Assessing Adequacy of Supports

Reporting

Settlement Agreement Provision

Within 12 months of the effective date of this Agreement, the Commonwealth shall ensure that the licensure process assesses the adequacy of the individualized supports and services provided to persons receiving services under this Agreement in each of the domains listed in Section V.D.3 above and that these data and assessments are reported to DBHDS.


Reports

Compliance Indicators

Compliance Indicators V.G.3

1. The DBHDS Office of Licensing (OL) develops a checklist to assess the adequacy of individualized supports and services (including supports and services for individuals with intensive medical and behavioral needs) in each of the domains listed in Section V.D.3 for which it has corresponding regulations. Data from this checklist will be augmented at least annually by data from other sources that assess the adequacy of individual supports and services in those domains not covered by the OL checklist.

2. The DBHDS Office of Licensing uses the checklist during all annual unannounced inspections of DBHDS-licensed DD service providers, and relevant items on the checklist are reviewed during investigations as appropriate. Reviews are conducted for providers at least annually pursuant to 12VAC35-105-70.

3. DBHDS informs providers of how it assesses the adequacy of individualized supports and services by posting information on the review tool and how it is assessed on the DBHDS website or in guidance to providers. DBHDS has informed CSBs and providers of its expectations regarding individualized supports and services, as well as the sources of data that it utilizes to capture this information.

4. The DBHDS Office of Licensing produces a summary report from the data obtained from the checklist. On a semi-annual basis, this data is shared with the Case Management Steering Committee and relevant Key Performance Area workgroups. These groups evaluate the licensure data along with other data sources, including those referred to in indicator #1, to determine whether quality improvement initiatives are needed. A trend report also will be produced annually for review by the QIC to ensure that any deficiencies are addressed. If improvement initiatives are needed, they will be recommended, approved, and implemented in accordance with indicators 4-6 of V.D.2.