APPENDIX O: Follow-up Process- March 10, 2011
Revised Process:
Providers that receive a Two Year License with 90% or more of the licensure indicators met
Providers meeting 90% or more of the applicable licensure indicators will conduct their own internal correction and follow up on the identified issues. The provider will then submit information on the status of correction to QE 60 days after the Service Enhancement meeting. This takes the place of direct follow-up by the QE surveyors.
Providers that meet the standard for 89% or less of the licensure indicators and/or are in deferred status
Providers that meet the standard for 89% or fewer of the applicable indicators will have follow-up activities conducted on site by the QE surveyors. On site follow-up activities also apply to providers in deferred status.
Sample size and selection revisions
For providers that receive a Two Year License with 80 to 89% of the licensure indicators met, follow up is conducted using a reduced sample.
In addition, the sample selection for follow-up is more purposeful and targeted to identified service types. If, for instance, a provider did not meet the standard in its residential supports for a particular indicator, but the particular standard was 100 % met within the placement service, then the sample for follow-up would be selected from its 24 hour residential service.
The sample for follow-up concentrates on those locations and individuals for whom the indicator(s) are relevant. Therefore, in advance of the follow-up, the provider prepares a list of applicable individuals to randomly select from for any “specialty indicator” that pertains to a sub-set of individuals served. For example, if the indicator “Special diets are followed” was not met, the provider will identify the locations where individuals have special diets. Sites/ individuals will be randomly selected to ensure that the provider has corrected items systemically.
The following table highlights the revised process:
Results at SEM;License level and
criteria / Scope of Follow-up / Size of Follow-up Sample
Two Year License
and 90% or more indicators Standard met / Provider conducts follow-up and submits information to QE / N/A
Two Year License
and between 80% and 89% indicators Standard met / QE reviews all indicators where standard was not met in survey / Reduced sample
Two Year License with Mid-cycle Review
(between 59% and 79% indicators Standard met) / QE reviews all indicators where standard was not met in survey / Full sample
Deferred status- (one or more critical indicators std. not met) / QE reviews all indicators where standard was not met in survey, inclusive of critical indicators, and issues license / Full sample
Specific procedures:
- DDS Office of Quality Enhancement(OQE)reviews findings with the provider at the Service Enhancement Meeting. The Provider is presented with the list of indicators which were not met noting these follow-up items at this time.
- 30 days after the Service Enhancement Meeting, the final provider report will be sent to the provider. The package will provide pertinent information including the follow-up date and whether the follow-up will be conducted by QE or the provider.
- When QE is conducting the follow-up, the provider will be informed of which indicators will be reviewed in which service types, and will asked to identify applicable individuals for specific indicators (within 45 days post- Service Enhancement meeting).
- One day prior to the QE follow-up, the provider will be informed of the specific locations and individual audits. The Team Leader will coordinate the follow-up process with the Provider Liaison.
- Follow-up is conducted 60 days post- Service Enhancement meeting. Follow-up will start with a meeting with the administrative staff. There are several indicators that require validation on site. However, there may be certain items that could be verified through review of documentation occurring at the administrative offices. To the extent possible, the Team Leader should work with the Provider Liaison to determine the most efficient but thorough way to accomplish the review.
- When the provider is conducting its own follow-up, it will be asked to complete and submit its findings on the attached form 60 days post- Service Enhancement meeting.
- OQE completes the follow-up report, and as applicable issues the license for agencies previously in deferred status.
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DEPARTMENT OF DEVELOPMENTAL SERVICES
LICENSURE AND CERTIFICATION
FOLLOW-UP REPORT
Completed by QE surveyors
Provider ______Provider Address ______
Survey Team ______Date(s) of Review: ______
Follow-up Scope and results:
Service Grouping / Licensure level and duration / # Critical Indicators std. met/ std. rated at follow-up / # Indicators std. met/ std. rated at follow-up / Sanction status prior to Follow-up / Combined Results post- Follow-up; for Deferred, License level / Sanction status post Follow-upResidential/ Home Supports
# locations
# Audits / Eligible for new business
(Two Year License)
Ineligible for new business
(Deferred status; Two Year with Mid-cycle review License) / Eligible for new business
(80% or more std. met; no critical indicators std. not met)
Ineligible for new business
(≤80% std. met and/or one or more critical indicator std. not met)
Employment / Day Supports
# locations
# Audits / Eligible for new business
(Two Year License)
Ineligible for new business
(Deferred status; Two Year with Mid-cycle review License) / Eligible for new business
(80% or more std. met; no critical indicators std. not met)
Ineligible for new business
(≤80% std. met and/or one or more critical indicator std. not met))
Summary of Ratings
Organizational Areas Needing Improvement on Standards not met:
Indicator # / Indicator / Area Needing Improvement / Status at follow-up / # met/ # rated at follow-up / RatingResidential/ Home Supports Areas Needing Improvement on Standards not met:
Indicator # / Indicator / Area Needing Improvement / Status at follow-up / # met/ # rated at follow-up / RatingEmployment/ Day Supportson Standards not met:
Indicator # / Indicator / Area Needing Improvement / Status at follow-up / # met/ # rated at follow-up / RatingPROVIDER FOLLOW-UP REPORT
Completed by Providers receiving a Two Year License with at least 90% of indicators met
Provider ______Provider Address ______
Name of Person completing form______Date: ______
Follow-up Scope and results:
Service Grouping / Licensure level and duration / # Indicators std. met/ std. rated at follow-upResidential/ Home Supports
Employment / Day Supports
Summary of Ratings
Organizational Areas Needing Improvement on Standards not met:
Indicator # / Indicator / Area Needing Improvement / Process utilized to correct and review indicator / Status at follow-up / Rating(met or not met)
Residential/ Home Supports Areas Needing Improvement on Standards not met:
Indicator # / Indicator / Area Needing Improvement / Process utilized to correct and review indicator / Status at follow-up / Rating(met or not met)
Employment/ Day Supportson Standards not met:
Indicator # / Indicator / Area Needing Improvement / Process utilized to correct and review indicator / Status at follow-up / Rating(met or not met)
Follow-up audit planning information – sent in advance when QE is conducting follow-up
The Follow-up review will start with a meeting at the Administrative offices to discuss the following items, the systems that you have initiated and your progress on meeting the following indicators. In addition, we will conduct site visits to the various locations where services are being provided.
60 day Follow-up will consist of the following number of audits, and review of the following indicators:
Organiz.indicator / 24
Hour
Res. / Indiv.
Home
support / Place-ment / Employ-ment. / Cent. Based
Wk / Com Based
Day / Respite
OVERALL
INDICATOR
FOR FOLLOW-UP / The number based on either the reduced audit or the full audit will be listed.
A check under the service type if assessing the indicator there e.g. if 100% met for the service, leave blank / # sites
#
Ind audit / # sites (or N/A)
#
Ind audit / # sites
#
Ind audit / # sites
(or N/A)
#
Ind audit / # sites
#
Ind audit / # sites
#
Ind audit / # sites
#
Ind audit
In order to conduct the follow-up efficiently the review will concentrate on those locations and individuals for whom the indicator(s) above are relevant. In addition, there are several indicators that are based on the evaluation of things that have transpired in the past 60 days, for example, restraint reporting. Therefore, if there are any “specialty indicators” as noted in the following attachment that require follow-up, please submit the following information 1-2 weeks in advance of the follow-up including what has occurred since the Service Enhancement meeting and referencing which sites/ individuals have the noted characteristics. Simply designate on the attached list of sites/ individuals by referencing the indicator number next to the location/ individuals which location/ individuals have at least one person with these characteristics. We will randomly select from these sites/ individuals to ensure that the Provider has corrected items systemically.
List of “specialty indicators” in which follow-up will be targeted to those individuals with the following characteristics:
Indicators / Topic / Information needed: List all sites/ individualswithin the services applicable above which have at least one person with these characteristics:L10 / Reduction of risk for individuals whose behaviors may pose a risk to themselves or others / Please reference locations which serve individuals who exhibit behaviors actions or conditions that pose a risk to themselves or others
L39 / Specialty dietary requirements are followed. / Please reference locations/ individuals who have special dietary needs.
L47 / Individuals are supported to become self-medicating / Please reference locations/ individuals who are on a path to independence/ do not need support to administer medications.
L56 / Restrictive practices for one individual that affect all individuals served at a location need to have a written rationale and have provisions so as to not unduly restrict the rights of others. / Please reference locations where any restrictive practices are in place or have the potential to be in place (e.g. door alarms; locks); locations where individuals served have behavioral needs.
L57-L60 / Behavior intervention plans are in writing and have the necessary reviews and approvals. / Please reference locations where individuals served have behavioral needs.
L61-L62 / Supports and health related protections have the necessary reviews and approvals. / Please reference locations where any supports and health related protections are in place or have the potential to be in place (e.g. bedrails); locations where individuals served have need for supports.
L63-L64 / Medication treatment plans. / Please reference locations where any medication treatment plans are in place or have the potential to be in place; locations where individuals served have behavioral / psychiatric needs.
L65-L66 / Restraint reporting / Please reference locations where physical restraints are utilized or have the potential to be in used; locations where individuals served have need for such support.
L67-L69 / Financial management and support / Please reference locations where individuals are supported in shared or delegated money management or have the potential to need such support.
L87 / Support strategies necessary to assist an individual to meet their goals and objectives are completed and submitted as part of the ISP. / Please reference locations in which one or more individuals have received an ISP within the past 60 days.
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