03/31/17 DRAFT
HANDOUT A
Example §1915(c) WaiverStatutory Assurance-Related Performance Measures
In the table below, there are some items for consideration regarding performance measures that pertain to,or could pertain to, a state’s self-directed service option under a§1915(c) Waiver. Importantly, this document can serve as a catalyst for discussion to both explain emerging CMS expectations (especially related to Administrative Authority and Financial Accountability) and to discuss opportunities that may exist for a State to gain information on the performance of self-directed services and supports (FMS and I&A) considered in the context of the statutory assurances. Statesmay wish to consider whether to include specific performance measures in their waivers (which will then require evidence reporting to CMS) or to use some performance measures for internal program management and quality improvement.
Statutory Assurance / Sub-Assurance / Potential Measure / Sampling Methodology (including any stratification) / FrequencyLevel of Care
The State demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant’s /waiver participant’s LOC consistent with care provided in a hospital, NF or ICF-ID-DD /
- An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.
- The process and instruments described in the approved waiver are applied appropriately and according to the approved description to determine initial LOC for participants.
Numerator: Number of participantsin the sample who had an approved Pre-Admission Evaluation (i.e., NF or ICF/DD LOC eligibility) prior to enrollment in the §1915(c) Waiver and receipt of Medicaid reimbursed HCBS during the review period.
Denominator: Total number of participants in the sample reviewed who were enrolled in the §1915(c) Waiver during the review period.
Number and percent of participants who had a Pre-Admission Evaluation (i.e., NF LOC eligibility determination) done using the approved process and instruments prior to enrollment in the §1915(c)waiver and receipt of Medicaid reimbursed HCBS.
Numerator: Number of participants in the sample who had a Pre-Admission Evaluation (i.e., NF or ICF/ID-DD LOC eligibility) conducted with approved process and instruments prior to enrollment in the §1915(c) A&D Waiver and receipt of Medicaid reimbursed HCBS during the review period.
Denominator: Total number of participants in the sample who were enrolled in the §1915(c) Waiver during the review period. / Stratified random sample of participants enrolled in the waiver including those using self-directed and traditional agency-based HCBS during the specified review period and 95% CI computed.
Stratified random sample
of participants enrolled in the waiver including those using self-directed and traditional agency-based HCBS during the review period and 95% CI computed. / Quarterly
Quarterly
.
Service Plans
The State demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants. /
- 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.
Numerator: Total number of participants in the sample for whom an assessment was completed that included the required elements and was completed within the timeframe as specified by the state during the review period.
Denominator: Total number of participants in the sample who had an assessment conducted during the review period. / Stratified random sample of participantsenrolled in the waiver including those using self-directed and traditional agency-based HCBSwho had assessments conducted during the review period and 95% CI computed. / Quarterly
- Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.
Numerator: Total number of participants’ records in the sample reviewed whose service plans were reviewed and updated prior to the participants’ annual review date during the review period.
Denominator: Total number of participants in the sample with Person-Centered Service Plan in place and a change in need documented during the review period.
Number and percent of participants’ Person-centered Service Plan that were revised /updated annually.
Numerator: Total number of participants in the sample who had their Person-centered Service Planrevised/updated during the review period.
Denominator: Total number of participants in the sample who scheduled to have their Person-Centered Service Plan revised during the review period. / Stratified random sample of participants who were enrolled in the waiver including those using self-directed and traditional agency-based HCBS with Person-centered Service Plans during the specified review period and 95% CI computed.
Stratified random sample of participantsenrolled In the waiver including those using self-directed and traditional agency-based HCBS who were scheduled to have an annual review of the Person-centered Service Plan conducted during the specified review period and 95% CI computed. / Annually
Annually
- Services are delivered in accordance with the Person-centered Service Plan, including the type, scope, amount, duration, and frequency specified in the service plan.
Numerator: Total number of participants in the sample who received services as specified in their Person-centered Service Plan during the review period.
Denominator: Total number of participants in the sample with Service Plans during the review period.
Number and percent of participantsin the sample who received services as identified in their Person-centered Service Plan.
Numerator: Total number of participantsin the sample who received services as identified in their Person-centered Service Plan.
Denominator: Total number of active participantsin the sample during the review month. / Stratified random sample of participants enrolled in the waiver including those using self-directed and traditional agency-based services with a Person-centered Service Plans during the specified review period and 95% CI computed.
Stratified random sample of participants enrolled in the waiver including those using self-directed and traditional agency-based HCBS with Person-centered Service Plans during the specified review period and 95% CI computed. / Quarterly
Monthly or Quarterly
Participants are afforded choice between/among waiver services and providers / Number and percent of participants’ records in the sample with an appropriately completed and signed freedom of choice form that specifies choice was offered between between/among all waiver services and providers including the self-directed service option.
Numerator: Total number of participant records in the sample with an appropriately completed and signed freedom of choice form that specifies choice was offered between/among all waiver services and providersincluding the participant-directed service option during the specified review period.
Denominator:Total number of participants records in the sample for the specified review period. / Stratified random sample of records of participantsenrolled in the waiver including those using self-directed and traditional agency-based HCBS during the specified review period and 95% CI computed.
Note: State may want stratify the sample by specific geographic regions to determine if there are gaps in providing participants choice between and among waiver services and providers, and in particular for the self-directed service option. / Quarterly or Annually
Qualified Providers
The State demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers. /
- 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
Numerator: Total number of providers in the sample whose records show they meet applicable standards to provide services.
Denominator: Total number of providers’ records in the sample in the specified review period. / Stratified random sample of waiver providers and individually-hired workers providing self-directed and traditional agency-based HCBS records during the specified review period and 95% CI computed.
Note: State may want to consider examining the results by type of waiver provider and individually-hired workers. / Quarterly
- The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements
Numerator:Total number of providers records in the sample that document that the state has screened and documented that they have met the qualifications/standards to provide services under the waiver during the review period.
Denominator: Total number of provider records in the sample for the review period. / Stratified random sample of waiver providers and individually-hired workers providing self-directed and traditional agency-based HCBS records during the specified review period and 95% CI computed. / Quarterly
- The State implements its policies and procedures for verifying that training is provided in accordance with State requirements and the approved waiver
Numerator: Total number of providers in the samplewhose records document that they have received the required training in accordance with State requirements and the approved waiver during the review period.
Denominator: Total number of providers’ recordsin the sample for during review period. / Stratified random sample of waiver providers and individually-hired workers providing self-directed HCBS records during the specified review period and 95% CI computed. / Quarterly
Health and Welfare
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, addresses and seeks to prevent instances of abuse, neglect, exploitation and unexplained death.
§1915(c) Waiver Application.
Numerator: Total number of reported critical and abuse/neglect/exploitation incidents marked resolved within the state’s specific requirements as documented in the
§1915(c) Waiver Application during the review period.
Denominator: Total number of reported critical and abuse/neglect /exploitation incidents entered into the system during the review period. / 100% / Monthly
Quarterly
Annually
- 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.
Numerator: Total number of participants’ records in the sample document thatthe participant (or their family participant/ authorized representative, as applicable) has received education /information at least annually about how to identify and report instances of abuse, neglect and exploitation during the review period.
Denominator: Total number of participants’ records in the sample for the review period.
Number of critical incidents reported during the specified review period.
Number of substantiated cases of abuse/fraud /exploitation reported during the specific review period.
Number of participants’ deaths reported during the specified review period.
Number and percent of substantiated cases of abuse/neglect /exploitation reported to protect participants’ health and welfare where investigation/follow-up was conducted using established state procedures.
Numerator: Total number of substantiated cases of abuse /neglect /exploitation reported in participants’ records included in the sample that document investigation/ follow-up was conducted using established state procedures during the specified review period.
Denominator: Total number of records in the sample that documented substantiated cases of abuse, neglect and exploitation during the specified review period.
100% of grievances are reported for follow-up within the state’s specific requirements as documented in the
§1915(c) Waiver Application.
Numerator: Total number of grievances reported within the state’s specific requirements as documented in the
§1915(c) Waiver Application during the review month.
Denominator: Total number of grievances received during the review month.
Number and percent ofparticipants that are contacted by case managers within the frequency identified in the state’s §1915(c) Waiver Application.
Numerator: Total number of active participantsin the sample who were contacted by case managers within the frequency identified in the state’s §1915(c) Waiver Application during the review month.
Denominator: Total number of referred, enrolled and active participantsin the sample during the review month. / Stratified random sample of records of participants enrolled in the waiver including those using self-directed and traditional agency-based HCBS during the specified review period and 95% CI computed.
100%
100%
100%
100%
100%
Stratified random sample of records of participantsenrolled in the waiver including those using self-directed and traditional agency-based HCBS during the review period and 95% CI computed. / Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Monthly
Monthly
- The State policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.
Numerator: Number of reported incidents of restrictive intervention used for participants using self-directed services in the sample during the review period.
Denominator:Number of critical incidents reported for participants using self-directed services in the sample during the review period. / 100% / Monthly
- 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.
Numerator: Number of participants’ records reviewed in the sample that indicate that they have received routine health care and screenings as specified in the state’s Health Standards during the review period.
Denominator: Total number of participants’ records reviewed in the sample during the review period. / Stratified random sample of records of participantsenrolled in the waiver including those using self-directed and traditional agency-based HCBSduring the specified review period and 95% CI computed. / Quarterly
Financial Accountability
The State must demonstrate that it has designed and implemented an adequate system for insuring financial accountability of the waiver program. / 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. / Number and percent of waiver claims in the sample paid using the correct rate as specified in the waiver application.
Numerator:Total number of waiver claims reviewed in the sample that were paid using the correct rate as specified in the §1915(c) Waiver Application during the review period.
Denominator: Total number of waiver claims in the sample paid during the review period.
Number and percent of claims in the sample submitted within 180 days of date of service.
Numerator: Total number of claims reviewed in the sample that were submitted within 180 of data of service during the review period.
Denominator: Total number of claims reviewed in the sample submitted during the review period.
Number and percent of claims paid for participants who were eligible on the date the service was provided.
Numerator: Total number of claims reviewed in the sample that were paid for participants who were eligible on the date the service was provided during the specified review period.
Denominator: Total number of claims in the sample that were paid during the review period.
Number and percent of claims submitted that were rejected.
Numerator: Total number of claims reviewed in the sample that were submitted and were rejected during the review period.
Denominator: Total number of claims reviewed in the sample that were submitted during the review period.
Number and percent of claims submitted that were denied.
Numerator: Total number of claims reviewed in the sample that were submitted and denied during the review period.
Denominator: Total number of claims in the sample that were submitted during the specified review period. / Stratified random sample of claims submitted for participantsenrolled in the waiver including those using self-directed and traditional agency-based HCBSduring the specified review period and 95% CI computed.
Note: State may want to stratify sample by types of service claims are submitted for to examine any variation.