applicant orientation to enrollment and provision of ... · pdf fileapplicant orientation to...

7/14/2016

1

>www.dpw.state.pa.us >www.dhs.state.pa.us

OFFICE OF DEVELOPMENTAL PROGRAMS

Applicant Orientation to Enrollment and Provision of Quality Services in the

Intellectual Disability Service

7.19.2016 1

>www.dpw.state.pa.us >www.dhs.state.pa.us7.19.2016 2

TABLE OF CONTENTS

The PA Intellectual Slide 3

Disabilities Service System

ODP Mission and Values Slide 12

Person Centered Planning Slide 18

Rules & Regulation Slide 27

ODP Waivers Slide 32

Becoming a Provider Slide 62

Provider Monitoring Slide 82

Incident & Risk Slide 90

Management

Financial Management Slide 105

Quality Management Slide 113

Provider Training Slide 120

Wrap Up Slide 123

Glossary [Attachment 1]

Resources [Attachment 2]

7/14/2016

2


THE INTELLECTUAL DISABILITY SYSTEM IN PA

The Office of Developmental Programs intends that all applicants

to provide waiver services for individuals with an intellectual

disability understand the Intellectual Disability [ID] system prior to

starting services


WHOM DO WE SERVE ?

Individuals with an intellectual disability who have been determined programmatically and

fiscally eligible and are registered with a county program

47.19.2016

7/14/2016

3


ID SERVICES

• The ID system is committed to providing opportunities to individuals for quality, integrated and community based supports

• Supports include:– Home and Community Based Services [HCBS] in an individual’s

home or local community– Non-residential supports including employment, job support and

facility based day services– Residential supports in group homes and Life Sharing settings

where an individual lives with others in a family setting.– Transportation– Therapies

• Services are available through the Consolidated and Person/Family Direct Support [PFDS] Waivers, base funding, and Intermediate Care Facilities for people with ID [ICFs/ID].

ID Services


STRUCTURE OF THE ID SYSTEM IN PA

Supports Coordination Organizations

Advocates

CMS

AE’sLicensing

Individual & Family

Providers

ODP

7/14/2016

4


WHO ARE WE?

• The Office of Developmental Programs [ODP] is the state office designated to administer and oversee supports and services to individuals with Intellectual Disability [ID] and Autism

• ODP delegates authority to County/Administrative Entities [AE]. AE’s are ODP’s delegates for assuring that federal and state requirements are met within their jurisdiction.

77.19.2016


WHO ARE WE - DHS ORGANIZATIONAL STRUCTURE

7/14/2016

5


WHO ARE WE - ODP ORGANIZATIONAL STRUCTURE FOR ID SERVICES


WHAT WE DO?

ODP is responsible for:– Managing Waivers

– Allocating waiver capacity

– Registering Providers

– Maintaining Online Web-Based Applications

– Overseeing Provider Monitoring

– Establishing rates

– Writing Policy

– Monitor AE’s

– Qualify SCO’s

– Monitor Supports Coordination Organizations [SCO’s]

County/AE’s are responsible for:– Providing technical assistance

and support to providers

– Qualifying providers

– Determining individual eligibility

– Authorizing services

– Monitoring providers

– IM4Q

– Managing waiver capacity

– Reporting and investigating incidents

– Maintaining and safeguarding waiver records

107.19.2016

7/14/2016

6


HOW TO STAY CONNECTED

• ODP communicates regularly with it’s stakeholders through: Listservs PA Bulletin Announcements Information Packets and Memos

• Provider Information Center [PIC]• Provider Associations• Meetings and Conferences


EVERYDAY LIVES

EVERYDAY LIVES

7/14/2016

7


CORE VALUES

ChoiceChoice

SafetySafety

FreedomFreedom

StabilityStability

IndividualityIndividuality

RelationshipsRelationships

ControlControlCollaborationCollaboration

MentoringMentoring

AccountabilityAccountability

Contributing to the Community Contributing to the Community

SuccessSuccess

QualityQualityCommunity

Integration

Community

Integration

Choice

Safety

Freedom

Stability

Individuality

Relationships

ControlCollaboration

Mentoring

Accountability

Contributing to the Community

Success

QualityCommunity

Integration

People Want Everyday Lives


ODP MISSION & VALUES

• ODP’s MissionThe mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.

• ODP’s VisionODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.

• ODP’s ValuesThe values articulated as principles in the Everyday Lives document and the values articulated in the Autism Task Force Report set the direction for the developmental disability service system. They provide context and guidance for policy development, service design and implementation, and decision-making.

7/14/2016

8


SELF DETERMINATION

• Self-determination is for everyone. • Everyone can make choices.• Everyone should have control over his

or her life.• Everyone is different and there is value in

difference; therefore supports need to be individualized.

• Everyday Lives are for everyone.


POSITIVE APPROACHES

Positive Approaches is a worldview, a movement, in which all individuals are

treated with dignity and respect, in which all are entitled to Everyday Lives.

7/14/2016

9


THE ID SYSTEM

What does this mean for you as a prospective provider?

177.19.2016


PERSON CENTERED PLANNING

Centered

7/14/2016

10


PERSON CENTERED PLANNING

Person Centered Planning is about an individual’s strengths, interests and

preferences to achieve a balance of what is important TO the person and FOR the

person.

7.19.2016 19


THE ISP

The ISP is the standardized planning document for individuals that follows the principles of

Everyday Lives and Person Centered Planning.

It addresses individual’s assessed needs; and designs services and supports that are meaningful

in an individual’s life.

7.19.2016 20

7/14/2016

11


HEALTH & SAFETY

MEDICAL INFORMATION

UNDERSTANDING COMMUNICATION

INDIVIDUAL PREFERENCES

FUNCTIONAL INFORMATION

THE ISP

PERSONALIZED OUTCOMES

SE

RV

ICE

S&

SU

PP

OR

TS


ISP TEAM

• The ISP team may consist of: The individual. The individual’s family, guardian, surrogate or

advocate. The Supports Coordinator [SC]. Providers of service. The common law employer or managing

employer if the individual has chosen to self-direct. Other people who are important in the individual’s

life and who the individual chooses to include.

7.19.2016 22

7/14/2016

12


PROVIDER ROLES IN ISP DEVELOPMENT

• Complete assessments, evaluations, and progress reports

• Direct Support Professionals [DSP] participate in the team meeting

• Provide updates to the ISP

• Train staff on the individual’s ISP

• Implement the authorized ISP

7.19.2016 23


SCENARIO 1

Shawn lives with her mother, but her Mom is getting too frail to lift or hold her. Shawn uses a wheelchair and her bedroom and bathroom are on the 2nd floor. Despite her physical challenges, Shawn is a very strong-willed person and refuses to move away from her Mom. The possibilities of Shawn having an everyday life is at risk.

Shawn is enrolled in the PFDS Waiver and receives job supports and transportation from ABC , Inc.

Shawn’s ISP stated that she needed a safer environment and staff supports due to her mobility issues. Her preferences were clearly stated that she wants to continue to live with her mother. Her ISP addressed her desire to move due to the physical challenges and the inability to assure her health and safety. However, in the Individual Preference section, it states that living with her mother is very important to her. Referrals were sent to providers with Shawn’s plan.

Shawn, with her team including her Mom and the SC chose XYC, Inc. While the cost for purchase or lease of a home are not allowable expenses (ODP will not participate in the cost of occupancy for private homes), the new provider and SC, however, assisted Shawn and her mom with referrals to a public agency to sell their home and develop a trust for Shawn to pay future rent. Shawn and her Mom both found an apartment that was accessible, and Shawn now receives job supports; transportation; home modifications and in-home supports under the PFDS Waiver.

247.19.2016

7/14/2016

13


BACK-UP PLAN

55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMS

HOME AND COMMUNITY-BASED SERVICES

Subchapter A. GENERAL PROVISIONS

§ 51.3. Definitions

Back-up plan—(i) A strategy developed by a provider to ensure the

HCBS the provider is authorized to provide is delivered in the amount, frequency and duration as specified in the

participant’s ISP.


ISPs


267.19.2016

7/14/2016

14


RULES & REGULATIONS


RULES & REGULATIONS

The Mental Health & Intellectual Disability Act of 1966

Chapter 1101 MA Regulations & Policy

55 PA Code Chapter 51 Waiver Program Regulations

55 PA Code Chapter 2380 Adult Training Facility Licensing Regulations

1915(c) Home and Community-BasedServices WaiverConsolidated Waiver

55 PA Code Chapter 2390 Vocational Facilities Licensing Regulations

1915(c) Home and Community-Based Services WaiverPerson/Family Directed Support Waiver

55 PA Code Chapter 6400 Community Homes Licensing Regulations

55 PA Code Chapter 6500 Family Living Homes Licensing Regulations

55 PA Code Chapter 3800 Child Residential and Day Treatment Facilities

55 PA Code Chapter 5310 Community Residential Rehabilitation Services for the Mentally Ill

ODP Waiver Provider Agreement

7/14/2016

15


55 PA Code Chapter 51

All Consolidated and P/FDS waiver services are regulated by 55 PA Code Chapter 51.

There are 4 subchapters to 55 PA Code Chapter 51:A. General provisions …51.1 B. Provider qualifications and

participation …51.11C. Payments for services …51.41 D. Closures and termination …51.151


CERTIFICATE OF COMPLIANCE

The following must be included with an Application for Certificate of Compliance/Licensure:

– Articles of Incorporation (if appropriate);

– Pennsylvania Department of State Fictitious Name Approval (if appropriate);

– Certificate of Occupancy (UCC permit);

– Civil Rights Compliance Questionnaire must be completed and mailed to the appropriate Bureau of Equal Opportunity office.

7.19.2016 30

7/14/2016

16


HIPAA

The Health Insurance Portability and Accountability Act (HIPAA)

• The Privacy Rule requires actions including:

- Notifying participants about their rights- Adopting and implementing privacy procedures- Training employees- Privacy Officer- Securing records

• Protected Health Information (PHI]• Information that a provider receives or creates about the

participant that relates to a past, present or future physical or mental health condition, or treatment or payment for the treatment that can be used to identify the participant.

• Must be kept confidentialhttp://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-

Simplification/HIPAAGenInfo/AreYouaCoveredEntity.html

7.19.2016 31


ODP WAIVERS

7/14/2016

17


ODP WAIVERS

• ODP’s ID Home and Community-Based Waivers ODP currently has 2 approved waivers:

• Consolidated• Person/Family Directed Support [P/FDS]

Each waiver specifies the types of services that may be provided in home and community settings

Each waiver caps the number of people who may receive services under the waiver

Each waiver limits the services to people with specific eligibility The need for services must be established through an assessment

process, reviewed and discussed with the planning team and documented in an ISP.

Each waiver includes standards to meet the required waiver assurances Individuals can only be in one waiver at a time Not every individual supported by ODP is enrolled in the Waiver.


WAIVER ASSURANCES

The Federal HCBS waiver assurances are:

• Level of Care

• Service Plan

• Qualified Providers

• Health and Welfare

• Financial Accountability

• Administrative Authority

7/14/2016

18


Intent of the Final Rule– To ensure that individuals receiving long-term

services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate

– To enhance the quality of HCBS and provide protections to participants

CMS FINAL RULE


WAIVER SERVICES

• Home and Community Habilitation• Companion• Behavior Supports• Licensed Day Habilitation*• Prevocational*• Residential Habilitation*• Transitional Work• Job Finding• Job Support• Physical Therapy• Occupational Therapy• Speech and Language Therapy• Visual and Mobility Therapy• Behavioral Therapy

• Nursing Services• Assistive Technology• Supports Broker• Respite• Transportation• Home and Vehicle Adaptations• Homemaker/Chore• Supports Coordination Services• Financial Management Services

– Agency with Choice (AWC)– Vendor Fiscal/Employer

Agency (VF/EA)• Vendor Services

– Public Transportation

7/14/2016

19


WAIVER SERVICE DEFINITION -Home and Community Habilitation

Home and Community Habilitation is a direct service (face-to-face) service provided in home and community settings to assist participants in acquiring, maintaining and improving the skills necessary to live and participate fully in community life. To the extent that Home and Community Habilitation is provided in community settings, the settings must be integrated in the general community.

Services consist of assistance, support and guidance (physical assistance, instruction, prompting, modeling, and reinforcement) in the general areas of self-care, health maintenance, decision making, home management, managing personal resources, communication, mobility and transportation, relationship development and socialization, personal adjustment, participating in community functions and activities and use of community resources.



The type and amount of assistance, support and guidance are informed by the assessed need for physical, psychological and emotional assistance established through the assessment and person-centered planning processes. The type and amount of assistance are delivered to enhance the autonomy of the participant, in line with their personal preference and to achieve their desired outcomes.

Through the provision of this service participants will acquire, maintain, or improve skills necessary for participants to live in the community, to live more independently, and to participate meaningfully in community life.

Participants receiving Residential Habilitation Services may elect to receive Home and Community Habilitation Services as an alternative to a licensed Day Habilitation or Prevocational Services. Under these circumstances the Home and Community Habilitation Service must occur anytime during the hours of 8:00 am – 5:00 pm, Monday through Friday. Refer to the service limit section below for information related to unit limitations when this occurs.

7/14/2016

20


WAIVER SERVICE DEFINITION Home and Community Habilitation

Home and Community Habilitation Services may provide the following supports to meet participants’ habilitative outcomes as documented in the ISP:

1. Assistance, support and guidance (prompting, instruction, modeling, reinforcement)that enables the participant to carry out activities of daily living such as personal grooming and hygiene, dressing, making meals, maintaining a clean environment.

2. Assistance, support and guidance that enables the participant to learn and develop practices that promote good health and wellness such as nutritious meal planning, regular exercise, carrying through prescribed therapies exercises, awareness and avoidance of risk including environmental risks, exploitation or abuse; responding to emergencies in the home and community such as fire or injury; knowing how and when to seek assistance when needed.

3. Assistance, support and guidance that enables the participant to manage his or her medical care including scheduling and attending medical appointments, filling prescriptions and self-administration of medications, and keeping health logs and records.

4. Assistance, support and guidance that enables the participant to manage his or her emotional wellness including self-management of emotional stressors and states such as disappointment, frustration, anxiety, anger, depression, PTSD and accessing mental health services. The service may include implementation of behavioral intervention plans as developed by other consulting professionals.



5. Assistance, support and guidance to enable the participant to fully participate, and when preferred, to direct the person-centered planning process including identifying who should attend and what the desired outcomes are.6. Assistance, support and guidance in decision making including guidance in identifying options/choices and evaluating options/choices against a set of personal preferences and desired outcomes. This includes assistance with identifying supports available within the community.7. Assistance, support and guidance that enables the participant to manage his or her home including arranging for utility services, paying bills, home maintenance, and home safety.8. Assistance, support and guidance that enables the participant to achieve financial stability through managing personal resources general banking and balancing accounts, record keeping and managing savings accounts andprograms such as ABLE accounts.

7/14/2016

21



9. Assistance, support and guidance that enables the participant to communicate with providers, care givers, family members, friends and others face-to-face and through use of the telephone, correspondence, the internet, and social media. The service may require knowledge and use of sign language or interpretation for individuals whose primary language is not English.10. Assistance, support and guidance that enables participant mobility by assisting them to use a range of transportation options including buses, trains, cab services, driving, and joining car pools, etc.11. Assistance, support and guidance that enables a participant to develop and maintain relationships with members of the broader community (examples include but are not limited to: neighbors, coworkers, friends and family)and to manage problematic relationships.12. Assistance, support and guidance that enables the participant to exercise rights as a citizen and fulfill their civic responsibilities such as voting and serving on juries; attending public community meetings; to participate in community projects and events with volunteer associations and groups; to serve on public and private boards, advisory groups, and commissions, as well as develop confidence and skills to enhance their contributions to the community.



13. Assistance, support and guidance that encourages the development of the participant’s personal interests, such as hobbies, appreciation of music, and other experiences the individual enjoys or may wish to discover.14. Assistance, support and guidance that enables the participant to participate in preferred activities of community life such as shopping, going to restaurants, museums, movies, concerts, dances and faith based services.15. Identification of risk to the person and the implementation of actions such as reporting incidents as required by ODP, the Older Adults Protective Services Act, the Adult Protective Services Act and the Child Protective Service Act, and/or calling emergency officials for immediate assistance.Home and Community Habilitation may also include elements of Companion services as long as these elements do not constitute more than half of the Home and Community Habilitation service.

7/14/2016

22



The staff providing the Home and Community Habilitation service must be awake during overnight hours for the purpose of performing tasks that require continual assistance as identified in the Individual Support Plan to ensure medical or behavioral stability and which are able to be performed by a non-licensed individual. These tasks include the following:• Taking vital statistics when monitoring has been prescribed by a licensed professional, such as post-surgical care,• Positioning the participant,• Performing range of motion exercises as directed by a licensed professional,• Administering prescribed medications (other than over the counter medications),• Applying prescribed treatments,• Monitoring for seizure activity for an individual with convulsive (grand mal) epilepsy that is not able to be controlled by medication.• Maintaining the functioning of devices whose malfunction would put the participant at risk of hospitalization, and• Crisis intervention for a participant in accordance with their behavior support plan.If the participant only needs supervision or assistance with evacuation in the event of an emergency during overnight hours, the appropriate service during this time period is Companion Services.



This service may be provided at the following levels:Specify applicable (if any) limits on the amount, frequency, or duration of this service:• Basic Staff Support - The provision of the service at a staff-to-individual ratio of no less than 1:6.• Level 1 - The provision of the service at a staff-to-individual ratio range of <1:6 to 1:3.5.• Level 2 - The provision of the service at a staff-to-individual ratio range of <1:3.5 to >1:1.• Level 3 - The provision of the service at a staff-to-individual ratio of 1:1.• Level 3 Enhanced - The provision of the service at a staff-to-individual ratio of 1:1 with a staff member who hasat least a 4 year degree or is a licensed nurse.• Level 4 - The provision of the service at a staff-to-individual ratio of 2:1.• Level 4 Enhanced - The provision of the service at a staff-to-individual ratio of 2:1 with at least one staff member who has at a minimum a 4 year degree or who is a licensed nurse. The second staff member must have at least a high school diploma.The use of enhanced levels of service is based on the participant’s assessed need, not the service worker’s personal qualifications. The fact that the service worker possesses a degree is not justification to use the enhanced level of service.

7/14/2016

23



This service can be delivered in Pennsylvania and in states contiguous to Pennsylvania. During temporary travel, this service may be provided in Pennsylvania or other locations as per the ODP travel policy.

Transportation necessary to participate in Home and Community Habilitation activities in the community is provided as a component of this service and the cost of this transportation is included in the rate paid to agency providers. For this reason, waiver Transportation services may not be authorized as a separate service for transportation related to Home and Community Habilitation activities supported by an agency provider.

Transportation is not a component of the Home and Community Habilitation service and is not included in the rate paid to individual providers. For this reason, waiver Transportation services as defined in this waiver (trip, mile and public transportation) may be authorized as a separate service for transportation related to Home and Community Habilitation activities supported by an individual provider.

Home and Community Habilitation may not be provided at the same time as any of the following: Companion Services, the direct portion of Supported Employment, Licensed Day Habilitation, Prevocational Services and Transitional Work Services. Home and Community Habilitation may be provided at the same time as any other waiver service not included in this list.



Home and Community Habilitation and Companion Services have a maximum limit of 24 hours (96 15-minute units) per participant per calendar day whether used in combination or alone. Home and Community Habilitation and Companion services that are authorized on an ISP may be provided by relatives/legal guardians of the participant. When this occurs, any one relative/legal guardian may provide a maximum of 40 hours per week of authorized Home and Community Habilitation or a combination of Home and Community Habilitation and Companion (when both services are authorized in the ISP). Further, when multiple relatives/legal guardians provide the service(s) each participant may receive no more than 60 hours per week of authorized Home and Community Habilitation or a combination of Home and Community Habilitation and Companion (when both services are authorized in the ISP) from all relatives/legal guardians. An exception may be made to the limitation on the number of hours of Home and Community Habilitation and Companion provided by relatives/legal guardians at the discretion of the employer when there is an emergency or an unplanned departure of a regularly scheduled worker for up to 90 calendar days in any fiscal year.

7/14/2016

24



As indicated above for participants residing in residential settings, Home and Community Habilitation Services may be used as an alternative either part-time or full-time for a Licensed Day Habilitation Service or a Prevocational Service. When this occurs the Home and Community Habilitation units are included in the combined unit limit for services that may not exceed 40 hours (160 15-minute units) per participant, per calendar week based on a 52 week year (Transitional Work Services, Supported Employment Services, licensed Day Habilitation Services and Prevocational Services).

Home and Community Habilitation Services cannot be provided in a licensed setting, unlicensed residential setting or camp. This service is provided in a participant's private home or other community setting.



Provider QualificationsLicense (specify):Certificate (specify):Other Standard (specify):IndividualAt least one staff member must be a Licensed Nurse when providing enhanced levels of Home andCommunity Habilitation and the participant's assessed needs require a licensed nurse provide theservice.At least one staff member must have at least a 4 year degree when providing enhanced levels of Homeand Community Habilitation and the participant's assessed needs require the degree.Current State motor vehicle registration is required for all vehicles owned, leased, and/or hired andused as a component of the Home and Community Habilitation Service.1.Have a waiver service location in Pennsylvania, Washington DC, Virginia or a state contiguous toPennsylvania (for an individual that is not a SSW).2.Have a signed ODP Provider Agreement on file with ODP (for an individual that is not a SSW).3.Complete standard ODP required orientation and training (for an individual that is not a SSW).4. Have at least a high school diploma for participants authorized to receive 2:1 enhanced Home andCommunity Habilitation. The other staff member must have at a minimum a 4 year degree or be alicensed nurse.5.New providers demonstrate compliance with ODP standards through completion of a self assessmentand validation of required documentation, policies and procedures (for an individual that is not a SSW).6.Be at least 18 years of age.7.Complete necessary pre/in-service training based on the ISP.8.Agree to carry out the Home and Community Habilitation outcomes included in the ISP.

7/14/2016

25



9.Be trained to meet the needs of the participant to carry out the ISP which includes, but is not limited to, communication, mobility and behavioral needs.10.Have criminal clearances as per 35 P.S. §10225.101 et seq. and 6 Pa. Code Chapter 15.11.Have child abuse clearance (when the Waiver participant is under age 18) as per 23 Pa. C.S. Chapter 63.12.Have automobile insurance for all automobiles that are owned, leased, and/or hired and used as a component of the Home and Community Habilitation Service.13.Have a valid driver's license if the operation of a vehicle is necessary to provide Home and Community Habilitation Services.14.Have Workers' Compensation Insurance in accordance with state statute or in accordance with ODP FMS policies.15.Comply with 55 Pa. Code Chapter 51 "Office of Developmental Programs Home and Community-Based Services" and other Department standards related to provider qualifications.16.Comply with and meet all standards as applied through each phase of the ODP Provider Monitoring Process (for an individual that is not a SSW).



Provider QualificationsLicense (specify):Certificate (specify):Other Standard (specify):Agency - Unlicensed Habilitation

At least one employee (direct, contracted, or in a consulting capacity) providing enhanced levels ofHome and Community Habilitation must be a Licensed Nurse when the participant's assessed needsrequire a licensed nurse provide the service.

At least one employee (direct, contracted, or in a consulting capacity) providing enhanced levels ofHome and Community Habilitation must have at least a 4 year degree when the participant's assessed needs require the degree.

Current State motor vehicle registration is required for all vehicles owned, leased, and/or hired andused as a component of the Home and Community Habilitation Service.

7/14/2016

26



Agencies must meet the following standards:1.Have a waiver service location in Pennsylvania, Washington DC, Virginia or a state contiguous to Pennsylvania. 2.Have a signed ODP Provider Agreement on file with ODP.3.Complete standard ODP required orientation and training.4.New providers demonstrate compliance with ODP standards through completion of a self assessment and validation of required documentation, policies and procedures.5.Have Commercial General Liability Insurance.6.Have automobile insurance for all automobiles owned, leased, and/or hired and used as a component of the Home and Community Habilitation Service.7.Have Workers' Compensation Insurance in accordance with state statute.8.Ensure that employees (direct, contracted, or in a consulting capacity) have been trained to meet the needs of the participant to carry out the ISP which includes but is not limited to communication, mobility and behavioral needs.9.Comply with 55 Pa. Code Chapter 51 "Office of Developmental Programs Home and Community-Based Services" and other Department standards related to provider qualifications.10.Comply with and meet all standards as applied through each phase of the ODP Provider Monitoring



Staff working for or contracted with the agency as well as volunteers utilized in providing this service if they will spend any time alone with a participant must meet the following standards:1.Be at least 18 years of age.2. Have at least a high school diploma for participants authorized to receive 2:1 enhanced Home and Community Habilitation. The other employee must have at a minimum a 4 year degree or be a licensed nurse.3.Complete necessary pre/in-service training based on the ISP.4.Agree to carry out the Home and Community Habilitation outcomes included in the ISP.5.Have criminal clearances as per 35 P.S. §10225.101 et seq. and 6 Pa. Code Chapter 15.6.Have child abuse clearance (when the Waiver participant is under age 18) as per 23 Pa. C.S. Chapter 63.7.Have a valid driver's license if the operation of a vehicle is necessary to provide Home and Community Habilitation Services.

7/14/2016

27


SUPPORTS COORDINATION

Supports Coordination is a critical service that involves the primary functions of locating,

coordinating, and monitoring needed services and supports for waiver participants


WAIVER CAPACITY

Waiver Capacity is the number of individuals that may be enrolled in the Consolidated and P/FDS

Waivers at any given time.

As of March 22, 2016, there are over 30,000 individuals enrolled in the waiver.

7/14/2016

28


PUNS

Waiver enrollment is prioritized based on the Prioritization of Urgency of Need for Services

(PUNS)


• The Individual Support Plan is the primary source of information for referrals to providers

• Waiver participants have the right to choose from any willing and qualified provider

• Providers shall respond to referrals with information to the individual, family and SC of whether they are able to offer the services in the plan or if not, why not.

• Providers must have a reasonable basis for rejecting a referral

REFERRAL & PROVIDER SELECTION

7/14/2016

29


• Services for individuals accepted by the Provider must begin within 45 days of waiver enrollment.

• If an individual selects another willing and qualified provider to replace the current provider, both providers shall cooperate during the transition between providers.

• A provider that is no longer willing to provide an HCBS to a participant shall provide written notice at least 30 days prior to the date of discharge.

PROVIDER ADMISSION & DISCHARGE POLICIES


CHOICE & CONTROL

• Federal policy encourages states to increase the level of choice and control to individuals with an intellectual disability.

• The Commonwealth has implemented programs for individuals and their families to self-direct services.

• Person Centered Planning enhances the choice and control that waiver recipients have in selecting services and providers

• Individuals and their families are encouraged and supported with making more decisions

7/14/2016

30


SERVICES & SUPPORTS DIRECTORY


Melissa has lived in a group home for a few years. She decided she will move to an apartment to be more independent. Her team plans to support her during and beyond this move.

The group home she left at Provider Z, now has an opening or a vacancy.

Since Melissa is still using her waiver ‘slot’ for the new place, the group home opening can only be filled by a person who is waiver eligible and has been approved by the AE and an individual who has selected Provider Z.

Some vacancies can remain vacant for a long time and cannot be billed. Therefore, a strong understanding and careful management of a provider’s capacity is essential.

SCENARIO 2

7/14/2016

31


WAIVER SERVICES


617.19.2016


BECOMING A PROVIDER

7/14/2016

32



7/14/2016

33


Provider information- ISP’s

- Service & Support Directory

- Service Authorizations

- Incident Management

- Provider Qualifications

- User Training Resources

- Claims Management

- Learning Management System [LMS]

Individuals’ information– Individual Support Plans

(ISPs)

– Assessment data

– Medical history

– Financial data

– Services and supports

– Service notes

– Other data related to individuals

7.19.2016 65

HCSIS, PROMISe™ & EIM


HCSIS REGISTRATION

7/14/2016

34


HCSIS REGISTRATION


HCSIS PROVIDER ACCESS

• The sidebar on the Provider Access screen contains additional options for each of the main areas of Provider Access.

• Links to Provider Qualification and Certification and Licensing System information can be accessed from this sidebar.

• This sidebar will be available after you log in to HCSIS through Provider Access.

7/14/2016

35



7/14/2016

36


Completes licensing

inspection application, if

applicable

Obtain Approval for Residential

Service Locations and Approved

Program Capacity

Path for Licensed Providers


Regulation – 55 Pa. Code

Title

Chapter 20 Licensure or Approval of Facilities and Agencies

Chapter 2380 Adult Training Facilities

Chapter 2390 Vocational Facilities

Chapter 3800 Child Residential Services

Chapter 5310 Community Residential Rehabilitation Services for the Mentally Ill

Chapter 6400 Community Homes for Individuals with Mental Retardation

Chapter 6500 Family Living Homes

6 Pa Code Chapter 11

Older Adult Day Living Centers

LICENSING

7/14/2016

37



PROVIDER QUALIFICATIONS

Consistent Standards &

Requirements

Opportunity for Willing Providers

Biennial Requalification

Participant Choice of Providers

Statewide Availability of

Qualified Providers

PROVIDER QUALIFICATION

7/14/2016

38


QUALIFICATIONS

STEP 1

An Applicant notifies the AE in which the applicant plans to serve the most waiver participants

STEP 2Applicants successfully complete the Provider Monitoring Tool for New Providers and Provider Qualification

Applicant completes the ODP Provider Documentation record

STEP 3

The applicant completes the provider qualification application in HCSIS

The applicant sends all necessary supporting documentation to the Lead AE

STEP 4

The AE reviews the application and documentation and determines if the applicant is qualified or contacts applicant for further information


ODP PROVIDER QUALIFICATION DOCUMENTATION RECORD

7/14/2016

39



The provider must complete the following actions before a PROMISe™ enrollment application is submitted

• New Provider Applicant Orientation• ODP Provider Agreement • HCSIS Registration • New Provider Monitoring Tool• Provider Qualification • Service Location Code

PROMISe™ ENROLLMENT

7/14/2016

40


PROMISe™

The reason for PROMISe™ Enrollment

• To enable the claims processing system (PROMISe™) to recognize you as an active provider.

• To receive a rate for reimbursement for the services enrolled

• To enable ODP providers to successfully submit claims into the claims processing system.

• To enable PROMISe™ to validate that your provider type and specialty is permitted to perform the service or services when submitting claims through PROMISe™.


Scenario 3

Phil owns a empty house. He is considering using this home to support people with disabilities. He has asked how he may get paid. The answer to this is not easy. • Phil could simply lease or sell the home to an individual or a

provider. In this case, he is a landlord and does not need to be enrolled in the system.

• If Phil wants to ‘rent rooms’ but not provide any waiver services, this is not eligible for ODP funding.

• Phil can establish a community home for people with an intellectual disability. He must complete the registration and enrollment process, become qualified for Residential Habilitation services, complete the Applicant Orientation to Enrollment and Provision of Quality Services in the Intellectual Disability Service System

• Get licensed, obtain ODP approval for site size, enroll in PROMISe™ and if Phil’s agency is the provider of choice for an individual enrolled in the Consolidated Waiver, begin services.

807.19.2016

7/14/2016

41


BECOMING A PROVIDER

• What does this mean for you as a prospective provider?

817.19.2016


PROVIDER MONITORING

7/14/2016

42


MONITORING OF PROVIDERS

• Licensing– DHS determines compliance with applicable regulations

• Provider Self-Assessment– Annual– Provider assesses their own compliance with 55 PA Code Chapter 51 and waiver

assurances

• Provider Monitoring– Biennial

• AE’s determine provider’s compliance with 55 PA Code Chapter 51 and waiver assurances

• ISP Monitoring by Supports Coordinators– Frequency determined by which waiver, ISP and special circumstances– Health, Welfare and Safety– Service Provision as specified in the ISP

• IM4Q– Independent monitors measure quality of life and level of individual and families’

satisfaction with services

7.19.2016 83


• Requirement per Consolidated and P/FDS Waivers and 55 Pa Code Chapter 51

• Must be completed and approved prior to qualification and before a PROMISe™ enrollment application is approved by ODP

• Required for providers both initially and on an ongoing basis

• Must be completed and approved prior to being authorized to provider Home and Community Based Services

PROVIDER MONITORING

7/14/2016

43


55 PA Code Chapter 51. OFFICE OF DEVELOPMENTAL PROGRAMSHOME AND COMMUNITY-BASED SERVICES


§51.24 Provider Monitoring(a) The Department will monitor a provider at the frequency specified in the approved applicable waiver, including approved waiver amendments.

(b) A provider shall review and analyze performance data provided by the Department and take appropriate steps to improve its performance based on the results of performance data.

(c) A provider shall complete the Department-approved provider monitoring documents during the provider monitoring process for the provider and the participants identified by the Department or the Department’s designee.

(d) A provider shall submit the completed provider monitoring documents electronically to the Department or the Department’s designee.

(e) A provider shall cooperate with the Department or the Department’s designee during a monitoring review.

(f) A provider shall ensure each finding discovered during a monitoring review is successfully remediated through a Corrective Action Plan [CAP].

7.19.2016 85

PROVIDER MONITORING


I N I T I A L LY ANNUAL LY B I ENN IA L LY AS NEEDED

PROVIDERSELF-ASSESSMENT

NEW PROVIDER MONIORING

AE ONSITE REVIEW

CORRECTIVE ACTIONS

PROVIDER MONITORING

7/14/2016

44


• Mission/vision statement

• Staff Qualification requirements

• Checking if staff or sub-contractors are eligible to provide waiver services

• Restraint policy

• Record Management

• Emergency disaster response plan

• Grievance procedures

• Policies/procedures for checking staff on LEIE, SAM and Medicheck

• Accessibility for Individuals who are deaf Protocol

• Response to individual health and behavioral emergencies/crises

• Ensure implementation of back-up plans

• Conflict of interest

• Ensure replacement of lost and damaged property

• Appropriate transition of individuals

• Incident Management

• Annual training curriculum, as per 55 PA Code Chapter 51

7.19.2016 87

PROVIDER MONITORING

Agency Policies and Procedures shall include:


PROVIDER MONITORING

7/14/2016

45


INDEPENDENT MONITORING 4 QUALITY

7.19.2016 89

Essential Data Elements (EDE) Survey

Satisfaction Choice and Control

Dignity Relationships

Respect and Rights Inclusion


7/14/2016

46


INCIDENT MANAGEMENT

ODP Incident Management Bulletin

# 6000-04-01Title 55, Human Services

Subpart A. Statement of PolicyChapter 6000

Subchapter Q Incident Management

7.19.2016 91


INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALLPROVIDERS WITHIN 24 HOURS

Abuse Law Enforcement ActivityDeath Missing PersonEmergency Closure Misuse of FundsEmergency Room Visits NeglectFire Psychiatric HospitalizationHospitalization Rights ViolationIndividual to Individual Abuse Suicide AttemptInjury Requiring Treatment Beyond First Aid

INCIDENT CLASSIFICATIONS TO BE REPORTED BY ALL PROVIDERS WITHIN 72 HOURS

Medication Error Restraints

7.19.2016 92

INCIDENT MANAGEMENT

7/14/2016

47


INCIDENT MANAGEMENT – CERTIFIED INVESTIGATIONS


LIFECYCLE OF AN INCIDENT

7.19.2016 94

ImmediatelyWithin 24 hours of report

entered in EIM

Within 24 Hours from the time of the report

Within 24 Hours from the time of the incident occurring

Within 60 days of the

finalized incident

Within 30 days of the

report

Within 10 days of the initiation of

investigation

7/14/2016

48


INCIDENT MANAGEMENT

Provider roles and responsibilities:(1) Assign an individual with overall responsibility for

incident management.(2) Develop a policy for incident management.(3) Ensure that staff, individuals and families are trained on

incident management policies and procedures.(4) Assign roles within their organization for reporting and

investigation of incidents.(5) Assure corrective action to individual incidents.(6) Conduct analysis of data on incidents and the quality of

investigations.(7) Identify and implement individual and systemic changes

based on risk management analysis.

7.19.2016 95


PROVIDER IM ROLES

• Point Person• Receive verbal or other reports of allegations or suspicion of incident• Safeguard the individual• Ensure Incident Report submitted• Communicate with others involved in investigation• Follow-up• Review of Incidents

• Incident Management Representative• Overall agency responsibility• Assure activities of initial reporter and point person are completed• Finalization of Incident Report within 30 days of incident• Peer Review• Evaluate the quality of incident investigations• Maintain an investigation file within the agency.

• Certified Investigator• Receive training and certificate • Maintains certification• Conduct prompt investigations• Enter investigation summary in EIM

7.19.2016 96

7/14/2016

49


PROVIDER IM RESPONSIBILITIES

• Promote the health, safety, rights and enhance the dignity of individuals receiving services.

• Ensure that staff and others associated with the individual have proper orientation and training to respond to, report and prevent incidents.

• Develop provider-specific policy/procedures for incident management.

• Provide ongoing training to individuals and families on the recognition of abuse and neglect.

7.19.2016 97


OVERSIGHT ENTITY’S ROLES

• Review actions to protect health, safety and rights that were taken by the provider

• Request additional information from providers regarding the incident, actions taken and recommend additional actions to protect health, safety and rights as appropriate

• Communicate with individual, their family, guardian or other designee as appropriate about the incident

• Assist with securing supports or services that are needed as a result of the incident

• Determine if an investigation needs to be completed in addition to the requirement placed upon the provider

7.19.2016 98

7/14/2016

50


CHILDREN’S AND ADULT’S PROTECTIVE SERVICES

• Adult Protective Services Act [APS] Act 70

• Older Adults Protective Services Act [OAPSA] Act 79-1987

• Child Protective Services Act [CPS] Act 3490

997.19.2016


INCIDENT MANAGEMENT


1007.19.2016

7/14/2016

51


Incident Management & Risk Management

Incident Management is reactive,

Risk Management is proactive.

7.19.2016 101


RISK MANAGEMENT

• Risk management promotes a positive quality of life for individuals with intellectual disability by ensuring their health, safety and well-being.

• A risk management system identifies factors that increase risk to individuals and to develop practices that reduce risk.

• A risk management system uses data to track incidents and plan preventative measures for the future

7.19.2016 102

7/14/2016

52


RISK MANAGEMENT

Provider risk management process needs to include, but not limited to:

• The review and analysis of incident management data, certified investigation findings and other information such as complaints, service reviews, etc.;

• Discovery of root cause and contributing factors directly related to occurrence; and

• Individual-specific and systemic actions to manage and/or mitigate risk.

• Providers must relate preventive measures directly to the cause of the incident for them to have an impact on occurrence or recurrence.

7.19.2016 103


Matthew, age 23, lives at home with his mother and brother. His brother is paid by a provider to provide Home and Community Habilitation services to him 3x a week. .

During a monitoring visit, Matthew tells the Supports Coordinator that his brother has been leaving him home alone so his brother can go out when he was supposed to be working with him.

Matthew’s ISP states that he needs supervision when in his home.

The Supports Coordinator [SC] discusses this with Matthew’s mother and identifies this as a concern in the service notes.

No incident was reported.

On the next monitoring visit by the SC, Matthew doesn’t say anything, and the SC didn’t bring it up either.

SCENARIO 4

7/14/2016

53


FINANCIAL MANAGEMENT


FINANCIAL MANAGEMENT – RATE SETTING

• Cost-based Rates• Cost Report Rates

• Average of Location Rates

• Area Average Rates

• Lowest Rates

• Department-established fee rates• Market-based approach

• Determination of cost components

• Geographical areas

• Vendor • Good or services offered to the general public

7.19.2016 106

7/14/2016

54


How Rates are Assigned to Providers

Once a provider has their account(s) established in HCSIS and PROMISe™ and have been qualified they can begin to add the services in HCSIS to each AE that will be authorizing services

Services are added by procedure code, by AE

Once the procedure code has been added, the procedure code will appear on a report for the rate to be added to PROMISe™

Once the rate is added to PROMISe™, the rate will be loaded to HCSIS and will be available for inclusion in an ISP

7.19.2016 107

FINANCIAL MANAGEMENT – RATE SETTING


FINANCIAL MANAGEMENT - CLAIMS

When Providers can bill for services

The provider’s Service and Supports Directory (SSD) is updated appropriately.

The provider’s service or services have already been attached to an Individual’s Support Plan (ISP) and authorized by the Administrative Entity

The provider has viewed the Service Authorization Notice(s) found in HCSIS > Provider Access prior to rendering and billing for an ODP service and has confirmed that the data elements contained in it are accurate

The provider has already rendered the service per the frequency indicated in each individual’s ISP, and that the service or services rendered are documented in your organization’s file notes or record keeping system.

7.19.2016 108

7/14/2016

55


• Every time a claim is billed, there must be supporting documentation which shows that the service that was billed matches the authorized service from the ISP.

• Providers are responsible to ensure that the amount, frequency, duration, staffing ratio, and types of services that are billed to PROMISe™ correctly match the authorizations from individual’s ISPs, and providers must maintain supporting documentation to substantiate each claim.

FINANCIAL MANAGEMENT – CLAIMS DOCUMENTATION


PROGRESS NOTES

7/14/2016

56


FINANCIAL MANAGEMENT – PROGRESS NOTES

• Progress notes must be written at least once a month if the service is provided at least monthly, (for example, Licensed Residential Habilitation service).

• Progress notes must be written every time a service is delivered if the service is occurring on a less than monthly basis, (for example Home & Community Habilitation and/or Companion Service).


FINANCIAL MANAGEMENT


1127.19.2016

7/14/2016

57


QUALITY MANAGEMENT


Quality Management is a methodology by which organizational performance is continuously measured, evaluated, and improved. Individuals and other stakeholders are engaged in designing and improving services.

7.19.2016 114

QUALITY MANAGEMENT

7/14/2016

58


QUALITY MANAGEMENT PLAN

The Quality Management Plan is a written document describing how the provider will measure and remediate its performance to provide quality services and comply with the approved applicable waiver, including approved waiver amendments and PA code 55 PA Chapter 51 regulations.

7.19.2016 115


CHAPTER 51. Subchapter A. § 51.25. QUALITY MANAGEMENT PLAN



§ 51.25. Quality Management Plan

(a) A provider shall meet the QM plan criteria developed by the Department.

(b) The provider shall create and implement a QM plan.

(c) The provider shall evaluate the following when developing a QM plan:

(1) The manner in which the provider will meet the Department’s QM plan criteria.

(2) The provider’s quarterly performance review data and available reports in HCSIS and EIM.

(3) The results from provider monitoring and SCO monitoring.

(4) Compliance with the requirements in 42 CFR 441.302 (relating to state assurances).

(5) Incident management data, including data on the incident target under § 51.17 (relating to incident management).

(6) Results of satisfaction surveys and reviews of grievances.

7.19.2016 116

7/14/2016

59


QUALITY MANAGEMENT - ODP’S PRIORITIES

What are ODP’s current priorities

• Achieving compliance with the quality improvement strategy

• Achieving compliance with incident management policies and procedures

• Improving results of provider and Supports Coordination Organization monitoring reviews and ensuring corrective action are successfully implemented.

• Improving waiver participant satisfaction with service provision through review of Independent Monitoring for Quality data in the Home and Community Services Information System.

• Reviewing and evaluating practices to promote employment and increase the number of individuals with an intellectual disability who are employed.

7.19.2016 117


QUALITY MANAGEMENT - ODP’S PRIORITIES [continued]

• Reviewing and evaluating practices to promote employment and increase the number of individuals with an intellectual disability who are employed

• Reviewing and evaluating life sharing opportunities and promote an increase in the number of individuals with an intellectual disability who live in life sharing arrangements

• Reviewing and evaluating practices to reduce and eliminate restraints.

• Reviewing and evaluating practices to increase awareness and ensure reduction in individual to individual abuse.

• Reviewing and evaluating practices to ensure each individual is supported in the use of an effective communication strategy.

• Reviewing and evaluating practices to ensure each individual receives the most inclusive, least restrictive services and supports.

• Diverting individuals from admission to State Centers and State Hospitals.

7.19.2016 118

7/14/2016

60




§ 51.23. Provider training

(a) A provider shall implement a standard annual training for the provider and staff.

(b) Before providing an HCBS to a participant, a provider shall ensurethat its staff have met any additional pre- and in-service trainingrequirements as detailed in a participant’s ISP.

(c) A provider shall retain documentation of completion of training foreach staff.

(d) A provider shall update annual training to reflect the Department’s current policies and procedures and emerging practices.

PROVIDER TRAINING


PROVIDER TRAINING

7/14/2016

61


PROVIDER TRAINING

• There are many specific trainings providers must offer staff at least annually

• These trainings differ depending on the type of service that is being delivered, if the service is licensed and what the specific chapter requires.

• 55 PA Code Chapter 51 regulations specifically require training for all staff in the following areas:

(1) Department policy on intellectual disability principles and values.

(2) Training to meet the needs of a participant as identified in the ISP.

(3) QM plan.

(4) Identification and prevention of abuse, neglect and exploitation of a participant.

(5) Recognizing, reporting and investigating an incident.

(6) Participant grievance resolution.

(7) Department-issued policies or procedures.

(8) Accurate billing and documentation of HCBS delivery.


Applicant Orientation to Enrollment and Provision of Quality Services in the Intellectual Disability Service System

• What does this mean for a prospective provider?– Stay Informed! – Read very carefully– Provide quality services– Search websites to learn updates on provider related

information. – Promote person centered practices– Assure individual’s health & safety– Adhere to federal and state requirements– Always cooperate with local, state or federal investigators– Meet critical deadlines– Be accountable

1227.19.2016

7/14/2016

62


Q & A’s


7/14/2016

63


1. Download the presentation online

2. Complete the Post-Test online and submit

3. Receive Certification of Successful Completion

4. Proceed with Provider Enrollment process

WHAT’S NEXT

applicant orientation to enrollment and provision of ... · pdf fileapplicant orientation to...

Documents