Quality –Documentation - Compliance · 2020-04-20 · Documentation – Things to Remember “If...
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David E. Wawrzynek MS MBA Wednesday, April 15, 2020, 1-2 pm Quality – Documentation - Compliance
Transcript of Quality –Documentation - Compliance · 2020-04-20 · Documentation – Things to Remember “If...
DavidE.WawrzynekMSMBAWednesday,April15,2020,1-2pm
Quality– Documentation-Compliance
QualityofBehavioralHealthServices-Defined
Thedegreetowhichbehavioralhealthcareservicesforindividualsandpopulationsincreasethelikelihoodofdesiredhealthoutcomes.
Doingtherightthingfortherightindividual,attherighttime,intherightwaytoachievethebestpossibleresult.
SixAimsforHighQualityServices– AllServicesShouldBe:
Safe – avoidingnegativeconsequencesfromcarethatisintendedtohelp.
Effective – providedbasedonbestpractices.
Patient-centered– respectfulofindividualpreferences.
Timely – reducingwaitsandpotentiallyharmfuldelays.
Efficient – supportedbygoodbusiness practices.
Equitable – providingcarethatunaffectedbypersonalcharacteristics.
QualityImprovement
Systematic andcontinuousprocesstoidentifygapsinsystemsandprocessesandmakechangesthatwillleadtobetterclientoutcomesandbetteragencyandsystem
performance.
QualityImprovementModel–FOCUS-Plan-Do-Check-Act(FOCUS-PDCA)
ModelbeginswiththeFOCUS Phase:
• Findanopportunitytoimprove.• Organizeaqualityimprovementteam.• Clarifycurrentknowledgeandprocessesthatinfluenceopportunitiestoimprove.• Understandvariationthatiscontributingtotheproblem.• Select/startthePDAcycletoimproveoutcomes.
ContinueontothePDCAphase
• Plan: Plantheaction,orapilottestoftheaction.Includeintheplanameasureofperformanceandmeansofdatacollection.
• Do: Implementthe intervention.Makesurenecessarydataaregenerated.
• Check: Collectandanalyzedatatoseewhethertheinterventionworksbeforemakingitpartofongoingdailyoperations.
• Act:Ifthenewprocessiseffective,makeitpartofongoingoperations.Ifthechangeisanincrementalstep,continueontothenextstepinthesubsequentPDCAcycle.Ifthenewprocessisnoteffective,usewhatwaslearnedtodesignanotherinterventionthatwillbetested inthenextPDCAcycle.
The“Act”ofonecycleinforms,orsometimes becomes,the“Plan”ofthenextcycle,creatingacontinuousprocessofimprovement.
WhenImplementingChangeFollowPrinciplesofChangeManagement
ChangeManagement
Planning forChange
ManagingChange
Reinforcingchange
Communications
Sponsorship
Coaching
TrainingandTools
Resistancemanagement
Documentation– WhyisitImportant?
• Documentationrecordshowtheclient’sneedsweremetbyserviceprovidersacrossthedifferenttypesandlevelsofcare.
• Continuityofcarerequiresarecordofwhatwasdone,whodidit,when,where,why,andhowitbenefittedtheclient.
• Essentialforriskmanagement,shareddecision-making,coordinationofcare,andevaluatingresults.
• FacilitatesQualityImprovementandUtilizationReview.• Neededtocomplywithlaws,regulationsandpayorexpectations.
QualitiesofEffectiveDocumentation
• Effectivedocumentationisclear,timelyandwell-organized.• Documentationisdone“contemporaneously.”• Documentationisconcise,factual,currentandspecific.
• Effectivedocumentationdemonstratescontinuityofcare.• Documentationcapturesbaselinefunctioninganddemonstratesclient’sprogress.• Showsprogressovertime.• Demonstrateshowclient’sneedswereaddressedacrossdifferentclinicalandsocialdeterminate'sofcareinterventions.
• Supervisorsshouldreviewclientrecordswiththeirstafftopromotequality,consistencyandregulatorycompliance.
TheGoldenTread
AssessmentdataDiagnoses–Strengths–PersonalGoals
AssessedNeedsServicePlanGoals
ServicePlanObjectivesInterventionsandServices
InteractionsDirectedbyserviceplan–recordedinprogressnotes
Commonredflagsorareasofconcern
• Documentationthatis“cookiecutter”• Includingnegativeprovideropinionsorlanguage• Includingprivatedetailsthatarenotrelevanttotreatmentgoals• WhenTreatmentPlans/ServicePlansandProgressNotesdon’tclearlytietogether
Documentation– ThingstoRemember
“Ifitisnotdocumented, itdidn’thappen.”
Moreisnotbetter;qualityoverquantity.
Itisnot“historytaking.”
Knowthemissionofyourprogram, theregulations,andthepurposebehind therequireddocumentation.
Itistheclient’srecord!Documentationshouldultimatelyservetheclient’sneedsandshowtheirprogress towardrecovery.
CorporateCompliance
ANORGANIZATION’SLONGTERMCOMMITMENTTOCONDUCT
BUSINESSINWAYSTHATPROMOTEDOINGTHERIGHT
THINGS.
APROCESSANDSTRUCTURETHATCONTINUALLYMONITORSTHATTHERIGHTTHINGSARE
BEINGDONE.
ABILITYANDWILLINGNESSTORESPONDTOCHANGESAND
PROBLEMSTHATAREIDENTIFIEDALONGTHEWAY.
ComplianceProgramApplicabilityasstatedin18NYCRRPart521
Everyrequiredprovidershalladoptandimplementaneffectivecomplianceprogram…Requiredproviders’complianceprogramsshallbeapplicableto:
• Billings• Payments• Medicalnecessityandqualityofcare• Governance• Mandatoryreporting• Credentialing• Otherriskareasthatareorshouldwithduediligencebeidentifiedbytheprovider”
Fraud,Waste,andAbuse
Fraud– wrongfulorcriminaldeceptionintendedtoresultinFinancialorpersonalgain
Waste– thoughtlessorcarelessexpenditure,mismanagementorabuseofresources
Abuse– excessiveorimproperuseofathing,ortousesomethinginamannercontrarytothenaturalorlegalrulesforitsuse.
Fraud,Wasteand,Abuse- Examples
• Billingforservicesthatwerenotprovided• Billingforunnecessaryservices• Intentionallybillingformoreexpensivetreatmentthanwasprovided• Givingmoneyorgiftstopatientsinreturnforagreeingtogetmedicalcare• AcceptingKickbacksforpatientreferrals
Consequences:Prison,fines,repaymentofMedicaidorMedicaredollars,and/orbeingplacedontheMedicaidExclusionList
EightElementsofaComplianceProgram
§ WrittenPoliciesandProcedures/CodeofConduct§ ComplianceProgramOversight§ TrainingandEducation§ Effective,ConfidentialCommunications§ EnforcementofComplianceStandards§ AuditingandMonitoring§ RespondingtoOffensesandDevelopingaCorrectiveActionPlan§ PolicyofNon-retaliationandNon-intimidation
ComplianceProgram– BestPractices
PoliciesandProcedures§ Publicationofcodeofconductand/orCompliancePlandocumentontheagency’sintranetand/orwebsite.
§ CompliancePlan documentoutlinesthebenefitsofaCorporateComplianceProgramasawaytoobtainbuy-in.
§ CodeofConductisreviewedannuallywithemployees,contractorsandgoverningbodyaspartofongoingcomplianceeducation.
ComplianceProgramOversight§ TheComplianceOfficerreportsdirectlytothegoverningboard,withdottedlineresponsibilitytoamemberofseniormanagement.
§ TheCEOreceivesregularreportsfromtheComplianceOfficeriftheComplianceOfficerdoesnotreportdirectlytotheCEO.
§ ComplianceCommitteemembershipincludesgoverningbody.
§ PrivacyOfficerandSecurityOfficerparticipateinCommitteemeetings.
§ ComplianceCommitteemeetsmonthly,bi-monthly.
ComplianceProgram– BestPractices
Education§ Useofanelectronictrainingandeducationsystemthattracksmandatorycomplianceeducationofemployees;notifiesofduedates.
§ Thecompliancetrainingmaterialsaretailoredtotheneedsofalllevelsandtheeducationalbackgroundsofallemployees.
§ Thecompliancemanual/codeofconductisdistributeduponhireandannually.
§ Regularcompliance-relatedinformation/education– newsletters;e-blasts,Compliance&Ethicsweek.
Effective,ConfidentialCommunication§ Thecomplianceprogramoperatesinanenvironmentoftransparencythroughoutalllevelsoftheorganization.
§ Clients/servicerecipientsreceiveinformationonhowtoidentifyMedicaidfraudandhowanyconcernscanbereportedtomanagement.
§ Providerusesposters/flyersabouttheComplianceProgramandthehotlinethatusespicturesaswellastexttocommunicatetheexpectationthatifyouseeorhearanything,youshouldreportit.
ComplianceProgram– BestPractices
Enforcement§ Employeeperformanceevaluationsincorporatecomplianceasoneindicatorofperformance,aswellasanemployee’sadherencetoapplicablelaws,regulations,andpolicies.
§ Disciplinepolicies,employeehandbookreferencesComplianceProgram.
AuditingandMonitoring§ Useofacomprehensiveself-assessmenttooltoplananddevelopanannualComplianceWorkPlan.
§ Internalmonitoringandauditingsystemsareusedthroughouttheorganization.
§ Apre-claimreviewprocessisusedpriortosubmissionofclaims.
§ AComplianceProgramassessmentisundertakenpriortotheDecembercertificationperiodtoidentifypotentialComplianceProgramgaps.Resultsaresharedwithgoverningbody.
ComplianceProgram– BestPractices
ResponseandCorrectiveAction§ ReviewOMIG’s,OIG’s,andCMS’swebsitesforregulatoryworkplansandalertsassociatedwithspecificareasoffocus;assessorganizationalriskinthoseareas;anddevelopappropriateactionplanstoaddresstheriskorweakness.
§ EstablishworkplanswithtargetdatesforactionandassignmentofstaffresponsibilitytoaddresscompliancerelatedissuesandComplianceProgramgapanalysis.
PolicyofNon-Retaliation/Intimidation§ ExitinterviewswithemployeesincludeaninterviewwiththeComplianceOfficer.
§ ComplianceOfficerreachesouttoformeremployees30daysafterformeremployee’sseparationdatetoinquireofanypossiblecompliancemattersobservedduringemployment.
