Nebraska Developmental Disabilities Stakeholder Conference Session 3; Administrative Track

Tips & Tools for Survey Compliance

Susan Kotas, Program Manager

The Community Based DD Surveyor team for agency (formerly “specialized”) providers is part of the DHHS Division of Public Health. We work collaboratively with other divisions, especially the Division of Developmental Disabilities, to contribute to the following DPH core functions:

  • Enforcing laws and regulations that protect health and ensure safety
  • Assuring a competent public health and personal healthcare workforce
  • Evaluating effectiveness, accessibility and quality of personal and population-based health services

Why do we have Surveys?

  • As 1 part of Nebraska’s process to assure the Centers for Medicare and Medicaid Services (CMS) that we are using matching funds for service delivery within the required guidelines. Just over 52% of the funds Nebraska uses for DD service delivery come from federal sources. If Nebraska would be found to fail to monitor the delivery of these services or be out of compliance, Nebraska could lose more than half of the funding we currently use for service delivery. State certification activities help providers identify and correct deficient areas before a more serious problem is created.
  • Every surveyor on my team has actually been involved in service delivery and cares deeply about the individuals in Nebraska who receive services, just like you do

Before – Preparation

  • Always be prepared – certification is an on-going process, not an event
  • Familiarity with regulations as a way of doing business, not “cramming” for a test
  • Policy and Procedures reviewed and updated to reflect actual practice on a regular basis; these are YOUR guidelines to your business and may be cited for not meeting statute or regulation but DHHS does not “approve” your policies and procedures
  • QA and QI systems consistently in use
  • Mock Surveys
  • Staff preparation

During – Certification Review

  • Treat surveyors and one another with respect and professionalism
  • Be truthful – balance putting your best foot forward with being truthful and having the documentation to demonstrate statements made
  • Respond promptly to surveyor requests
  • Ask for clarification if there is confusion or if there are questions about exactly what a surveyor is requesting

After – Follow Up

  • Respond in a timely manner and according to directions in the certification report letter
  • Submit a POI that addresses all 5 components listed in 4-002.10B (optional template link sent with all citation reports)

(a)Specific

(b)Date completion expected

(c)Means to prevent recurrence

(d)Who is responsible by title

(e)Signed and dated

  • Implement, track, and report implementation of the approved POI
  • Maintain and submit documentation to support changes and implementation of the POI
  • The POI is not the place to argue citations, make excuses, or air internal dirty laundry about your staff or systems. All certification documentation may become public record, thus use sample key codes and job titles, not names for staff or persons served.

Investigations, POI follow up visits, other non-scheduled reviews and information requests

  • Situations arise outside of the one or two year certification cycle that require review and in some cases, additional follow up. In 2016, more than 2,700 complaints were received and reviewed by our team of about 10 surveyors
  • My survey team only has authority over Title 404 NAC regulations. Other teams may also provide oversight including Public Health Licensure teams regarding Professional Licensure (Title 172 NAC, specifically chapters 95 and 96 regarding Medication Aides and Title 175 NAC Chapter 3 for Centers for the Developmentally Disabled or CDDs), Children and Adult Protective Services (CPS and APS), law enforcement, and other regulatory agencies such as the fire marshal, local zoning ordinances, etc. Providers need to meet all the statutes, regulations, and guidelines based on the services they provide and the location where they operate
  • Title 404 NAC 4-013.02I states that “The provider must ensure that all administrative records and records relating to the individual served are made available for review by authorized representatives of the Department.” Title 404 NAC 4-003.08 specifies “Access to DD Provider: The provider must allow access by Department staff to all records or other documents relating to the operation of the provider, and all individuals served, as the Department deems necessary.”

Summary

  • Providers and staff don’t need to be fearful of the certification process or surveyors
  • Being prepared, proactive, and professional makes everything easier
  • The regulations and certification processes are intended to ensure quality services. Use the regulations to help you achieve that goal
  • Look at the certification process as an opportunity to improve the services delivered and make your agency even better!

Resources

  • Title 404 NAC Regulations
  • DHHS-DDD Public Website

Make sure you are subscribe to provider bulletins!

  • DHHS-DPH Public Health Website

Providers’ submission points for:

Issue/Regulation / Contact Point
Requests for Alternative Compliance
1-003.01 / DDD – Deputy Director

Please note that provider bulletin 17-08 issued May 4, 2017 ONLY
eliminates alternative compliance requirements for CDDs.
Letter of Intent to apply for certification
4-002.02 / DDD – Provider Relations/Technical Assistance

Application for Initial certification
4-002.04 / DDD – Provider Relations/Technical Assistance

Application for Recertification
4-002.09 / Public Health Community Based Services DD surveyor shared mailbox
Or Fax (402) 742-2352
Plans of Improvement (cert and complaint) and quarterly POI updates
4-002.10B / Public Health Community Based Services DD surveyor shared mailbox
Provider policy and procedure manuals and updates 4-002.09A 14.d and 4-003.04 / DDD
Or Fax (402) 471-8792 or (402) 742-2309
Notification Requirements 4-002.09D (Ownership, director, service option change, expansion of geographic area) as well as changes to contact information for the provider directory / DDD -
Or Fax (402) 471-8792 or (402) 742-2309
Provider Internal Investigation Reports
4-008.01 #5c / At this time, providers do not need to automatically submit every internal investigation report. Providers are still required to complete internal investigations in accordance with all regulations as well as their own policies and procedures including timelines. Internal investigation reports must be made available to DDD and/or PH DD Surveyors within 14 calendar days if requested for specific incidents. Any current agreements regarding sharing investigation reports with service coordination should continue.
Quarterly incident report summaries (QA/QI)
4-008.01 #5d / DDD – Quality Unit

Or fax (402) 471-8792 or (402) 742-2309
Subcontracts 11-002.01 #3 / Service Coordination prior to utilization of services

General guidance for other issues:

*interpretation of regulations - DDD Provider Relations/Technical Assistance

*questions or issues related to the certification process, citations, or other compliance issues, contact the surveyor involved or the survey team manager in Public Health. (Susan Kotas, Public Health Manager for Community Based Certification)

*other questions including billing, contracts, technical assistance, contact the appropriate unit in Developmental Disabilities.

Mailing Addresses:

DDD Central Office (including the Quality Unit)

DHHS Developmental Disabilities

P.O. Box 98947

NSOB 3rd Floor

Lincoln, NE 68509-8947

DHHS Division of Public Health

Licensure Unit, NSOB 1st floor

PO Box 94986

Lincoln, NE 68509-4986

Fax (402)742-2352

“Helping People Living Better Lives”|pg. 1