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Appendix K – Consolidated Waiver Program 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

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Quality Focus Area 1 - Level of Care (LOC) and Participant Access

Desired Outcome: Participants have access to home and community-based services and supports in their community. Following the acceptance of an offer of CWP Waiver Program services by a participant or his/her legally authorized representative (LAR) or family, a HCSSA documents the participant’s eligibility and completes the assessment form. For the NF waiver, the HCSSA must complete and submit the form electronically to the Texas Medicaid and Healthcare Partnership (TMHP), DADS MMIS agent, who determines the participant’s level of care (LOC). For the ICF/MR waiver, the HCSSA submits the form to DADS staff, who approve or deny the LOC . Enrollment in CWP is prohibited without an approved LOC. A renewal of a participant’s service plan is also prohibited if the Participant’s LOC is not current.

Assurance 1 1.1: An evaluation of level of care (LOC) is provided to all applicants for whom there is a reasonable indication that services may be needed in the future.

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

Responsible Entity (RE): NF: TMHP; ICF/MR: DADS - PS
Discovery Method and Frequency of Measurement (DMFM): NF: TMHP’s Long Term Care Portal (electronic system); ICF/MR: manually by DADS PS staff, Ongoing

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

QI: 100 percent of LOCs are reviewed.

RE: NF: TMHP; ICF/MR: DADS - PS
DMFM: NF: TMHP’s Long Term Care Portal (electronic system); ICF/MR: manually by DADS PS staff, Ongoing

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

QI: Percent of time the assessment form is used to determine LOC.

RE: NF: TMHP; ICF/MR: DADS - PS
DMFM: NF: TMHP’s Long Term Care Portal (electronic system); ICF/MR: manually by DADS PS staff, Ongoing

Assurance 1.4: The State monitors LOC decisions and takes action to address inappropriate LOC determinations.

QI: Percent of LOC determinations found to be incorrect, when challenged.

RE: NF: TMHP; ICF/MR: DADS - PS
Discovery Method and Frequency of Measurement: NF: DADS A&I; ICF/MR: DADS PS staff, Ongoing

Assurance 1.5: Information and Referral: Participants and families can readily obtain information concerning the availability of services, how to apply.

QI: Percent of participants indicating satisfaction with information provided regarding availability of services and how to apply.

RE: DADS-QAI; DMFM: PES Survey, biennially;

Assurance 1.6: Intake and eligibility determination processes are understandable and user friendly.

QI: Percent of participants who felt the determination process was understandable and user friendly.

Responsible Entity: DADSQAI; DMFM: PES Survey, biennially;
Assurance 1.7 Services are initiated promptly when the applicant is determined eligible and selects services.

QI: Percent of service plans that are initiated within one month of plan authorization.

RE: DADS-QAI;.
DMFM: QAI Data Mart – Quarterly;

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Quality Focus Area 2–Individual Service Plan

Desired Outcome: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community. The HCSSA facilitates individual service planning. Service plans (plans of care) are developed using a person-directed planning process. The HCSSA coordinator convenes a service planning team that must include the participant and the participant’s legally authorized representative (LAR) and, at the invitation of the participant or LAR, other individuals important in developing the service plan such as providers of waiver or non-waiver services and family or friends. The HCSSA is responsible for assuring the plan is reviewed and revised at least annually and whenever indicated by changes in the participant’s service needs.

Assurance 2.1: Plans of Care address all participant’s assessed needs (including health and welfare risk factors) and personal goals, either by type of service or other means.

QI: Percent of participant records evidencing that the HCSSA initiates, coordinates, and facilitates the person-directed planning process to meet the desires and needs as identified by the participant and LAR;

QI: Percent of providers presenting evidence that a participant, participant’s family or LAR participated in the development of support methodologies to address outcomes identified through the person-directed planning process.

RE: DADS-A&I, DADS-RS; HCSSA
DMFM: On-Site HCSSA Review, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; HCSSA Quality Assessment and Performance Improvement (QAPI) program.

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

QI: Percent of participants whose service plan evidences development of the service plan in accordance with State policy and procedure; Percent of people reporting that case managers asked about their preferences.

RE: DADS-A&I, DADS-RS; DADS-QAI; HCSSA.
DMFM: On-Site HCSSA Review, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; HCSSA QAPI program, annually; PES Survey, every other year (biennially).

Assurance 2.3: Service plans are updated/revised when warranted by changes in the waiver participant’s needs.

QI: Percent of participant records evidencing updated/revised service plan when participant needs warrant changes.

Responsible Entity: DADS-A&I; DADS-RS.
DMFM: On-Site HCSSA Review, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter.

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 service plans that provide all program components authorized in a participant’s service plan; Percent of people reporting that “needed” services were available.

RE: DADS-A&I; DADS-RS, and DADS-QAI.
DMFM: On-Site HCSSA Review, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; PES Survey, every other year (biennially)

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 participants or LARs that were given choice between waiver services and institutional care;

QI: Percent of providers who employ/contract with a service provider of the participant’s or LARs choice if that service provider is qualified.

QI: Percent of providers who inform the participant or LAR of provider’s obligation to assist and cooperate with the participant’s or LARs request to transfer to another CWP Waiver Program provider.

RE: DADS-A&I, DADS-RS, HCSSA.
DMFM: On-Site HCSSA Review, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; HCSSA QAPI program, annually; On-site Provider Review, annually.

Assurance 2.6: Participants have the authority and are supported to direct and manage their own services to the extent they wish.

QI: Percent of participants who are offered the ability to manage their own services; Percent of participants who choose to manage their own services.

RE: DADS-A&I
DMFM: On-Site HCSSA Review, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; HCSSA QAPI program, annually; SAS System, Ongoing

Assurance 2.7: Ongoing Monitoring: Regular, systematic and objective methods – including obtaining the participant’s feedback – are used to monitor the participant’s well being, health status, and effectiveness of the service in enabling the individual to achieve his or her personal goals.

QI: Percent of participants surveyed who report satisfaction with their services and supports in terms of addressing health and well being, and enabling the participant to achieve his or her personal goals.

RE: DADS-QAI
DMFM: PES Survey biennially; Long Term Services and Supports Quality Review of CWP Program, biennially

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Quality Focus Area 3-Qualified Providers - Capacity and Capabilities

Desired Outcome: There are sufficient service providers and they possess and demonstrate the capability to effectively serve participants. During on-site reviews of CWP 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 standards, contract requirements and adhere to other State standards.

QI: Percent of providers that are qualified by licensing, certification, or State regulations; percent of providers meeting HCSSA licensure requirements.

RE: DADS-RS, PS
DMFM: On-site provider Reviews, annually for ALFs; On-site HCSSA Reviews, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter.

Assurance 3.2: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

QI: Percent of providers of waiver services meet minimum background/training qualifications; Percent of providers meeting HCSSA licensure requirements.

RE: DADS A&I
DMFM: On-site provider contract monitoring  

Assurance 3.3: The State identifies and rectifies situations where providers do not meet requirements.

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

RE: DADS-RS, A&I; 
DMFM: On-site provider Reviews, annually for ALFs, during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter for HCSSAs; On-site monitoring reviews, every 24 months (biennially)

Assurance 3.4: The State implements its policies and procedures for verifying that training is provided in accordance with state requirements and the approved program requirements.

QI: Percent of on-site reviews that include review of evidence that providers are qualified and trained as required by state rules and the waiver; Percent of on-site reviews of HCSSAs that include review of evidence that providers are qualified and trained as required by State rules.

RE: DADS-RS; DADS-A&I;.
DMFM: On-site provider reviews, annually; On Site HCSSA Reviews, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter.

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Quality Focus Area 4-Health and Welfare - Participant Safeguards

Desired Outcome: Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices. DFPS is statutorily responsible for investigating allegations of abuse, neglect, or exploitation of participants enrolled in the CWP Waiver Program. DFPS forwards to DADS a report of each of its investigations along with its determination that the allegation was confirmed or not confirmed or that results of the investigation were inconclusive. In accordance with state law, DADS maintains an Employee Misconduct Registry that includes the names of persons DADS or DFPS has confirmed to have abused, neglected, or exploited a participant receiving services through a Home and Community-based Services Waiver Program. In addition, in accordance with federal law, DADS maintains a Nurse Aide Registry (NAR) that lists certified nurse aides. The NAR indicates if an aide has been confirmed to have abused, neglected, or exploited a resident of a licensed NF. Providers must consult these registries prior to offering employment to a non-licensed service provider and refrain from employing that person if either registry indicated the person was confirmed to have abused, neglected, or exploited a participant. Texas state law prohibits providers from employing a person whose criminal background indicates the person has been convicted of certain felonies. Providers are required to complete pre-employment criminal background checks for each non-licensed applicant that will provide services to a participant enrolled in the CWP Waiver Program.

Assurance 4.1: The State, on an ongoing basis, identifies and addresses and seeks to prevent instances of abuse, neglect and exploitation.

QI: Percent of providers demonstrating that personnel are trained and knowledgeable of acts constituting ANE, the requirements to report allegations of ANE, and methods to prevent ANE;

QI: Percent of providers that comply with the requirement to not employ service providers ineligible due to information contained within criminal history checks, the nurse-aide registry or the employee misconduct registry

RE: DADS-RS; A&I.
DMFM: On-Site provider reviews, annually for ALFs, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; On-site monitoring reviews, every 24 months (biennially)

Assurance 4.2: The State, on an ongoing basis, identifies and addresses and seeks to prevent instances of abuse, neglect and exploitation.

QI: Percent of providers that inform all participants and participants’ families or LARs, instruct staff, and follow requirements in regard to ANE;

QI: Percent of providers that, upon confirmation of ANE by DFPS, take appropriate action to prevent recurrence of ANE;

QI: DADS staff reviews all reports of findings of ANE investigations and, if corrective action on the part of a waiver provider is warranted, follow up is conducted by DADS staff.

QI: Percent of providers reporting critical incidents monthly;

QI: Percent of participant records reviewed evidencing the participant or LAR was informed orally and in writing of the process for filing complaints about service coordination, waiver service provision, and complaints about ANE;

QI: Percent of complaints addressed by DADS.

RE: DADS-RS, A&I, and DADS-CRS.
DMFM: On-site provider Reviews, annually for ALFs, for HCSSAs, DADS-RS completes during the first year of operation, approximately 18 months after the initial survey and at least every 36 months thereafter, DADS-A&I completes by the 11th month of first year of the contract period and then every 24 months thereafter; On-site monitoring  reviews, Every 24 months (biennially); Allegations of ANE Review, Ongoing; SAS System: Critical Incident Reporting subsystem, Monthly; DADS-CRS complaint data base – Ongoing.

QI: Percent of assisted living providers that comply with safeguards related to the use of restrictive interventions; Percent of complaints related to restrictive interventions.

RE: DADS-RS
DMFM: On-site program provider review – annually; HCSSA Complaint Log.

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Quality Focus Area 5 - Administrative Authority and Fiscal System Performance

Desired Outcome - Administrative: The system supports participants efficiently and effectively and constantly strives to improve quality. 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.

Desired Outcome - Financial Accountability: Program providers enter billing claims into the MMIS billing system, which assigns the correct reimbursement rate associated with the billing code entered by a program provider. The MMIS billing system automatically rejects any claim that is entered with an unauthorized billing code or for a service not included in a participant’s authorized service plan.

Assurance 5.1: The Medicaid agency or operating agency conducts routine, ongoing oversight of the waiver program.

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

RE: HHSC.
DMFM: Review by State Medicaid Agency, ongoing.

QI: The operating agreement is reviewed for updates.

RE: HHSC.
DMFM: Review by State Medicaid Agency, ongoing.

QI: The need to update operating agreements is identified.

RE: HHSC.
DMFM: Review by State Medicaid Agency, ongoing.

QI: The operating agreement has been updated.

RE: HHSC.
DMFM: Review by State Medicaid Agency, ongoing.

QI: The operating agreement is current.
RE: HHSC
DMFM: Annual review by State Medicaid Agency.

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

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

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

RE: HHSC
DMFM: Review of reports by the State Medicaid Agency, Review of the 372s submitted

Assurance 5.2: Consumer claims are coded and paid according to the waiver reimbursement methodology.

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

RE: DADS-CFO
DMFM: Provider Claims System, Ongoing

Assurance 5.3: Codes used to bill participant claims are appropriate for the service provided.

QI: Percent of dollars reimbursed for services provided to a participant that are correctly coded.

RE: DADS-CFO, DADS A&I.
DMFM: On Site Billing and Payment Reviews, Biannually; On-Site HCSSA Contract Monitoring Reviews, annually; Desk reviews of requests for adaptive aids, minor home modifications and dental services, Ongoing System Performance

Assurance 5.4: The service system promotes the effective and efficient provision of services and supports by engaging in a systematic data collection and analysis of program performance and impact.

QI: Percent of accurate prior authorization of services.

RE: DADS QAI.
DMFM: QAI Data Mart, Quarterly.

QI: Percent of service utilization based on service plan and actual service utilized.

RE: DADS QAI
DMFM: QAI Data Mart, annually at a minimum

QI: There is a systemic approach to the continuous improvement of quality in the provision of services.

RE: DADS QAI.
DMFM: NCI Survey, biennially.

QI: Per Capita costs.

RE: DADS QAI
DMFM: QAI Data Mart, annually at a minimum

 

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Updated: December 14, 2010