National Quality Improvement for The

National Quality Improvement for the

HCB Services

Suggested Threshold Criteria

and

Quality Improvement FeaturesGoals

Prepared by: :

Human Services Research Institute

Cambridge, Massachusetts

Under Subcontract to:

The MEDSTAT Group, Inc.

CMS Contract No. 500-96-006, Task Order No. 2

Prepared for:

The Centers for Medicare and Medicaid Services

Draft

July 27September 18, 2002

National Quality Improvement for HCB Services

SUGGESTED THRESHOLD CRITERIA AND QUALITY IMPROVEMENT GOALSFEATURES

Prepared by

Human Services Research Institute

for the

Centers for Medicare and Medicaid Services

National Quality Improvement for HCB Services

FRAMEWORK FOR SYSTEMS ANALYSIS

I.Introduction to the Suggested Threshold Criteria and Quality Improvement GoalsFeatures

Purpose of a Systems Analysis:

The Suggested Threshold Criteria and Quality Improvement GoalFeatures has been developed to identify the strengths A systems analysis assists in identifying where the absence of or gaps and/or weaknesses in the state’s quality assurance systemsin the quality assurance system have directly caused or contributed to a problem within the state’s for the HCBS Mental Retardation/Developmental Disabilities waiver services. Assuming the cause(s) of problems has yet to be discovered, a systems analysis would be the first step undertaken by tThe technical assistance team wouldill use totohese the criteria to identify specific areas within QA domains that may be missing or inadequately articulated. where improvements are needed (e.g., changes in regulations, policies, reporting and/or monitoring activities, training). The function of the criteria is not to find fault or lay blame, nor are theycriteria “mandates” that the state must adhere to in order to meet CMS requirements. Rather the criteria are used to:

Ensure that consultants to the National Quality Improvement for the HCBS use uniform criteria when reviewing a state’s quality assurance system and processes;
Offer states the opportunity to use the criteria to complete a self-assessment of their quality assurance system and processes;
Offer CMS Regional Offices the opportunity to use the criteria to further their understanding of key features of quality assurance systems and processes.

Criteria have been established in seven domains. The domains are derived from the HCBS waiver protocol and the Once completed, the results of the analysis along with the overall recommendations for improvement will be presented to the state and to CMS. State officials and CMS would then determine if the state can develop its own strategies or if technical assistance should be provided in the identified areas. Systems analysis is not done to find fault or lay blame. Rather it is an exploration in collaboration with the state to identify the areas where technical assistance is needed.

II.Systems Analysis Criteria:

The structure of an effective se specific features should be included in a state’s quality assurance and improvement system for MR/DD waiver services addresses desired outcomes in the context of interrelated parts of the system (reliable information gathering, analysis, and feedback criteria). Under systems analysis the criteria of an effective system are labled domains, components, QI threshold and QI features. . Following is a description of each section of the criteria:

Domains and Sub-Domains: These broad categories of a state’s quality assurance and improvement system for individuals served through the HCBS program. The domains are based upon the HCBS waiver protocol “Quality Framework” that was developed by CMS and HSRI to focus attention on desired outcomes of HCBS quality management and improvement efforts. The domains along with the more specific and descriptive sub-domains follow:

and the “Quality Framework” that was developed by CMS and HSRI to focus attention on desired outcomes of HCBS quality management and improvement efforts. The domains along with the sub-domains are as follows:

Domain / Associated Sub-domains

Participant access

(on hold) /

Information/referral
Intake and Eligibility
User-friendly processes
Eligibility determination
Referral to Community Resources
Individual choice of HCBS
Prompt Initiation

Participant-centered service planning and delivery

Participant-centered service planning

Assessment
Participant decision making
Free choice of providers
Service plan
Participant direction

Service delivery
Ongoing service and support coordination
Service provision
Ongoing monitoring
Responsiveness to changing needs

Provider capacity and capabilities

Provider networks and availability
Provider qualifications (including a sub-category for
Staff recruitment, retention, training and competency)
Provider performance

Participant safeguards

Abuse, neglect and exploitation
Major and unusual incidents (including a sub-category for death reporting and mortality review)
Housing and environment
Behavior interventions
Health and medication management
Personal safety and security
Natural disasters and other public emergencies

Participant rights and responsibilities

Civic and human rights
Participant decision making authority
Alternate decision making
Due process
Grievances

Participant outcomes and satisfaction

Participant satisfaction
Participant outcomes

System performance

System performance appraisal
Quality improvement
Participant & stakeholder involvement

Suggested Components: These are the major systems the state has in place to support individuals with mental retardation and other developmental disabilities and include the following:

State regulations and/or policies and procedures

Staff requirements and competency

Information gathering, analysis and reporting structure

Monitoring and follow-up procedures

A major component that is missing or needs better definition in a state would indicate why a systemic problem is occurring and may target where technical assistance may be needed.

Threshold Criteria Features: Thesedefinespecific attributes define the “essential” contentattributesareas that should form form the foundationbasis of the state’s quality assurance effortsprocesses in each of the domains. A characteristic that is missing or not well defined in a state would indicate why a systemic problem is occurring and may target where technical assistance may be needed. AttributesCharacteristics define what processes and outcomes need tothat should be in placepresent but do not prescribe or dictate how they should be implemented in a state.

The systems analysis also includes Quality Improvement GoalsFeatures, while not essential, are attributes that will enhance and improve the quality assurance system over time, specific added features that enhance and improve the quality assurance system over time, including, but not limited to the following examples:

computerized data collection systems;
integrated management reports that compare different types of data for tracking,and analysis and benchmarking for service and systemic improvements over time;
strategies to include consumers, families and other stakeholders in quality assurance and improvement efforts;
strategies to build an increasingly more competent workforce and to acknowledge the contributions of direct support professionals.

Following are the thresholdsuggested threshold criteria and quality improvement featuregoals for each of the domains described above.The system analysis criteria are located in section V.

III. Completing a Systems Analysis

A state or the technical assistance team can use the criteria to complete the systems analysis. The strengths and opportunities for improvement in specific aspects of the state’s quality assurance and improvement systems are identified by using the “Systems Analysis Criteria” to answer the following questions:

1.What specific feature(s) of the state’s quality assurance and improvement system is identified as needing improvement (from the CMS wavier review and/or as identified by the state)?

2.Where are the strengths in the state’s quality assurance and improvement system (using the system criteria located in Section IV)?

3.What is the source of the gaps in the state’s system (using the systems analysis criteria located in Section IV)?

4. From #3 above, what are the priority areas for improvement and technical assistance?

5.What factors may limit the ability to achieve improvements?

6.What factors may enhance the ability to achieve improvements?

7.In what ways can the TA team assist the state to achieve these results?

Suggested Threshold Criteria and Quality Improvement GoalFeatures

IV. Technical Assistance Systems Analysis Report Format

Human Services Research Institute

National Quality Improvement for HCB Services

Systems Analysis Report Format

Name

Address

Telephone

Section I: Presenting Request and Scope of Review

Section II: Documentation Reviewed/Other Information Reviewed/Persons Interviewed

Section III: Summary of the State’s System/Strengths/Areas for Improvement

Section V: Specific Recommendations for Enhancing System

Section VI: (Optional) Areas for Further Inquiry/Information that would refine consultant’s analysis

Jrowe/Systems changeHuman Services Research Institute/Threshold Analysis1/26/2019

Systems Analysis Criteria

Domain II: Participant-centered sService planning and delivery[1]
Components / Suggested Threshold Criteria Features / Quality Improvement GoalsFeatures

Purpose/Mission

Identify the importance of person-centered planning and supports in the agency’s mission.

Regulations and/or policies and procedures

Describe person-centered planning principles and importance of respecting individual choice and preferences.

Describe a person-centered planning process and addresses outcomes such as choice and satisfaction.
Describe person-centered planning principles.

Define a reliable method to assess individual preferences goals, needs and abilities and needs.
Identify goals, abilities and needs in person-centered plans.
Specify that services and supports in the plan must be consistent with the identification of individual strengthsgoals, needs and preferencesabilities and needs.
Include the individual in the person centered planning process.
With the individual’s consent, invite participation by supportive family, advocates and others in the person’s circle of support.
Define a process for the individual, advocates and/or family to request a formal review or appeal of the person-centered plan.
Require individual (or designee) consent to the plan.
Define a process to monitor implementation of the plan including modifying the plan when individual needs or circumstances change.
Require that information and support be available to the individual to make informed choices among qualified providers.

Staff requirements and competency /

Provide statewide training in person-centered planning for case managers and others involved in planning.

Provide training in person-centered planning for direct support staff.

Require training in risk planning and the designandof individual-specific health and safety provisions.
Provide training for families and individuals regarding the implementation of person-centered plans. /

Provide training for families and individuals regarding the implementation of person-centered plans.

Information gathering, analysis and reporting / Use aggregate data on individual needs to determine demand and necessary changes in system design.
Have a mechanism to link individual needs with resource allocation.
Conduct review of consumer and family satisfaction on a regular basis. /

Use aggregate data on individual needs to determine demand and necessary changes in system design.
Have a mechanism to link individual needs with resource allocation.

Monitoring and follow-up procedures / Use person-centered plans to measure accomplishment of individual goals.
Use person-centered plans to determine that individuals are receiving the services and supports outlined.Provide technical assistance in instances of unsatisfactory performance in person -centered aspects of supports.
Identify strengths, preferences and goals in person-centered plans. /

Provide technical assistance in instances of unsatisfactory performance in person-centered aspects of supports.

Comments:
Domain III: Provider cCcapacity and cCcapabilities – Provider Qqualifications
Components / Suggested Threshold FeaturesCriteria / Quality Improvement FeatureGoals
Purpose and Mission /

Licensing rules and protocols are tTied licensing rules and protocols to the agency’s purpose and mission.

/ Licensing rules and regulations spell out desired outcomes such as choice, relationships, and inclusion
Regulations and/or policies and procedures /

Describe requirements for reporting, investigating and following -up on critical incidents.
Describe requirements for reporting, investigating and following -up on allegations of abuse/, neglect and exploitation allegations.
Specify rights for individuals including right to privacy, personal possessions, confidentiality, choice, and community participation.
Specify rights regarding civic participation including voting.
Describe procedures for safeguarding clientindividuals’ funds.
Specify requirements regarding training individuals and families with respect toabout their rights.
Describe procedures when restrictive interventions are needed (e.g., psychotropic medications).
Describe restraint procedures.
Specify requirements regarding health screening and treatment including dental services.
Describe medication administration requirements.

Emergency procedures are in place

Describe the necessity to treat people with dignity and respect and to support cultural and religious values.
Specify transportation, environmental and communication adaptations where required.
Describe requirements for financial capacity.
Specify the necessity for policies and procedures regarding the recruitment and retention of direct support staff.
Specify necessity for back-up coverage and emergency situations.
Require criminal background checks be conducted forfor potential staff.

Specify basic orientation requirements for direct support staff.
Require the following staff knowledge and training:

Procedures for reporting serious incidents and potential abuse/neglect and other agency emergency procedures;
CPR, universal precautions and other lifesaving procedures;

Individualized health needs;
Person-centered practices;

Individual health needs;
Person-centered practices;
Human rights. /

Spell out desired outcomes such as choice, relationships, and inclusion in licensing/certification rules and regulations.
Require client training for individuals regarding health and wellness practices.
Require human rights committee to review restrictive practices
Specifiesy outcome -based internal evaluation.
Requires long-term plan to increase the competence and retention of direct support staff.
Specifiesy participation of families and people with disabilities on agency boards.
Stresses need to support individuals to participate in self-advocacy activities.
Assess staff competency in person-centered practices.

Staff requirements and competency /

Provide a standard “operations” manual for all reviewers.
Provide training and interpretative guidelines to ensure consistency of practice statewide.

Specify standards of competency and training for reviewers.Criminal background checks are required
Staff are trained regarding procedures for reporting serious incidents and potential abuse/neglect and other agency procedures
Staff are trained in CPR, universal precautions and other lifesaving procedures
Staff are knowledgeable regarding client health needs
Staff receive training in person-centered practices

Staff are trained regarding human rights

Provide Staff competency in person-centered practice is assessedtraining for state reviewers in person-centered practices.
Include people with disabilities and family members in reviews.

Information (data) gathering
& analysis /

Includes on -site observations and structured interviews with service participants.
Data from reviews is iIncluded data from reviews in a data base of all state providers.

State reviewers are trained in person-centered practices
Information is aAnalyzed the data to determine trends.
Information collected is lLinked information collected to other system data including incident reviews and abuse/neglect investigations. /

Link information collected to other system data including incident reviews and abuse/neglect investigations.People with disabilities and family members are included in reviews

Monitoring and follow-up procedures /

Specify a de-briefing with the provider regarding findings.
Require timely completion of agency review reports.

Use Iinformation from reviews is used to provide technical assistance to the provider.

Specify procedure for immediate identification and follow-up for critical issues affecting individuals’ health, safety or rights.

Agency staff are de-briefed regarding findings
Completion of agency reports occurs in a timely fashion
Specify procedures for follow-up to ensure that deficiencies are corrected.

Specify procedures to sanction providers with serious and/or repeated deficiencies.

Data on reviews is made available to the public.
Use information from reviews to provide technical assistance to the provider.

Comments:
Domain III: Provider Ccapacity and cCapabilities –
sStaff Rrecruitment, Reretention, tTraining and cCompetency
Components / Suggested Threshold FeaturesCriteria / Quality Improvement FeatureGoals
Purpose/Mission /

Identify in the mission the importance of valuing direct support staff and the importance of the partnership among people with disabilities, families and staff.
Define direct support in a professional manner (e.g., defined foundation of skills, ethics, and knowledge).

Identify a code of ethics for direct support staff.
Regulations and/or policies and procedures /

Require training and education be consistent Training/educational requirements are consistent with multiple responsibilities of direct support staff and the needs of individuals served.
Employ screening provisions to eliminate known criminals and abusers from employment.
Require all employees to report abuse, neglect and exploitation.

Involve direct support staff in key decision-making bodies.
Promote the advocacy role of direct support staff.

Staff requirements and competency

Specify performance criteria and training requirements for direct support staff and case managers.
Promote competency-based training for staff.
Link promotion of direct support staff to the the mastery of skills that reflecting the multiple responsibilities of direct support.
Standardize a basic curricul curricula to train direct support staff in basic preparation topics to support individuals with developmental disabilities to include:
Training required by state regulation;
Understanding developmental disabilities;
Health and prevention;
Human and civil rights;
Identifying and reporting incidents of abuse and neglect and other types of incidents;
Positive behavior supports and psychotropic medications;
Procedures for emergencies and crisis situations.

Link on-the-job training with secondary and post-secondary degrees.
Use high performance practices to recruit staff (e.g., consortium approaches, multi-media, internet, and realistic job preview).
Use high performance practices to retain staff (e.g., mentoring, participatory management, skilled supervision, bonuses, recognizingation for exemplary employees).
Support a statewide recruitment initiative.
Develop linkages with community colleges, vocational\/technical schools and other educational resources.
Develop linkages with state/regional workforce development activities (e.g., state/federal Departments of Labor, One-Stop Career Centers, regional employment boards).
Collect and disseminate information regarding retention practices (mentoring, participatory management, skilled supervision, retention bonuses, adequate wage and benefits, career opportunities).

Information (data) gathering and analysis /

Collect data to determine staff retention, recruitment and staff turnover rates on a regular basis.
Review and use information regarding workforce stability to inform workforce policy.

Make information regarding workforce stability available to all concerned stakeholders.
Provide regular updates on workforce development initiatives.

Monitoring and follow-up procedures

Use workforce stability data to flag providers where the quality of services may be in jeopardy.

Comments:
Domain IV: Participant Safeguards –
Investigations of Aabuse, nNeglect and eExploitation
Components / Suggested Threshold FeaturesCriteria / Quality Improvement FeatureGoals
Regulations and/or policies and procedures /

Define what constitutes abuse, neglect, and exploitation.
Define the group (e.g., agency, unit) responsible for referral and conducting investigations.
Describe those who areisa mandatory reporters of abuse and neglect allegations.
Specify timelines for thereporting, conducting the investigation, completing reports, and taking subsequent action.
Specify procedures for puttingto initiate protective services in place pending the outcome of an investigation.
Describe the steps needed to be taken to determine whether an allegation of abuse can be substantiated, and the nature of written reports that should be submitted.
Define a confidentiality policy to protect sources of information.
Define when and how to involve law enforcement.
Define roles and responsibilities when multiple agencies are involved in reporting and/or for conducting investigations.
Specify a process for appealing the results of an investigation.
Limit access to consumer sensitive information.

Staff requirements and competency

Specify that investigators must be free from conflict of interest.
Provide a standard “operations” manual for all investigators.
Specify standards of competency and training for investigators.
Provide sufficient education and training opportunities for case managers, direct support staff and other mandatory . reporters about abuse and neglect (e.g., prevention, recognizing abuse and neglect, confidentiality, reporting requirements).

Provide staff training for staff ion recognizing factors that place individuals at higher risk for abuse, neglect and exploitation.

Information (data) gathering and analysis /

Maintain accurate data on abuse, neglect and exploitation for tracking, follow-up and trend analysis
Specify a process for reviewing the data periodically to determine trends.

Develop a computerized data collection system for abuse, neglect and exploitation.
Integrate investigations data collection with other types of incidents (e.g., medication errors, injuries, restraints, deaths).

Disseminate yearly aggregated data on all incidents (including abuse, neglect and exploitation) for trend analysis and prevention.
Analyze data to identify groups of individuals who are at higher risk for abuse, neglect and exploitation.
Establish quality improvement targets and strategies for prevention of abuse, neglect and exploitation over time.

Monitoring and follow-up procedures

Specify timelines for remediationgying aof the specific circumstance, based on the recommendations of the investigator.
Specify changes in policies and/or practice based upon documented recommendations from a review of the data.
Track system improvements (e.g., training protocols) resulting from recommendations.

Comments:
Domain IV: Participant Safeguards – Major and Uunusual iIncident rReporting Ssystems
Components / Suggested Threshold FeaturesCriteria / Quality Improvement FeatureGoals
Regulations and/or policies and procedures /

Describe the specific population for whom incidents must be reported.
Define different types and levels of incidents.
Define timelines for reporting different levels of incidents (e.g., immediate reporting, 24-hour reporting).
Specify who is responsible for reporting incidents.
Specify when to notify other agencies/authorities (e.g., medical, fire/ambulance, public safety).
Limit access to consumer sensitive information.
Establish criteria regarding when and to whom incidents must be reported.
Specify the types of incidents that must be reported to state agencies.
Establish protocols for responding after an incident has been reported (e.g., responsible parties, timelines).

Staff requirements and competency