Provider Monitoring Process

Transcription

1 1 Provider Monitoring Process This statewide provider monitoring process is applicable for all qualified providers including Agency With Choice (AWC) Financial Management Services (FMS) providers that deliver services funded through the Consolidated and/or Person/Family Directed Support (P/FDS) waivers (waivers). The provider monitoring process established by this document excludes Intermediate Care Facilities for persons with Mental Retardation (ICFs/MR), Supports Coordination Organization (SCO) providers, Vendor Fiscal/Employer Agent (VF/EA) FMS providers and all providers delivering only base-funded services. As part of the ODP quality management strategy, provider monitoring has been designed to be comprehensive, standardized and measurable. Standard processes, tools and data collection documents assist ODP with verifying that providers are qualified and services are provided in compliance with the waivers, regulations, policies and procedures, and the current Provider Agreement for Participation in Pennsylvania s Consolidated and P/FDS Waivers (Provider Agreement) or any approved revisions. Provider monitoring must verify compliance with the assurances defined in the waivers in accordance with 42 CFR , and allow ODP to verify providers compliance with federal regulations and the waivers. The Administrative Entity (AE) shall ensure the health and welfare of individuals at all times. If the AE determines there is an imminent threat to the health and welfare of an individual, the AE shall take immediate steps to ensure the health and welfare of the individuals and contact the appropriate regional ODP office. Based on circumstances, the AE shall proceed according to the ODP incident management policy or as determined appropriate by the regional ODP office. Provider monitoring activities must be conducted in accordance with all federal and state statutes, including the Health Insurance Portability and Accountability Act (HIPAA) requirements. Electronic distribution of materials is permitted; if the parties involved have the means to distribute, receive and read information in electronic form, and as long as the electronic distribution of the materials is completed in a secure and protected manner in compliance with HIPAA requirements. The section below identifies several terms which are new and applicable to provider monitoring: AE audit: The 3 rd phase of provider monitoring which includes an on-site review validation by the AE of the provider s submitted provider monitoring tool completed during the provider reporting phase and the submission of the AE s report to ODP regarding its on-site review of the provider.

2 2 AE report: The report developed and submitted by the AE to ODP which summarizes the information collected by the provider monitoring tool during the AE s on-site review of the provider during the AE audit phase. Lead AE: The AE with which the most individuals served by the provider are registered. On-site review: The validation of the provider s compliance with the waivers, regulations, policies and procedures, and the current Provider Agreement for Participation in Pennsylvania s Consolidated and P/FDS Waivers (Provider Agreement) or any approved revisions, using the provider monitoring tool. Each provider conducts an on-site review of itself during the provider reporting phase and each AE conducts an on-site review of a provider during the AE audit phase. Performance review: The 1 st phase of provider monitoring when providers are supplied with important performance data that may be used by the provider to devise improvement plans, while at the same time giving the provider an early indication of performance below statewide averages. Performance review report: Data the provider requests through the Home and Community Services Information System (HCSIS) reporting screen during the performance review phase. Provider reporting: The 2 nd phase of provider monitoring when each provider conducts an on-site review of itself and completes the provider monitoring tool to assess its structure and practices which enable the provider to meet compliance with regulations, waiver requirements, Provider Agreement conditions and policies and procedures. Reviewing AE: the AE that conducts an on-site review of a provider who renders services in multiple counties. Provider Monitoring Phases The three phases of the provider monitoring are: performance review, provider reporting and AE audit. The performance review phase is initiated quarterly and the provider reporting phase occurs annually for all providers, while the AE audit phase will typically occur once every two years for providers based on ODP s distribution methodology. The following chart identifies the schedule of provider monitoring phases and associated activities:

3 3 Quarters/ Months 1 st quarter July August September 2 nd quarter October November December 3 rd quarter January February March 4 th quarter April May June Provider Monitoring Phases Performance Review Provider Reporting AE Audit Beginning July 1 ODP makes performance reports available to all providers. Performance explanations and improvement strategies, requested by AEs as applicable. Performance reports available to all providers. Performance explanations and improvement strategies, requested by AEs as applicable. Performance reports made available to all providers. Performance explanations and improvement strategies, requested by AEs as applicable. Performance reports made available to all providers. Performance explanations and improvement strategies, requested by AEs as applicable. Beginning July 1 ODP determines the distribution of individuals for onsite reviews, and provides distribution to providers (providers enrolled, qualified and providing a service on June 30) and AEs by September Providers new to ODP service system as of July 1) conduct provider reporting activities. Provider reports for new providers due prior to rendering a service. October 1 all providers shall conduct provider reporting activities using distribution of individuals provided by ODP. By December 31 provider reports for active providers due to ODP Providers new to ODP service system conduct provider reporting activities. Provider reports for new providers due prior to rendering a service. ODP shall provide to the AEs, a copy of the provider monitoring tools completed by the providers identified in the distribution of providers given to the AEs during the 1 st quarter of the provider monitoring process the previous year. Beginning January 1, 2012 ODP analyzes results of provider reports and makes revisions to process, tools, distribution methodology, etc. as appropriate and warranted Providers new to ODP service system conduct provider reporting activities. Provider reports for new providers due prior to rendering a service. Providers new to ODP service system conduct provider reporting activities. Provider reports for new providers due prior to rendering a service. Beginning July 1 ODP determines distribution of providers, and provides distribution to AEs for AE audits by September Beginning July 1, 2012 ODP analyzes results of AE audit reports and makes revisions to process, tools, distribution methodology, etc. as appropriate and warranted. On October 1 AEs begin scheduling dates for on-site reviews with providers. Beginning January 15 AEs conduct onsite reviews of providers and distribution of individuals provided by ODP during 1 st quarter of the provider monitoring process the previous year. AEs submit AE reports to ODP as completed. By March 31 on-site reviews conducted by reviewing AEs that provide reports to lead AEs must be completed. AEs continue to conduct on-site reviews and submit AE reports to ODP as completed. By April 30 all on-site reviews must be completed. All reviewing AE on-site reviews must be submitted to lead AEs. AE audit reports for on-site reviews conducted between January 1 and April 30 are due to ODP as outlined, but no later than June 30.

4 4 Phase 1: Performance Review Data and trend information is made available by ODP quarterly to all providers through the Home and Community Services Information System (HCSIS). The purpose of these reports is to supply providers with individual performance data that may be used by the provider to devise improvement plans, while at the same time giving the provider an early indication of performance below statewide averages. A response to the performance data may be requested by the AE or ODP. The performance review phase will be implemented as follows: On a quarterly basis, ODP announces which reports to pull in HCSIS through its ODP listserv list. To register for the ODP listserv list, please access DPW s listserv website at: ODP listserv list. The performance review reports are requested through the HCSIS reporting screen. Once requested, the reports are generated through an overnight process and are accessed through the provider s HCSIS report inbox. A provider reviews and analyzes the performance review report and takes appropriate steps to improve its performance based on the results of the analysis. When follow up is requested by the AE or ODP based on the performance data on the reports, the provider is required to respond electronically to the AE with an explanation within 15 calendar days for review and approval, and if requested by the AE or ODP, a Corrective Action Plan (CAP) as directed by ODP or its designee. o The timelines and required content of a CAP or Directed Corrective Action Plan (DCAP), when required within the provider monitoring process, shall be implemented as directed by ODP or its designee. o In the event the provider is a multi-county provider, the response based on the data review from the provider shall be submitted to the lead AE. o When there is a lead AE, the lead AE shall communicate with the appropriate reviewing AEs in addition to the provider. Following the review of a provider s response, the AE shall notify the provider, and the reviewing AE if applicable, whether the response requires further follow up or a CAP. The AE shall monitor the provider at any time the AE determines necessary or as requested by ODP to ensure implementation of a CAP or DCAP.

5 5 The flow chart below depicts the implementation of the performance review phase: Fig. 1: Performance Review Phase Flow

6 6 Phase 2: Provider Reporting Provider reporting is the provider s assessment of its structure and practices that enable the provider to meet regulations, waiver requirements, Provider Agreement conditions and policies and procedures. The on-site review conducted by the provider during the provider reporting phase assists the provider with assessing its compliance level and preparedness for the next phase of provider monitoring, the AE audit. At the same time, the provider s completed provider monitoring tool results provide ODP with a baseline to track and trend the statewide compliance of providers across these provider monitoring tool measures. Each provider shall conduct provider reporting by completing the standardized provider monitoring tool based on the distribution of individuals given to the provider by ODP. For more information on the ODP distribution of individuals methodology, please access the Provider Monitoring Distribution Methodologies link on the ODP provider monitoring website at: Doing Business With ODP. A person or entity that wants to provide services in the ODP service system must complete its initial enrollment and qualify to provide a service. The person or entity shall then complete an abbreviated provider monitoring tool and submit it to the AE, prior to the AE authorizing the service and prior to the service being rendered by the provider. The abbreviated provider monitoring tool contains specific measures from the complete provider monitoring tool which can be applicable to a new provider. A provider is one that is enrolled and qualified with ODP, and rendering at least one waiver-funded service. The provider reporting phase shall be implemented as follows: Beginning July 1, 2011 and annually thereafter ODP determines the distribution of individuals for on-site reviews conducted by each current provider, and provides the distribution to the AEs and current providers by September 30. All providers which are current providers as of June 30 shall receive the ODP random distribution of individuals and be included in the provider reporting phase following that June 30. As of October 1, 2011 and annually thereafter, each current provider shall conduct its provider on-site review using the provider monitoring tool available on ODP s provider monitoring website and submit its completed provider monitoring tool electronically to ODP, no later than December 31, 2011 and annually thereafter. ODP shall review the submitted provider monitoring tools for timeliness and completion. January 1, 2012 and annually thereafter, ODP shall provide to the AEs, a copy of the provider monitoring tools completed by the providers.

7 7 Although ODP will review the submitted provider monitoring tools for timeliness and completion, each provider must be prepared to validate the information submitted in the provider monitoring tool, during the AE audit phase of provider monitoring. Documentation that can be used to support the information submitted in the provider monitoring tool shall be retained by the provider. The inability to produce such documentation when requested during an on-site review conducted by the AE may be treated as non-compliance and the AE or ODP may seek enforcement measures accordingly. The flow chart below depicts the implementation of the provider reporting phase: Fig 2: Provider Reporting Phase Flow

8 8 Phase 3: AE Audit The on-site review conducted by the AE during the AE audit phase is a validation of the provider s submitted provider monitoring tool. Providers are selected for this onsite review based on the ODP distribution of providers given to the AEs during the 1 st quarter of the provider monitoring process, as well as based on the outcome of the provider s compliance with the provider reporting phase. For more information on the ODP distribution of providers methodology, please access the Provider Monitoring Distribution Methodologies link on the ODP provider monitoring website. Every provider shall be selected to participate in an AE audit at least once every two years. By September 30, 2011 and annually thereafter, ODP assigns each provider to one of two groups monitoring group 1 or monitoring group 2. ODP may reassign a provider s monitoring group based on the volume of new providers that become enrolled during a given year or based on the provider s compliance with the provider reporting phase of provider monitoring. If ODP determines it must reassign a provider to the alternative monitoring group, ODP shall notify the provider and the AE of this reassignment. Between September 30, 2011 and December 31, 2011, and annually thereafter, AEs shall notify each provider selected in the distribution of providers and schedule tentative dates for the on-site reviews to occur. AEs and providers shall cooperate to identify two or three possible dates for the on-site reviews to occur, as it may be necessary to cancel a scheduled date due to unforeseen circumstances. All on-site reviews must be scheduled by December 31 and at least 15 days in advance of the onsite visit. On-site reviews shall be conducted by AEs between January 15 and April 30 of each year. The on-site review of the provider is conducted by the AE using the standardized provider monitoring tool developed by ODP that examines standards and measures of compliance derived from the waiver requirements, Provider Agreement and ODP written policies and procedures. ODP recommends the AE complete a monitoring tool on paper during the visit to the provider, and then complete and submit the electronic version of the monitoring tool once the AE has returned to its office. After the on-site review, the AE shall prepare an AE audit report which summarizes the information collected by the provider monitoring tool. For more information on the AE audit report, please access the AE Audit Report link on the ODP provider monitoring website. In instances where a provider renders services in multiple AEs, the on-site review is conducted by the lead AE in its own county, along with reviewing AEs conducting onsite reviews in the other counties where the provider renders services. A lead AE is designated by ODP based on the AE with which the most individuals served by the provider are registered. ODP shall reassess the designation of the lead AE or reviewing

9 9 AEs annually. The AE audit phase is different depending on whether it involves the onsite review of a provider that renders services in only one county or in multiple counties. AE Audit of a Single-County Provider: The AE audit phase for providers that render services in only one county shall be implemented as follows: ODP distributes the distribution of providers for the on-site review to the lead AE by September 30, 2011 initially and annually thereafter. The lead AE shall use the distribution of providers in conjunction with the distribution of individuals provided by ODP to both the provider and lead AE during the 1 st quarter of the provider monitoring process the previous year. Between September 30 and December 31, the lead AE notifies the provider of its selection in the distribution and schedules possible dates for the on-site review to occur. o The lead AE and provider shall coordinate the on-site review date(s) together and cooperate to allow each entity an appropriate amount of time to conduct the AE audit activities. The lead AE shall conduct its on-site review of the provider by April 30, 2012 initially and annually thereafter. The lead AE shall conduct the on-site review by completing the provider monitoring tool in paper format. The lead AE conducts the on-site review at the provider's corporate location and may also conduct the on-site review through visiting the provider s service locations where individuals registered with the lead AE receive waiver services. The lead AE completes the electronic version of the provider monitoring tool based on its on-site review of the provider, and submits the tool to ODP within 30 calendar days of conducting the on-site review. The lead AE prepares the AE audit report and submits the AE audit report to the provider for review within 30 calendar days of the on-site review date, and directs the provider to develop a CAP, if necessary. o If applicable, the provider shall submit a requested CAP within the time frame given by the lead AE or ODP as applicable. The provider shall review the report. Within 15 calendar days of receiving the AE review report, the provider may submit a dispute or response to the report to the lead AE. However, a response is not required. If a CAP was requested by the lead AE, the lead AE reviews the CAP from the provider and determines if further action is required by the provider.

10 10 Following the review of a provider s CAP or dispute or response as applicable, the lead AE shall do at least one of the following as appropriate within 15 calendar days: o Notify the provider that its response to the AE audit report was accepted. o Notify the provider that its response to the AE audit report was not acceptable, and request a CAP from the provider. o Approve the provider s CAP. o Request a revised CAP from the provider. o Notify the provider that the AE shall provide a Directed Corrective Action Plan (DCAP) developed by the lead AE for the provider to implement. o Notify the provider that it must participate in training or technical assistance provided by the lead AE. The lead AE shall monitor the provider as the lead AE determines necessary or as requested by ODP to ensure implementation of AE audit activities. The lead AE submits the AE audit report, and if applicable, the provider s dispute or response and CAP or DCAP to ODP for review and approval within 60 calendar days of the on-site review date, but no later than June 30, 2012, initially and annually thereafter. ODP shall review the submitted materials and provide its approval or provide direction to the lead AE, as applicable, in regard to further actions required by the provider and the lead AE. AE Audit of a Multi-County Provider: The AE audit phase for providers that render services in multiple counties shall be implemented as follows: ODP distributes the distribution of providers for the on-site review to the lead AE by September 30, 2011 initially and annually thereafter. ODP also identifies the reviewing AEs for the lead AE. The lead AE is responsible to provide the distribution list to its reviewing AEs. The lead and reviewing AEs shall use the distribution of providers in conjunction with the distribution of individuals provided by ODP to both the provider and AE during the 1 st quarter of the provider monitoring process the previous year. Between September 30 and December 31, the lead and reviewing AEs must notify each provider of its selection in the distribution and schedules tentative dates for the on-site review to occur.

11 11 o The lead AEs and reviewing AEs shall cooperate and conduct monitoring activities, such as deciding if one AE shall make all phone call contacts with and on-site reviews of a provider, in the most effective and efficient manner which is appropriate for the AEs and providers involved. o The lead and reviewing AEs and provider shall coordinate the on-site review date(s) together and cooperate to allow each entity an appropriate amount of time to conduct the AE audit activities. The reviewing AE conducts an on-site review of the provider using its distribution of individuals in addition to being responsible for the coordination and completion of the AE audit phase among the other designated reviewing AEs. Designated reviewing AEs are responsible for on-site reviews within the applicable county or AE. Each reviewing and lead AE shall conduct its on-site review of the provider by March 31, 2012 initially and annually thereafter. Each lead and reviewing AE shall conduct its on-site review by completing the provider monitoring tool in paper format. The AE conducts the on-site review at the provider's corporate location and may also conduct the on-site review through visiting the provider s service locations where individuals registered with the AE receive waiver services. Lead AEs shall complete the entire monitoring tool, while reviewing AEs shall only complete the questions in the monitoring tool related to the distribution of individuals, which are specifically identified as such in the monitoring tool. Each lead and reviewing AE completes the electronic version of the provider monitoring tool based on its on-site review of the provider, and submits the tool to ODP within 30 calendar days of conducting the on-site review, but in no event to be submitted later than April 30, 2012 initially and annually thereafter. o ODP shall provide copies of the completed provider monitoring tools to the lead AEs as requested. The reviewing AEs each prepare an AE audit report and submit the AE review report to the lead AE. The lead AE consolidates the reviewing AEs audit reports into one AE review report. The lead AE provides the AE audit report to the reviewing AES and provider for review within 30 calendar days of the provider s last on-site review date, and directs the provider to develop a CAP if necessary.

12 12 o If applicable, the provider shall submit a requested CAP within the time frame given by the AE. The provider shall review the report. Within 15 calendar days of receiving the AE audit report, the provider may submit a dispute or response to the report to the lead AE. However, a response is not required. If a CAP was requested by the lead AE, the lead AE reviews the CAP from the provider and determines if further action is required by the provider. Following the review of a provider s CAP or dispute or response as applicable, the lead AE shall do at least one of the following as appropriate within 15 calendar days: o Notify the provider and reviewing AEs that the provider s response to the AE audit report is accepted. o Notify the provider and reviewing AEs that the provider s response to the AE audit report is not acceptable, and request a CAP from the provider. o Notify the provider and reviewing AEs that the provider s CAP is approved. o Notify the provider and reviewing AEs that a revised CAP is requested from the provider. o Notify the provider and reviewing AEs that the lead AE shall provide a DCAP developed by the lead AE for the provider to implement. o Notify the provider and reviewing AEs that the provider must participate in training or technical assistance provided by the lead AE. The lead and reviewing AEs shall monitor the provider as the AEs determine necessary or as requested by ODP to ensure implementation of AE review activities. The lead AE submits the AE audit report, and if applicable, the provider s dispute or response and CAP or DCAP to ODP for review and approval within 60 calendar days of the provider s last on-site review date, but no later than June 30, 2012, initially and annually thereafter. ODP shall review the submitted materials and provide its approval or provide direction to the lead AE, as applicable, in regards to further actions required by the provider, the lead and reviewing AEs. The flow chart below depicts the implementation of the AE audit phase:

13 13

14 14 Fig 3: AE Audit Phase Flow

15 15 Unscheduled on-site monitoring: An AE may conduct unscheduled on-site monitoring. The AE must notify the appropriate regional ODP before making an unscheduled on-site monitoring visit. If such monitoring reveals that there is a clear and imminent threat to the health and welfare of an individual, the AE shall notify the appropriate regional ODP immediately regarding the situation. ODP may choose to attend an unscheduled on-site monitoring visit conducted by the AE. The AE is not required to complete the full on-site monitoring tool when conducting an unscheduled on-site monitoring, but shall use the on-site monitoring tool during its unscheduled on-site monitoring. The AE may choose what portions of the monitoring tool are applicable, unless portions of the tool were specified by the regional ODP to be completed. The AE shall conduct its unscheduled on-site monitoring by completing the provider monitoring tool in paper format. Subsequent to any unscheduled on-site monitoring visits, the AE shall: Require any appropriate response or action from the provider such as a CAP or implementation of a DCAP, similar to those action steps identified in the data review section. Take steps to ensure the health and welfare of individuals at all times and proceed as directed by ODP. Submit the unscheduled on-site monitoring report to the provider for review within 30 calendar days following the on-site monitoring. o If the provider disputes the unscheduled on-site monitoring findings, the provider shall provide a dispute or response to the AE within 15 calendar days. Complete an unscheduled on-site monitoring report. The AE shall submit the unscheduled on-site monitoring report and provider s dispute or response (if applicable) to the appropriate regional ODP for review within 60 calendar days of the unscheduled on-site monitoring date. ODP shall provide technical assistance and guidance to the AE and provider as requested and as determined necessary to support all provider monitoring activities. ODP may request that the AE conduct a follow up unscheduled on-site monitoring visit or ODP may conduct its own unscheduled on-site monitoring visit. Follow-up Status:

16 16 The AE or ODP places a provider in follow-up status when a provider fails to submit an acceptable CAP or implement a DCAP or fails to meet required timelines. Under follow-up status, the AE or ODP may require additional actions from the provider, including but not limited to: Attendance and participation in enhanced training and technical assistance. Implementation of a DCAP. The AE may: Provide a DCAP or request assistance from OPD with developing a DCAP for the provider to implement. Review the provider s qualifications. Recommend to ODP, the provider be subject to on-site review more often than once every two years. Recommend to ODP, the restriction or disqualification of the provider. ODP may also: Require the provider to participate in the on-site review phase more than once every two years. Implement sanctions including, but not limited to freezing or altering waiver enrollment or approved program capacity. Refer the provider to the appropriate licensing unit for further review. Implement restriction of the provider to deliver some or all waiver services.