Routine Monitoring - PowerPoint Presentation

Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency Presented by Mary T. TrippPolicy Unit LeaderDMH/DD/SAS Accountability Teamon behalf ofthe NC DHHS-LME/MCO-Provider Collaboration Workgroup at the NC Association of Rehabilitation FacilitiesAnnual Leadership ConferenceMay 1, 2014

Focus of this WorkshopThe Impetus for Streamlining Provider Monitoring An Introduction to the New Tools for Routine Monitoring of LIPs and Provider Agencies Achieving Increased Accountability and Positive Outcomes Through Partnerships 2

Streamlining Provider Monitoring

What happened to Gold Star, and what led to this new way of monitoring? Waiver Expansion Continuous Quality ImprovementReduce Administrative Burden on Providers and LME-MCOs per Session Law 2009-451 (SB 202) Business Practices Sub-Committee of the LME-MCO & Provider Standardization Committee4

What happened to Gold Star, and what led to this new way of monitoring? CONTINUED A greatly streamlined, non-duplicative, standardized process needed for local monitoring.The Provider Monitoring Workgroup expanded to include representatives from:NC Council of Community Programs Business Practices Sub-Committee NC Providers Council BenchmarksProfessional Association Council 5

We heard you!! 6

Stakeholder GroupsBenchmarksN C Council of Community ProgramsNC Providers CouncilProfessional Association Council 7

Professional Association CouncilAddiction Professionals of NCLicensed Professional Counselors Assoc. of NCNational Association of Social Workers-NC Chapter NC Association for Marriage & Family TherapyNC Counseling AssociationNC Nurses AssociationNC Psychiatric AssociationNC Psychological AssociationNC Society for Clinical Social Work8

LME-MCOs NC CouncilDMH/DD/SASDMA DHSR Benchmarks NC Prov. Council PAC Individuals & Families 9

Quality Providers = Quality Services = Best Possible Outcomes for Individuals and Families 10

The Who-What &When of the Review ToolsThe Routine Review Tools are used with two provider types: LIP Review Tool is used with LIPs in a solo or group practice where only outpatient / basic benefit services are provided.Agency Review Tool is used with provider agencies that provide any service(s) other than outpatient services exclusively.11

Routine MonitoringIncludes: Routine Review Post-Payment Review May be used together or separately.State-funded and Medicaid-funded services 12

Remember… Any of the monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns 13

Routine Monitoring of Provider AgenciesIncludes: All GS §122C MH/IDD/SA services that are not licensed by DHSR (e.g., Supervised Living, Unlicensed AFLs). All GS §122C MH/IDD/SA services that are licensed by DHSR, but are not surveyed annually (e.g., PSR, Day Treatment, ADVP-IDD, SAIOP, SACOT, etc.).See “Licensed MH/DD/SA Services and Frequency of Surveys Conducted by DHSR Mental Health Licensure and Certification Section” in the Provider Agency workbook. 14

No Monitoring by LME-MCOsThe following services are referred to the appropriate licensing agency:Therapeutic Foster Care (Licensed by DSS under GS §131D)Hospitals (Licensed by DHSR Acute and Home Care Licensure Section)ICF-IID -formerly ICF/MR- (Licensed by DHSR Mental Health Licensure Section)15

Limited Monitoring by LME-MCOsPRTF – Post-payment and reported health and safety issuesLicensed Residential Facilities – Post-payment and reported health and safety issues Opioid Treatment – Post-payment and reported health and safety issues16

SemanticsDecision made to stop using Gold Star as the name of the NC provider monitoring process.Confusion between Gold Star, the process, and Gold Star, the highest level to be achieved. Gold Star as a term remains as the highest level achievable.17

What’s New or Different18 NC Provider Monitoring Process Gold Star Provider Monitoring

What’s New or DifferentFrequency:Routine monitoring occurs on a 2-year cycle as opposed to annually.19

What’s New or Different20 The scoring and weighting of the review items has been revised.

What’s New or Different 21Each of the following areas has aclearly defined sample size:Incident ReportingRestrictive InterventionsComplaintsFunds ManagementMedication Management

What’s New or Different22 Plans of correction are used to address systemic issues rather than individual non-compliance items.

What’s New or Different 23AFLs that are not under the waiver are reviewed every 2 years (previously those sites were reviewed based on the profile level.(AFLs under the Innovations Waiver are still required to be reviewed annually).

What’s New or Different24 The minimum overall passing score for routine monitoring increased to 85% from 75%.

What’s New of DifferentThe initial on-site Health and Safety Review is not required if the service is located in a site that is licensed by DHSR. 25

What’s Been Accomplished?Routine Provider Agency Tool reduced from 158 items to 18 items Agency Post-Payment tools were reduced from an average of 16 to an average of 12 itemsLIP Review Tools (routine, office site and post- payment) went from 63 items to 4926

What’s Been Accomplished?Focus is on rules related to systemic trends and quality of care Elimination of duplication by using existing data such as review of IRIS reports, review of provider policies, submitted reports27

What’s Been Accomplished?Tool has been developed to obtain feedback from providers via SurveyMax (to be implemented May 1, 2014). Webinars are being taped as a follow-up to statewide training.FAQs from training and provider monitoring mailbox are posted on the Provider Monitoring web page for broad dissemination.28

Provider Monitoring SurveyNotification Received notification of date of on-site review in accordance with guidelinesInformation needed for the review was included in the notification letter29

Provider Monitoring SurveyProcess Reviewers introduced themselves in a professional manner.Reviewers were knowledgeable about the services that were reviewed.Reviewers followed the guidelines for scoring the items on the tools.Was able to have an open discussion with reviewers.Had adequate time to provide the requested information. 30

Provider Monitoring SurveyResults A clear explanation was given for all non-compliances found.Specific areas of non-compliance found during the routine review and the post-payment reviewDid the review result in a payback?Did the review result in a plan of correction?Does the provider plan to appeal any non-compliant findings? 31

Routine Review Tools For Provider Agencies(Emphasis on IDD Services)

Routine Monitoring of Agencies that Provide IDD Services Two Components:Routine Review ToolPost-Payment Review ToolInnovations Waiver PPR ToolOther Specialized ToolsUnlicensed AFL Provider Review ToolHealth, Safety and Compliance Review Tool33

Routine Review ToolBasic Elements: Rights NotificationService AvailabilityCoordination of CareIncidents Restrictive Interventions Complaints 34

Additional Elements on Routine Review Tool Protection of Property (as applicable)Funds Management (as applicable)Medication Review (as applicable) 35

How to Navigate the Excel Workbook, RM&DM andClinical Coverage Policies36

Rights Notification 37

Item 1: There is evidence that the individual or LRP has been informed of their rights. 10A NCAC 27D .0201. Sample is 30 service events Notification includes:Rules to be followed and possible penalties.How to obtain a copy of one’s service planInformation received within 3 visits or 72 hours (for residential)How to contact Disability Rights North CarolinaAll areas above must be met to rate this item “Met” 38

Item 2: The individual has been informed of the right to consent to or to refuse treatment. 42 CFR 438.100 (Enrollee Rights), G.S. 122C-57(d); 10A NCAC 27D .0303 (c) Sample is same 30 service events as in Item 1Review documentation indicating the individual or LRP has been informed of the right to consent to or refuse treatment.Signed consent must be present for each record in the sample to rate this item “Met” 39

Item 3: The individual is informed of right to treatment, including access to medical care and habilitation, regardless of age or degree of disability. G.S. 122C-51 Sample is same 30 service events as in Item 1Must specifically inform, in writing, of right to Tx, including access to medical care and habilitation, regardless of age or disability.Right to an individualized written treatment plan and right to access medical care.All records in the sample must have the above to rate this item “Met.” 40

Item 4: The individual has been notified that release/ disclosure of information may only occur with a consent unless it is an emergency or for other exceptions. G.S. § 122C-55 or in 45 CFR 164.512 of HIPAA. 10A NCAC 26B .0205 Sample is same 30 service events as in Item 1Confidential information may not be released without written consent except in the case of an emergency.Each element of the required notice listed in Statute must be explained in writing or verbally, but individual must sign that they have been explained.Each record in the sample must have the above to rate this item “Met.” 41

Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202 Sample is the same 30 service events as in Item 1Individual’s nameName of facility releasing informationName of individual(s), facility(ies) to whom information is releasedSpecific information to be releasedPurpose of the release 42

Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202CONTINUED Length of time consent is validStatement that consent can be revokedDate consent signedMust include a statement regarding the protection of HIV and SA information and disclosure requirements under 42 CFR Part 2Each record in the sample must include authorizations with all elements to rate this item “Met.”43

Incidents, Restrictive Intervention & Complaints 44

Item 6: Level I incidents were classified appropriately and reported in accordance with 10A NCAC 27G .0602(3), 10A NCAC 27G .0103(b)(32) and 10A NCAC 27G .0604. Sample is 10 Level I Incident ReportsThe reviewer is able to go back up to 1 year in order to obtain the sample.Determine if each incident was classified appropriatelyIncidents related to med errors, restrictive intervention or search and seizure must be included in Level I quarterly report. If not, technical assistance will be provided.If NO incidents, item is rated “N/A.” All incidents must be classified correctly to rate this item “Met.” 45

Item 7: For all Level II and Level III incidents reported, follow-up was conducted and recommendations were implemented in accordance with 10A NCAC 27G .0603 - .0604. Sample is 10 Level II and III ReportsPre-site: Review incidents in IRIS to determine if follow-up completed and recommendations implemented.On-site: Review provider documentation for follow-up and implementation of recommendations for outstanding Level IIs and IIIs.Review incident log or list against IRIS to determine if all incidents were submitted. Each incident must have been reported, follow-up occurred and recommendation implemented to rate this item “Met.” 46

Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. Sample is 10 Incidents of Restrictive InterventionPre-site:Review policy & procedure on Restrictive Intervention and determine if all elements of rule are included.Each RI sampled must be in the submitted corresponding Quarterly Summary and in IRISOn-site: Review RI log to ensure compliance with rule 47

Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. CONTINUED Agency policy and procedure must meet requirements of rule; and Each RI in sample must be conducted per policy and per elements in rule to rate this item “Met.”This item requires 100% compliance as part of the assessment for Health & Safety 48

Item 9: The provider is responsive to complaints received per timelines in policy. 10A NCAC 27G .0201 Sample is 10 ComplaintsPre-site: Review provider Complaint Policy & Procedure for addressing and resolving complaints/grievances (elements not in rule). There must be a defined procedure.On-site: If there are not 10 reports, go back up to 1 year if needed. If still not 10, review the number found.Policy & Procedure must be present and implemented in all complaints reviewed to rate this item “Met.” 49

Coordination of Care / Service Availability

Item 10: As required by Clinical Coverage Policy, there is documentation that coordination of care is occurring between providers involved with the individual. CCPs 8A through 8P (8C 7.2.2 for LIPs) Sample is same 30 service events as in Item 1Coordination of Care requirements vary per service definitionEvidence must be writtenCommon requirements include but are not limited to: case management; coordination with medical, psychiatric or other providers; coordination in crisis or discharge planning; participation in child & family teamsIf individual does not agree to contacting other providers, refusal must be documented. 51

Item 11: There is evidence that the provider serves as the first responder or has made access to behavioral health crisis services available 24/7/365 either provided directly by the agency or through written agreements. – CCP 8A, 8C 7.4Sample is same 30 service events as in Item 1Providing 24/7/365 per service definitionDocumentation will vary: first responder procedures and staffing logs, written arrangements with other entities for crisis services; notification to individuals of how to access services in a crisis 52

53 THE FOLLOWING ITEMS, #s 12 & 13 ,APPLY ONLY TO 24 HOUR FACILITIES THAT SEE AN INDIVIDUAL FOR MORE THAN 30 DAYS, INCLUDING UNLICENSED AFLS.

Protection of Property & Management of Funds 54

Item 12: The agency has a current policy that outlines how the requirements for protecting an individual's property in accordance with 10A NCAC 27F .0104 are met. Pre-Site Review: Review policies and procedures to ensure that property is safe from theft, damage, destruction, loss and misplacement. To be completed at LME-MCO.This is a policy review only, but all areas must be covered for this item to be rated as “Met.” 55

Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105. Sample is 1-5 records of individuals whose funds are managed by the agency. If less than 5 individuals in home, review records for all. Review most recent quarterly accounting statement for all records in the sample to ensure they reflect all transactions. (Note - these records may not be kept in the clinical/service record as they contain financial information.) Ensure that each person's money is managed separately from the agency's funds and accounts. 56

Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105 CONTINUEDThere must be an accounting statement for each person which at a minimum summarizes the financial transactions to rate this item “Met.” Additionally, 85% must be achieved across the sample (4 of 5 records met) for this item to be scored as met. 57

Medication Review

Item 14: Medications are stored appropriately, including separate storage for each service recipient, separately for each type of use, in refrigerator, behind secure lock, and secured for individuals self-administering. 10A NCAC 27G .0209. Sample is 5 records from individuals who receive medication from the agency. Inspect medication storage area to ensure that medications are stored appropriately, and consistent with the requirements in the rule. Medication storage may include separate Ziploc bags, boxes, or other containers, as long as the labels with the person's name remain intact for each medication. Any medication samples received from the physician must be stored in the same way as other medications.100% must be achieved for each item for the record to be rated “Met”. 59

Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender. 10A NCAC 27G .0209. Sample is same 5 records from item 14.Review the record to ensure there is a written order that has been signed or countersigned and dated by the responsible physician/physician extender. Enter the number of medications for both prescribed and over the counter medications as the number of possible items on the Medication Review Sheet. 60

Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender. 10A NCAC 27G .0209 CONTINUEDIf an individual receives psychotropic drugs, his/her drug regimen must be reviewed by a pharmacist or physician at least every 6 months.100% compliance must be achieved for this item to be rated “Met” (per individual).61

Item 16: The medication label matches the physician's order. 10A 27G .0209. Sample is same 5 records from item 14.Ensure label on bottles/packaging matches the physician's order. In some cases, the brand name of the drug will have been dispensed, in other generic per order. 100% must be achieved for each item for the record to be rated as “Met.” 62

Item 17: The medication listed on the MAR matches the physician's order. 10A 27G .0209. Sample is same 5 records from item 14. Ensure that each physician's order is listed within the MAR. Any medication samples received from the physician are recorded in the same way on the MAR.If an individual administers his/her own medication at an agency site, the medication must be listed on the MAR.100% must be achieved for each item for the record to be rated “Met.” 63

Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff. 10A NCAC 27G .0209. Sample is same 5 records from item 14.Documentation of medication education provided to the individual/LRP should be reviewed for each prescribed or over-the-counter medication if ordered by the agency physician. 64

Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff. CONTINUED Medication education may be given orally or in writing documentation may be in the prescribing physician's note may be documented in writing according to agency policy Medication education is required for all medications prescribed by the provider agency’s physician. 100% must be achieved for each item for record to be rated “Met” 65

Post-Payment Review Tools for IDD Services

Organization of PPR ToolsThe PPR Tool questions address these areas: Authorizations/Consents/Eligibility/ Service Orders/PlansService DocumentationQualifications/Training of Service Providers/Record Checks/Supervision67

The Post-Payment Review Tools Available for Provider Agencies Child & Adolescent Day TreatmentDiagnostic AssessmentInnovations WaiverOutpatient Opioid TreatmentPsychiatric Residential Treatment Facility (PRTF)Residential TreatmentGeneric – used for all services other than those in 1 – 6 above. 68

PPR Tools for Providers of IDD Services Some providers offer a wide array of cross-disability services. The specific PPR tool(s) that will be used during a review is based on the service array represented in the sample of paid claims.The PPR tools are based on service definition-specific requirements including staff qualifications.The Generic Tool and the PPR Tool for the Innovations Waiver would typically be used to review IDD services.Most questions on the Generic Tool are also found on the other 6 agency tools.69

Basic Components of the Post-Payment Review Tools ConsentsReferralsAuthorizationsEligibilityService OrdersService Plans 70

Basic Components of the Post-Payment Review Tools Service DocumentationStaff QualificationsTraining of Service ProvidersHealth Care Registry CheckCriminal Background CheckSupervision71

Post-Payment Review Tool for the Innovations Waiver Authorizations/Continued Need Review/Plan of CareValid ISP for the date of serviceService DocumentationValid consent for treatmentValid signature of the person who provided the serviceInterventions/Treatment for the duration of the service billedQualifications/Supervision/Record Checks 72

Post-Payment Review Tool for the Innovations Waiver Optional QuestionsDocumentation includes an assessment of progress towards goalsDocumentation indicates the requirements of the service definition were metDocumentation in the quarterly summary reflect the individual’s progress toward the short-range goals and the long-range projections listed in the ISP73

Basic Components of the Post-Payment Review Tools The Generic Post-Payment Review Tool74

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid consent for treatment in the service record? 10A NCAC 27G.0205; CCP 8CQ1 on the Generic Agency ToolQ3 on the LIP ToolReview for a consent for treatment signed by the individual or LRP on or prior to the date of service being reviewed.A separate consent for treatment form is not necessary if the individual/LRP has signed the PCP/service plan. 75

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans The individual/LRP signature on the treatment plan or PCP is sufficient to demonstrate consent.  If written consent is not obtained, the provider must produce a written statement as to why consent could not be obtained.76

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a referral from an approved source prior to the date of service, if applicable? CCP 8C 5.4.1, 5.4.2 and 7.3.6 Children under 21 need an individual verbal or written referral from a CCNC/CA (Carolina Access) primary care provider, the LME-MCO or a Medicaid-enrolled psychiatrist.Referrals may be accepted from schools or DSS, but must still be supported by one of the referral sources above.77

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED Documentation of the verbal or written referral includes the name and NPI # of the individual or agency making the referralServices provided by a physician do not need a referralIndividuals 21 or over may be self-referred or referred by another source. If not self-referred, referral must be documented.78

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid utilization management authorization for the service billed, if applicable?Prior approval needed after:16 unmanaged visits/calendar year for children under 218 unmanaged visits/calendar year for adults 21 or overIf unmanaged visits were exceeded review for LME-MCO authorization that covers date of serviceE&M codes for medication management do not require prior authorization.79

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Does the recipient meet entrance criteria per the service definition? CCP 8AQ3 on Generic Agency ToolDo the results of the Comprehensive Clinical Assessment (CCA) support the level of care for the treatment service recommended? CCP 8CQ14 on the LIP Tool80

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED Review the Entrance Criteria listed in the service definition against the CCA. The CCA must support the required criteria.The CCA must support the level of care (CALOCUS, CASII, LOCUS, ASAM) for the treatment service recommended.81

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid service order for the service billed, if applicable? CCP 8CQ5 on the LIP ToolThe need for a service order matches the need for an authorization.If needed, service must be ordered on or before date of service.If a PCP is not required, a separate service order form can be used. See Service Plan question for services ordered via PCPs. 82

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid/appropriate service plan current for the date of service? CCP 8A, 8C.Q2 on Generic Agency ToolQ4 on the LIP ToolThe format required by service definition is used. Plan is rewritten annually and/or updated/ revised:If the needs of the person have changed On or before assigned target dates When a new service is added When a provider changes 83

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED If the plan is a PCP, the service must be identified in the Action Plan to be ordered via appropriate signature on the PCP.If the service does not require a PCP, a separate service order form is acceptable.84

Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans CONTINUED Dated SignaturesMedicaid-funded services must be ordered by a licensed MD or DO, licensed psychologist, licensed nurse practitioner or licensed physician’s assistant unless otherwise noted in the Service Definition.Each service order must be signed and dated by the authorizing professional. Dates may not be entered by another person or typed in. No stamped signatures unless there is a verified Americans with Disabilities Act [ADA] exception. 85

Service DocumentationIs the documentation signed by the person who delivered the service? CCP 8A, 8C – 7.3Q4 on the Generic Agency ToolQ7 on the LIP ToolSignature includes credentials, license, or degree for professionals; position name for paraprofessionals. Credentials/job titles may be typed, stamped or handwritten. Do not rate “Not Met” if credentials are missing. If it is a systemic issue, require a Plan of Correction.86

Service DocumentationCONTINUED The note is written and signed by the person who provided the service [full signature, no initials]. “Written” means “composed.” If a signature is questionable, request the provider’s signature log to validate the signature. Documentation is completed within 24 hours of the day the service is provided.87

Service DocumentationCONTINUED In order for a service to be billable, the note must be written or dictated within 7 working days (for the staff who provided the service). After the 24-hour time frame, the note shall be entered as a “late entry” and include a dated signature. If an electronic note is used and late entries are tracked/stamped in the system, this will meet documentation requirements.If there is no note for the date being audited, then audit questions related the qualifications, training, supervision, record checks of the staff who provided the service are rated “N/A.”88

Service DocumentationCONTINUED If there is an unsigned note, review and rate other questions related to the note accordingly. Questions related to the staff person remain rated as “N/A." Do not assume based on handwriting that you can identify the service provider.89

Service DocumentationDoes the service note relate to goals listed in the service plan? CCP 8CQ8 on the LIP ToolNote reflects purpose of the interventionNote states, summarizes and/or relates to a goal or references a goal # in the service plan.Goal is not expired or overdue for reviewIf goal does not match the goal # indicated, review all goals to see if it relates to another goal 90

Service Documentation Does the service documentation include an assessment of progress toward goals? CCP 8CQ9 on the LIP ToolOptional – Q14 on Generic Agency ToolService note needs to indicate progress made toward the goal/effectiveness (how it turned out for the person; how did he/she respond to the intervention)If the information is not in the traditional section of the note, read the entire narrative note to determine if it was addressed.91

Service DocumentationDoes the documentation reflect the specific service billed? CCP 8C Q10 on LIP ToolService documented must match procedure code billed.Intervention must match procedure code billed.No provider may bill H codes.92

Service Documentation Does the documentation reflect treatment for the duration of the service billed? CCP 8A, 8CQ5 on Generic Agency ToolQ12 on the LIP ToolIntervention relates to the stated purpose of goalIntervention/Treatment documented justifies amount of time billed – reasonably took place in the amount of time documentedThere is actual treatment reflected in the intervention related to goals, symptoms, diagnoses 93

Service DocumentationCONTINUED The following are not billable:Verifying eligibility and obtaining prior approvalCompleting NCTOPPSInternal agency supervision94

Service DocumentationIs the service note individualized specific to the date of service? CCP 8A, 8C Q6 on Generic Agency ToolQ11 on the LIP ToolReview notes around the date of service.Notes should vary from day to day and person to personNo xeroxed notes with dates or signatures changedNo handwritten notes copied throughout with different service dates 95

Service DocumentationCONTINUED Look very closely if you see any of the following:Exact wording across 2 or more notes for one person or across recordsConflicting pronouns (he/she, him/her)The name or identifying information of another individual is found within the service note.96

Service DocumentationDo the units billed correspond to the duration documented on the service note? Provider Participation and Electronic Claims System agreementsQ7 on Generic Agency ToolDuration of periodic services must be documentedBilling and duration must be an exact match, however, if fewer units are billed than documented do not rate “Not Met”97

Service DocumentationDoes the documentation indicate that the requirements of the service definition/rule were met? CCP 8A Optional – Q13 on Generic Agency ToolReview CCP 8A for service definitionEach service definition include allowable activities, team composition (if applicable) and other critical elements98

Service DocumentationIs there documentation that coordination of care is occurring with both medical and non-medical providers involved with the individual receiving services? CCP 8CQ15 on LIP ToolMay be found in service notes, summary reports, documentation of telephone calls, Tx planning notesCoordination of Care expected as applicable for example with primary care, LME-MCO, other mh/dd/sa service providers 99

Qualifications/Training of Service Providers/Record Checks/SupervisionIs there documentation that the staff is qualified to provide the service billed? Q8 on Generic Agency ToolQ13 on LIP ToolReview personnel record for each person who provided a serviceVerify both required education and experience are evident Use Qualification Checklist (there is one for each PPR Tool) which lists education and training required for the service100

Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED If service provider is unknown (note not signed or illegible or unverifiable my signature log), rate all staff related questions as “N/A.”Do not assume based on handwriting in a note that you can identify the provider of an unsigned note.If staff name is typed but not signed, review for qualifications but rate “Not Met” for the question about the note being signed.101

Qualifications/Training of Service Providers/Record Checks/Supervision Is the staff supervision plan implemented as written? 10A NCAC 27G .0104, .0203Q9 on Generic Agency ToolSupervision plan must be in place for Associate Professional and Paraprofessional staff. If staff is a QP or licensed, rate this item “N/A.”Evidence of implementation is based on requirements of the plan. For example, most plans include the frequency/duration of required supervision.Determine if documentation of supervision matches with the supervision plan requirements.An agency policy on supervision, even if it includes frequency/duration of supervision is not acceptable as an individual supervision plan102

Qualifications/Training of Service Providers/Record Checks/SupervisionWas there a Health Care Registry check completed for the staff prior to this event’s date of service [unlicensed employees only]? GS 131E-256, 10A NCAC 27G .0202Q10 on Generic Agency ToolThere may be no substantiated findings of abuse or neglect.Ensure the registry check belongs to the staff being reviewed (check name, SSN if available, etc.) 103

Qualifications/Training of Service Providers/Record Checks/SupervisionDid the provider agency require disclosure of any criminal conviction by the staff person(s) who provided this service? [for unlicensed services and staff hired to provide licensed services prior to 3/24/05] 10A NCAC 27G .0202Q11 on Generic Agency ToolDisclosure statements most often found on employment application or in a separate statement completed during application process.If no disclosure statement, a request for a criminal record check prior to the date of service is acceptable104

Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED If disclosures are not in place and is a systemic issue, assign a POC even if background checks are evident.The criminal record disclosure must have occurred prior to the date of service.105

Qualifications/Training of Service Providers/Record Checks/SupervisionWas the appropriate criminal record check completed prior to this date of service? GS 122-80Q12 on Generic Agency ToolNot required for licensed staffDetermine date of hireGeneral Statute Requires the Following:If applicant had been a resident of NC for less than 5 years, must have consent for a State and National background check before conditional employmentIf applicant had been a resident for 5 years or more, must have consented to a State check before conditional employment. 106

Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED The provider, within 5 days of conditional employment must submit request to the DOJ to conduct the criminal background check. A NC county or company with access to the Division of Criminal Information data bank may conduct the check.You do not need to see the actual background check results, auditors need only see the request.For purposes of the PPR, the request must occur prior to the date of service.Do not rate “Not Met” if the request did not occur prior to conditional employment. Rate “Not Met” only if it did not occur prior to the date of service or not at all. 107

Specialized Tools 108

Specialized Tools for Provider AgenciesUnlicensed AFL Review Tool Looks at health and safety issues and compliance with the personnel and training requirements of providers and staff Is required to be completed annually for AFL services under the Innovations Waiver Is completed every two years for all other unlicensed AFL sites109

Specialized Tools for Provider AgenciesUnlicensed AFL Review Tool Home Environment Medical preparedness plan; emergency informationFirst aid supplies; storage of medicationAvailability of meals, food, water, individual privacyAccessible transportationSafety and cleanliness of facility and groundsPersonnel – background checks; backup staffing planTraining on individual-specific needs and the required skills/competencies for staff position/role 110

Specialized Tools for Provider Agencies  Health, Safety and Compliance Review Tool Is only for the initial review of services that operate out of a setting that is not licensed by DHSR (e.g., Unlicensed Supervised Living Programs).Is used when an unlicensed service moves to a new location which is not co-located with a licensed service.Subsequent reviews of these services would utilize the Routine Review Tool.111

Specialized Tools for Provider Agencies  Health, Safety and Compliance Review Tool Medical preparedness plan, fire and disaster plan and drillsFirst aid suppliesAvailability of meals, food, waterSafety and cleanliness of facility and groundsProvision for individual privacyEmergency information: first aid, CPR poison control protocol posted or easily accessible 112

Some Monitoring Process Points 113

Sample SelectionThe sample that is selected to conduct the majority of the routine review is based on paid claims. The exceptions are incidents, restrictive interventions, complaints, funds management and medication review which may fall outside of the service events selected from paid claims.114

Selection of the Review PeriodFor the majority of the review, the sample of paid claims will be based on claims paid starting 6 months before the scheduled on-site visit through the next 3 months (~ 90 days). Example: If the date of the on-site is May 1, the sample will drawn from randomly selected claims that were paid between December 1 – February 28.The timeframe for incidents, restrictive interventions, complaints, funds management and medication review can go back up to 1 year in order to obtain an adequate sample.115

Notification of Routine MonitoringProvider agencies and LIPs will be notified in writing 21 – 28 calendar days prior to the date of review. Provider agencies and LIPs will be notified of specific service records needed for review no less than 5 business days prior to the date of review.116

During MonitoringLIPs and Agencies should have staff available to help navigate records/documentation if needed. It is not required to be present during the review, but having staff available can enhance the process.If documentation for a specific item is not immediately available, it will be accepted at any time during the on-site review. 117

Exit InterviewAn Exit Interview will occur following the on-site review to provide the LIP or agency with some immediate feedback: General impressions on preparedness and results of the reviewGeneral information on any major findings, trends, etc.Expectations, if any, for technical assistance needed, plan of correction and follow-upVerify contact(s) for receipt of report: Name, Mailing Address, Email Address.118

Reports and Plans of Correction Comprehensive findings will be reported by the LME-MCO within 15 calendar days.Ensure POC is specific, detailed and addresses each of the systemic areas noted in the findings.Fully implement the POC – seek technical assistance as warranted. 119

Scoring & Weighting 120

Scoring The three (3) scoring options are:MetNot MetNot Applicable (N/A) 121

Scoring Enhanced Guidelines:More specific More pertinent to general program operations 122

Scoring The threshold for passing each section of the routine review tool is 85%. (Exception: On the Agency Tool, if the Restrictive Interventions item is missed, the entire section on Incidents, Restrictive Interventions and Complaints is failed).The minimum overall score for the routine review tool is also 85%. 123

WeightingThe weight for any item scored as “N/A” is distributed across the other items in that section. 124

Weighting Non-compliance on certain items results in the individual record being scored as “Not Met:”Authorization to Release RecordsAll elements required by rule must be included in the record release form in order for this item to be scored as “Met.” [See Record Release Checklist] Medication Review Tool If any of the following requirements is out-of-compliance, the individual record is “Not Met.” [see Medication Review Checklist] Medication Order Properly Signed/Countersigned by Prescribing Physician Medication Label Matches the Medication Order List of Medications on the MAR match the Medication Order Documentation that Medication Education Occurred 125

Weighting Non-compliance on certain items results in the entire section to be scored as “Not Met:”Restrictive InterventionsIf the Restrictive Intervention question is “Not Met” for any event reviewed, the entire section on Incidents, Restrictive Interventions and Complaints is failed. 126

What happens if a provider agency does not pass the monitoring or review? 127

LME-MCO Responsesto Unsuccessful MonitoringOne or more of the following may occur, specific to individual LME-MCO policy. Technical AssistancePlan of CorrectionRecoupment (for Post-Payment Reviews only)Targeted InvestigationLME-MCOs will inform providers and LIPs of their process for appeal or reconsideration. 128

Internal Quality Assurance….will only involve review of documents needed to determine the met/not met/NA status for the review tool questions ….less anxiety-provoking when providers (LIPs and agencies) use the tool as a pre-review self-assessment.129

Internal Quality AssuranceThe best offense is a good defense.  Do you have a system in place that ensures audit-readiness at all times?130

Transparency  131

Internal Quality Assurance  132

Internal Quality Assurance  Be Proactive133

Internal Quality Assurance  Do you have a system in place that ensures audit-readiness at all times?134

Customer Service One to Another

Important Things to Remember: 136

Remain abreast of applicable policies, rules, regulations, standards and other information provided by the Division of MH/DD/SAS Administrative Publications and all other standards established by the Federal Government, State of NC or LME-MCO per contractual agreement.Comply with contractual obligations as denoted in individual contracts with respective LME-MCOs. Provide services as delineated in individual contracts with respective LME-MCOs. Use Provider Monitoring Tool for agency audits http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/tools.html Providers 137

Develop and manage service benefit plans; coordinate and monitor services provided. Use DHHS Provider Monitoring Tools for agency audits http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/tools.html. Also completes fiscal and billing audits (Post-Payment Reviews).Reviews when complaints are received. Targeted/Focused Monitoring. Incident Report reviews. Managed Care Organization (LME/MCO ) 138

General Monitoring Courtesies139

Greet and welcome. Make introductions.Demonstrate respect.Be professional. Be calm and friendly. Discuss openly when there is disagreement. Remember to: 140

Ask questions. To share, without hesitation, if the review becomes too disruptive for the participants.Demonstrate integrity throughout the process.Ensure transparency.Remember to: 141

The process is not personal; it is a system – we all have shared accountability.Providers need to ensure preparedness, and LME-MCOs need to demonstrate patience, e.g. information may not be readily available and/or resources may be limited. Other Reminders: 142

We must all work collaboratively. Collaboration will ensure an effective, efficient, and successful process.Assume positive intent - monitoring is a learning experience, not a punitive exercise.Be engaged in the information and dialogue.Other Reminders: 143

Complete the survey as means to further improve the process. Most importantly, remember the primary objective is to ensure the health and safety of all the participants supported in the MH/I/DD/SAS system.Other Reminders: 144

Ask questions when indicated. Provide responses to questions.Ensure responses are accurate and to the point.Stick to the question; do not talk around it. Responses should be referenced-based as needed. Asking and Answering Questions: 145

Make sure the question is understood in its entirety. Recognize the difference between “I think” and “I know.” Asking and Answering Questions: 146

Efforts to resolve at the lowest possible level have proved ineffective. There is lack of professionalism. Actions are not in accordance with standard operating practices for the MCO or Provider. There is continued disagreement concerning a particular issue. Additional support is warranted. Seek Recourse When: 147

Partners Making a Difference 148 148

Parking Lot Issues 149

More to Do…This is a developing list of things to accomplish:Will there be a standard monitoring report from the LME-MCOs? Will there be a standard response to unsuccessful monitoring?Review and revise as needed, the POC policyAdvanced levels of Provider Monitoring developmentDetermine lead LME-MCOMore research needed on ability to do PPRs on TFC150

We want to hear from you!! 151

Questions Please send any questions or comments about the Provider Monitoring Tools or process to the following mailbox:provider.monitoring@dhhs.nc.gov Please put either “FEEDBACK” or “QUESTION” in the subject line!152

Additional Information & UpdatesAdditional background information about the DHHS Provider Monitoring Process can be found on the Provider Monitoring web page: http://www.ncdhhs.gov/mhddsas/providers/ providermonitoring/index.htm Check the Announcements page for new postings.153

Continued Collaboration 154

DHHS-LME/MCO-Provider Collaboration WorkgroupProvider OrganizationsJanet Breeding, NC Providers Council Sally Cameron, PACCeleste Dominguez, BenchmarksCaroline Fisher, BenchmarksLakisha Marelli, BenchmarksMargaret Mason, NC Providers Council 155

DHHS-LME/MCO-Provider Collaboration Workgroup Leslie Gerard, CenterPointBeth Lackey, Partners Rhonda Little, Cardinal InnovationsEugene Naughton, CenterPoint Alison Rieber, Alliance Sherry Reece-Cota, Partners Carol Robertson, Sandhills CenterKaren Salacki, EastpointeClaudia Salgado, CenterPointOnika Wilson, Cardinal Innovations NC Council of Community Programs 156

DHHS-LME/MCO-Provider Collaboration WorkgroupBeverly Bell, DMA Cynthia Coe, DMH/DD/SASStephanie Gilliam, DHSRVince Newton, DMH/DD/SASPatrick Piggott, DMASandee Resnick, DMH/DD/SASNancy Rogers, DMH/DD/SASMichael Schwartz, DMH/DD/SASAdolph Simmons, DMAGlenda Stokes, DMH/DD/SASRobin Sulfridge, DHSRSuzanne Thompson, DMH/DD/SASMary Tripp, DMH/DD/SASPeiChi Wu, DMH/DD/SAS DHHS Staff 157

Helpful InformationDMH/DD/SS Provider Monitoring link for tools, guidelines and updated information: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/index.htm Records Management and Documentation Manual: http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/rmdmanual-final.pdf DMA Clinical Coverage Policies: http://www.ncdhhs.gov/dma/mp/ DMH/DD/SAS Plan of Correction Policy and forms: http://www.ncdhhs.gov/mhddsas/providers/POC/ index.htm DHSR Mental Health Licensure Section: http://www.ncdhhs.gov/dhsr/mhlcs/mhpage.html 158

Transparency The Key to Positive Outcomes and Accountability 159