Settlement Agreement Provision

V.A-B

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Reports

• FY20 DD Quality Management Plan
• FY20 DD Quality Management Plan and Appendices
• FY21 DD Quality Management Plan
• FY22 DD Annual Report and Evaluation
• FY23 DD Annual Report and Evaluation

Compliance Indicators

Compliance Indicators V.B

The Commonwealth’s Quality Management System includes the CMS approved waiver quality improvement plan and the DBHDS Quality Management System.

1. DBHDS Quality Management System shall:
   1. Identify any areas of needed improvement;
   2. Develop improvement strategies and associated measures of success;
   3. Implement the strategies within 3 months of approval of implementation;
   4. Monitor identified outcomes on at least an annual basis using identified measures;
   5. Where measures have not been achieved, revise and implement the improvement strategies as needed;
   6. Identify areas of success to be expanded or replicated; and
   7. Document reviewed information and corresponding decisions about whether an improvement strategy is needed.
2. The DBHDS Quality Management System is comprised of the following functions:
   1. Quality Assurance
   2. Quality Improvement
   3. Risk Management
3. The Offices of Licensing and Human Rights perform quality assurance functions of the Department by determining the extent to which regulatory requirements are met and taking action to remedy specific problems or concerns that arise.
   1. The Office of Licensing assesses provider compliance with the serious incident reporting requirements of the Licensing Regulations as part of the annual inspection process. This includes assessing whether:
      1. Serious incidents required to be reported under the Licensing Regulations are reported within 24 hours of discovery.
      2. The provider has conducted at least quarterly review of all level I serious incidents, and a root cause analysis of all level II and level III serious incidents;
      3. he root cause analysis, when required by the Licensing Regulations, includes i) a detailed description of what happened; ii) an analysis of why it happened, including identification of all identifiable underlying causes of the incident that were under the control of the provider; and iii) identified solutions to mitigate its reoccurrence.
   2. DBHDS monitors compliance with the serious incident reporting requirements of the Licensing Regulations as specified by DBHDS policies during all investigations of serious injuries and deaths and during annual inspections. DBHDS requires corrective action plans for 100% of providers who are cited for violating the serious incident reporting requirements of the Licensing Regulations.
4. The DBHDS quality improvement system is led by the Office of Clinical Quality Improvement and structured by organizational committees with the Quality Improvement Committee (QIC) as the highest quality committee for the Department, and all other committees serve as subcommittees, including the: Mortality Review Committee, Risk Management Review Committee, Case Management Steering Committee, Regional Quality Councils, and the Key Performance Area Workgroups: Health & Wellness, Community Inclusion & Integration, Provider Capacity & Competency.
   1. The Office of Clinical Quality Improvement leads quality improvement through collaboration and coordination with DBHDS program areas by: providing technical assistance and consultation to internal and external state partners and licensed community-based providers, supporting all quality committees in the establishment of quality improvement initiatives, use of data and identification of trends and analysis, and developing training resources for quality improvement.
   2. The Office of Clinical Quality Improvement oversees and directs contractors who perform quality review processes for DBHDS including the Quality Services Reviews and National Core Indicators.  Data collected from these processes are used to evaluate the sufficiency, accessibility, and quality of services at an individual, service, and systemic level. 
   3. The QIC ensures a process of continuous quality improvement and maintains responsibility for prioritization of needs and work areas.
   4. The QIC maintains a charter and ensures that all sub-committees have a charter describing standard operating procedures addressing:
      1. The charge to the committee
      2. The chair of the committee
      3. The membership of the committee
      4. The responsibilities of chair and members
      5. The frequency of activities of the committee (e.g., meetings)
      6. Committee quorum
      7. Periodic review and analysis of reliable data to identify trends and system-level factors related to committee-specific objectives and reporting to the QIC.
   5. The QIC sub-committees report to the QIC and identify and address risks of harm; ensure the sufficiency, accessibility, and quality of services to meet individuals’ needs in integrated settings; and collect and evaluate data to identify and respond to trends to ensure continuous quality improvement. The QIC sub-committees evaluate data at least quarterly, identify at least one CQI project annually, and report to the QIC at least three times per year. 
   6. Through the Quality Management Annual Report, the QIC ensures that providers, case managers, and other stakeholders are informed of any quality improvement initiatives approved for implementation as the result of trend analyses based on information from investigations of reports of suspected or alleged abuse, neglect, serious incidents, and deaths.
5. DBHDS has a Risk Management Review Committee (RMRC) that has created an overall risk management process for DBHDS that enables DBHDS to identify, and prevent or substantially mitigate, risks of harm.
   1. The RMRC reviews and identifies trends from aggregated incident data and any other relevant data identified by the RMRC, including allegations and substantiations of abuse, neglect, and exploitation, at least four times per year by various levels such as by region, by CSB, by provider locations, by individual, or by levels and types of incidents.
   2. The RMRC uses the results of data reviewed to identify areas for improvement and monitor trends. The RMRC identifies priorities and determines quality improvement initiatives as needed, including identified strategies and metrics to monitor success, or refers these areas to the QIC for consideration for targeted quality improvement efforts. The RMRC ensures that each approved quality improvement initiative is implemented and reported to the QIC. The RMRC will recommend at least one quality improvement initiative per year.
   3. The RMRC monitors aggregate data of provider compliance with serious incident reporting requirements and establishes targets for performance measurement indicators. When targets are not met the RMRC determines whether quality improvement initiatives are needed, and if so, monitors implementation and outcomes.
   4. The RMRC conducts or oversees a look behind review of a statistically valid, random sample of DBHDS serious incident reviews and follow-up process. The review will evaluate whether:
      1. The incident was triaged by the Office of Licensing incident management team appropriately according to developed protocols;
      2. The provider’s documented response ensured the recipient’s safety and well-being;
      3. Appropriate follow-up from the Office of Licensing incident management team occurred when necessary;
      4. Timely, appropriate corrective action plans are implemented by the provider when indicated.
      5. The RMRC will review trends at least quarterly, recommend quality improvement initiatives when necessary, and track implementation of initiatives approved for implementation. 
   5. The RMRC conducts or oversees a look-behind review of a statistically valid, random sample of reported allegations of abuse, neglect, and exploitation. The review will evaluate whether:
      1. Comprehensive and non-partial investigations of individual incidents occur within state-prescribed timelines;
      2. The person conducting the investigation has been trained to conduct investigations;
      3. Timely, appropriate corrective action plans are implemented by the provider when indicated.
      4. The RMRC will review trends at least quarterly, recommend quality improvement initiatives when necessary, and track implementation of initiatives approved for implementation.
   6. At least 86% of the sample of serious incidents reviewed in indicator 5.d meet criteria reviewed in the audit. At least 86% of the sample of allegations of abuse, neglect, and exploitation reviewed in indicator 5.e meet criteria reviewed in the audit. 
6. The Commonwealth shall require providers to identify individuals who are at high risk due to medical or behavioral needs or other factors that lead to a SIS level 6 or 7 and to report this information to the Commonwealth. 
7. The Commonwealth shall meet the following:
   1. At least 86% of the people supported in residential settings will receive an annual physical exam, including review of preventive screenings, and at least 86% of individuals who have coverage for dental services will receive an annual dental exam.
   2. At least 86% of people with identified behavioral support needs are provided adequate and appropriately delivered behavioral support services.
   3. At least 95% of residential service recipients reside in a location that is integrated in, and supports full access to the greater community, in compliance with CMS rules on Home and Community-based Settings.
   4. At least 95% of individual service recipients are free from neglect and abuse by paid support staff.
   5. At least 95% of individual service recipients are adequately protected from serious injuries in service settings.
   6. For 95% of individual service recipients, seclusion or restraints are only utilized after a hierarchy of less restrictive interventions are tried (apart from crises where necessary to protect from an immediate risk to physical safety), and as outlined in human rights committee-approved plans.
   7. The Commonwealth ensures that at least 95% of applicants assigned to Priority 1 of the waiting list are not institutionalized while waiting for services unless the recipient chooses otherwise or enters into a nursing facility for medical rehabilitation or for a stay of 90 days or less.  Medical rehabilitation is a non-permanent, prescriber-driven regimen that would afford an individual an opportunity to improve function through the professional supervision and direction of physical, occupational, or speech therapies. Medical rehabilitation is self-limiting and is driven by the progress of the individual in relation to the therapy provided.  When no further progress can be documented, individual therapy orders must cease.
8. The Commonwealth ensures that individuals have choice in all aspects of their goals and supports as measured by the following:
   1. At least 95% of people receiving services/authorized representatives participate in the development of their own service plan.
   2. At least 75% of people with a job in the community chose or had some input in choosing their job.
   3. At least 86% of people receiving services in residential services/their authorized representatives choose or help decide their daily schedule.
   4. At least 75% of people receiving services who do not live in the family home/their authorized representatives chose or had some input in choosing where they live.
   5. At least 50% of people who do not live in the family home/their authorized representatives chose or had some input in choosing their housemates.
9. DBHDS implements an incident management process that is responsible for review and follow-up of all reported serious incidents, as defined in the Licensing Regulations.
   1. DBHDS develops incident management protocols that include triage criteria and a process for follow-up and coordination with licensing specialists and investigators, and human rights advocates as well as referral to other DBHDS offices as appropriate.
   2. Processes enable DBHDS to identify and, where possible, prevent or mitigate future risks of harm.
   3. Follow-up on individual incidents, as well as review of patterns and trends, will be documented.