Quality Assessment & Improvement (QA&I) Process Cycle 1, Year …... · 2020. 1. 2. · Resources >...

Quality Assessment & Improvement (QA&I) Process – Cycle 1, Year 3 (2019-2020)

Questions and Answers Updated as of 1/2/20

Contents: GENERAL PROCESS QUESTIONS .................................................................................................................... 1

GENERAL SELF-ASSESSMENT QUESTIONS..................................................................................................... 4

AE SPECIFIC QUESTIONS ............................................................................................................................... 6

AE General Questions ............................................................................................................................... 6

AE Self-Assessments ................................................................................................................................. 7

AE Onsite Review of Providers .................................................................................................................. 7

AE Questions Tool ..................................................................................................................................... 9

SCO SPECIFIC QUESTIONS ........................................................................................................................... 12

ID/A SCO General Questions ................................................................................................................... 12

ID/A SCO Self-Assessment ...................................................................................................................... 12

ID/A SCO Questions Tool ........................................................................................................................ 13

AAW SCO General Questions .................................................................................................................. 14

AAW SCO Self-Assessment ...................................................................................................................... 14

AAW SCO Questions Tool ........................................................................................................................ 15

PROVIDER SPECIFIC QUESTIONS ................................................................................................................. 15

ID/A Provider General Questions ............................................................................................................ 15

ID/A Provider Self-Assessment ............................................................................................................... 18

ID/A Provider Questions Tool ................................................................................................................. 18

AAW Provider General Questions ........................................................................................................... 20

AAW Provider Self-Assessment .............................................................................................................. 19

AAW Provider Questions Tool ................................................................................................................ 22

Quality Management Plan Questions ......................................................................................................... 22

Quality Assessment & Improvement (QA&I) Process – Cycle 1, Year 3 (2019-2020) Questions and Answers from the Dedicated Mailbox

Updated as of 1/2/20

Cycle 1, Year 3 FAQs are posted on the MyODP.org website (https://www.myodp.org/) Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources

1

GENERAL PROCESS QUESTIONS

Q# Questions Answers

1. Does the QA&I Process replace Provider Monitoring, Supports Coordination Organization (SCO) Monitoring, Administrative Entity (AE) Oversight and Adult Autism Waiver (AAW) Monitoring Process?

•

Yes, effective July 1, 2017, the QA&I Process obsoletes (replaces) three oversight and monitoring processes for the Intellectual Disability/Autism (ID/A) waivers. For AAW, the QA&I Process went into effect on July 1, 2019 and replaces the AAW Monitoring Process.

2. Are self-assessments required during the year in which the entity is selected for their onsite or only during the 2 "off" years?

All entities must submit a self-assessment annually as part the new QA&I Process.

3. When will we learn what 3-year cycle will be an onsite?

AEs are selected alphabetically, with a total of 16 AEs being reviewed in a given year. AEs that begin with A – Cl will get an onsite Year 1. AEs that begin with Co – Le will get an onsite Year 2. AEs that begin with Lu – Y will get an onsite Year 3. ID/A and AAW SCOs are based on individuals selected in the ODP sample and the SCO that is authorized in the individual’s ISP. ID/A and AAW Providers are determined by the last digit of the Master Provider Index (MPI) #. Digits 0, 1 and 2 will get an onsite Year 1. Digits 3, 4 and 5 will get an onsite Year 2. Digits 6, 7, 8 and 9 will get an onsite Year 3.

4. When will onsite be for the 1st year? All onsite reviews will occur between September 1st and December 31st of every year.

5. When can we expect to receive our sample?

For self-assessments, all entities will choose their own sample which will include 1% with a minimum of 5 and a maximum of 10 records as part of their self-evaluation of performance. These will include a cross-section of individuals served, funding/program types, and locations and types of services. For onsite reviews in the ID/A waivers, entities will receive the sample from their Regional QA&I Coordinator, or AE for Providers, two weeks prior to the onsite review date. In the AAW, entities will receive the sample from a Bureau of Autism (BAS) Regional Office Representative prior to the desk review.

https://www.myodp.org/




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6. All AEs, Providers and SCOs pick their own samples for their self-assessment. But for onsite reviews, ODP will pick the SCO and AE sample and the AEs will pick the Provider sample?

In the ID/A waivers, ODP will provide AEs and SCOs with a sample that will be used for desk and onsite reviews conducted by ODP two weeks prior to the onsite review date. In addition, ODP will identify which Providers receive an onsite based on the last digit of the MPI # and share this list with the Assigned AEs. The Assigned AEs are then responsible for pulling an individual sample for each Provider. In the AAW, ODP will provide SCOs and Providers with the sample that will be used for desk and onsite reviews prior to the desk review.

7. Are we supposed to include any Agency with Choice (AWC) Financial Management Services (FMS) participants in this QA&I sample?

If an individual receives only AWC services, they should be included in the AWC FMS QA&I sample to respond to questions related to AWC FMS activities. If an individual receives AWC and additional services, they can be included in the QA&I sample. This question is not applicable to the AAW.

8. How do we know if we need to do a self-assessment or an onsite each year?

All entities must submit a self-assessment electronically on an annual basis by August 31st. Onsite reviews are: AEs are selected alphabetically, with a total of 16 AEs being reviewed in a given year. AEs that begin with A – Cl will get an onsite Year 1. AEs that begin with Co – Le will get an onsite Year 2. AEs that begin with Lu – Y will get an onsite Year 3. ID/A and AAW SCOs are based on individuals selected in the ODP sample and the SCO that is authorized in the individual’s ISP. ID/A and AAW Providers are determined by the last digit of the MPI #. Digits 0, 1 and 2 will get an onsite Year 1. Digits 3, 4 and 5 will get an onsite Year 2. Digits 6, 7, 8 and 9 will get an onsite Year 3.

9. I don't know who my QA&I Regional Coordinator is or their contact

information.

Please refer to the “QA&I ODP Contacts” list posted on the MyODP Training & Resource Center under the QA&I Contact List section for the contact information for ODP Contacts involved in the QA&I Process. This contact list provides the QA&I contact information for the AAW, Agency with Choice (AWC) Financial Management Services, Claim and Service Documentation Review, and ID/A. As a reminder, all questions related to the ID/A QA&I Process must be sent to the appropriate QA&I Regional Coordinator and cc the QA&I Mailbox.





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Q# Questions Answers If you have questions about the QA&I AWC FMS questions, you can reach out to [email protected]

If you have questions about the AAW QA&I Process, you can contact the QA&I Resource account at [email protected]. Please include “AAW QA&I Question” in the subject line for each email.

10. Will there be a process document that describes timeframes, due dates, expectations for all stakeholders?

Yes, the QA&I Process document is available on the MyODP Training & Resource Center website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources) and is titled “Office of Developmental Programs Quality Assessment & Improvement Process”.

11. Most ODP forms are not printer friendly (even too large to print on legal size paper); are the new forms going to accommodate printing without having to tape together to view the entire form?

Yes, except for the QA&I Review Spreadsheet for each entity, which due to its size will likely not be printer friendly. A QA&I Review Spreadsheet is available for AEs, SCOs and Providers and includes questions specific to the entity.

12. Are we required to keep all the documentation for the 3 years until an onsite assessment occurs?

Yes, all documentation related to the QA&I Process should be kept following the ODP record retention requirements established in the regulations or AE Operating Agreement.

13. Are State Centers excluded from this QA&I Process?

Yes, State Centers are excluded.

14. How does an entity update its primary or secondary contacts for the QA&I process?

Any changes to the primary and/or secondary contacts should be submitted by using the following link: ODP Quality Assessment & Improvement Contact Information Form. This link is also available on the MyODP Training & Resource Center website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources) under the QA&I Contact List section. As a reminder, it is the responsibility of the entity to ensure that this information remains up to date.

15. The timeframe for each question is 12 months from the date of the review unless otherwise specified. Since, QA&I Process notification was July 1, 2019, does that indicate the date mark to begin the 12-month review?

The 12 months back is from the date you start the review of your entity, not the notification. If you started your review on July 1st, then your 12-month period would go back to July 1, 2018. If you start your review any day in July, your 12-month period would go back to July 1, 2018 because the review period should always go back to the first day of the month.

16. Will the questions that are noted as exploratory be scored?

Some of the exploratory question will be scored. Questions that are non-scored are identified in each tool.


mailto:[email protected]


http://www.myodp.org/


https://odpqaicontactinfoupdate.questionpro.com/

https://odpqaicontactinfoupdate.questionpro.com/






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17. How will the answers to the individual interviews be used?

A summary of the individual interview responses will be included in the Comprehensive Report that is sent to entities who get an onsite. If this summary identifies areas where the entity could improve performance, it is expected that the entity looks at incorporating it into their Quality Management Plan. The interview questions are non-scored and entities will not get specific answers.

18. Is a separate tool for vendor-only and transportation-only providers?

For this first cycle, there is not a separate tool for vendor-only or transportation-only providers. We will take this into consideration for next cycle.

19. As a Provider, our agency received an onsite review in Cycle 1, Year 1 but we were contacted about scheduling an interview for an individual we serve for Cycle 1, Year 2.

QA&I individual interviews are offered to all individuals in the ID/A and AAW core samples (in the ID/A waivers the sample is based on the AE an individual receives support in). This does not mean that the Provider of supports will receive another onsite review.

20. What tasks are required for the onsite review? Does the entity complete file reviews and attempt to remediate or wait to hear from the onsite team?

An entity is expected to remediate any noncompliance found during the QA&I Process which includes the self-assessment and onsite reviews. Reviewing the QA&I Process document which is posted on the MyODP Training & Resource Center website is recommended as it outlines the steps of the process including remediation.

21.

GENERAL SELF-ASSESSMENT QUESTIONS


22. When are self-assessments due? The due date for self-assessments for all entities is August 31st.

23. If I am an entity that serves both the AAW and ID/A waivers, do I need to submit separate Self-Assessments?

Yes, for Cycle 1, Year 3, if an entity is enrolled in both the AAW and ID/A waivers they must submit two Self-Assessments using the separate hyperlinks sent by the respective ODP program offices on July 1st.

24. What are the criteria for the self-assessment sample?

For self-assessments, all entities will choose their own sample which will include 1% with a minimum of 5 and a maximum of 10 records as part of their self-evaluation of performance. These will include a cross-section of individuals served, funding/program types, and locations and types of services.

25. Is there a printable document that mirrors what we will need to submit to QuestionPro? If so, where is this available so we can print it and have it ready to enter into the system in the proper format on August 31st?

At this time, no there is not a printable document that mirrors what you will need to submit to QuestionPro; however, all documents needed to complete the self-assessment are posted on the MyODP Training & Resource Center website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources). Each entity has a separate section where the documents needed are posted.





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Q# Questions Answers • The QuestionPro hyperlink which is issued on July 1st is for data entry of the

responses from the documents posted.

26. If I have a question that needs remediation, do I mark the appropriate remediation action that I took, or do I need to do all the remediation actions listed?

You will choose the remediation action option(s) that were completed.

27. How are responses to be entered into QuestionPro? I see the requirement that they be entered into QuestionPro within 7 days of the interview. QuestionPro requires that we complete the questions in sequential order and cannot skip ahead to certain portions. Is there a separate link for entering responses to the self-assessment interviews?

QuestionPro entries for the self-assessment must be completed by 08/31 for your entity. There is a QA&I Review Spreadsheet for all entities posted on MyODP. It will help answer all the questions prior to QuestionPro entry. Using the QA&I review spreadsheet will allow you to work on answering all questions in stages and then transferring the answers into QuestionPro. Completing individual interviews are optional during the self-assessment. Providers who choose to complete individual interviews for the self-assessment portion are only required to use the QA&I Interview Questions Tool, a separate link for entry into QuestionPro will not

be given.

28. Can an entity reuse sample names or is it expected that a unique sample is drawn by each entity each year?

ODP’s expectation is that a unique sample is drawn each year.

29. If State Centers are excluded should we not pick individuals who reside in a State Center as part of our sample?

Correct, the sample should not include individuals who reside in a State Center.

30. Can an entity choose to select more individuals as part of their self-assessment then the minimum requirement?

Yes, any entity can review more than the 1% as long as they do not exceed the maximum of 10.

31. In reference to selecting individuals across funding streams can you clarify what funding streams are included in this?

The funding streams for the ID/A waivers are: Consolidated, Person/Family Directed Supports (P/FDS), Community Living and TSM (Base and SC Services Only). Please note that individuals in the AAW should not be included in the Self-Assessment sample for the ID/A waivers (and vice versa). Only individuals from the ID/A waiver should be included in the ID/A Self-Assessment sample and only individuals from the AAW should be included in the AAW Self-Assessment sample.

32. Is there a list of exploratory questions?

There is not a stand-alone listing of exploratory questions. All exploratory questions are identified as “exploratory” in the last column on each tool.

33. Do entities need to send the Submission Checklist documents if

Submission of the checklist documents are only required when entities are scheduled for the full QA&I review, which includes an onsite review.





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Q# Questions Answers they are not having an onsite review?

34. Does the self-assessment have to be

electronically filled out?

The self-assessment consists of two parts. You must complete the QA&I Review Spreadsheet that is available on MyODP. Additionally, you must submit the results of your work electronically in QuestionPro. (You should have received the link for QuestionPro on 7/1). All entities getting an onsite review must submit the completed QA&I Review Spreadsheet to the appropriate person.

• ID/A AEs and SCOs: ODP Regional Coordinators

• ID/A Providers: The Assigned AEs

• AAW SCOs and Providers: Patrick Keating ([email protected]) If you are NOT scheduled for an onsite review this year, no submission of the QA&I Review Spreadsheet is required. Please note that any documentation related to the QA&I Process can be requested by ODP at any time.

35. When submitting the QM plan, should we submit the plan document and the action plan

document or just the plan?

Both the plan and action steps should be submitted.

36. I’m trying to add names to the QA&I Review Spreadsheet and it says the cells are locked.

The names and MCI numbers can be added to the cells that are boxed in red in the picture below.

37. Can an entity potentially have 2 separate samples – one for the record review and one for the

interview?

No. During the self-assessment review, if an entity chooses to complete individual interviews, those interviews should be completed with individuals from the selected sample and not a different set of individuals.

38.

AE SPECIFIC QUESTIONS

AE General Questions





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39. Are AEs responsible for coordinating

IM4Q interviews?

No, AEs are not responsible to coordinate QA&I interviews with the local IM4Q programs.

40. For Providers working on their self-assessments, many of the questions do not apply to them as transportation only providers/homemaker-chore providers and/or providers without samples. What instructions should AEs give them in terms of completing their surveys and entering information via QuestionPro?

Please instruct these Providers to utilize the QA&I Provider Review Spreadsheet and answer all questions that apply to them and utilize the NA options whenever they are available. Also instruct them to keep documentation related to their responses to the self-assessment. We will take this into consideration for next cycle.

41.

AE Self-Assessments


42. Will samples be the same during self-assessment and onsite?

As AEs are completing their self-assessment, individuals must be selected following the criteria outlined in the QA&I Process. While there may be some overlap in the sample selected for an onsite review and the self-assessment; for the most part, the sample will be different since each entity will be choosing their own sample as part of the self-assessment process.

43.

AE Onsite Review of Providers


44. What is the AE's role in reviewing a

Provider self-assessment in years

they do not have an onsite?

It is the intention that all entities engage in quality improvement (QI) activities during the two-year period between their formal QA&I onsite review. All entities are required to review the results of their self-assessments to prioritize QI opportunities. Annually, at the completion of the self-assessment process, ODP will issue an aggregate report of self-assessment results and analysis statewide. This report will be used to inform the QA&I process throughout the year and technical assistance targeted to AEs, SCOs and Providers.

45. Will AEs be selecting samples for

Providers to use during onsite or will

The AE will select the sample for QA&I onsite review of Providers assigned to the AE for review. Providers are required to select their own individual record sample for the self-assessment.





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Providers be selecting their own

samples?

46. Will there still be Reviewing AEs?

ODP no longer uses the terms “Lead AE” and “Reviewing AE.” The QA&I Process uses the terms “Assigned AE”.

47. When will the AEs be notified of the

Providers in the sample?

ODP will notify AEs of all Providers included in the onsite review pull by July 31st.

48. When will the list of Assigned AEs for

Providers be posted on the MyODP

website?

A list of all entities who are receiving an onsite review will be posted on MyODP

by August 1st. This list is broken down by region and entity.

49. How will Providers know who their Assigned AE is?

The AE with the most individuals authorized with the Provider is designated as the Assigned AE. If the Provider does not serve any individuals, the Assigned AE is the AE that reviewed the Provider’s most recent Provider Qualification (PQ) application. This information is reflected on the QA&I ODP Contacts List in the Assigned AE column of the Providers tab.

50. Will AEs receive an email for the link for QAI Process?

Emails which contain the hyperlink to the self-assessments are sent out to all entities on July 1st. For Provider QA&I onsite reviews, the primary contact of the Assigned AE will receive two separate emails which contain hyperlinks to the Provider QA&I onsite tool and the Individual Interview Tool for AEs by Sept. 1st.

51. The AE will select 1% of participants with a minimum of 5 and a maximum of 10 for individuals who are registered with the Assigned AE and are authorized and actively receiving services from the Provider being reviewed. Basically, almost every Provider will fall into that maximum of 5 individuals reviewed unless they have more than 600 individuals authorized. And the only Providers who will have a sample of 10 reviewed will have over 1000 individuals?

Yes, any provider that serves 500 individuals or less will have the minimum sample size of 5. Providers who serve 1000 or more individuals will have the maximum sample of 10.

52. Is there a certain report that you would like or recommend AEs use when creating their samples for Providers?

Currently, there is no one specific report that ODP recommends AEs use when creating their samples for Providers receiving an onsite review; however, the Service Authorization Notice and Provider Service Details Report are options that are available in HCSIS to use.





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53. What about "new" Providers that do not have a sample, or Providers that served individuals in the past but are not currently? Should any questions that refer to a sample be marked "N/A"? Many of them don't list N/A as an option.

For the QA&I process, a Provider should be monitored regardless of whether or not they are providing services. Any questions that reference the sample will be NA and an NA response has been provided where applicable.

54. Does repeated non-compliance mean non-compliance for the same question that was cited during a previous monitoring cycle? If yes, then do we, this year, utilize monitoring data from the prior PM process as our guide there?

Yes, if the same topical area exists in both PM and QA&I and was cited during PM, this would be considered repeated non-compliance. Yes, the data from the prior PM process should be used.

55. If a Provider’s 1% sample size is 6, can the AE decide to select the maximum of 10 people for the onsite/desk review for that particular Provider?

Yes, an AE can review more than the 1% as long as they do not exceed the maximum of 10.

56. The instructions for AEs are to select additional participants that do not overlap with the sample for onsite review, but most providers don’t have a full sample of 10 because they are smaller agencies. Should we complete the desk review for the participants in the onsite review sample?

For the sample, ODP understands that some providers have a limited sample pool and the AE can complete a review of the same individuals in this situation. You would complete a desk review for all individuals in your sample.

57. The guidance in the Provider Tool for Qs 36, 37, 41, 42 and 43 state that we are to review 25% of staff – is this 25% of all staff at the Provider entity? Is there a minimum and/or maximum of Provider staff to be reviewed?

ODP has received inquiries regarding workload efforts in relation to conducting a review of training questions that guide the reviewer to review 25% of staff, but no less than 5 Provider staff”. ODP has determined that for Cycle 1, Year 3, the guidance in training questions Qs 36, 37, 41, 42 and 43 will be revised to reflect the following: “The reviewer will review 25% of staff, but no less than 5 Provider staff and a maximum of 25 Provider Staff.” This change is effective as of 10/18/19. If the AE has already completed a review of more than 25 staff, the additional records reviewed must be included in the Review Spreadsheet and Corrective Action Plan, as applicable. Any onsite reviews completed after the date of this email distribution should follow the revised guidance.

58. Remediation action for Q38 and 39 – CPS training/voiding of claims – The current remediation language for

For Cycle 1 only, the following standards apply:





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Q38 and Q39 states “The Provider voids claims for all staff who did not complete the Department approved training on CPS and Provider staff completes the Department approved training on CPS”. How is this standard being applied?

Self-Assessment Review: If the Provider identified a non-compliance to Q38 and/or Q39 during the self-assessment phase, the Provider should immediately take action and have staff trained. No further action will be taken by the AE based on the self-assessment findings, documentation and remediation of all staff meeting training requirements. Provider Onsite Review:

• Staffing ratio 1:1 – if staff is not trained, the provider must void all claims and train staff.

• Staffing ratio includes more than one direct service professional – If there is at least one staff who completed the Department approved CPS training, the Provider will be exempt from voiding the associated CPS claims. In addition, ALL staff who did not complete CPS training, must do so within the required timeframe identified via the CAP process.

For Cycle 2 starting July 1, 2020, Providers will be held accountable for ensuring that all direct service professionals, program specialists, and supervisors of direct service professionals who provide CPS are trained in accordance with waiver requirements. If staff are not trained regardless of staffing ratio, voiding of claims will be enforced.

59.

AE Questions Tool


60. If someone transferred from P/FDS to Consolidated Waiver (or vice versa) within the last Fiscal Year, are they considered “newly enrolled” when answering the Self-Assessment questions? Or, is “newly enrolled” specific for those individuals who had previously been Base or SC only?

Newly enrolled questions should be answered for individuals who are going from Base/SC Services Only to a Waiver. These questions should not be answered for individuals moving from waiver to waiver.

61. Q12 – The QA&I Review Spreadsheet is showing “FALSE”.

Answer "Yes", "No" or "NA" to the 5 criteria (12.1 – 12.5) and then the answer for Q 12 will populate. The answer is listed as "FALSE" until all 5 criteria are answered.

62. Q12.4 Criteria 4 – AE sends the Comprehensive Report to all Providers within 30 calendar days of all onsite activities being completed Per the QA&I Process document dated 6/6/19, the Comprehensive Report should be sent to the entity

This question is being asked to ensure that AEs are sending Comprehensive Reports to the Providers so that they have a complete picture of their onsite review for a given year. ODP has revised this question with the highlighted information and the question now reads as follows: “AE sends the Comprehensive Report to all Providers timely.” The guidance for this question has also been revised to align with the new question and the highlighted information is included below.





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upon approval of all remediation. How should AEs answer this question?

• The reviewer validates that the AE submitted the QA&I Comprehensive Report to the Provider upon approval of all remediation or if there is no remediation within 30 calendar days of completion of all onsite activities, including interviews but no later than March 31st.

• The reviewer should review no more than 10 randomly selected QA&I Provider reviews. ➢ Mark YES if the AE submitted the QA&I Comprehensive Report to the Provider

timely. ➢ Mark NO if the AE did not submit the QA&I Comprehensive Report to the Provider

or the QA&I Comprehensive Report was not submitted timely. ➢ Mark NA if the AE has not been assigned any Providers to review by ODP.

NOTE – Reason(s) for non-compliance must be indicated in the comment field for this question.

63. Q42 – States “the individual was newly enrolled in the last fiscal year” – does this also apply to an individual who changed waivers or strictly an individual who is being enrolled in a waiver for the first time? Same question applies to individuals that may have gone into Reserve Capacity due to an extended stay in a hospital/rehab facility.

Newly enrolled are not people who transfer from one waiver to another or when they come off reserved capacity. As a reminder, newly enrolled questions should be answered for individuals who are going from Base/SC Services Only to a Waiver. These questions should not be answered for individuals moving from waiver to waiver.

64.





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SCO SPECIFIC QUESTIONS

ID/A SCO General Questions


65. Will SCOs be monitored by every

county that we work with or just by

the lead county?

ODP conducts the QA&I Review of SCOs. SCOs will be reviewed based on Service Location regardless of lead counties.

66. It appears that the SCO could have a desk review every year if they support individuals in multiple counties and if any of the individuals are chosen for the core sample of an AE which is having their onsite review.

Yes, the SCO could have a desk review every year if an individual from the SCO is part of the AE sample. A desk review consists of ODP doing the desk review NOT the SCO. The SCO would be required to complete any remediation that may be found during desk review, but this is the only responsibility of an SCO during non-onsite years.

67. Can we review each other’s results

on MyODP?

Yes, the comprehensive reports will be posted on MyODP without the attachments.

68.

ID/A SCO Self-Assessment


69. Should SCO's coordinate with the AE

when pulling sample records or

should we each pull separate

records?

No, SCOs should pull their own sample.

70. Will SCOs receive a unique link via

email as we did with SCO monitoring

to complete this new process and

when will we receive this link?

Yes, an email which contains a unique hyperlink will be sent out to all entity primary contacts on July 1st. If a SCO did not receive the email which contains the hyperlink on July 1st, please contact the QA&I mailbox at [email protected].

71. For the desk review, are we to be using the names that were used for the QA&I Individual Interview Pre-survey? Does the SCO and AE agree upon names? Or does ODP send us

No, we ask that you choose a different sample outside of the list of individuals identified for interviews. All entities choose their own sample for self-assessments. No agreement or approval is needed.







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the 10 they picked from the pre-surveyed?

72.

ID/A SCO Questions Tool


73. Can you provide clarification on what ODP is looking for on Question #11 on the self-review? Is a statement of what we are doing sufficient for a Yes?

This is an exploratory question which means it is non-scored to get an idea of what current processes and policies you have in place to collaborate with OVR.

74. Qs 18-22 – Are the training records

only for current employees?

Yes, you should only look at the training records of current employees. Please also ensure that you are following the guidance associated with each training question.

75. Q54 – How would I score for any individuals who have gestural communication?

The answer is based on how the SC communicates with the individual. If the person communicates via gestures and no additional support is needed mark NA. If the person needs additional support and all options were explored mark Yes. If there is a need for communication assistance and no further options were explored, mark No.

76. Q77 - Employment services. Can this be N/A if the person is retired?

Yes

77. Q80 - Is this a “Yes” or “No” if all waiver Providers except the Transportation Service Provider attended and signed the ISP signature page?

Transportation services have always been exempt from this requirement as ODP understands that they do not attend the meetings. If every other Provider was present, this is a Yes.

78. Qs 18 & Q20 – Are we to review 25% of all SCs at the SCO? Is there a minimum and/or maximum number of SCs to be reviewed?

ODP has received inquiries regarding workload efforts in relation to conducting a review of training questions that guide the reviewer to review 25% of staff, but no less than 5 SCs”. ODP has determined that for Cycle 1, Year 3, the guidance in training questions Qs 18 and Q20 will be revised to reflect the following: “The reviewer will review 25% of staff, but no less than 5 SCs and a maximum of 25 SCs.” This change is effective 10/18/19. If ODP has already completed a review of more than 25 staff, the additional records reviewed must be included in the Review Spreadsheet and Corrective Action Plan, as applicable. Any onsite reviews completed after the date of this email distribution should follow the revised guidance.





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79.

AAW SCO General Questions


80. Who completes the desk and onsite reviews for AAW SCOs?

All QA&I desk and onsite reviews for entities in the AAW will be conducted by one or more BAS Regional Office Representatives.

81. Can an SCO receive a desk or onsite review every year if they support an individual(s) in the AAW Core sample?

If an SCO is selected in more than one year of the QA&I cycle, the records from the sample will be reviewed from that SCO but ODP may or may not elect to do an additional onsite review of that SCO. SCOs will be expected to remediate any findings if included in multiple reviews of the QA&I cycle.

82. As an SCO, what happens if we do not work with anyone in the Core samples during the three-year cycle?

Any SCO that has not been included in the 1st or 2nd year QA&I review will be automatically included the third year of the QA&I cycle for review.

83. Is the SCO Tool and SCO QA&I Review Spreadsheet for the AAW different than what I am using for the ID/A waivers?

Yes, in Cycle, 1, Year 3, the SCO Tool and corresponding QA&I Review Spreadsheet for the AAW are different than what is used for the ID/A waivers.

84. Where are the Comprehensive

Reports posted?

The comprehensive reports will be posted on MyODP without the attachments.

85. How do we know who our assigned

BAS Regional Office Representative

is?

All entities receiving an onsite review will receive an Onsite Participation Letter and Submission Checklist by July 31st. This documentation will identify the assigned BAS Regional Office Representative.

86.

AAW SCO Self-Assessment


87. We did not receive an email on July

1st with the QuestionPro link. What

should we do?

If an SCO does not receive the email with the hyperlink on July 1st, they should send an email to the QA&I mailbox at [email protected]. Please make sure to add “AAW QA&I Question” in the subject line.

88. We are not currently working with

any individuals in the AAW. Do we

still need to complete the Self-

Assessment?

Yes, the Self-Assessment must be completed by all entities annually whether they’ve worked with an individual or not. Please refer to the guidance in the AAW QA&I SCO Tool regarding how to respond to each question.

89. What do we do with our self-

assessment during the years we do

not have an onsite visit?

It is the intention that all entities engage in quality improvement (QI) activities during the two-year period between formal QA&I onsite review. All entities are required to review the results of their self-assessments to prioritize QI opportunities. Annually, at the completion of the self-assessment process, ODP






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will issue an aggregate report of self-assessment results and analysis statewide. This report will be used to inform the QA&I process throughout the year and technical assistance targeted to SCOs and Providers.

90.

AAW SCO Questions Tool


91. With regards to the staff qualifications questions (#16-#20), which SC(s) need to be reviewed?

AAW SCs to be reviewed will be identified based on individuals selected in the Core Sample and the SC(s) authorized in the individual’s ISP. The time frame for review is three full months preceding the date of the review.

92.

PROVIDER SPECIFIC QUESTIONS

ID/A Provider General Questions


93. In a 3-year cycle, how do the Providers know what year of the Cycle we are starting with?

The QA&I process began July 1, 2017 and started with Cycle 1, Year 1 (C1Y1). All Providers must complete a self-assessment annually (all 3 years of a Cycle). Provider onsite reviews are determined by the last digit of the Provider’s Master Provider Index (MPI) #. Digits 0, 1 and 2 will get an onsite Year 1. Digits 3, 4 and 5 will get an onsite Year 2. Digits 6, 7, 8 and 9 will get an onsite Year 3. Providers newly qualified will be included in the QA&I Review during the next FY.

94. Will Provider samples only include individuals from the lead AE, or will Providers have to sample individuals from other AEs if Providers render services to them?

For the self-assessment, the sample should include a cross-section of individuals served, funding/program types, and locations and types of services. For the QA&I Onsite review, the AE will select 1% of participants with a minimum of 5 and a maximum of 10 for individuals who are registered with the Assigned AE and are authorized and actively receiving services from the Provider being reviewed. ODP no longer uses the terms “Lead AE” and “Reviewing AE”. The QA&I Process uses the terms “Assigned AE”.





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Q# Questions Answers Assigned AE is the AE assigned to monitor and qualify a Provider by ODP. The AE with the most individuals authorized with the Provider is designated as the Assigned AE. If a Provider does not serve any individuals, the Assigned AE is the AE that reviewed the Provider’s most recent Provider Qualification (PQ) application.

95. Will Providers have prior notice of the AE selected sample prior to the onsite review?

Yes, the Provider will be notified by the Assigned AE of the selected sample two weeks prior to the onsite review date.

96. Is this monitoring due every two years like Provider Monitoring was due?

No, the new QA&I cycle will occur over a 3-year period with each of the entities receiving a full QA&I review at least once within that period.

97. As a provider, I don't see much of a

difference between QA&I and

Provider Monitoring. Am I seeing

this correctly?

ODP’s intention with streamlining of the previous AE Oversight, SCO Monitoring and Provider Monitoring processes was to eliminate multi-layered process and unnecessary duplication; create more time to focus on the experience of individuals; create more time to focus on quality improvement; a desire to move away from hierarchical compliance and remediation toward collaborative partnerships that foster technical assistance and shared learning; and improve methods for collecting and using data in a timely way.

98. Will Provider Qualification be

eliminated with the new QA&I

process?

No, all Providers who wish to remain a willing and qualified Provider for ODP will need to complete the ODP Provider qualification process.

99. It appears Providers only must submit the checklist and supporting documentation when they have an onsite review. Is that correct?

The checklist is for Providers who are part of the QA&I review – the QA&I review is a combination of the desk review and onsite review, which occurs at least once for each AE, SCO and Provider during the QA&I cycle. Yes, only Providers who are getting an onsite will need to submit the checklist and supporting documentation.

100. If an individual is pulled in core

sample and that Provider isn’t due

for an onsite what happens?

ODP’s expectation of Providers in the years they are not due for an onsite is to participate in the interview process as applicable and ensure follow-up on any reported issues related to health and safety or service quality if an individual they provide services to is part of the core sample.

101. If a Provider is qualified but not

providing services, will they be

included?

Yes, a Provider who is in qualified status will be included in the QA&I review regardless of whether or not they serve any individuals.

102. Timeline clarification for interviews

and onsite. 2-day onsite closure. The

AE gives me a 2-week window. Could

Yes, this is possible. All interviews can take place before, during or after an onsite review.





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Q# Questions Answers the AE interview someone before I

even know the sample?

103. Could you explain more what is

going to be posted on My ODP for

Providers and AEs?

After an onsite review is completed for an entity, a copy of the final comprehensive report will be posted on MyODP. This will only include the comprehensive report, not any attachments or appendices.

104. When AE comes to review, they have

the capability to look at other

counties. What type of releases will

we need to prepare for that?

When the Assigned AE is coming to a Provider organization for an onsite review, the individuals selected in the sample would be from the Assigned AE only.

105. Is there a template for the

department approved room and

board contract that is to be signed

annually? If so where is it located?

The DP 1051 (in both English and Spanish) is the current room and board form and should be used. It is located on MyODP under Resources > Intellectual Disability Resources > Forms.

106. After completing QuestionPro self-assessment, if I’m getting an onsite review this year, I should send the completed QA&I Provider Review Spreadsheet to my AE? After that, because it’s an onsite year, I should wait to hear from my Assigned AE for a date and a list of individuals for a new sample?

Yes, you must send the completed QA&I Provider Review Spreadsheet to your Assigned AE as well as forward the email response from QuestionPro with your self-assessment entry. The Assigned AE will then contact you to schedule the onsite visit and provide you with the names of individuals they will be reviewing.

107. Should we answer questions only for services that we provide, or do we need to answer the questions for all services we are qualified to provide?

The Data and Policy questions are agency specific, if you have been determined eligible or qualified to provide a service the question applies. The responses to the individual record review questions should reflect what service is being provided to that individual. N/A options have been provided in instances where the question(s) does not apply to the individual being reviewed.

108. If we aren’t getting an onsite this year, we do not need to send any documentation upon completion of the self-assessment?

The requirement is that you complete the self-assessment process and forward the confirmation page from your entry into QuestionPro to the Assigned AE. The spreadsheet and any other documentation used to complete the self-assessment is required to be kept and provided only if requested.

109. If an agency is currently the Provider of several different services through ODP, ALL services would have their data reported within the one self-assessment for that agency?

If your agency has multiple MPI numbers, each MPI # is required to submit a separate self-assessment. The Provider Tool has questions that encompass the different services, so different entries are not needed for each service. The provider questions have “N/A” options so that if your agency does not render the service you have an option to select.

110.





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ID/A Provider Self-Assessment


111. Should provider samples only include individuals with waiver funding?

No, the sample should include a cross-section of all individuals served, funding/program types, and locations and types of services.

112. Will the sample that the Provider chooses be also used by the Assigned AE for the onsite review?

No, the Assigned AE will pull a separate sample.

113. Will Providers receive a unique link

via email as they did with Provider

Monitoring to complete this new

process and when will Providers

receive this link?

Yes, an email which contains a unique hyperlink will be sent out to all entity primary contacts on July 1st. If a Provider did not receive the email which contains the hyperlink on July 1st, please contact the QA&I mailbox at [email protected].

114. We have folks in many programs including bus passes and mileage. Does this sample draw include mileage and bus pass people?

If the only service an individual receives is mileage or bus pass, these individuals should not be a part of your sample. Your sample should include individuals that your agency provides services to in addition to mileage or bus pass. CLARIFICATION - If transportation services is the only service rendered, a sample of individuals should still be selected from that provider for review. The information provided during the July 19, 2017 training and the FAQs is in reference to providers who offer multiple services including transportation.

115. One of our centers is being acquired by another company in mid-August. What does that do to our requirement of completing this

process by August 31st?

If your agency will continue to provide services at other centers, you will need to complete the self-assessment. When choosing your sample, please do not choose anyone from the center that is being acquired by another company.

116. The Provider is picking a list of 5-10 individuals that they will review for the QA&I tool. Are these any individuals or only individuals for the Assigned AE? How does the Provider find out who the Assigned AE is?

For self-assessments, all entities must choose their own sample of individuals, which will include 1% with a minimum of 5 and a maximum of 10 records. This sample will include a cross-section of individuals served, including all funding/program types, locations and types of services.

The Assigned AE information is reflected on the QA&I ODP Contacts List in the Assigned AE column of the Providers tab and will be included on the onsite list which is posted on the MyODP website with the QA&I Process resources.

117.

ID/A Provider Questions Tool







19


118. We have a policy regarding freedom of choice and access but there is no specific mention of access to food. However, we do not service anyone with a restrictive procedure in place. Do we need to add access to food to the policy?

The policy should be updated to include all required elements.

119. Qs 24-26 – What about people who leave our service and go into nursing homes for skilled care or hospice?

The source document for these questions is 55 Pa Code Chapter 51 Section 51.31, which specifies “willing and qualified provider” so these questions apply when individual transitions to a new ODP Provider.

120. Qs 36, 37 and 41 – Do we review 25% of all staff that work with individuals in the sample or 25% of all staff?

Providers should review 25% of all staff regardless of if the staff works directly with

individuals in the sample or not. Per 55 Pa Code Chapter 51 regulations, staff is

defined as follows: “Employees, contractors or consultants that provide an HCBS

through direct contact with a participant or are responsible for the provision of an

HCBS.”

121. Qs 38 and 39 - CPS training - the ODP CPS training “Community Participation Support for Direct Support Professionals” should be completed by Program Specialists and Supervisors, for all agencies qualified for CPS, even if there is no sample/ authorizations, correct?

The waiver says “All Staff” need to complete the training by 07/01/2018 or within

60 days of hire even if there are no current authorizations. If they register to

provide the service, they must follow all qualifications as if they were providing

the service.

122. Qs 47 and 49 – Can you tell me what the difference is between these two questions?

After reviewing both questions, it has been determined that Q47 and Q49 are similar in nature. Therefore, for the self-assessment, Providers should select the same response for Q49 as they did for Q47. For Provider onsite reviews, AEs will not answer Q49. ODP has updated the Provider Tool and QA&I Review Spreadsheet to reflect this change.

123. Q 69 – What is a critical incident verses an incident?

Critical incidents are defined as incidents in the IM Bulletin (Bulletin 6000-04-01, Incident Management) as those requiring an investigation at any level.

- Abuse

- Neglect

- Misuse of funds

- Rights Violation

- Death

124. Q71 - If the individual had incidents but victim’s assistance was not appropriate/needed for those

When an incident of abuse, neglect, or any crime occurs, the individual should be offered support to contact Victims Assistance services. This question should not accept “informal counseling” as a measure for meeting compliance.





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Q# Questions Answers particular incidents, how do we answer?

When a crime occurs (regardless of who the perpetrator is), the individual (victim) must be offered the option and support to contact law enforcement to report the crime. In addition, the individual should be offered the option and support to contact Victims Assistance programs.

125. Qs 36, 37, 41, 42 and 43 – Are we to review 25% of all Provider staff at the Provider entity? Is there a minimum and/or maximum number of Provider staff to be reviewed?

ODP has received inquiries regarding workload efforts in relation to conducting a review of training questions that guide the reviewer to review 25% of staff, but no less than 5 Provider staff”. ODP has determined that for Cycle 1, Year 3, the guidance in training questions Qs 36, 37, 41, 42 and 43 will be revised to reflect the following: “The reviewer will review 25% of staff, but no less than 5 Provider staff and a maximum of 25 Provider Staff.” This change is effective 10/18/19. If the AE has already completed a review of more than 25 staff, the additional records reviewed must be included in the Review Spreadsheet and Corrective Action Plan, as applicable. Any onsite reviews completed after the date of this email distribution should follow the revised guidance.

126. Remediation action for Q38 and 39 – CPS training/voiding of claims – The current remediation language for Q38 and Q39 states “The Provider voids claims for all staff who did not complete the Department approved training on CPS and Provider staff completes the Department approved training on CPS”. How is this standard being applied?

For Cycle 1 only, the following standards apply: Self-Assessment Review: If the Provider identified a non-compliance to Q38 and/or Q39 during the self-assessment phase, the Provider should immediately take action and have staff trained. No further action will be taken by the AE based on the self-assessment findings, documentation and remediation of all staff meeting training requirements. Provider Onsite Review:

• Staffing ratio 1:1 – if staff is not trained, the provider must void all claims and train staff.

• Staffing ratio includes more than one direct service professional – If there is at least one staff who completed the Department approved CPS training, the Provider will be exempt from voiding the associated CPS claims. In addition, ALL staff who did not complete CPS training, must do so within the required timeframe identified via the CAP process.

For Cycle 2 starting July 1, 2020, Providers will be held accountable for ensuring that all direct service professionals, program specialists, and supervisors of direct service professionals who provide CPS are trained in accordance with waiver requirements. If staff are not trained regardless of staffing ratio, voiding of claims will be enforced.

127.

AAW Provider General Questions





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128. Who completes the desk and onsite reviews for AAW Providers?

All QA&I desk and onsite reviews for entities in the AAW will be conducted by one or more BAS Regional Office Representatives.

129. We’ve not served anyone in the AAW, do we still need to participate in the QA&I Process?

Yes, all AAW entities are responsible for participating in the QA&I Process whether they’ve worked with an individual in the AAW or not. Providers whose last digit of the MPI number ends in 0, 1 and 2 will be reviewed onsite in Year 1, numbers 3, 4 and 5 will be reviewed onsite in Year 2 and numbers 6, 7, 8 and 9 will be reviewed onsite in Year 3. ODP will notify Providers included in the review at the start of each cycle year.

130. Is the Provider Tool and QA&I Review Spreadsheet for the AAW different than what I am using for the ID/A QA&I Process?

Yes, in Cycle, 1, Year 3, the Provider Tool and corresponding QA&I Review Spreadsheet for the AAW are different than what is used for the ID/A waivers.

131. Where are the Comprehensive Reports posted?

The comprehensive reports will be posted on MyODP without the attachments.

132. How do we know who our assigned BAS Regional Office Representative is?

All entities receiving an onsite review will receive an Onsite Participation Letter and Submission Checklist by July 31st. This documentation will identify the assigned BAS Regional Office Representative.

133.

AAW Provider Self-Assessment


134. We did not receive an email on July 1st with the QuestionPro link. What should we do?

If a Provider does not receive the email with the hyperlink on July 1st, they should send an email to the QA&I mailbox at [email protected]. Please make sure to add “AAW QA&I Question” in the subject line.

135. We are not currently working with any individuals in the AAW. Do we still need to complete the Self-Assessment?

Yes, the Self-Assessment must be completed by all entities on an annual regardless if they’ve worked with an individual or not. Please refer to the guidance in the AAW QA&I Provider Tool regarding how to respond to each question.

136. Are individual interviews required for the Self-Assessment?

No, individual interviews are optional for the Self-Assessment.

137. What do we do with our self-assessment during the years we do not have an onsite visit?

It is the intention that all entities engage in quality improvement (QI) activities during the two-year period between formal QA&I onsite review. All entities are required to review the results of their self-assessments to prioritize QI opportunities. Annually, at the completion of the self-assessment process, ODP will issue an aggregate report of self-assessment results and analysis statewide.






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Q# Questions Answers This report will be used to inform the QA&I process throughout the year and technical assistance targeted to SCOs and Providers.

138.

AAW Provider Questions Tool


139. We are scheduled for a desk and onsite review but did not have an AAW individual identified in the Core sample. How will the questions regarding staff qualifications be answered?

If the Provider does not have an individual selected in the Core Sample, the AAW Sampling and Claims Lead will select one individual receiving AAW services from the Provider that will determine which Provider Staff will be reviewed. The staff qualifications documentation will be requested as part of the desk review.

140.

Quality Management Plan Questions


141. Is a review of the Quality Management Plan and accompanying Action Plan a part of the QA&I process for AEs, SCOs, and Providers?

Yes, ODP and/or the AE, as appropriate, will review and evaluate each entity’s QM Plan and accompanying Action Plan as part of the QA&I Process. This review occurs during the year each entity undergoes a full review.

142. How often must AEs, SCOs, and Providers update QM Plans and accompanying Action Plans?

Current Chapter 51 regulations require SCOs and Providers to update QM Plans at least every two years, while Chapter 6100 regulations, when promulgated, will require SCOs and Providers to update QM Plans at least every three years. While these minimum requirements exist, ODP promotes the best practices that QM Plans are written and/or updated each fiscal year, and that QM Action Plans are used and updated throughout each fiscal year. In addition, if an area in need of systemic improvement is identified during the QA&I Process, and an update is needed to the QM Plan and/or Action Plan in order to address this finding, the entity will be expected to submit an updated QM Plan and/or Action Plan to the Regional QA&I Review Team or AE, as appropriate, as part of its Plan to Prevent Recurrence (PPR). This update will be due within 30 days of the date of the closure of the entity’s Comprehensive Report.





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143. What are ODP's requirements for stakeholders to attend QM Certification Classes?

ODP encourages all AEs, SCOs, and Providers to send staff involved in QM Plan and Action Plan development and in the QA&I Process to QM Certification Classes. ODP requires that at least one member of the AE Review Team that monitors Providers using QA&I Process becomes QM Certified.

144. How do I obtain technical assistance in developing QM Plans and Action Plans?

For all entities: The first point of contact for technical assistance in developing QM Plans and Action Plans begins in your organizations with any staff who have become ODP QM Certified. For ID/A AEs and SCOs: The second point of contact is the ODP Regional QA&I Coordinator, who will collaborate with ODP’s QM Staff for input when indicated. For ID/A Providers: The second point of contact is the AE Review Team Lead. AEs may collaborate with ODP’s Regional QA&I Coordinator when indicated. For AAW SCOs and Providers: The second point of contact is to send inquiries to the QA&I Resource Account at [email protected] with “AAW QA&I Question” in the subject line. AAW Regional QA&I Leads will collaborate with ODP’s QM Staff for input when indicated. ODP QM Staff continue to offer QM Certification Classes, open to AEs/Counties, SCOs, Providers, HCQUs, and ODP Staff. Four classes will be available in fall 2019. Please refer to the ODP Announcement 19-079 that outlines dates, locations, and requirements for these classes. ODP QM Staff will schedule additional classes in spring and fall 2020 and ongoing as long as the need for training exists. Please watch for future communications that will include details.

145. How do I fold a QM Plan and/or Action Plan updated as a consequence of the QA&I Process into the fiscal year cycle for QM Planning?

If you have the applicable QM Plan and accompanying Action Plan Focus Area already in place, and findings from the QA&I Process prompt you to update these documents,

o Update your existing Action Plan until it’s time to develop your new fiscal year QM Plan and Action Plan, then

o Update your QM Plan and Action Plan to begin July 1.

If you discover an area where you need to develop a new QM Plan and accompanying Action Plan Focus Area,

o Add that new Focus Area, Goal and Target Objective to the existing QM Plan that will carry you to June 30th of the following fiscal year.

o This may mean your Target Date is more than 12 months away. o Add Action Plan steps to achieve the Target Objective.

Implement the new work immediately with continuation in the following fiscal year.






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146. If an agency updates the QM Plan to incorporate either self-assessment or QA&I process review results, and then the following year the percentage has increased and is no longer an area of concern, should the agency keep it in their QM plan?

The agency should develop a strategy to assure the improved level of performance is sustained, and for ongoing evaluation of the entity’s performance in that area. With those strategies in place, that Desired Outcome and supporting Target Objective can be removed, and the entity can focus on a new area.

147. Is ODP looking to see if QM Plans have ODP’s mission, vision and values verbatim?

No. ODP is looking for each entity to choose Focus Areas and Desired Outcomes to work on those areas that promote ODP’s mission, vision, and values. Examples of Desired Outcomes are listed on p. 4 of the Provider, SCO, and AE Questions Tools for both the ID/A Waivers and the AAW.

148. What if you find something systemic with an SCO? Should it be part of the AE plan?

If a systemic problem is identified within an SCO, that problem should be incorporated into the SCO’s QM Plan and Action Plan. If a systemic opportunity for improvement is identified that depends on involvement of both an AE and SCO in the ID/A waivers, such as increasing employment or ensuring critical revisions are completed on time, the AE and SCO should consider collaboration. Each entity involved should include the relevant Focus Area, Desired Outcome and Target Objective, based on its role in the process, in the respective QM Plan and Action Plan.

149. A. I have a current QM plan for

2017-2019. Once I complete the

self-assessment, is it the

expectation that I will revise the

plan based on areas that show a

need for improvement?

B. If this is what is to be

completed, am I sending in the

revised QM plan or the current

one, as I am not certain I will

have the plan corrected by the

Aug 31 deadline?

C. Finally, my QM plan includes the

actions to be taken for

remediation—is this ok?

Yes, if opportunities for systemic improvement are identified during the self-assessment, you should update your QM Plan and/or accompanying Action Plan accordingly. Although the minimum requirement to update QM Plans is every two years based on Chapter 51 regulations and will be every three years when Chapter 6100 regulations are promulgated, ODP promotes the best practices that QM Plans are written and/or updated each fiscal year, and that QM Action Plans are used and updated throughout the fiscal year. ODP asks entities scheduled for onsite review in a given year to submit their QM Plan and Action Plan prior to the onsite review date. QM Plans and Action Plans do not need to be submitted in other years unless requested. In a year when you are undergoing an onsite review, you can send what you have completed to ODP by the due date specified. If you decide to update it further, you can provide the updated version to the Regional Coordinator when you get the two-week notification letter for onsite review. No, remediation is not documented on a QM Plan and Action Plan. Remediation is action taken in response to each individual problem identified through the review process and is entered into the respective database for each entity and/or the Corrective Action Plan (CAP) document. A Plan to Prevent Recurrence (PPR) of individual problems is summarized in the PPR section of the CAP document.





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Q# Questions Answers QM Plans and Action Plans are used to develop and document quality improvement projects when an opportunity for systemic improvement is chosen or required. For example, an entity develops a QM Plan and Action Plan when choosing to work on one of ODP’s ISAC Recommendations, such as increasing competitive integrated employment for all those who wish to work or ensuring all those who are in need of a communication system have one. QM Plans and Action Plans are also required and developed when performance of an entity in an area is < 86% and, after analysis, it is found that the issues are systemic—occurring throughout the organization—and a quality improvement plan and action plan are needed in order for the organization to improve its processes and sustain the changes made.

ODP has developed and provides QM Plan and Action Plan templates on MyODP.org at https://www.myodp.org/course/view.php?id=181. If an entity chooses to create its own QM Plan and Action Plan forms, during the review process ODP will look for the same elements that appear in ODP’s templates to be incorporated into these documents. ODP encourages all stakeholders to attend QM Certification Class for more in-depth discussion on developing QM Plans and Action Plans. Dates and locations for these classes are posted on MyODP.org at https://www.myodp.org/calendar/view.php?view=upcoming&course=1.

150.


https://www.myodp.org/course/view.php?id=181

https://www.myodp.org/calendar/view.php?view=upcoming&course=1

Quality Assessment & Improvement (QA&I) Process Cycle 1, Year …... · 2020. 1. 2. · Resources >...

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