Settlement Agreement Provision

V.I.1-4

---

Reports

• Quality Service Review – Round 5 Aggregate Report, SFY2023
• Provider Transportation Summary QSR Round 5
• Provider Transportation Summary QSR Round 4
• Quality Service Review – Round 4 Aggregate Report SFY2022
• Quality Service Review – Round 3 Aggregate Report SFY2022
• Quality Service Review – Round 3 Appendices A-V CSB Specific Region Service Type SFY2022
• Quality Service Review – Round 3 Appendix W Aggregate Individual Interview Responses SFY2022
• Quality Service Review – Round 2 Aggregate Report SFY2021
• Quality Service Review – Round 1 Aggregate Report State Fiscal Year 2021

Compliance Indicators V.I.1-3

Compliance Indicators V.I.1

1. The Commonwealth conducts Quality Service Reviews (“QSRs”) annually on a sample of providers, with the goal that each provider is sampled at least once every two to three years, comprised of Person- Centered Reviews (“PCRs”) and Provider Quality Reviews (“PQRs”), to evaluate the quality of services at an individual, provider, and systemwide level and the extent to which services are provided in the most integrated setting appropriate to individuals’ needs and preferences. QSRs utilize information collected from, at a minimum, the following sources for PCRs and PQRs:

a. Face-to-face interviews of individual waiver service recipients, family members, or guardians (if involved in the individual’s life); case managers; and service providers.

b. Record reviews: case management record, the ISP, and the provider’s record for selected individuals; the provider’s administrative policies and procedures, incident reports, the provider’s risk management and quality improvement plans; documents demonstrating compliance with the provider’s contractual requirements, as applicable; and the KPA Performance Measure Indicator (PMI) data collected by DBHDS referred to in V.D.2.

c. Direct observation of the individual waiver service recipient at each of the provider’s service sites (e.g., Residential and/or Day Programs) as applicable for the individuals selected for review.

2. The DBHDS QSR Contractor will:

a. Prior to conducting QSRs, develop a communications plan and orient providers to the QSR process and expectations.

b. Ensure interviews of individual waiver service recipients are conducted in private areas where provider staff cannot hear the interview or influence the interview responses, unless the individual needs or requests staff assistance and, where not conducted in private, it will be documented. Interviews with provider staff are conducted in ways that do not permit influence from other staff or supervisors.

3. The Quality Service Reviews assess on a provider level whether:

a. Services are provided in safe and integrated environments in the community.

b. Person-centered thinking and planning is applied to all service recipients.

c. Providers keep service recipients safe from harm, and access treatment for service recipients as necessary.

d. Qualified and trained staff provide services to individual service recipients. Sufficient staffing is provided as required by individual service plans. Staff assigned to individuals are knowledgeable about the person and their service plan, including any risks and individual protocols.

e. Individuals receiving services are provided opportunities for community inclusion.

f. Providers have active quality management and improvement programs, as well as risk management programs.

4. The Quality Service Reviews assess on a system-wide level whether:

a. Services are provided in safe and integrated environments in the community.

b. Person-centered thinking and planning is applied to all service recipients.

c. Providers keep service recipients safe from harm and access treatment for service recipients as necessary.

d. Qualified and trained staff provide services to individual service recipients. Sufficient staffing is provided as required by individual service plans. Staff assigned to individuals are knowledgeable about the person and their service plan, including any risks and individual protocols.

e. Service recipients are provided opportunities for community inclusion.

f. Services and supports are provided in the most integrated setting appropriate to individuals’ needs and consistent with their informed choice.

Compliance Indicators V.I.2

1. The QSRs assess on an individual service-recipient level and individual provider level whether:

a. Individuals’ needs are identified and met, including health and safety consistent with the individual’s desires, informed choice and dignity of risk.

b. Person-centered thinking and planning is applied and people are supported in self direction consistent with their person-centered plans, and in accordance with CMS Home and Community Based Service planning requirements. Person centered thinking and

planning:

i. Is timely and occurs at times and locations of convenience to the individual.

ii. Includes people chosen by the individual.

iii. Reflects cultural considerations of the individual.

iv. Is conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who have limited English proficiency.

v. Provides necessary information and support to ensure that the individual directs  the process to the maximum extent possible and is enabled to make informed choices and decisions.

vi. Has strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants.

vii. Offers informed choices to the individual regarding the services and supports they receive and from whom.

viii. Records alternative home and community-based settings that were offered to the individual.

ix. Includes a method for the individual to request updates to the planas needed.

c. Services are responsive to changes in individual needs (where present) and service plans are modified in response to new or changed service needs and desires to the extent possible.

d. Services and supports are provided in the most integrated setting appropriate to individuals’ needs and consistent with their informed choice.

e. Individuals have opportunities for community engagement and inclusion in all aspects of their lives.

f. Any restrictions of individuals’ rights are developed in accordance with the DBHDS Human Rights Regulations and implemented consistent with approved plans.

2. Information from the QSRs is used to improve practice and quality of services through the collection of valid and reliable data that informs the provider and person-centered quality outcome and performance results. DBHDS reviews data from the QSRs, identifies trends, and addresses deficiencies at the provider, CSB, and system wide levels through quality improvement processes.

3. The summary results of the QSR for each provider (Person-Centered Reviews and Provider Quality Review) will be posted for public review.

4. Summary data will be provided by the QSR vendor to the QIC for review on a quarterly basis to inform quality improvement efforts aligned with the eight domains outlined in section V.D.3.a-h. The QIC or other DBHDS entity utilizes this data to identify areas of potential improvement and takes action to improve practice and the quality of services at the provider, CSB, and system-wide levels.

5. DBHDS shares information from the QSRs with providers and CSBs in order to improve practice and the quality of services.

6. Whenever a QSR reviewer identifies potential abuse, neglect, or exploitation, a potential rights restriction in the absence of an approved plan, or a rights restriction implemented inconsistently with the approved plan, the reviewer shall make a referral to the DBHDS Office of Human Rights and/or the Department of Social Services adult/child protective services, as applicable.

Compliance Indicators V.I.3

1. 100% of reviewers who conduct QSRs are trained and pass written tests and/or demonstrate knowledge and skills prior to conducting a QSR, and reviewer qualifications are commensurate to what they are expected to review.

2. Each provider will be reviewed by the QSR at least once every two to three years. Where possible, the QSR samples will target providers that are not subject to other reviews (such as NCI reviews) during the year. Sufficient information is gathered through the samples reviewed to draw valid conclusions for each individual provider reviewed.

3. To address the requirements of a look-behind, inter-rater reliability has been assessed for each reviewer annually, with 80% or higher target against another established reviewer or a standardized scored review, using either live interviewing and review of records or taped video content. Any reviewer who does not meet the reliability standards is retrained, shadowed, and retested to ensure that an acceptable level of reliability has been achieved prior to conducting a QSR. The contract with the vendor will include a provision that during reliability testing, the reviewer does not have any access to other reviewers’ notes or scores and cannot discuss their rating with other reviewers prior to submission.

4. QSR reviewers receive and are trained on audit tools and associated written practice guidance that:

a. Have well-defined standards including clear expectations for participating providers.

b. Include valid methods to ensure inter-rater reliability.

c. Consistently identify the methodology that reviewers must use to answer questions. Record review audit tools should identify the expected data source (i.e., where in the provider records would one expect to find the necessary documentation).

d. Explain how standards for fulfilling requirements, such as “met” or “not met”, will be determined.

e. Include indicators to comprehensively assess whether services and supports meet individuals’ needs and the quality of service provision.