Quality Management and Utilization Reviews 

DD Manual Chapter 6

1. Manual Pg 1, 

   1. Clarify/Detail/Specify who is DMAS's "designated agent"

      1. Various mentions of “designated agent” - needs specificity

         1. Pg1/1st paragraph/2nd sentence

         2. Pg 1/2nd section/2nd paragraph/1st sentence

         3. Pg 1/2nd section/3rd paragraph/1st sentence

         4. Pg 2/4th paragraph/sub-bullet 1

   2. Clarify/Detail/Specific "Provider" (don’t generalize all providers because not providers are not all monitored/paid/created equal)

      1. Manual Pg 3, bullet 1, 2nd sentence.

      2. Manual Pg 3, bullet 2

      3. Manual Pg 3, bullet 3, last sentence

      4. Manual Pg 4, bullet 1

   3. "...on providers that are found to provide services in excess of established norms, ..." (1st paragraph/4th sentence)

      1. Detail/Clarify what “established norms” mean?

      2. This should specifically address those providers that do not provide services in accordance with the regulations

   4. State the regulations instead of using this loose language "DMAS participation standards and policies" 

      1. The next sentence is the first time they even mention the regs.

   5. general grammar problem at the top of page 2

      1.  should be a comma following the word "individuals”

2. Manual Pg 2, 2nd paragraph, 1st sentence

   1. Clarify/Detail who is "staff"? (2nd paragraph/1st sentence,

      1. 2nd paragraph, 4th sentence

      2. seems to refer to "staff" as the QMR team, but then in the very next sentence, they've switched to "staff" being part of the provider agency.

      3. Also, "staff" may request licenses, but not all providers are required to have those on staff.

3. Manual Pg 2, 2nd paragraph, 6th sentence

   1. Expand on CD services and do not only specify the EOR.  There are many roles that are necessary for CD services to work efficiently for Clients.

   2. SFs do not have to be RNs.  An RN license is not necessary to fulfill the role/responsibility of a CDSF.

4. Manual Pg 2, 3rd paragraph, 2nd sentence

   1. The regulations supersede this manual.  Stating compliance with "DMAS provider agreements and policies", undermines the weight of the regulations.

5. Manual Pg 2, 4th paragraph, 3rd sentence

   1. Clarify/Distinguish the title “Provider”.  There are many providers of services within the DD Waivers, and the term provider should not be used interchangeably since every provider has different requirements.

      1. For example, lumping all as “Providers” gives the illusion that every provider requires licensing.  However, as a CDSF provider, we know we are not required to obtain/maintain a license.

      2. Be Specific.

6. Manual Pg 3, bullet 1, 1st sentence

   1. Utilize regulations and not generalization of "within the program's guidelines"?

7. Manual Pg 3, bullet 1, 3rd sentence

   1. Clarify what is considered to be "the individual's record"?

      1. Should it be noted on an official DMAS form, or somewhere in the CDSF records?

      2. Define/clarify hat is classified as "any substantial change"?

         1. Provide detailed guidance of what the requirement is for "documentation of such change".

8. Manual Pg 3, bullet 1, 4th sentence

   1. CDSFs should not be required to "obtain any other services that the individual requires to remain in the community (e.g, durable medical equipment and supplies, etc.)”.  

      1. CDSFs cannot bill or receive payment for that and it is not our responsibility.  Reporting that need to the Support Coordinator is one thing.

         1. Remove the "or" that follows that requirement and replace it with "so that the Support Coordinator can obtain any other services,...."

9. Manual Pg 3,

   1. bullet 3, 2nd sentence

      1. Define/Clarify/Specify who is considered "provider staff"

      2. Define/Clarify/Specify who is the "provider agency representative"?

         1. In the case of Service Facilitation, this is not clear. The SF is the one both in communication with the individual AND the one responsible for the oversight of the plan.

   2. bullet 3, last sentence

      1. Detail where to find a comprehensive list of quality of supports instead of listing "some" of them.

         1. Not every provider is licensed, and as such, we are only following the regulations with support from the manuals.

   3. bullet 4

      1. Does this give permission to utilize electronic signatures now?

         1. Detail that regulatory change if so.

10. Manual Pg 4

    1. "maintain a record"

       1. Details/Clarification requested.  This is confusing. 

          1. The next sentence mentions forms.

          2. Are these forms required/approved for use?  Detail form numbers/criteria.

       2. 1st full paragraph - "DMAS will review the provider's performance in all the outcome areas to determine the provider's ability to achieve high quality supports..."

       3. This is where that word "provider" gets used interchangeably.

       4. The SF writes outcomes based on Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual, not for the SF to provide to the individual.

       5. Detail who is the "provider" and whose performance DMAS is reviewing?

    2. General thoughts:  now the language is referring to DMAS.  "DMAS will review", "DMAS will evaluate", "DMAS may require".  Before, in this same document, it refers to "staff".  Detail who “staff” is and whether or not it is DMAS or another entity.  Clarification requested.

    3. 2nd full paragraph - Denoting the regulations would be best used here.

    4. bullet 1 More detail requested:

       1. who is the designated agent? 

       2. Detail what an on-site review is/means

          1. we are 100% remote organization that has the capacity to maintain a work from home model and we do not have a "site".

       3. Detail what a "desk review" is

       4. I'm assuming that means they do it remotely, but I'm not sure.

          1. Define “periodically"

    5. bullet 5, sentence 1

       1. Detail what "daily records" and "support logs" are for CDSF providers

       2. In sentence 2, it says "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider.

          1. Detail which provider that is: the SF provider agency?  the PCA provider?

          2. Clarify what is being measured here.

    6. bullet 6 - We require further clarification "DMAS staff will meet with designated staff to conduct an exit conference."

11. Manual Pg 5

    1. bullet 1 Why is provider underlined? Who is "staff"?

    2. Previously the manual did not cite the regulations, and now here, the manual begins to include them again.

       1. Consistency is suggested for ease and reference

    3. bullet 3: Who is submitting this letter to these other agencies?

12. Manual Pg 8, bullet 1, sub-bullet 5

    1. TYPO -  there's a parenthesis missing there.

13. Manual Pg 10, bullet 3

    1. Why is "the waiver enrollment date" underlined? 

14. Manual Pg 11, Category titled "Services are Delivered, Reviewed, and Modified as Needed"

    1. Clarification requested:

       1. Is this for all providers or specific to Case Management?

       2. The first bullet/sub-bullet seems to speak to each service provider;

       3. then the second sub-bullet is specific to Case Management

       4. Then the third sub-bullet goes back to "each service provider"

15. Manual Pg 12, main bullet 1, sub-bullet 1

    1. What official DMAS form is to be used for the quarterly review?

    2. There is currently absolutely no consistency from CSB to CSB on what documentation is required to be used for Quarterly Reports.

    3. There is also no consistency as to what has to be in that quarterly review.  

16. Manual Pg 13, 1st sub-bullet

    1. "All providers must be invited to the meeting and participate in the development of the new ISP annually."

       1. Are CDSF providers required to be present at the ISP meeting?

          1. ISP meetings can last for up to 3hours

          2. There currently is no compensation structure for an SF to attend an ISP meeting if the meeting does not align with the SFs visit.

          3. Service Facilitators who can attend can only bill for a reassessment visit

17. Manual Pg 13, Services Delivered are Consistent...., bullet 1, sub-bullet 2

    1. "The number of hours does require authorization."

       1. Clarification Requested: What hours?

          1. MT Units?  PCA hours?  Respite Hours?  Companion Hours?  The hours the SF is working?

18. Manual Pg 15, bullet 2 - billing for CD services will not be supported by a timesheet that is signed.  This point in the manual needs to be removed. 

    1. EVV requirements are now the standard (paper timesheets went away a long time ago, so the EOR/PCA no longer “sign” but rather “approve” digitally).

    2. Time is either logged via app, online portal, or by calling in using IVR.

19. Manual Pg 19, bullet 1

    1. This is the responsibility of the CSB/BHA, not CDSF, and why the use of the general term “providers” is so confusing and needs a remedy.

20. Manual Pg 23, Support Coordinator/Case Manager/Provider Responsibilities

    1. The word “Provider” should be removed and stop being used interchangeably but rather specifically.  The first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider.