organizational structure outlining key administrative functions. Source Document: Waiver Assurance on Administrative Authority Reviewers will review the organizational structure. Is the function of assuring Waiver Compliance identified? If the function is identified, mark 'Yes' If the function is not identified, mark 'No' If an organizational structure is not available, mark N/A Question 9 Oversight Area: Organizational Structure 5

6 Compliance Standard: There is a written organizational structure outlining key administrative functions. Source Document: Waiver Assurance on Administrative Authority Reviewers will review the organizational structure. Is the function of Incident Management/Risk Management identified? If the function is identified, mark 'Yes' If the function is not identified, mark 'No' If an organizational structure is not available, mark N/A Question 10 Oversight Area: Organizational Structure Compliance Standard: There is a written organizational structure outlining key administrative functions. Source Document: Waiver Assurance on Administrative Authority Reviewers will review the organizational structure. Is the function of Quality Management identified? If the function is identified, mark 'Yes' If the function is not identified, mark 'No' If an organizational structure is not available, mark N/A Question 11 Oversight Area: Organizational Structure Compliance Standard: There is a board of directors, or governing body, if required by the corporate structure. Source Document: PA Bulletin Title 19 Chapter 23 Section 23.8 Reviewers will review relevant information. Is the following documentation available for the Board of Directors or Governing Body? a. Description of composition b. By-laws c. Frequency of meetings d. Meeting minutes If ALL of the above are available, mark 'Yes' 6

7 If ANY of the above is not available, mark 'No' If a Board of Directors or governing body is not required by the corporate structure, mark N/A and include an explanation in the Section Comments below Question 12 Oversight Area: Transportation Compliance Standard: All transportation services are authorized in accordance with current and approved service definitions. Source Document: Service Definitions Reviewers will confirm that the provider transports people for a fee (compensation). If the provider transports people for a fee (compensation), do they have a PUC (public utility commission) license? Note: "Incidental" transportation, Carpooling and free transportation are exempt from requiring a PUC. If the provider transports people for a fee (compensation), and has a PUC License, mark Yes If the provider transports people for a fee (compensation), and does not have a PUC License, mark No If the provider does not fit the definition or if you do not provide transportation services, mark N/A Question 13 Oversight Area: Mission & Vision Compliance Standard: There is a mission/vision statement that supports ODP s mission, vision, values and quality framework. Source Document: MR Bulletin Quality Management Strategy of the Office of Developmental Programs, MR Bulletin Principles for the Mental Retardation System Reviewers will review the organization's mission and vision. Does the mission/vision statement reflect the principles of Everyday Lives. Please reference Everyday Lives: Making it Happen for more information. If the statement does address Everyday Lives principles, mark 'Yes' If the statement does not address Everyday Lives principles, or if the Provider does not have a mission or vision statement, mark 'No' 7

8 Question 14 Oversight Area: Staffing Compliance Standard: Staff are trained and qualified to provide supports to individuals as required in the ISPs. Source Document: Waiver Assurance on Qualified Providers, Provider Agreement,ODP Bulletin: Provider Qualification Reviewers will review policies and procedures. Does the provider have policies and/or procedures to ensure that the following staff qualification requirements are met (for unlicensed services only)? a. Orientation / Staff Training b. Background Checks (criminal history, child abuse, FBI) c. All staff are 18 years old or older If each area has been addressed, mark 'Yes' If any area is not addressed, mark 'No' If the Provider currently provides only licensed services, mark N/A Question 15 Oversight Area: Regulatory and Policy Requirements Compliance Standard: The provider has a process in place to ensure ongoing compliance with qualification requirements as specified in MR Bulletin Source Document: MR Bulletin , Process for Qualification and Disqualification of Waiver Providers Are all of the Provider's services qualified initially and on-going within 365 days as required? If all of the provider's services are qualified or re-qualified within 365 days, mark 'Yes' If the provider has services that are not qualified or were not re-qualified within 365 days, mark 'No' Question 16 Oversight Area: Regulatory and Policy Requirements 8

9 Compliance Standard: The Provider maintains a policy consistent with MR Bulletin Elimination of Restraints through Positive Practices. Source Document: MR Bulletin # Elimination of Restraints through Positive Practices Reviewers will review the Provider's policy on restraints. Does the policy address the following: a. Staff Training requirements b. Positive Approaches c. Internal review committee s responsibilities d. Data Collection e. Plan for reduction and eventual elimination of restraints If each area has been addressed, mark 'Yes' If any area is not addressed, mark 'No' If the Provider provides only unlicensed services, mark N/A Question 17 Oversight Area: Regulatory and Policy Requirements Compliance Standard: The Provider is in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Source Document: Health Insurance Portability and Accountability Act (HIPAA) Does the provider retain a Business Associates Agreement [BAA] with all AE s with whom the provider is supporting individuals? If the provider retains the BAA with ALL required AEs, mark 'Yes' If the provider does not retain a BAA with one or more required AEs, mark 'No' Question 18 Oversight Area: Regulatory and Policy Requirements Compliance Standard: The provider has a written policy for retention and access to records in compliance with MR Bulletin Provider Billing Documentation Requirements for Waiver Services. Source Document: MR Bulletin Provider Billing Documentation Requirements for Waiver Services Reviewers will review policy and procedures. Does the policy include provisions for the following: 9

10 a. The preservation of records until the expiration of 4 years after the waiver service is provided, unless otherwise specified; b. The restriction of use or disclosure of information for purposes directly related to the implementation of the ISP; c. The availability and accessibility of the records to the SC, AE, ODP and the US Health & Human Services Department. If the policy includes provisions for ALL of the above, mark Yes' If the policy does not include a provision for one or more of the above, mark No' Question 19 Oversight Area: Contingency Planning Compliance Standard: Providers have an Emergency Disaster Response plan for natural disasters. Source Document: MR Bulletin Quality Management Strategy of the Office of Developmental Programs; Focus Area II: Participant-Centered Service Planning and Delivery, Focus Area IV: Participant Safeguards Does the provider have a documented Emergency Disaster Response plan that addresses individual s safety and protection, communications and/or operational back-up plans? If the provider has a documented Emergency Disaster Response plan that includes all of the above, mark Yes If the provider does not have a documented Emergency Disaster Response plan or if the plan does not include all of the above, mark No Question 20 Oversight Area: Contingency Planning Compliance Standard: Provider has procedures on how to respond to individual health and behavioral emergencies and crises. Source Document: MR Bulletin Incident Management, MR Bulletin Elimination of Restraints through Positive Practices, Waiver assurances appendix G-3, (relating to participant safeguards), Provider Agreement conditions #1 & 2 Are there policies and procedures on how to respond in cases on individual health and behavioral emergencies and crises? If the provider has a documented policy, mark Yes If the provider does not have a documented policy, mark No 10

11 Question 21 Oversight Area: Complaints Compliance Standard: The Provider has policies and/or procedures for responding to individuals, family advocates and general public complaints. Source Document: Waiver Assurance on Health and Welfare Reviewers will review policies and procedures. Is there a policy for the investigation and resolution of complaints? If the provider has a written policy, mark Yes If the provider does not have a written policy, mark No Question 22 Oversight Area: Incident Management Compliance Standard: The provider implements PA's incident management policy. Source Document: MR Bulletin Incident Management 55 Pa. Code Chapter 6000 subchapter Q Incident Management. Reviewers will review the policy and procedures. Does it meet the following requirements of the MR Bulletin Incident Management? a. There is a written policy to support incident management b. The policy addresses taking timely and appropriate action in response to incidents c. The policy addresses reporting of incidents d. The policy addresses certified investigation of incidents e. The policy addresses taking corrective action in response to incidents If all of the above provisions have been addressed in a policy, mark 'Yes' If any of the above provisions have not been addressed in a policy, mark No' Question 23 Oversight Area: Incident Management Compliance Standard: Investigations are completed timely, thorough and objectively in accordance with the Certified Investigator s Manual. 11

12 Source Document: Certified investigation manual, 55 Pa Code Chapter 6000 subchapter Q Incident Management Reviewers will review the latest Peer Review. Was a peer review completed within the last 365 days? If a peer review was completed within the last 365 days, mark Yes If a peer review was not completed within the last 365 days, mark No If there have been no Certified Investigations completed by the Provider, mark N/A Question 24 Oversight Area: Incident Management Compliance Standard: Investigations are completed timely, thorough and objectively in accordance with the Certified Investigator s Manual. Source Document: Certified investigation manual, 55 Pa Code Chapter 6000 subchapter Q Incident Management Reviewers will review the latest Peer Review. Are the Peer Review findings documented? If the peer review findings are documented, mark Yes If the peer review findings are not documented, mark No If there have been no Certified Investigations completed by the Provider, mark N/A Question 25 Oversight Area: Incident Management Compliance Standard: Investigations are completed timely, thorough and objectively in accordance with the Certified Investigator s Manual. Source Document: Certified investigation manual, 55 Pa Code Chapter 6000 subchapter Q Incident Management Were follow up recommendations from the Peer Review implemented? If the follow-up recommendations have been implemented, mark Yes' If the follow-up recommendations have not been implemented, mark No' If there were no follow-up recommendations, mark N/A 12

13 Question 26 - Comments Box Please enter any comments related to Policy and Procedure questions where you responded, "N/A." Include the question #s in your response. If you did not respond, N/A to a question in this section, please type N/A in the comments box.. 13