3 cmcs quality memo narrative

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1 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 ltimore, Maryland 21244-1850 Ba Modifications to Quality Measures and Reporting in §1915(c) Home and Community-Based Waivers 2, 2014 March 1 This document provides information on modifications to the quality assurance systems needed to mee t the assurances for §1915(c) waivers. The National Association of States United in Aging and Disability (NASUAD), National Association of State Directors of Developmental Disabilities Services (NASDDDS) and National Association of Medicaid Directors (NAMD), a long with waiver administrators from eleven states and the National Quality Enterprise worked with CMS for over a year to develop and refine these changes. Other stakeholders also had opportunity to comment through conference and webinar sessions. These changes strengthen the oversight of beneficiary health and welfare and realign the re porting requirements. We believe this changed emphasis will improve the success of home and community based programs. The current quality assurance system requires that states develop and measure performance indi cators in fourteen areas (one each for waiver administrative authority, health and welfare of participants, and financial integrity, three each to measure levels of care and that providers meet qualifications, and five in the area of service planning and delivery). Each waiver must have its own quality assurance system. States submit an evidentiary report on all of their performance mea sures approximately eighteen months prior to the waiver renewal date that includes the mediation taken for each systemic and individual instance when a p erformance measure has re less than 100% compliance. The highlights of this modified quality assurance system include: 1. Health and welfare monitoring and outcomes are emphasized; 2. Although states must continue to remediate issues, the reporting on individual re mediation to CMS will not be required except in substantiated instances of abuse, ne glect or exploitation; and when the threshold of 3. States’ quality improvement projects/remediation will be required compliance with a measure is at or below 85%. 1

2 The statutory requirements for §1915(c) waivers are not changed and states are still required to monitor all of the waiver assurances as before. This update clarifies the expectations of CMS The continuous quality that states should provide to meet the waiver assurances. on the reporting improvement cycle remains the same as illustrated below. This communication covers the following topics: 1. Assurances and Subassurances (Discovery) 2. Reporting on Individual Remediation (Remediation) 3. Quality Improvement Projects (Improvement) 4. Consolidating Reporting Across Multiple Waivers 5. Determining if an Assurance has Been Met 6. Timeframes for Implementation 7. Appendix I: Crosswalk of Former and New Subassurances 8. Appendix II: Technical Guidance for Including the Quality Improvements in Version 3.5 of the Waiver Management System (WMS) §1915(c) Template CMS encourages states to think creatively about performance measures, and to measure those items of most importance to the individuals being served, such as those seen on incident reports s. In this way, we think the needs of those using waiver or reported as concerns by stakeholder services can be best met. We will work with a state that wants to track progress over time (i.e. specific annual targets on a type of incident). 1. Assurances and Subassurances (Discovery) The assurances and subassurances continue to be built on the statutory requirements of the contains a crosswalk of the previous and new waiver. Appendix I of this bulletin §1915(c) assurances and subassurances language. Administrative Authority : There is no change in the Administrative Authority assurance, and there is still no subassurance for this section. A performance measure should be developed and tracked for any authority that the State Medicaid Agency (SMA) delegates to another agency for that waiver. For example, if the unless it is already captured in another performance measure SMA delegates the service plan responsibilities, but there is already a performance measure that 2

3 tracks service plans, there would be no need to include another performance measure for that activity in the administrative authority section. Level of Care: There is no change in the Level of Care assurance, although the subassurance to will no longer be reported. States are still measure annual levels of care (reassessments) expected to be sure that annual levels of care are determined, but no longer are asked to track a The other two subassurances (that applicants with reasonable performance measure in this area. likelihood of needing services receive a level of care determination, and that the processes are The detailed changes are followed as documented in the waiver application) remain the same. located in Appendix I: Crosswalk of Former and New Subassurances. Qualified Providers: The qualified provider assurance and three subassurances remain the same. The state must still have performance measures that track that providers meet licensure/certification standards, that non-certified providers are monitored to assure adherence to waiver requirements, and that the state verifies that training is given to providers in accordance with the waiver. These are detailed in Appendix I: Crosswalk of Former and New Subassurances. Service Plan: The service plan assurance remains the same, although one subassurance (development of service plans in accordance with waiver policy) will no longer require reporting of a performance indicator. A change was made to the subassurance that requires a performance measure on choice between institutional and waiver services as well as between waiver services and providers so that it now requires a measure on choice of waiver services and providers only. States are still required by statute to offer waiver beneficiaries a choice of institutional care, but CMS no longer expects reporting on that choice. The other two service plan subassurances (that plans address all assessed needs and goals, and that services are delivered in accordance with the service plan) remain the same. The detailed changes are located in Appendix I: Crosswalk of Former and New Subassurances. : The state associations and state representatives’ workgroup agreed that Health and Welfare more extensive health and welfare is one of the most important assurances to track, and requires to benefit the individuals receiving services for instance, by using data to prevent future tracking incidents. The current quality system has modified the assurance, turn ed the previous assurance into a new subassurance, and add ed three additional health and welfare subassurances. The resulting health and welfare assurance and subassurances are as follows: Assurance - The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. The State demonstrates on an ongoing basis that it identifies,  Subassurance - addresses and seeks to prevent instances of abuse, neglect, exploitation and unexplained death. 3

4  The State demonstrates that an incident management system is in Subassurance - place that effectively resolves incidents and prevents further similar incidents to the extent possible. Subassurance - The State policies and procedures for the use or prohibition of  restrictive interventions (including restraints and seclusion) are followed.  The State establishes overall health care standards and monitors Subassurance - those standards based on the responsibility of the service provider as stated in the approved waiver. Financial Accountability: Like health and welfare, financial accountability previously had an assurance but no subassurances. Waiver program integrity is critically important and can only be achieved with strong financial accountability in addition to the other waiver assurances covered Although the workgroup did not recommend changes in financial accountability in this bulletin. the assurance, making reporting, CMS modified the previous assurance into a subassurance, and creating a new subassurance as follows: Assurance – The State must demonstrate that it has designed and implemented an adequate system for insuring financial accountability of the waiver program. Subassurance -  The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered.  Subassurance - The State provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle. Reporting on Individual Remediation 2. CMS is modifying the requirements about individual remediation. Although states must continue to remediate problem areas, we require reporting on individual activities only in the instances of Previously, substantiated abuse, neglect and/or exploitation. in the quality reporting required for conducted for each each waiver cycle, CMS required a report on individual remediation activities performance measure. This will allow the state to focus energy on remediation of systemic will continue to be reported (see Quality Improvement Projects, below). problem areas which protections for individuals by ensuring This refocus on system’s review will provide the greater the system adjusts to meet the needs of the individuals served. 3. Quality Improvement Projects investigate whenever a performance In the current quality system, CMS requires that states and conduct systemic remediation (Quality Improvement Projects – indicator is not fully met, QIP) However, in collaboration with the unless they can demonstrate the QIP is not warranted. be required when the performance indicator workgroup, quality improvement projects will now falls below a threshold of 86%. Any performance measure with less than an 86% success rate warrants further analysis to determine the cause. A QIP must be implemented once the cause is CMS accepted by CMS that a QIP is not necessary. justification found unless the state provides strongly encourages states to seek stakeholder involvement in the development of QIPs. A QIP may take any of several forms. It may be training, revised policies/procedures, additional specific There may be an existing state initiative for a staff, different staffing patterns, etc. 4

5 problem area that can be targeted to waiver participants at-risk, such as a falls prevention systems change to alert for program. There may be an information timeliness of home visits, levels of care and service plans, potentially addressing several performance measures at once. We encourage use of existing state or regional resources wherever they will address the problem area. Each QIP must measure it was effective. If not, other the impact to determine whether interventions should be explored. This will ensue that the needs of the individuals served are addressed and resolved in a systemic manner. The Evidence Report submitted for each waiver must document QIP(s) including status to date. Although it may take time for an effect to occur, the benchmark of 86% is the expectation. 4. Consolidating Reporting Across Multiple Waivers When waivers are managed and monitored similarly, it is expected that discovery and improvement activities would be the same, and that the state will achieve some administrative efficiencies by consolidating quality improvement activities. In addition, this holistic measure will ensure that the system for the waivers is responsive to the needs of all individuals served. CMS may accept a consolidated evidence report for multiple waivers when they meet the following five conditions: 1. Design of the waivers is the same or very similar; 2. This sameness or similarity is determined by comparing waivers on the approved waiver application appendices: a. Participant Services, b. Participant Safeguards, and c. Quality Management; The quality management approach is the same or very similar across waivers, 3. including: a. Methodology for discovering information (e.g., data systems, sample selection), Manner in which individual issues are remedied, b. Process for identifying and analyzing patterns/trends, and c. d. Majority of the performance indicators are the same; 4. The provider network is the same or very similar; and 5. Provider oversight is the same or very similar. 95 is A simple random sample of the combined populations with a confidence level of at least . sufficient if the conditions listed above are met. Results of this sampling will reflect the performance of the combined system. (initial, amendment, or renewal) must identify other waivers Each 1915(c) waiver application with which it will be consolidated for reporting purposes. This application will also propose when the consolidated evidence report will be submitted. When some performance indicators are not the same, the state will also propose when the measures will be reported. They can either be reported with the consolidated measures, or at the time when that particular waiver’s evidence report would be due if the reporting wasn’t consolidated. Determining If An Assurance Has Been Met 5. 5

6 The CMS Regional Office will evaluate each evidentiary report to determine whether the waiver(s) has/have met each of the assurances. In order to meet each assurance, the following must occur: 1. Performance measure evidence is presented for each subassurance; 2. The performance measure evidence for each subassurance is at or above 86% in all waiver years, OR quality improvement projects have been initiated for each subassurance with a measure below 86%, OR CMS accepts justification for why a performance improvement plan was not initiated to address the performance issue ; and The state has provided an aggregated report on the individual remediation of 3. substantiated instances of abuse, neglect and exploitation under the Health and Welfare Subassurance Two. An assurance is not considered met if a performance measure for any subassurance stays below 86% for three or more consecutive years regardless of whether a performance improvement project has been implemented unless the measure has had steady improvement over the years and exceed 85% the following year the state and CMS agree that performance is likely to 6. Timeframe for Implementation All new waiver applications and renewals submitted after June 1, 2014 must incorporate these adopt these quality changes earlier through submission of modifications. The state may elect to an amendment, renewal or new §1915(c) waiver following March 1, 2014. States may want to consolidated consolidation of waivers will necessitate amendments to each consider that waiver’s quality plan . Appendix II provides a technical guide on how to incorporate the new changes in the Waiver Management System version 3.5 Waiver Template. Narrative changes, such as consolidation of of the Waiver multiple waiver evidentiary reporting should be described in Appendix H Application as illustrated in Appendix II. 6

7 APPENDIX I CURRENT vs. REVISED ASSURANCES/SUBASSURANCES CROSSWALK: - CURRENT REVISION SUMMARY – REVISED LEVEL OF CARE LEVEL OF CARE Assurance - The State demonstrates that it No change in assurance -- Assurance The State demonstrates that it - Assurance and instrument(s) implements the processes implements the processes and instrument(s) description. specified in its approved waiver for ved waiver for specified in its appro evaluating/ evaluating/ reevaluating an applicant's/waiver reevaluating an applicant's/waiver participant's level of care consistent with care participant's level of care consistent with care - provided in a hospital, NF, or ICF/ - ID DD provided in a hospital, NF, or ICF/ ID DD Subassurance I. An evaluation for LOC - is provided to all applican ts for whom An evaluation for LOC is Subassurance a. - there is reasonable indication that provided to all applicants for whom services may be needed in the future. there is reasonable indication that services may be needed in the future. Subassurances - b Current LOC -- subassurance regarding reevaluations has been deleted. States , per b. [ LOC of enrolled Subassurance - The must still statutory requirement, members is reevaluated at least annually conduct annual reevaluations, but are ] or as specified in the approved waiver. no longer required to report evidence on reevaluations. The processes and c. Subassurance - instruments described in the approved waiver are applied appropriately and Revised LOC - ii will be applicable to according to the approved description to The processes and II. Subassurance - LOCs only. States will no longer initial . determine participant level of care instruments described in the be required to report evidence on approved waiver are applied annual reevaluations. appropriately and according to the approved description to determine . initial participant level of care 7

8 SERVICE PLAN - REVISED CURRENT SERVICE PLAN REVISION SUMMARY - - The State demonstrates it has Assurance Assurance - The State demonstrates it has Assurance -- No change in assurance designed and implemented an effective designed and implemented an effective system description. reviewing the adequacy of service plans for for system for reviewing the adequacy of service . plans for waiver participants. waiver participants - Service Subassurance i. a. Subassurance - Service plans address plans address all members’ assessed needs all members’ assessed needs (including health and safety risk th and safety risk (including heal factors) and personal goals, either by factors) and the provision of waiver services or through other me ans. goals, either by the provision personal of w aiver services or through other Subassurance The state monitors b. [ service plan development in means. accordance with its policies and ] procedures. b Current SP Subassurances -- - Subassurance c. S ervice plans are - has been deleted. subassurance at least annually or updated/ revised States must still develop service plans when warranted by changes in the in accordance with their policies and waiver participant’s needs. procedures, but will not be required to report evidence on adherence to - Subassurance d. Services are delivered their policies/procedures. in accordance with the service plan, including the type, scope, amount, duration, and frequency specified in Service plans are ii. Sub - assurance - the service plan. updated/ revised at least annually or warranted by changes in the when waiver participant’s needs. e. Subassurance Participants are - [ afforded choice : Between waiver - Current SP e has been revised as SP - services and institutiona ] l care; and iii. Services are delivered - Subassurance ses on monitoring iv. SP - iv now focu between/among waiver services and in accordance with the service plan, participants’ choice between/among providers . including the type, scope, amount, waivers services and providers. duration, and frequency specified in States, per statutory requirement, the service plan. must still offer individuals choice between institutional and HCBS care, but will no longer be required to Subassurance iv. pants are Partici - uch report evidence on whether s afforded choice between/among . choice was provided waiver services and providers. 8

9 QUALIFIED PROVIDERS CURRENT QUALIFIED PROVIDERS - REVISED - REVISION SUMMARY - Assurance The State demonstrates that it has Assuranc Assurance - The State demonstrates that it has e -- No change in assurance designed and implemented an adequate designed and implemented an adequate system description. for assuring that all waiver services are system for assuring that all waiver services are provided by qualified providers. qualified providers. provided by tate verifies that Subassurance - i. a. Subassurance - The S The S tate verifies that providers initially and continually providers initially and continually meet No change in Subassurances -- meet required licensure and/or required licensure and/or certification subassurances. certification standards and adhere to standards and adhere to other standards prior to their furnishing other waiver services. standards prior to their furnishing waiver services. The State monitors Subassurance b. - - non licensed/non - certified provider s to assure adherence to waiver The State monitors ii. Subassurance - requirements. - certified provider s licensed/non - non to assure adherence to waiver Subassurance - The State implements c. its policies and procedures for verifying equirements. r that training is provided in accordance with State requirements and the approved waiver . The State implements iii. Subassurance - its policies and procedures for verifying ining is provided in that tra accordance wi th State requirements and the . approved waiver 9

10 REVISED - HEALTH AND WELFARE - CURRENT REVISION SUMMARY HEALTH AND WELFARE - On an ongoing basis the state Assurance Assurance description Assurance - Assurance The state demonstrates it has -- - designed and implemented an effective revised to focus on health and welfare identifies addresses and seeks to prevent system for assuring waiver participant health more broadly. instances of abuse, neglect and exploitation. and welfare. Subassurances -- Four new The State i. Subassurance -- es added that provide subassuranc demonstrates on an ongoing basis specificity to the intent of the Health ntifies, addresses and seeks that it ide consistent and Welfare Assurance, to prevent instances of abuse, with what is reflected in the Waiver neglect, exploitation and unexplained Application, Appendix G -- death. Safeguards. T Subassurance -- ii. he State demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further s imilar incidents to the extent possible. policies -- Th e S tate iii. Su assurance b and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed. The S -- Subassurance iv. tate establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver. 10

11 REVISED FINANCIAL ACCOUNTABILITY FINANCIAL ACCOUNTABILITY - CURRENT REVISION SUMMARY - - State financial oversight exists to -- wording Assurance – The State must demonstrate that Assurance Assurance Assurance it has designed and implemented an adequate revised to more broadly reflect the assure that claims are coded and paid for in system for insuring financial accountability of accordance with the reimbursement financial accountability requirement. the waiver program. methodology specified in the approved waiver. Subassurance - The State provides i. Subassuranc e -- CMS added one evidence that claims are coded and subassurance to address rate paid for in accordance with the reimburs ement methodology methodology, with expectation that specified in the approved waiver and the State would continue to report only for services rendered. evidence that claims are coded and paid in accordance with the rate methodology specified in the ii. The State provides Subassurance - approved waiver. evidence that rates remain consistent with the approved rate methodology . throughout the five year waiver cycle 11

12 CURRENT ADMINISTRATIVE AUTHORITY ADMINISTRATIVE AUTHORITY - - REVISED REVISION SUMMARY -- – The Medicaid Agency retains No change in assurance Assurance nce Assura The Medicaid Agency retains - - Assurance ultimate administrative authority and ltimate administrative authority and u description. responsibility for the operation of the waiver responsibility for the operation of the waiver program by exercising oversight of the program by exercising oversight of the performance of waiver functions by other state performance of waiver functions by other Sub assurance -- This Assurance state agencies (if - state and local/regional non - state agencies (if and local/regional non currently has no subassurances . appropriate) and contracted entities appropriate) and contracted entities. associated with it, and none have been added. Performance Measures (PMs) are required for delegated functions unless covered by PMs associated with other Assurances. And as necessary and applicable, States should continue to focus performance measures on:  Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver  Equitable distribution of waiver openings in all geographic areas covered by the waiver  Compliance with HCBS settings requirements and other new regulatory components 12

13 - REMEDIATION REPORTING REMEDIATION REPORTING – REVISION SUMMARY REVISED CURRENT does not have to be reported in Evidence Report must include Remediation Changed from requiring remediation aggregated reports to only reporting on Evidence Report remediation reports substantiated cases of abuse, neglect Exception: Substantiated instances of Tables/charts on number and types of   and exploitation. remediation actions taken in response abuse, neglect and exploitation to instances of < 100% compliance on a given Performance Measure Expectation that State has a mechanism for Constitutes evidence that remediation  States may be audited to ensure they at individual level has occurred - measuring its effectiveness in addressing non are conducting remediation where performance indicated by a lower than 86% e. performanc Mechanism and measurement results  e subject to audit by CMS ar 13

14 APPENDIX II: Technical Guidance for Including the Quality Changes in Version 3.5 of the Waiver Management System (WMS) §1915(c) Template The following sections include excerpts from the Waiver Management System (WMS). Pertinent sections to quality system changes are highlighted. Instructions and/or directions enclosed in brackets no longer apply. The text in blue italics is taken from the WMS, and the text in black instructs what should be done to incorporate the new quality improvements. Please note the sampling and remediation sections are still needed for each assurance. Appendix A: Administrative Authority The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] This last sentence no longer applies for this or any performance measure. For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Performance Indicators for Administrative Authority are Add Performance Measure needed to assure the Medicaid Agency is monitoring specific tasks delegated to an operating or other agency when performance on those tasks are not already being captured in other performance measures. For this and all subsequent performance measures complete the full charts as in the past. 14

15 Appendix B: Level of Care : Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator At least one performance indicator needed Add Performance Measure - assurance: The levels of care of enrolled participants are reevaluated at least annually [Sub or as specified in the approved waiver .] This sub -assurance does not need to be reported on any longer. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator 15

16 [ ] Not needed for this subassurance Add Performance Measure 1. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed Appendix C: Qualified Providers Sub-Assurances: 1. Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable 16

17 For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed 2. Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements. For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this Not applicable waiver (i.e., data presented must be waiver specific). ] For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed 3. Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver. For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this Not applicable waiver (i.e., data presented must be waiver specific).] For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the 17

18 performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed Appendix D: Service Plans Sub-Assurances: 1. Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed Sub-assurance: The State monitors service plan development in accordance with 2. its policies and procedures. Performance Measures 18

19 For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator No longer needed for this subassurance [ Add Performance Measure ] Sub-assurance: Service plans are updated/revised at least annually or when 3. warranted by changes in the waiver participants needs. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure At least one performance indicator needed Sub-assurance: Services are delivered in accordance with the service plan, 4. including the type, scope, amount, duration and frequency specified in the service plan. 19

20 Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator At least one performance indicator needed Add Performance Measure -assurance: Participants are afforded choice: [ 5. Sub Between waiver services and ] between/among waiver services and providers. institutional care; and Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this Not applicable. waiver (i.e., data presented must be waiver specific).] For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator At least one performance indicator needed to Add Performance Measure measure availability of choice between/among waiver services and providers. 20

21 Appendix F: Participant Rights and Appendix E: Participant Direction of Services There is no space in the Version 3.5 Appendix E or Appendix F to add performance measures. However, the state may add measures for either or both of these areas in Appendix G: Participant Safeguards. Appendix G: Participant Safeguards Assurance: The State, on an ongoing basis, identifies, addresses and seeks to prevent the occurrence of abuse, neglect and exploitation. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. [Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add at least one performance indicator for the assurance Add Performance Measure above, PLUS add one for each of the following subassurances: Subassurance -- The State demonstrates that an incident management system is in place that effectively  resolves those incidents and prevents further similar incidents to the extent possible -- Subassurance The State policies and procedures for the use or prohibition of restrictive interventions  (including restraints and seclusion) are followed. 21

22 Subassurance -- The State establishes overall health care standards and monitors those standards based on  the responsibility of the service provider as stated in the approved waiver. The state may elect to include performance measures on participant direction and/or participant rights in this section as well. Appendix I: Financial Accountability 1. Methods for Discovery: Financial Accountability State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Performance Measures For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include . [Each performance measure must be specific to this waiver numerator/denominator (i.e., data presented must be waiver specific).] Not applicable For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate. Performance Measure/Indicator Add Performance Measure Add at least one performance indicator for this assurance above, PLUS add one for the following subassurance: - Subassurance The State provides evidence that rates remain consistent with the approved  rate methodology throughout the five year waiver cycle. 22

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