The CMS Quality Review Process

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The CMS Quality Review Process

• Suzette Seng, CMS Region VI
• Jessica Hickey, CMS Region VI

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CMS - HCBS

• CMS - Centers for Medicare and Medicaid Services
• Federal Agency
• Jointly funds Medicaid programs with the states
• State and Federal governments have joint
  responsibility for overseeing the quality of
  Medicaid programs
• HCBS - Home and Community-Based Service
• Medicaid HCBS funded through waivers
• 1915c waivers
• Allow states to provide waiver services/supports
  to persons at risk of institutionalization

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Waiver Program Facts and Figures

• Approximately 300 programs
• Nearly 1 Million Individual Participants
• HCBS Spending - 2006 (www.hcbs.org)
• - 299 B - 9 of Medicaid Spending
• - 99 B -26 of Medicaid LTC Spending

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Rapid GrowthWaiver Expenditures

• 1993 2.8 Billion
• 1995 4.6
• 1997 8.2
• 1999 11.2
• 2001 14.8
• 2003 18.9
• 2005 22.7
• 2006 25.6

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Quality in the Waivers

• GAO Investigation and 2003 Report
• Lack of services, weak care plans and inadequate
  case management
• States not required to provide much information
  on QM to CMS
• Lack of CMS oversight
• CMS not providing guidance on QM to States
• State QIS and CMS oversight must improve

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CMS Prior Approach

• Minimal information about quality in waiver
  application
• Minimal annual reporting on quality (372)
• On-site reviews once every 5 years
• Findings based on non-representative samples
• Findings - snap-shot in time

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Principles CMS Waiver Quality Initiative

• States have primary responsibility for first line
  monitoring to assure access, service delivery,
  provider qualifications, health and welfare,
  administrative authority, and financial
  accountability
• States will provide evidence to CMS that they
  have met the waiver assurances
• CMS will ensure states are meeting the assurances
  through the review of evidence that States
  provide.

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CMS Action Plan, September 2003

• Provided states with more detailed guidance
  regarding HCBS quality management
• Required states to submit more specific
  information about their quality management system
  prior to waiver approval
• Requested that states provide timely and adequate
  information to CMS in annual waiver report
• Improve CMS oversight.

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Quality as a Priority

• 2004 CMS Interim Procedural Guidance
• Established evidentiary approach
• Clarified the review process
• State Medicaid Agencies have the first line
  responsibility for quality assurance
• Focus on design implementation of QMS
• CMS role Assess State processes for ensuring
  monitoring of the quality assurances
• Emphasis on continuous quality improvement not a
  point it time/look-behind)

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HCBS Waiver Quality Life Cycle
CMS
State Ongoing Communication
State Submits to CMS
Initial Application with QM Strategy
Renewal Application with QM Strategy
CMS Assess- ment Report
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CMS - States Collaborated on the Revised Waiver
ApplicationVersion 3.1, April 2005

• State Association representatives involved
  throughout the process
• NASUA State Units on Aging - 3
• NASDDDS Developmental Disability Directors - 3
• NASMD Medicaid Directors - 3
• NASHIA Head Injury Administrators - 3
• Cash and Counseling Projects - 1
• CMS Central and Regional Staff involved

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CMSs HCBS Quality Initiative

• NEW WAIVER APPLICATION
• Design of your quality management system
• How will you know about address problems it in
  a timely way?
• What will be done to monitor the system on an
  ongoing basis?
• Who will do it?
• EVIDENCEYearly reporting on waiver quality to
  CMS.
• New 373Q (Implementation Date TBD)
• Reports on whether waiver is operating as
  intended
• Reports on what state did to fix problems it
  discovered
• ONGOING DIALOGUE between CMS and States
• Review of evidence
• Conference calls, emails, On-site visits

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Steps in the Quality Review Process

• CMS Sends A Request for Evidence
• State Submits Evidence to CMS
• CMS Reviews Evidence
• CMS Regional Office Conducts Site Visit at least
  once per waiver cycle
• CMS Issues Draft Report to State
• State Responds to CMS Draft Report
• CMS issues Final Report Incorporating State
  comments.

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IPG Timeline
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Submitting Evidence

• States are instructed to submit evidence
  demonstrating monitoring of the following
  assurances (42 CFR 441.301 441.302)

• Level of Care
• Plan of Care
• Qualified Providers

• Health and Welfare
• Administrative Accountability
• Financial Accountability

• States should avoid submitting items that focus
  solely on processes such as state operating
  manuals, policies and procedure guides, etc.

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Evidence

• Evidence is
• Qualitative and quantitative data collected by
  the state (or other operating agencies) as a
  result of monitoring processes
• Aggregated, trended and applied to the overall
  waiver population
• Evidence is not
• State policies and procedures
• Individualized information of any type
• If QA/QI strategy is under development
• State should submit a plan with relevant
  timelines for implementation

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Quality Life Cycle

• Design Build in mechanisms to
• - prevent problems from happening
• - identify bad things asap
• - address problems quickly
• Discover Execute your plan to uncover problems as
  they happen
• Remediate Execute your plan to address problems
  in a timely fashion
• Improve Learn from what didnt work and develop
  strategies for re-designing the system, if
  necessary.

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Quality Life Cycle
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QIS - Everyones Job

• Each level
• Collects information
• Aggregates information
• Analyzes for patterns/trends
• Reviews analyzes previous levels trend
  identification, remediation, follow-up
• Conducts further investigation as appropriate

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Statutory Assurances42 CFR 442.302

• A 1915(c) waiver shall not be granted unless the
  State provides the following assurances
• Level of Care
• Plan of Care/Freedom of Choice
• Qualified Providers
• Health and Welfare
• Administrative Authority
• Financial Accountability

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Level of Care

• An evaluation of Level of Care (LOC) is provided
  to all participants for whom there is reasonable
  indication that services may be needed in the
  future
• LOC determinations are conducted in a timely
  fashion and are reevaluated at least annually or
  as specified in the approved waiver
• The process and instruments described in the
  approved waiver are applied to determine LOC
• The State monitors level of care decisions and
  takes action to address inappropriate LOC
  determinations

Appendix B-6 Evaluation/Reevaluation of Level of
Care
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Evidentiary Examples

• Summary reports that include any one or
  combination of the following and are based on a
  significant sample
• Record reviews (on and off-site)
• Interviews
• Analysis of surveys, focus groups or interviews
• Performance monitoring of agencies involved in
  LOC determination
• Mortality reviews
• Meeting minutes
• Summary of corrective actions

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Plan of Care

• Plan of Care (POC) addresses all participants
  assessed needs and personal goals, either by
  waiver services, Medicaid State Plan or through
  other means
• The State monitors POC development in accordance
  with its policies and procedures and takes
  appropriate action when it identifies
  inadequacies in the development of POCs
• POCs are updated/revised when warranted by
  changes in the waiver participants needs
• Services are delivered in accordance with the POC

Appendix D-1 Service Plan Development
Appendix D-1 Service Plan Development
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Evidentiary Examples

• Summary reports that include any one or
  combination of the following and are based on a
  significant sample
• Record reviews (on and off-site)
• Interviews
• Analysis of surveys, focus groups or interviews
• Reports of monitoring service refusals and
  analysis
• Performance monitoring of agencies involved in
  POC
• Mortality reviews
• Reports from state monitoring that compare the
  participants needs, POCs and case notes and
  whether needed revisions are made
• Meeting minutes
• Summary of corrective actions

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Plan of CareFreedom of Choice

• Two types of freedom of choice
• Between waiver services and institutional care
• Between/among waiver services and providers

Appendix B-7/Appendix F-1
Appendix B-7 Freedom of Choice Appendix
C-2-f Open Enrollment of Providers
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Evidentiary Examples

• Results of focus groups or interviews with
  participants/family
• Analysis of complaints and/or incident reports
• Minutes of committee meetings showing evaluation
  of findings and recommendations including
  strategies for improvement developed
• Summary of file/case reviews (on and off-site)
• Summary of corrective actions

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Qualified Providers

• The state verifies on a periodic basis, that
  providers meet required licensing and/or
  certification standards and adhere to other state
  standards
• The state monitors non-licensed/non-certified
  providers to assure adherence to waiver
  requirements
• The state identifies and rectifies situations
  where providers do not meet requirements
• The state implements its policies and procedures
  for verifying that training is provided in
  accordance with the state requirements and the
  approved waiver

Appendix C Waiver Service Specifications,
Provider Qualifications
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Evidentiary Examples

• Summary reports that include any one or
  combination of the following and are based on a
  significant sample
• Reports from state monitoring (licensing
  agencies)
• Training verification records
• Provider performance monitoring
• Mortality reviews
• Critical events and incidents
• Medication administration data reports
• Reports of onsite monitoring and observation
• Meeting minutes
• Summary of corrective actions

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Health and Welfare

• The State must assure that the necessary
  safeguards have been taken to protect the health
  and welfare of recipients of the services.
• State must identify, addresses, and seeks to
  prevent instances of abuse, neglect, and
  exploitation.

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Health and Welfare

• In the event of identified abuse, an analysis
  must be conducted of abuse, neglect and
  exploitation trends and strategies implemented
  for prevention.
• This can be done in part by way of
• Complaint system in place
• Critical Incident Management System
• Routinely monitoring participants health and
  safety
• Conducting a trend analysis and
• Developing and implementing revised policies and
  procedures as a result of lessons learned.

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Evidentiary Examples

• Ongoing monitoring reports
• Reports and analysis of complaints, abuse,
  neglect and exploitation
• Results of investigations and actions taken
• Reports and action taken on plan of care
  discrepancies
• Participant Experience Survey
• Minutes of committee meetings that show review of
  monitoring, recommended actions and follow-up
  reports.
• i.e, Mortality Review Committee implementation
  of QA/QI Strategies.

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Evidentiary Example

• Description of the state quality management
  program with evidence of activities such as
  monitoring and developing review reports
• Focus groups
• Targeted Reviews
• Quality Improvement projects
• Committee minutes
• Record of actions taken
• Record of service denials and appeal requests
• Annual appraisals of the Quality Improvement
  Program.

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Administrative Authority

• There must be one Single State Agency designated
  per 1902(a)(5) to administer the Medicaid
  program.
• Per 42 CFR 431.10, all policies must be
  developed or approved by the SMA and be in
  writing
• The 1915(c) waiver is an agreement between the
  SMA and CMS.

Appendix A Waiver Administration and Operation
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Administrative Authority

• The State must submit evidence of its monitoring
  of all delegated functions, and implementation of
  policies and procedures related to its
  administrative authority over the waiver program,
  including
• memoranda of agreements,
• description of roles and responsibilities
  relative to program operations, monitoring, and
  remediation or system improvements instituted
  when problems are identified in the operation of
  the waiver program.

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Evidentiary Example

• Administratively delegated functions must be
  clearly written in an MOU between the SMA and the
  delegated entity, and monitored by the SMA.
• i.e., The SMA must establish a uniform, statewide
  rate methodology.
• (exception waiver of statewideness)

Appendix A Waiver Administration and Operation
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Financial Accountability

• The SMA must assure financial accountability for
  funds expended for HCBS provide for an
  independent audit of its waiver program and will
  maintain or make it avaialble to HHS.
• State financial oversight must exists to assure
  that claims are coded and paid in accordance with
  the reimbursement methodology specified in the
  approved waiver.

Appendix I-2 Rates, Billing and Claims
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Financial Accountability

• The State must submit results of its financial
  monitoring process for verifying maintenance of
  appropriate financial records as specified in
  approved waiver.
• The State must demonstrate that State staff and
  providers are interviewed periodically to
  identify and address potential financial
  irregularities.
• State demonstrates that site visits are conducted
  with providers to verify that they maintain
  financial records in accordance with provider
  agreements/contracts.

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Evidentiary Examples

• Audit Reports
• Monitoring Reports
• Management meeting minutes that reflect analysis,
  recommendations and actions taken.

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Thomson Reuters- National Quality Contractor

• Contract with CMS since 2001
• - Sub Contractor HSRI (MR/DD)
• TA over 100 Waiver Programs in 40 states
• - QIS Waiver Application
• - Evidence Requests
• - PES
• - Self Direction
• - Quality Products

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