Quality Management and Utilization Reviews Introduction Page 1: • First paragraph, 2nd sentence - who is DMAS’s “designated agent”? Recommend clarification between DMAS QMR staff and any subcontracted contractor for financial audits, etc. • First paragraph, 4th sentence states “DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, ..." Comment: Shouldn't this be just on those that do not provide services in accordance with the regulations? What does "established norms" mean? Language needs to be changed or definition of “established norms” needs to be provided. General Requirements Page 1: • Second paragraph, 1st sentence states "DMAS participation standards and policies". Comment: Shouldn’t this refer to regulations as in the following sentence? If “standards and policies” is retained - definition or citation needs to be included. Page 2: • 1st sentence - general grammar problem - comma needed following the word "individuals”. • Second paragraph, 1st sentence - Who is "staff"? We assume “DMAS QMR staff” in this instance. Comment: Helpful to state and delineate between DMAS QMR staff and provider staff within this paragraph and others to provide clarity. Also, "staff may request licenses” - However, not all providers are required to have staff that is licensed. Add “providers and staff required to have licenses”. Differentiate between requirements of services that are licensed and services that are not licensed regarding criminal background checks and what “documentation” is required. • Third paragraph, 2nd sentence - Again, the requirement to be in compliance with "DMAS provider agreements and policies" Comment: Shouldn’t this refer to regulations? If “standards and policies” is retained - definition or citation needs to be included for clarity. • Fourth paragraph, 3rd sentence - Use of the word "provider" here. Comment: Assume this means the Agency Provider and not the Personal Care provider. However, “provider” is used interchangeably for both throughout document. “Staff” is also used interchangeably throughout the document. Clarity and specificity is needed consistently. Page 3: • Bullet 1, 1st sentence - states "within the program's guidelines"? Should this be "in accordance with regulations"? • Bullet 1, 2nd sentence - Same comment as above related to the use of the word "provider". • Bullet 1, 3rd sentence - Comment: What is considered to be "the individual's record"? Add specific reference to what record. Is it enough to document these things in a provider’s system? Also, what is classified as "any substantial change"? And what specific "documentation of such change" is required? Please add specificity. • Bullet 1, 4th sentence - Recognize that provider’s responsibility to identify “substantial changes” and inform the Support Coordinator. Comment: However, it is the Support Coordinator’s role to obtain and coordinate those services that the individual requires to remain in the community and not the provider. The "or" that follows that requirement should be replaced with "so that the Support Coordinator can obtain any other services,...." • Bullet 3, 2nd sentence - Clarity needed. Comment: Who is considered "provider staff"? and who is the "provider agency representative"? In the case of Service Facilitation - clarity is needed since the SF is the one both in communication with the individual AND the one responsible for the oversight of the plan. • Manual Pg 3, bullet 3, last sentence ? where should the "providers" find the remaining list of quality of supports if this is just "some" of them? Remember, not every provider is licensed, so we are only following the regulations and this handbook. • Manual Pg 3, bullet 4 ? are we allowed to use electronic signature now? Where did that change in the regulations? Page 4: • Bullet 1 - Use of "provider" again and "maintain a record"? Comment: Can that be just be in the provider’s system? It's confusing since the next sentence mentions the forms. So is the "record" the "form"? Are those one and the same? Why not use the same word for both spots? • 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..." Comment: This is where that word "provider" gets used interchangeably again. The SF writes outcomes based on the Part 3, but the outcomes are for the Personal Care Attendant to provide to the individual and not for the SF to provide to the individual. So, who is the "provider" whose performance DMAS is reviewing? Further clarification is needed. • General Comment on consistency - The language is now referring to DMAS. "DMAS will review", "DMAS will evaluate", "DMAS may require". Before, in this same document, it refers to "staff". Consistency is needed throughout. • 2nd full paragraph - Shouldn’t the regulations be mentioned here instead of “policies and procedures”? • Bullet 1 - Further clarity is needed. What exactly is meant by "periodically"? • Bullet 5, sentence 1 - A sentence is needed to differentiate Service Facilitation and CD services from other services and their specific requirements. States "Staff" will meet with at least one individual or PCG to determine satisfaction with the provider. Which provider is that? The SF provider agency? Or the PCA provider? Not clear regarding what would be measured for SF. Page 5: • Bullet 1 - why is "provider" underlined? Who is "staff"? Appreciate the reference to regulations vs “policies and procedures”. • Bullet 3 - Who is submitting this letter to these other agencies? Specificity needed. Comprehensive and Ongoing Assessment and Planning Page 8: Bullet 1, sub-bullet 5 - A parenthesis is missing here. Page 10: Bullet 3 - Why is "the waiver enrollment date" underlined? Services are Delivered, Reviewed and Modified as Needed Page 11: Comment: Is this for all providers or specific to Case Management? The first bullet/sub-bullet seems to speak to each service provider, but then the second sub-bullet is specific to Case Management. Then the third sub-bullet goes back to "each service provider". Recommend to separate and list bullets under either provider and case management for clarity Page 12: Main Bullet Comment: Sub-bullet 1 - Provide specificity in Manual. What DMAS form is to be used for the quarterly review? There is currently no consistency from CSB to CSB on what documentation is required to be used for quarterlies. There is also no consistency as to what has to be in that quarterly review. Specificity would be helpful to provide consistency. Page 13: • 1st sub-bullet ? "All providers must be invited to the meeting and participate in the development of the new ISP annually." Are SF required to be present at the meeting? Service Facilitators are not compensated for this meeting and can only bill for a reassessment visit. These meetings can be up to 3+ hours. Services Delivered are Consistent With Service Limits Page 13: Bullet 1, sub-bullet 2 - Comment: Need additional specificity for Service Facilitation - recommend separate sub-bullet. "The number of hours does require authorization." What hours? MT Units? PCA hours? Respite Hours? Companion Hours? The hours the SF is working? Page 15: Bullet 2 Comment: Paper timesheets went away a long time ago, so the EOR and employee will not be signing them. Time is either logged via app, online portal, or by calling in using IVR. So billing for CD services will not be supported by a timesheet that is signed. This point in the manual needs to be removed. Support Coordinator/Case Manager/Provider Responsibilities Page 23: Comment: Need to REMOVE “Provider” from this section. “Provider” should not be included in this title when the first paragraph says that the following things are the responsibility of the support coordinator/case manager, and doesn't mention the provider? None of the things listed are the responsibility of the provider.