Section IX: Quality Management

• "Section IX: Quality Management" is also available in Portable Document Format. (PDF, 114KB, 24pg.)

Introduction

An effective, comprehensive Quality Management Program (QMP) combines quality assurance and quality improvement strategies to assure there is a system in place that continuously measures performance, identifies opportunities for improvement and monitors outcomes. For this program to be successful, participants, waiver providers, DOH and all contracted entities must work collaboratively to identify and address problems. This can only be done through open and effective communication between all entities.

By following the activities provided in the QMP outlined in this section, each provider can achieve the greatest probability of success serving participants in a manner that reflects the highest level of quality. This can be measured through participant success and overall satisfaction pursuing desired goals.

Table of Contents

• Framework for a Quality Management Program
• NHTD Quality Management Program
  • Level One
  • Level Two
  • Level Three
  • Level Four
  • Level Five
• CMS Waiver Assurances
  • A. Level of Care (LOC) - Nursing Home Eligibility
    • 1. Waiver applicants for whom there is reasonable indication that waiver services may be needed in the future are provided an individual LOC evaluation.
    • 2. The LOC of enrolled participants are reevaluated at least annually or as specified in the approved waiver.
    • 3. The processes and instruments described in the approved waiver are applied to determine LOC.
    • 4. The state monitors LOC decisions and takes action to address inappropriate LOC determinations.
  • B. Individual Service Plan (ISP)
    • 1. Service Plans address all participants' assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.
    • 2. The state monitors Service Plan development in accordance with its policies and procedures and takes appropriate action when it identifies inadequacies in Service Plan development.
    • 3. Service Plans are updated/revised at least annually or when warranted by changes in the waiver participant's needs. In the (6) months.
    • 4. Services are delivered in accordance with the Service Plan, including in the type, scope, amount, duration, and frequency specified in the Service Plan.
    • 5. Participants are afforded choice between waiver services and institutional care.
    • 6. Participants are afforded choice between/among waiver services and providers.
  • C. Qualified Providers
    • 1. The state verifies that providers meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services; and the state verifies on a periodic basis that providers continue to meet required licensure and/or certification standards and/or adhere to other state standards; and the state monitors non-licensed/non-certified providers to assure adherence to waiver requirements.
    • 2. The state implements its policies and procedures for verifying that provider training has been conducted in accordance with state requirements and the approved waiver.
  • D. Health and Welfare
    • 1. There is continuous monitoring of the health and welfare of waiver participant and remediation actions are initiated when appropriate.
    • 2. The state, on an on-going basis, identifies and addresses and seeks to prevent the occurrence of abuse, neglect and exploitation (SRI policy).
  • E. Administrative Authority
    • 1. The Medicaid (NYS Department of Health) agency retains ultimate authority and responsibility for the operation of the waiver by exercising oversight over the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
  • F. Financial Accountability
    • 1. Claims for federal financial participation in the costs of waiver services are based on state payments for waiver services that have been rendered to waiver participants, authorized in the service plan, and properly billed by qualified waiver providers in accordance with the approved waiver.
• NHTD Quality Management Program Tools and Processes