Texas Department of Aging and Disability Services
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Community Living Assistance and Support Services (CLASS)
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New Contract and Fiscal Compliance Monitoring Tools: Community Living Assistance and Support Services (CLASS) Overview

Kathie Carleton-Morales, DADS, Contract Oversight & Support
Kathie.Carleton-Morales@dads.state.tx.us
Laura Seymer, DADS, Contract Oversight & Support
Laura.Seymer@dads.state.tx.us
External Stakeholder Presentation
October 5, 2011

Monitoring Tools Project

Project Goal

  • Comprehensive, Risk-Based Contract Monitoring Protocol and Tools

Contract and Fiscal Compliance

  • Contract Oversight and Support (COS), in coordination with several Department of Aging and Disability Services (DADS) areas and with external stakeholder feedback, developed a new contract monitoring protocol and ten contract and fiscal compliance monitoring tools

Monitoring tools provided to contract staff for implementation September 2009:

  • Assisted Living/Residential Care/Out of Home Respite (AL/RC/OHR)
  • Day Activity and Health Service (DAHS)
  • Home and Community Support Services (HCSS), Community Based Alternatives (CBA)
  • Home-Delivered Meals (HDM)
  • Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS)

Monitoring tools provided to contract staff for implementation March 2010:

  • Adult Foster Care/Out of Home Respite (AFC/OHR)
  • Home and Community Support Services, Consolidated Waiver Program (CWP)
  • Consumer Directed Services (CDS)
  • Medically Dependent Children Program (MDCP)
  • Transition Assistance Services (TAS)

Benefits

  • Consistent, standardized monitoring across DADS regions
  • Improved data integrity
  • Provides closure for the contractor and contract manager at the exit conference
  • Communication prior to exit, re: missing documentation
  • At exit, final results provided

Major Changes

March 2011, COS removed several items related to HCSSA licensure to reduce overlap with items that DADS Regulatory Services surveys.  These include:

  • Notice of Complaint procedures
  • Notice of Rights and Responsibilities
  • Attendant Employability (Criminal History, Employee Misconduct, Nurse Aide Registry, and, as applicable, age requirement)
  • Physical, Occupational and Speech Therapy provided in accordance with the physician’s/practitioner’s order

March 2011, COS deployed the tools in Excel resulting in the following benefits:

  • Embedded logical formulas assess responses to preliminary questions to determine the response to a standard- improved data integrity
  • Scores calculate automatically on Compliance Summary
  • Data is extracted from Excel tools and imported into a database
  • Database is used to analyze, trend and report data (e.g., 1915 (c) waiver assurances, legislative inquiries, etc.)

Tool Framework

  • Sampling
  • Notice Letter
  • Entrance Conference
  • Contract and Fiscal Compliance Monitoring by Program
  • Exit Conference
  • Risk Assessment

Sampling

  • Random
  • Five percent of the population served with a minimum of 4 individuals per contract
  • Allows expansion of sample size to determine prevalence of non-compliance with a maximum of 30

Review Period

  • Contract Compliance – 12 months for most standards
    • Some standards are not dependent on a review period
    • Some standards look at a smaller timeframe
  • Fiscal Compliance – Minimum of two months

Note: Due to the March 2011 revision to 40 Texas Administrative Code (TAC) Chapter 45, relating to CLASS program requirements and revisions to the CLASS Provider Handbook effective June 2011, the review period will exclude months prior to June 2011.  For example, a review scheduled for November 2011 would encompass the period of June 2011 through August 2011, a three month review period instead of the usual twelve month review period.  The number of months included in the review period will increase incrementally until a twelve month review period is established.

Notice Letter

  • Two week advance notice
  • Establishes the review location
  • Identifies the contract(s) under review
  • Identifies the needed documents and records
  • Requests an agency overview of business operations

Entrance Conference

  • Provides opportunity to
  • Establish purpose
  • Identify key contacts
  • Obtain information and records needed by the review team
  • Obtain agency overview
    • Independent audit
    • Taxing authority status
    • Wage and hour claims
    • Bankruptcy status

Contract and Fiscal Compliance Monitoring Tool Based on

  • Current Program Rule
  • CLASS Provider Handbook

Exit Conference

  • Present contract and fiscal compliance review findings
  • Identify required action
  • Review process for requesting an
    • Administrative Review
    • Administrative Hearing
  • Allows contractor to submit "management response" within 3 work days

Risk Assessment

  • During FY2012, DADS will begin to use performance history, financial indicators and compliance results to assess level of risk

Contract and Fiscal Compliance Monitoring Tools

Each program tool includes multiple components:

  • Monitoring Workbook
  • Staff Qualifications/Training Table
  • Individual Work Paper (IWP)
  • Units of Service Tables for Hourly Services, Dental, Adaptive Aids and Minor Home Modifications (applicable to CLASS DSA)

Monitoring Workbook

  • Compiles findings for all standards reviewed
  • Compiles information documented from all components (Staff Qualifications/Training Table, IWP, Units of Service Tables, etc.)
  • Compliance score for each standard
  • Overall compliance score
  • Includes a demand for payment notice for identified over-billing errors

Staff Qualifications/Training Table

  • Single listing of employees/attendants for review of:
    • orientation and training requirements for all staff (unlicensed or licensed/certified)
    • verification of completion of background checks for unlicensed attendants/employees
    • includes review of additional hiring requirements (age, relationship to the individual, etc.)
  • Populates related standards in the Monitoring Workbook

Individual Work Paper (IWP)

  • For selected standards, provides ability to record answers by sample consumer
  • Framework for consistent review and documentation of information
  • Populates the Monitoring Workbook

Units of Service Tables (CLASS DSA)

  • Hourly Services
    Provides calendars for entry of documented hourly services (e.g., Nursing, Habilitation, Specialized Therapies, etc.)
  • Dental, Adaptive Aids, Minor Home Modifications
    Provides a worksheet for entry of information needed to assess compliance

CLASS Tool Highlights

Contract & Fiscal Compliance Monitoring Tools
Available at: http://www.dads.state.tx.us/providers/contractcompliance/class/index.html
Community Living Assistance and Support Services - Contract Management Agency (CLASS- CMA) Review Standards

  • Policies and Procedures
  • Staff Qualifications and Training
  • Case Management
  • Billing

I. Policies and Procedures

  • Complaints Documented and Investigated
  • Safeguard Individuals
  • Quality Assurance
  • Case Manager Back Up
  • Screen Employees and Contractors for Exclusions

II. Staff Qualifications and Training

  • Staff Meet Required Qualifications
  • Completion of Background Checks
    • Review Program Director, Case Managers and other staff who worked with the CLASS CMA program and who were hired during the 12 month review period
    • Completion of DPS, EMR and NAR checks within required timeframes
    • Eligible for employment
  • Staff Training

III. Case Management

  • Initial Face- to- Face
  • Pre- Enrollment Activities
  • Initial Service Planning Team (SPT)
  • SPT Enrollment Activities
  • SPT Renewal Activities
  • SPT Revisions
  • Individual Program Plan (IPP) Quarterly Reviews
  • Individual Medicaid Eligibility
  • Transfer Activities
  • Service Suspension
  • Notifications

IV. Billing

  • Over Billing (verify monthly contact)

Community Living Assistance and Support Services - Direct Service Agency (CLASS- DSA) Review Standards

  • Policies and Procedures
  • Staff Qualifications and Training
  • Medicaid Eligibility
  • Pre-Enrollment
  • Service Planning
  • Immediate Jeopardy
  • Transfer
  • Reduction/Suspension/Termination of Services
  • Specialized Therapies
  • Habilitation/Habilitation Pre-Vocational Services
  • Respite Services
  • Nursing Services
  • Behavioral Support
  • Auditory Enhancement Training
  • Supported Employment
  • Occupational Therapy
  • Physical Therapy
  • Speech Therapy
  • Dental Services
  • Adaptive Aids
  • Minor Home Modifications

I. Policies and Procedures

  • Screen Employees and Contractors for Exclusions
  • Staff Back Up
  • Safeguard Individuals

II. Staff Qualifications and Training

  • Staff Meet Required Qualifications
  • Staff Training
  • CPR Certification

III. Medicaid Eligibility

  • Monthly Verification of Eligibility
  • Notification of Ineligibility

IV. Pre-Enrollment

  • Nursing Assessment, Adaptive Behavior Assessment and MR/RC Assessment Completed as Required
  • Submission of MR/RC Assessment (F8578) and Related Conditions Eligibility Screening Instrument (F8662) to DADS
  • Submission of Additional Documentation
  • Provide the CMA DADS Approved MR/RC
  • Inform the Individual of his/her Rights & Responsibilities

V. Service Planning- Applicable to Enrollment

  • DSA Participation as part of the Individual’s SPT
  • Development of a Service Back Up Plan as applicable
  • Completion of the Habilitation Plan as Required
  • Service Initiation

V. Service Planning- Applicable to Renewal

  • Submission of MR/RC Assessment (F8578) and Related Conditions Eligibility Screening Instrument (F8662) to DADS
  • Inform the Individual of his/her Rights & Responsibilities
  • DSA Participation as Part of the Individual’s SPT
  • Development of a Service Back Up Plan as applicable
  • Completion of the Habilitation Plan as Required
  • Submission of Proposed Renewal Individual Plan of Care (IPC) & Habilitation Plan to DADS

V. Service Planning- Applicable to Revisions/Changes

  • DSA Correspondence with the CMA regarding routine revisions to the IPC/IPP
  • DSA Report of Changes in Individual Status to the CMA

VI. Immediate Jeopardy

  • Submission of Required Documentation to the CMA
  • Submission to the CMA Within the Required Timeframe

VII. Transfer

  • Transferring DSA Provides Records to the Receiving DSA Within the Required Timeframe
  • Receiving DSA Initiates Services on the Transfer Effective Date

VIII. Reduction/Suspension/Termination of Services 

  • Reduction
    • DSA Provides Services in the Amount Authorized in the Prior IPC, Pending Appeal
  • Suspension
    • DSA Notification to the CMA of a Situation that Necessitates Services to be Suspended

VIII. Reduction/Suspension/Termination of Services 

  • Termination With Advanced Notice
    • DSA Notification to the CMA of a Situation that Necessitates Services to be Terminated
    • DSA Accommodates a Face-to-Face SPT as Scheduled by the CMA
    • DSA Provides Services in the Amount Authorized in the Prior IPC, Pending Appeal

VIII. Reduction/Suspension/Termination of Services 

  • Termination Without Advanced Notice
    • DSA Notification to the CMA of a Situation that Necessitates Services to be Terminated
    • When Aware of a Situation Placing the Health and Safety of the Case Manager/Service Provider in Immediate Jeopardy, DSA Made Appropriate Referrals and Attempted to Resolve the Situation

IX. Specialized Therapies

  • Specialized Therapies Provided in Accordance with the IPC
  • DSA Obtained Physician’s Orders for Each Authorized Specialized Therapy
  • DSA Quarterly Reviews
  • Billing

X. Habilitation/Pre-Vocational Services

  • Habilitation Services Provided as Authorized and in Accordance with the IPC
  • Pre-Vocational Services Provided as Authorized and in Accordance with the IPC
  • DSA Quarterly Reviews
  • Billing

XI. Respite Services

  • Respite Services Provided as Authorized and in Accordance with the IPC
  • Billing

XII. Nursing Services

  • Nursing Services Provided as Authorized and in Accordance with the IPC
  • Nursing Assessments Completed as Required
  • Billing

XIII. Behavioral Support

  • Behavioral Support Services Provided in Accordance with the IPC
  • DSA Quarterly Reviews
  • Billing

XIV. Auditory Enhancement Training

  • Auditory Enhancement Training Provided in Accordance with the IPC
  • DSA Quarterly Reviews
  • Billing

XV. Supported Employment

  • Supported Employment Services Provided in Accordance with the IPC
  • DSA Quarterly Reviews
  • Billing

XVI. Occupational Therapy

  • DSA Quarterly Reviews
  • Billing

XVII. Physical Therapy

  • DSA Quarterly Reviews
  • Billing

XVIII. Speech Therapy

  • DSA Quarterly Reviews
  • Billing

XIX. Dental Services

  • Completion of Request for Adaptive Aids, Medical Supplies or Minor Home Modifications, Part C
  • Obtain Dental Treatment Plan Prepared by a Dentist Within the Required Timeframe
    • If a Delay, DSA Notification to the Case Manager and Individual/LAR
  • Service Initiated Within the Required Timeframe
    • If a Delay, DSA Notification to the Case Manager and Individual/LAR
  • Billing

XX. Adaptive Aids

  • Completion of Request for Adaptive Aids, Medical Supplies or Minor Home Modifications, Part C (F3660)
  • Obtained Recommendation by Appropriate Licensed Professional for Each Adaptive Aid
  • If $500 or more, Obtained Written Specifications as Required
  • If $500 or more, Purchased From the Most Cost Effective Supplier
  • Delivered Within the Required Timeframe
    • If a Delay, DSA Notification to the Case Manager and Individual/LAR
  • Documentation of Completion of Purchase
  • Billing
  • Delivery of Authorized Item

XXI. Minor Home Modifications

  • Completion of Request for Adaptive Aids, Medical Supplies or Minor Home Modifications, Part C (F3660)
  • Obtained Owner Approval
  • If $1000 or more, Obtained Written Specifications as Required
  • Written Specifications Include Required Elements
  • If $1000 or more, Obtained At Least 3 Written Bids Within the Required Timeframe
  • If $1000 or more, Obtained Written Justification When Higher Bid Chosen
  • Initiated Construction Within Required Timeframe
  • Construction Complete Within Required Timeframe
    • If a delay, DSA Provided Notice to the CMA
  • MHM Inspected Within Required Timeframe
  • Completion of Purchase Within Required Timeframe
  • Billing

How to Access the Tools

The Contract Compliance and Fiscal Monitoring tools are available at: http://www.dads.state.tx.us/providers/contractcompliance/class/index.html or, from the CLASS Providers webpage, scroll to the Related Links near the bottom of the page and click on "New Contract and Fiscal Compliance Monitoring Tools for CLASS".

Go Live Date

November 2011

Questions and Answers

Through 10/12/2011, questions may be submitted to COS at CLASS.MonitoringTool@dads.state.tx.us
Responses to questions submitted to COS, as well as, those recorded during the Webinar will be posted to the DADS Webpage 10/21/2011.

DADS will post the revised tools prior to implementation.

THANK YOU FOR YOUR PARTICIPATION

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Updated: February 18, 2014