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9/10/2021
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Patricia W. Tulloch RN, BSN, MSN, HCS-D
Senior Consultant
845-889-8128
COMPLIANCE READINESSCONTINUOUS QUALITY
IMPROVEMENT
PROGRAM GOALS
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➢ Identify required elements for New York State
Licensed Home Care Provider Continuous Quality
Improvement (CQI) Programs.
➢ Clarify common priority CQI initiatives and helpful
benchmark data.
➢ Discuss tips and tools that support CQI.
➢ Quick Reference Take Aways
NYS DAL Updates on In Person Visits & Waiver Updates
Sample CQI Agenda
Sample Employee Infection Report & Log
NYS DOH Clinical Record Audit Tool
Perform a Self-Assessment. Where are Your Gaps?
Mitigate Your Compliance Risks
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PROGRAM NOTES
➢ This information is intended for informational
purposes only and is updated for information up to
September 10, 2021.
➢ Note that CMS, CDC, the New York State
Department of Health, New York State Medicaid and
all regulatory bodies update official information on a
regular basis during this Public Health Emergency.
➢ Please reference the resources listed on the last slides
to continue to track and update on all relevant
provider developments on this topic.
➢ This information is not intended to render medical,
legal, financial, accounting or other professional
advice. Seek expert relevant assistance as needed. 3
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POST WEBINAR 2 QUESTIONS
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➢ Can aide skills assessments be completed virtually?
No
➢ Is orientation/supervision required for each
new/temporary aide. Can this be virtual?
Yes, orientation/supervision for each new/temporary
aide is required.
As of August 23, 2021, aide orientations/supervisions
may no longer be virtual. (Reference DAL 21-11Tool)
➢ Reference the NYS DOH Memorandum for Expired
Waivers.
➢ Agency Considerations
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POST WEBINAR 2 QUESTIONS
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m➢ Is the TB Risk Assessment a Self Assessment?
No. A medical professional (MD, RN, PA, CNS) must
perform and document the TB Risk Assessment
Questionnaire.
➢ Please clarify the annual TB testing for a person born in
another country with high levels of TB.
Personnel who risk exposure to active TB through
travel of a month or more to a region of high
incidence are recommended to undergo pre-and post-
travel symptom screening. Post-travel screening
should occur more than 8 weeks after returning and
serial TB screening and testing may be warranted for
employees who regularly visit these regions.
➢ Reference NYS DOH DAL 21-05
TB Testing Clarification
ONE MORE WEBINAR 2
QUESTION
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➢ How do we handle the situation when the MLTC
has authorized a PCA but the patient has oxygen,
ostomy or other complex care needs? Can we
place a HHA in these situations?
You may only place the PCA services that are
authorized by the MLTC.
However, you must notify the MLTC that this
patient’s care needs require a higher level of care.
Document those calls.
Ensure the PCA is not providing care out of their
scope of practice.
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WAIVER EXPIRATION UPDATES
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m➢ NYS OHIP Memorandum
✓ MLTCs In-Person UAS Assessments
✓ MLTCs Physician Authorizations
➢ NYS DOH Memorandum DAL 21-09
✓ Inservice Requirements
➢ NYS DOH DAL 21-11 (See Webinar DAL Tool)
✓ Waiver Updates for HH & Hospice
▪ Resume in-home & in-person supervisions
▪ Resume in-home & in-person assessments
& reassessments
▪ Resume in-home annual evaluations
▪ Reminders: Health Assessments
➢ Bottom Line Here
✓ Ensure staff understanding of all waiver
updates
LHCSA STANDARDS
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➢ 766.1 Patient Rights
➢ 766.2 Patient Service Policies and
Procedures
➢ 766.3 Plan of Care
➢ 766.4 Medical Orders
➢ 766.5 Clinical Supervision
➢ 766.6 Patient Care Records
➢ 766.9 Governing Authority
➢ 766.10 Contracts
➢ 766.11 Personnel
➢ 766.12 Records and Reports
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CQI REQUIREMENTS➢ Section 766.9 Governing Authority
➢ Appoint a quality improvement committee to establish
and oversee standards of care. The quality improvement
committee shall consist of a consumer and appropriate
health professional persons.
➢ The committee shall meet at least four time a year to:
➢ Review policies pertaining to the delivery of the health care
services provided by the agency and recommend changes in such
policies to the governing authority for adoption.
➢ Conduct a clinical record review of the safety, adequacy, type
and quality of services provided which includes:
➢ Prepare and submit a written summary of review findings to the
governing authority for necessary action.
➢ Assist the agency in maintaining liaison with other health care
providers in the community.9
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MORE ON CQI REQUIREMENTS
➢ Conduct a clinical record review of the safety,
adequacy, type and quality of services provided which
includes:
✓ Random selection of records of patients currently
receiving services and patients discharged from the
agency within the past 3 months and;
✓ All cases with identified patient complaints as specified in
subdivision of this section.
➢ Clinical Record Audit Considerations
➢ Must audit both active and discharged clinical records
➢ Must audit to assess safety, adequacy, type and quality of
services
➢ Sample Size10
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BOTTOM LINE
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➢ Know Your Regulations & Standards
Consolidate the DAL Updates
✓ Annual Review & Update Policies, Procedures
& Practices
✓ Document to Support all Required Regulatory
& Billing Standards
✓ Attend HCP/CHC Webinars & Conferences to
Clarify Policies & Practices
➢ Proactively Mitigate High Risk Issues
✓ Internal Compliance & Quality Audits
➢ Update Your CQI Indicators Annually
✓ Consider High Risk Indicators
✓ Include Survey Plans of Correction
CQI BASICS
➢ Members
✓ Appointed by the Governing Authority
➢ Schedule: At Least Four Times Per Year
➢ Agenda Items: See Sample Reference CQI Agenda
➢ Minutes
✓ Clear Data Review
✓ Committee Discussion
✓ Committee Recommendations to the Governing Authority
➢ Report to Governing Authority
✓ May be the CQI Minutes or Summary of Minutes with Recommendations per Topic
➢ Continuity & Follow-up
✓ Ensure Follow-up on Topics, When Discussed & Needed 12
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SAMPLE CQI AGENDA
➢ Requirements
➢ Incidents & Accidents/Occurrences (I&Os)
➢ Both Patients & Employees
➢ Complaints
➢ Both Patients & Employees
➢ Infections
➢ Both Patient & Employees
➢ OSHA
➢ Exposures (Needlesticks/TB/Other)
➢ COVID-19 Exposures
➢ Emergency Disaster Plan
➢ Activations
➢ Plan Updates
➢ Utilization Review
➢ Active & Discharged Records; Complaint Files
➢ Policies & Procedures: New & Revised
➢ Other: Survey POC Updates
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MORE ON CQI AGENDA
➢ Consider Other Provider Select Indicators
➢ Patient & Employee Satisfaction
➢ PPD Conversions
➢ Timely supervisory visits completed on the day the aide
initiated service
➢ Timely & complete TB Risk Assessment Questionnaire
➢ POC Indicators
➢ Specific to your last survey & Plan of Correction
➢ Example: Utilization of CHRC Form 105 within 30 days
of aide termination
➢ Example: Updated Personnel on HCS
➢ Compliance Reports: Contract Audit Results
➢ Community Liaison Report
➢ HHATP/PCATP Indicators14
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MORE ON CQI AGENDA
➢ HHATP/PCATP Indicators
➢ Report Program Outcomes
➢ Audit Trainee Files
➢ Report Trainee Program Evaluations
➢ Other Program Indicators
➢ Program CQI Indicators
➢ Number of Trainees who completed Training Program
➢ Number of Trainees who passed the program and received
a certificate
➢ Number of Trainee Files compliant with all requirements
for the Training Program
➢ Number of trainees employed by the agency
➢ Trainee Satisfaction with Training Program
➢ Discussion & Recommendations15
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PROVIDER ISSUES: CQI➢ Operational (Process Issues)
✓ Committee members do not include a consumer
✓ Not scheduled four times per year
✓ Minutes lack details & recommendations
✓ Policies & Procedures not reviewed & updated
✓ Lack of follow-up on recommendations
➢ Documentation
✓ Be specific regarding the issue, discussion & recommendations
✓ Example: TB Risk Assessment not performed by health professional
Discussion: Confusion regarding the changed policy
Plan: Educate staff regarding updated policy and form
Recommendation: Monitor & report to CQI quarterly on the
implementation of the TB Risk Assessment Questionnaire
➢ Recommendations: Monitor in Quality Committee for
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INCIDENTS & ACCIDENTS
➢ Sample Data Review
➢ 32 I & O’s Reported
➢ 11 Falls (11 On Service Hours; 0 Not on Service Hours)
➢ 11 Falls resulted in:
➢ 9 – No injury
➢ 1 – Elbow bruise
➢ 1 – Elbow skin tear
➢ 21 Other Incidents
➢ 10 skin issues
➢ 2 respiratory issues
➢ 2 behavior outbursts
➢ 7 Employee related issues
➢ 3 accusations of theft
➢ 1 drug use in client’s home
➢ 3 late without notifying client/agency
➢ Committee Discussion
➢ Recommendations
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MORE ON INCIDENTS & ACCIDENTS
➢ Sample Data Review & Presentation
➢ Committee Discussion
➢ Recommendations
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CQI I & O’S
➢ Committee Discussion
➢ Incident Actions and/or Resolutions Reviewed
➢ Number of aides coached; replaced and/or terminated
➢ Committee discussed fall rates and care options.
➢ DPS discussed the need for more specific interventions to decrease falls.
➢ Recommendations
➢ Update Admission Packet with Patient/Family Education to minimize falls
➢ Update aide inservice on fall prevention
➢ Educate RNs on specific fall prevention on aide Plan of Care
➢ Expand clinical record audits to include fall prevention on aide plans of care
➢ Recommendations Forwarded to Governing Authority 19
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COMPLAINTS
➢ Sample Data Review
➢ 4 Patient Complaints
➢ Aide not performing light housekeeping per Plan of Care
➢ Aide not arriving on time
➢ Aide cannot speak Spanish
➢ Aide sleeping during work hours
➢ Committee Discussion
➢ DPS reported the investigation and resolution for each complaint
➢ Aides were counseling and/or replaced
➢ Patient satisfaction with resolution reported for each complaint
➢ Recommendations
➢ Ensure complete documentation of all complaints, investigations
& resolutions on Complaint Forms
➢ Ensure completion of Complaint Log
➢ Ensure HR personnel files are updated for aide counseling 20
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CQI I & OS’ (OSHA)➢ Employee Reportable OSHA Incidents
➢ Definitions➢ OSHA Reporting Criteria for Work Related Incidents
➢ Record those work-related injuries and illnesses that result in:
➢ Death
➢ Loss of consciousness
➢ Days away from work
➢ Restricted work activity or job transfer, or
➢ Medical treatment beyond first aide
➢ OSHA Reporting Criteria for COVID-19 for Employees➢ Fatality-COVID Related & Work Related COVID Confirmed
➢ Work Related COVID Confirmed
➢ Find date of positive test
➢ Determine number od days between test and death
➢ If death is within 30 days: Contact OSHA via telephone/Online within 8 hours of Death Notification
➢ If death is past 30 days – no notification required but must be on OSHA 300 Form
➢ COVID-19 Employee Infections➢ Report on Infection Reports & Log
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MORE ON CQI OSHA
➢ Employee Community COVID-19 Confirmed
➢ Work Related
➢ Document on OSHA 300 Log/Form for those employees with lost
time
➢ Work Related
➢ No time lost. No need to document on OSHA 300 Log/Form
➢ Considerations
➢ Work Related Most Often Cannot be Determined
➢ Caution: See Legal Counsel
➢ All Infection Reports & Logs are Confidential
➢ Only report as an aggregate to CQI
➢ Do NOT use any names during CQI
➢ Do NOT document names in CQI minutes22
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INFECTIONS
➢ Sample Data Review
➢ Patients & Employees
➢ Patients (See Sample Report)
➢ 6 Non-COVID Patient Infections
➢ 1 Pneumonia
➢ 3 UTIs
➢ 1 Leg Infection
➢ 1 Arm infection (post cat scratch)
➢ O Patient COVID Infections
➢ Committee Discussion
➢ 4 Patients hospitalized
➢ All patients placed on antibiotic therapy
➢ Recommendations
➢ Ensure all aides have PPE and are updated on PPE, infection control and when to report patient changes to the agency
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EMERGENCY DISASTER
PREPAREDNESS
➢ Sample Agency Data Review
➢ Participation in EDP Drills
➢ Staff Contact List Not Updated
➢ EDP Patient Roster Not Updated Per NYS DOH Requirements
➢ Missing caregiver contact numbers
➢ Committee Discussion
➢ Update Policy & Procedure for Who Updates the Staff
Contact List & Frequency of Updates
➢ EDP Roster Updates: Who; How; When
➢ Oversight for Both
➢ Recommendations
➢ Policy & Procedure Updates
➢ CQI Monitoring for 202124
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QUARTERLY RECORD AUDITS
➢ Sample Clinical Record CQI Data Review (See Tool)
➢ Clinical Indicators (10 Clinical Records: 8 Active & 2 Discharge) Complaint Files Next
➢ 9/10 records contained signed & dated consents for services
➢ 9/10 records contained a completed financial liability statement
➢ 8/10 records contained initial orders signed & dated by the MD in a timely manner (1 year)
➢ 10/10 records contained timely recertification orders
➢ 7/10 records conducted timely nursing reassessments
➢ ½ discharge records has completed and timely discharge summaries
➢ 7/10 records had timely aide supervisory visits
➢ 5/10 records duty sheets matched the aide Plan of Care
➢ Determine Safe, Adequate & Appropriate
➢ Document Percent (%) Records: Safe; Adequate & Appropriate
➢ Committee Discussion
➢ Recommendations25
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MORE ON CLINICAL RECORD
REVIEW➢ More on Sample Data Review & Presentation
➢ Timely Aide Supervisory Visits: Initial & Every 6 Months
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CLIENT SATISFACTION➢ Sample Data Review
➢ Third Party Vendor or Provider Based Surveys
➢ Indicators
➢ Would Recommend Agency
➢ Ability of Caregiver
➢ Communication with Agency
➢ Client/Caregiver Compatibility
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MORE ON CLIENT SATISFACTION➢ Other Provider Examples: Agency Satisfaction Survey
➢ Committee Discussion & Recommendations
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COMMON PROVIDER ISSUES
➢ Operational
✓ Systematic Processes to Report & Collect CQI Data
✓ Staff Not Updated on Required Agency Policies & Procedures
✓ Complaints
✓ Incidents & Accidents
✓ OSHA
✓ Not a Designated Person Responsible & Accountable to Oversee
CQI Data Collection, Consolidation & Reporting
✓ Data Complexity & Confusion
✓ No Follow-up On Data or Process Issues Identified by CQI
➢ Documentation
✓ Provider forms are not complete
✓ Example: Complaint Log Not Complete for Resolution; Resolution
Date & Name of Person Investigating & Resolving Complaint
➢ Recommendations: Review CQI Processes 29
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OTHER CQI CONSIDERATIONS
➢ Value Based Purchasing (VBP) Indicators
✓ Prevent Rehospitalization
✓ Pneumonia
✓ Urinary Tract Infections
✓ Sepsis
✓ Other
✓ VBP Indicators: MLTC Contract Reports
✓ Integration with CQI: Audit for Aide POC & Outcomes
➢ High Risk Indicators
✓ Agency Specific
✓ Industry Specific
➢ Bottom Line
✓ How Do You Continue to Improve Care & Services?
✓ How Do You Document Those Improvements?30
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RESOURCE WEB SITES
www.cms.govCenters for Medicare & Medicaid Services
www.health.ny.govNew York State Department of HealthLHCSA Regulations & DALs
www.omig.ny.gov
New York State Office of Medicaid Inspector General
OMIG Work Plan
www.oig.hhs.govOIG (Office of Inspector General)
www.cms.gov/medicare/mr
Medicare Medical Review Program 31
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