Appendix J – CLASS MFP Quality Management Strategy

The following acronyms are used in the attached quality management strategies:

ANE - Abuse, Neglect, and Exploitation
A&I - DADS Access and Intake Division
CDSA - Consumer Directed Service Agency
CFO - Chief Financial Officer
CMS - Centers for Medicare and Medicaid Services
DADS - Department of Aging and Disability Services
DMFM - Discovery Method and Frequency of Measurement
EQRO - External Quality Review Organization
HCSSA - Home and Community Support Services Agency
HHSC - Health and Human Services Commission
ICF/MR - Intermediate Care Facility for Persons with Mental Retardation
ISP - Individual Service Plan
LAR - Legally Authorized Representative
LOC - Level of Care
MCO - Managed Care Organization
MMIS - Medicaid Management Information System
MN - Medical Necessity
NF - Nursing Facility
P/F - Provider/Facility
PS - DADS Provider Services Division
QAI - DADS Quality Assurance and Improvement Office
RE - Responsible Entity
RS - DADS Regulatory Services Division
PS - DADS Provider Services Division
TMHP - Texas Medicaid and Healthcare Partnership

Quality Focus Area 1 - Level of Care and Participant Access

Following the acceptance of an offer of CLASS Program services by an applicant or his/her LAR or family, a CLASS provider case manager and registered nurse collect documentation of the individual’s eligibility for an ICF/MR Level of Care (LOC) VIII and perform necessary assessments to complete the LOC form. For an initial LOC determination the case manager must submit supporting medical documentation establishing the presence of a related condition. DADS staff must approve or deny the level of care submitted. A new LOC must be completed and submitted annually along with the annual renewal of a participant’s ISP.

Assurance 1.1: An evaluation of level of care (LOC) is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

Quality Indicator (QI): Percent of initial LOCs reviewed by DADS.

Responsible Entity (RE): Provider Services (PS).
Discovery Method and Frequency of Measurement (DMFM): CLASS Desk review, on-going.

Assurance 1.2: Enrolled participants are reevaluated at least annually or as specified in its approved waiver.

QI: PS reviews 100 percent of LOCs at least annually.

RE: DADS Provider Services (PS).
DMFM: CLASS Desk Review, on-going.

Assurance 1.3: The process and instruments described in the approved waiver are applied to determine LOC.

QI: Percent of time the LOC is determined using instruments described in the approved waiver, including one of the waiver-approved adaptive behavior instruments.

RE: DADS, CLASS provider.
DMFM: CLASS Desk Review, on-going.

Assurance 1 .4: The State monitors LOC decisions and takes action to address inappropriate LOC determinations.

QI: Number of LOC determinations found to be incorrect when challenged by, or on behalf of, the applicant/participant.

RE: PS
DMFM: CLASS Desk Review.

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Quality Focus Area 2 - Individual Service Plan (ISP)

CLASS provider agency case managers facilitate individual service planning. ISPs are developed using a person-directed planning process. The case manager convenes a service planning team that must also include the individual or the individual’s LAR, the provider agency nurse or program director, a direct care worker, and, at the invitation of the individual or LAR, other individuals important to developing the service plan such as providers of non-waiver services and family or friends. The case manager is responsible for assuring the plan is reviewed at least quarterly and revised at least annually or whenever indicated by changes in the individual’s service needs.

Assurance 2.1: Individual Service Plans (ISP) address participant’s assessed needs and personal goals, either by waiver service or through alternate resources.

QI 2.1.1: Percent of ISPs that are signed by an individual, individual’s family or LAR.

RE: DADS PS,
DMFM: CLASS Desk Review, P/F Monitoring reviews, annually.

QI 2.1.2: Percent of initial and annual ISPs submitted with justification of services.

RE: PS.
DMFM: CLASS Desk Review, P/F monitoring reviews, at initial enrollment, annually.

QI 2.1.3: Individual Service Plans (ISP) address participant’s assessed needs and personal goals, either by waiver services or through alternate resources.

RE: PS. QI: Identified service changes on ISP amendments are submitted along with justification for changes.
DMFM: P/F monitoring review, annually.

Assurance 2.2: The State monitors ISP development in accordance with its policies and procedures and takes appropriate action when it identifies inadequacies in the development of ISPs.

QI2.2.1: Percent of on-site program provider reviews that include monitoring of compliance with policies and procedures concerning ISP development.

RE: PS.
DMFM: P/F monitoring reviews, annually.

QI 2.2.2: Percent of program providers required to submit corrective action plans to correct non-compliance with policies and procedures concerning ISP development.

RE: PS.
DMFM: P/F monitoring reviews, annually

QI 2.2.3: Percent of respondents reporting that case managers asked about their preferences;

RE: Quality Assurance and Improvement (QA & I).
DMFM: NCI Survey, biennially.

Assurance 2.3: ISPs are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.

QI 2.3.1: Percent of program providers required to submit corrective action plans to correct non-compliance with policies and procedures concerning ISP updates or revision.

RE: PS.
DMFM: P/F monitoring review, annually.

QI 2.3.2: Percent of respondents reporting that “needed” services were available.

RE: QAI.
DMFM: NCI Survey, biennially.

Assurance 2.4: Services are specified by type, amount, duration, scope, and frequency and are delivered in accordance with the service plan.

QI: Percent of monitored providers who provide all CLASS service components authorized in an individual’s ISP.

RE: DADS PS.
DMFM: P/F monitoring review, annually.

Assurance 2 5: Participants are afforded choice: 1) between waiver services and institutional care and 2) between/among waiver services and providers.

QI: Percent of individuals’ records evidencing individuals are afforded choice between waiver services and institutional care.

RE: PS.
DMFM: CLASS Desk Review, annually.

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Quality Focus Area 3 - Qualified Providers

During P/F monitoring reviews and licensure reviews of CLASS Program providers, DADS staff sample personnel records to verify that all minimum provider qualifications are met and required training has been accomplished.

Assurance 3.1: The State verifies, on a periodic basis, that providers meet required licensing and/or certification standards and adhere to other state standards prior to furnishing waiver services.

QI: Percent of monitored/surveyed program providers that maintain HCSSA licensure.

RE: PS, Regulatory Services (RS).
DMFM: P/F monitoring reviews, annually and Licensure Surveys, every 3 years (HCSSA).

Assurance 3.2: The State verifies on a periodic basis that providers continue to meet required licensure and/or certification standards and/or adhere to other state standards.

QI: Percent of monitored/surveyed program providers that assure that personnel who provide services to individuals are qualified by licensing, certification, and State regulations.
RE: PS, RS.
DMFM: P/F monitoring reviews, annually.

Assurance 3.3: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

QI: Percent of monitored program providers who provide evidence that non-licensed providers of waiver services meet minimum background and training qualifications.

RE: PS, RS.
DMFM: P/F monitoring reviews, annually and CDSA Reviews, biennially.

Assurance 3.4: The State identifies and remediates situations where providers do not meet requirements.

QI: Percent of on-site program provider reviews resulting in required corrective action to address non-compliance with requirements related to provider qualifications.

RE: PS.
DMFM: P/F monitoring reviews, annually and CDSA Reviews, biennially.

Assurance 3.5: The State implements its policies and procedures for verifying that training is provided in accordance with state requirements and the approved waiver.

QI: Percent of accepted corrective action plans addressing non-compliance with training and qualifications of providers.

RE: PS.
DMFM: P/F monitoring reviews, annually.

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Quality Focus Area 4 - Health and Welfare - Participant Safeguards

DFPS is responsible for investigating allegations of abuse, neglect, or exploitation of individuals enrolled in the CLASS Program. In accordance with state law, DADS maintains an Employee Misconduct Registry that includes the names of persons confirmed to have abused, neglected, or exploited an individual receiving services. In addition, in accordance with federal law, DADS maintains a Nurse Aide Registry that lists certified nurse aides. The Nurse Aide Registry indicates if an aide has been confirmed to have abused, neglected, or exploited a resident of a licensed nursing facility. CLASS providers must consult these registries prior to offering employment to a non-licensed service provider and refrain from employing that person if either registry indicates the person was confirmed to have abused, neglected, or exploited an individual receiving services. State law prohibits program providers from employing a person whose criminal background indicates the person has been convicted of certain felonies. Program providers are required to complete pre-employment criminal background checks for each non-licensed applicant that will provide services to an individual enrolled in the CLASS Program.

Each CLASS provider agency is required to keep a log of complaints and complaint resolutions which will be monitored during on-site reviews by DADS’ staff.

Assurance 4.1: There is continuous monitoring of the health and welfare of waiver participants and remediation actions are initiated when appropriate.

QI 4.1.1: Percent of program providers required to submit plans of correction related to health, safety, or welfare.

RE: PS.
DMFM: P/F monitoring reviews; annually.

QI 4.1.2: Percent of program providers whose plans of correction related to health, safety, or welfare were accepted.

RE: PS.
DMFM: P/F monitoring reviews, annually.

QI 4.1.3: Percent of program providers whose licenses were terminated due to non-compliance with requirements related to health and welfare.

DMFM: P/F monitoring reviews, annually.

Assurance 4.2: The State, on an on-going basis, identifies, addresses and seeks to prevent instances of abuse, neglect and exploitation (ANE).

QI 4.2.1: Percent of program providers whose licenses were terminated due to non-compliance with requirements related to criminal background and registry checks.

RE: PS, RS.
DMFM: P/F monitoring reviews, annually; CDSA Reviews, biennially; and Licensure Surveys, every three years.

QI 4.2.2: Percent of providers presenting evidence that required criminal history and registry checks are performed in compliance with state requirements.

RE: PS, RS.
DMFM: P/F monitoring reviews, annually; CDSA Reviews, biennially; and Licensure Surveys, every three years.

QI 4.2.3: Percent of providers presenting evidence that participants are informed orally and in writing of process for filing complaints including processes for reporting ANE.

RE: PS, RS.
DMFM: P/F monitoring reviews, annually; CDSA Reviews, biennially; and Licensure Surveys, every three years (HCSSA).

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Quality Focus Area 5 - Administrative Authority and Fiscal System Performance

In accordance with 42 CFR §431.10 (e), HHSC is the single state Medicaid agency and retains administrative authority over the waiver program. The initial waiver, subsequent amendments, CMS 372 reports and all state rules for waiver program operations are subject to the review and approval/disapproval of the Commission. Additionally, HHSC long-term care Medicaid staff is actively involved in the development of quality assurance activities at DADS. In September 2004, HHSC staff convened a meeting of senior staff at DADS to initiate base-lining and evaluation activities in regard to the new CMS waiver guidelines. At that meeting, HHSC staff presented the new CMS guidelines and related quality assurance information along with the direction that the operating agency review the new requirements and develop strategies to accomplish the required results. Since that time, HHSC and DADS staff have held regular status and update meetings directed at evaluating current quality systems and identifying and prioritizing enhancements. These meetings have resulted in plans to: enhance data reporting to HHSC; base-line current activities using the CMS sponsored waiver review matrix developed by the Muskie School of Public Service; to initiate joint on-site reviews of program providers; and evaluate the development of a quality management strategy that spans more than one waiver and potentially other types of long-term care services. HHSC’s involvement and oversight in the development of enhanced waiver quality assurance mechanisms under the new CMS guidelines will assure HHSC oversight of all areas of waiver operations.

Assurance 5: The Medicaid agency or operating agency conducts routine, ongoing oversight of the waiver program.

QI 5.1: The operating agreement identifying policy-setting and oversight responsibilities is on file.

RE: DADS, HHSC.
DMFM: State Medicaid Agency Review, on-going.

QI 5.2: The operating agreement is reviewed for updates.

RE: HHSC.
DMFM: State Medicaid Agency Review, annually

QI 5.3: The operating agreement is current.

RE: HHSC.
DMFM: State Medicaid Agency Review, at least annually.

QI 5.4: The need to update operating agreements is identified.

RE: HHSC.
DMFM: State Medicaid Agency Review, on-going.

QI 5.5: The operating agreement has been updated. The operating agreement is under review by State Medicaid Agency legal staff. Elements of the new waiver process as well as name changes of the agencies under recent state law are being considered for inclusion in the update.

RE: HHSC.
DMFM: HHSC, on-going.

QI-6: The State Medicaid Agency monitors implementation of the agreement to assure provisions are executed.

RE: HHSC.
DMFM: Review of actions taken under the State Medicaid Agency’s administrative authority, on-going.

QI-7: The operating agency reports the results of its monitoring activities to the State Medicaid Agency.

RE: HHSC and DADS.
DMFM: Review of reports by State Medicaid Agency, on-going.

QI-8: The operating agency submits the results of its monitoring to the State Medicaid Agency annually via the CMS 372 report.

RE: DADS.
DMFM: Review of 372s submitted, annually.

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6. Financial Accountability

Program providers enter billing claims into the Claims Management System, which assigns the correct reimbursement rate associated with the billing code entered by a program provider. The Claims Management System automatically rejects any claim that is entered with an unauthorized billing code or for a service not included in a participant’s authorized ISP. On a monthly basis, Provider Services Contracts tracks the money recouped due to percent of correctly coded claims reimbursed according to reimbursement methodology billing errors.

Assurance 6: Participant claims are coded and paid according to the waiver reimbursement methodology.

QI-6.1: Percent of correctly coded claims reimbursed according to reimbursement methodology.

RE: PS.
DMFM: Claims Management System, on-going.

QI-6.2: Codes used to bill participant claims are appropriate for the service provided.

RE: DADS.
DMFM: Amount of dollars recouped from providers as a result of P/F reviews when claims for services to participants were found in error due to incorrect coding.
RE: PS.
DMFM: P/F Monitoring reviews, annually.

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Updated: December 14, 2010