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Authors Posts by Carol Ferenz

Carol Ferenz

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Office of Developmental Programs (ODP) Announcement 20-002 requests comments regarding Proposed Heightened Scrutiny Information for Residential Services locations. Comments are being sought on attachments #1–#3 until 11:59 pm on Monday, February 17, 2020.

To be compliant with the Centers for Medicare and Medicaid Services (CMS) Home and Community-Based Settings (HCBS) rule, ODP must identify and complete onsite reviews of all service locations that are presumed to have the qualities of an institution. The purpose of these onsite reviews will be to determine whether each service location can overcome the institutional presumption by either showing proof that the requirements contained in the CMS HCBS rule are currently met, or by ensuring the requirements will be met within a timeframe specified by ODP (but no later than March of 2022).

If ODP determines that the service location does not currently meet the requirements but has a plan to meet them within the timeframe specified by ODP, the service location must be submitted to CMS for a heightened scrutiny review. CMS will then determine whether the service location has the qualities of a home and community-based setting and does not have institutional qualities.

Homes that are identified as one of the following will require an onsite heightened scrutiny review by ODP due to having the potential of isolating individuals living in the home from the broader community:

  • Farmstead – These settings are often in rural areas on large parcels of land, with little ability to access the broader community outside the farm. Individuals who live at the farm typically interact primarily with people with disabilities and staff who work with those individuals. Individuals typically live in homes only with other people with disabilities and/or staff. Their neighbors are other individuals with disabilities or staff who work with those individuals. Daily activities are typically designed to take place onsite so that an individual generally does not leave the farm to access HCBS or participate in community activities. For example, these settings will often provide a place onsite to receive clinical (medical and/or behavioral health) services, day services, places to shop and attend church services, as well as social activities where individuals on the farm engage with others on the farm, all of whom are receiving Medicaid HCBS. While sometimes people from the broader community may come onsite, people from the farm do not go out into the broader community as part of their daily life. Thus, the setting does not facilitate individuals integrating into the greater community and has characteristics that isolate individuals receiving Medicaid HCBS from individuals not receiving Medicaid HCBS.
  • Gated Community – These settings typically consist primarily of people with disabilities and the staff that work with them. Often, these locations will provide residential, behavioral health, day services, social and recreational activities, and long-term services and supports all within the gated community. Individuals receiving HCBS in this type of setting often do not leave the grounds of the gated community in order to access activities or services in the broader community. Thus, the setting typically does not afford individuals the opportunity to fully engage in community life and choose activities, services and providers that will optimize integration into the broader community.

* Campus – These settings have multiple co-located and operationally related (i.e., operated and controlled by the same provider) service locations/homes/facilities that congregate a large number of people with disabilities together and provide for significant shared programming and staff, such that people’s ability to interact with the broader community is limited. This could include group homes on the grounds of a private Intermediate Care Facility (ICF) or numerous group homes co-located on a single site or in close proximity (multiple units on the same street or a court, for example).

More information published by CMS on the HCBS rule, including heightened scrutiny requirements, can be found here. Attachment 1 lists locations requiring an onsite heightened scrutiny review from ODP. Attachment 2 and Attachment 3 are the proposed tools for evaluating and reviewing the listed sites. Questions pertaining to this announcement and accompanying attachments may be directed to this email.

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Today — Monday, January 27, 2020 — the Office of Vocational Rehabilitation (OVR) released the following announcement:

“OVR is pleased to inform you of positive news regarding customers who are on OVR’s Order of Selection (OOS) wait list. On February 1, 2020, we will begin processing at least 2,200 customers off the wait list with priority given to eligible customers who have been on the wait list the longest. We will continuously re-evaluate opportunities to move more cases off the wait list after February 1. Please note that updates to OVR’s Order of Selection web page and related materials will be posted on January 31, 2020.”

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The Office of Developmental Programs (ODP) released notification on Tuesday, January 14, 2020 of the new Provider Agreement for Participation in Pennsylvania’s Consolidated Waiver, Person/Family Directed Support Waiver, Adult Autism Waiver and Community Living Waiver (“Waiver Programs”) that will serve as the statewide “Provider Agreement” between providers of waiver-funded services and ODP, the Department of Human Services, as the Pennsylvania State Medicaid Agency effective January 1, 2020.

This letter from ODP Deputy Secretary Kristin Ahrens was not included in the original distribution. The letter provides further clarification on the applicability of the new Provider Agreement and includes a due date for submission of the signed agreement. In addition, the Provider Agreement Form and Instructions have been updated. Every waiver provider must complete an agreement.

  • The legal entity of each waiver provider is required to submit only one agreement for that legal entity, regardless of the number of services provided or the number of service locations operated by the legal entity.
  • Each agreement must include the original signature of the provider’s Chief Executive Officer/Director/Owner.
  • Please also provide a copy of your agency’s IRS letter 147C to verify the agency’s legal name and FEIN.
  • Completed agreements may be submitted to ODP as an attachment via email.

Completed agreements may also be submitted by traditional mail to:

Department of Human Services Office of Developmental Programs
Attention: Provider Enrollment
625 Forster Street, Room 413
Health and Welfare Building
Harrisburg, PA 17120

Questions relating to the provider agreement process may be directed to the ODP Provider Enrollment Unit. Please note; this agreement is effective as of January 1, 2020. Agreements must be returned by March 1, 2020 to the ODP Provider Agreement resource account. Questions regarding this notification should also be directed to this account.

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ODP Announcement 20-003 contains the Quality Assessment and Improvement (QA&I) Annual Statewide Report for Cycle 1 Year 2, FY 2018-2019 that provides a summary and evaluation of the results of QA&I reviews of Administrative Entities (County Programs), Supports Coordination Organizations (SCOs), and Service Providers during the Cycle 1, Year 2 (C1Y2) evaluation period. This Annual Statewide Report is sorted into geographic regions across the commonwealth and discusses successes and opportunities for systemic quality improvement discovered during QA&I reviews.

Recommendations are included for several areas:

Quality Focus Area Recommendations
ODP commends the efforts of all entities to develop QM Plans and Action Plans in alignment with ODP’s Mission, Vision, and Values, and to use a data-based approach to identify priorities for quality improvement. Specific opportunities for improvement in the area of improving quality include:

  • All are encouraged to align QM Plan Goals and Desired Outcomes with ODP’s Mission, Vision, and Values;
  • ODP will continue working with AEs and providers to analyze provider performance in developing QM Plans that reflect ODP’s Mission, Vision, and Values, reviewing and evaluating performance data in selecting priorities for QM plans, and analyzing and revising QM Plans at least every three years, then develop strategies for improvement in all three areas; and
  • AEs are reminded of the requirement for at least one member of the QA&I Provider Review Team to become QM Certified, and to ensure that the current ODP QM Certified staff recertify every two years.

Employment Focus Area Recommendations
ODP commends AEs, SCOs, and Providers for their demonstrated efforts to promote Employment First and support individuals to obtain and sustain integrated employment in their communities and encourages these efforts to continue. Opportunities for improvement include:

  • ODP encourages Small Group Employment & Transitional Work Providers to develop policies supporting individuals to transition to CIE;
  • All SCOs are encouraged to designate Employment Leads to promote and coordinate Employment First efforts within each entity and across stakeholders;
  • SCs are encouraged to continue to identify individuals’ interests and goals related to employment and ensure ISPs reflect person-centered steps to achieve these interests and goals;
  • Providers should ensure individuals are supported in obtaining employment through job interviewing; and
  • ODP encourages providers to analyze their performance in ensuring fading plans are developed and implemented for individuals receiving ongoing job coaching and support, then strategize for improvement and track progress.

Communication Focus Area Recommendations
Results in the Communication Focus Area indicate strength in providing financial support to address communication needs where warranted and in offering communication support to individuals in need of assistance when receiving SC services. Opportunities for improvement also exist, and include:

  • ODP will continue to work with providers to analyze provider performance in maintaining staff or available contractors who are certified to communicate with people who are deaf or hard of hearing, then strategize for improvement and tracking progress;
  • When a need for communication assistance is identified, SCs should explore options for communication assistance with individuals when appropriate and support individuals to choose;
  • Providers are encouraged to continue to ensure staff are trained on each individual’s communication plan and/or formal communication system; and
  • Providers should ensure that individuals’ progress notes related to communication outcomes include progress measured on one or more of the communication indicators established.

Recommendations on Person-Centered Service Planning and Delivery

ODP recognizes AEs, SCOs, and providers for consistent efforts to include individuals and people important to them in developing ISPs, ensuring all assessed needs are addressed in ISPs, and updating ISPs in a timely manner. Recommendations for improvement in the area of Person-Centered Service Planning and Delivery include:

  • All SCOs should continue to ensure risk mitigation strategies are incorporated into ISPs when risks are identified to support individuals’ health and safety;
  • ODP will work with SCOs to focus efforts on including people of the individual’s choice in the ISP process, improving monitoring of service delivery at the required frequency, and ensuring that justification of services not being provided as authorized is documented; and
  • AEs and SCOs should continue to work collaboratively to ensure ISPs are approved within 365 days of prior Annual ISP.

Recommendations on Self-Direction, Choice, and Control
ODP incorporated exploratory questions in order to track performance and encourage providers to continue to develop and implement policies that ensure individual rights are respected. Providers should review the use of independent living technology or remote monitoring and follow up to establish and implement policies ensuring the applicable consent forms are obtained and on file.

Recommendations on Community Participation
ODP commends AEs and SCOs for initiating conversations with individuals about community activities of their choice, including necessary supports for those activities in ISPs, working to ensure the same degree of community access and choice for individuals who are served as others without a disability enjoy, and monitoring individuals’ experience to ensure community participation occurs.

  • ODP encourages stakeholders to ensure that community activities are incorporated into person-centered ISPs for all individuals.
  • SCOs should ensure the individual monitoring tool is used to record if the individual, who is receiving community participation supports, is engaged in community activities aligned with their preferences at the rate identified in their ISPs and in accordance with the waiver.

Recommendations on Individuals’ Wellness Supports
ODP recognizes AEs, SCOs, and providers for their efforts to promote wellness and to respond to opportunities for improvement in this area, which include:

  • Providers should identify resources that support wellness and share the information with individuals and families;
  • Providers of residential or in-home community support services should ensure that 100% of individuals complete all health care appointments, screenings, and follow-up as prescribed; and
  • SCOs should review results for addressing health care needs and investigate and close any gaps to ensure continuous improvement.

Recommendations on Health and Safety
ODP encourages providers to continue efforts to ensure all reportable incidents are entered into EIM, follow-up on corrective actions, and review and analyze incidents at least quarterly. Opportunities for improvement in the area of Health and Safety remain and include:

  • ODP will continue to analyze SCO performance in assuring all individuals receive information about how to identify and report abuse, neglect, and exploitation and know the steps to take to protect themselves;
  • ODP will continue its efforts to support providers to finalize incidents within 30 days by monitoring and evaluating ongoing provider performance, implementing information system improvements that facilitate the process, and updating incident management policies and practices;
  • SCOs should review their performance data, practices, and procedures for following up on corrective actions, then develop and implement strategies for improvement using QM Plans and Action Plans;
  • Providers should ensure the incident management peer review process is completed and documented and QM Plans and Action Plans should be implemented when warranted.
  • All AEs should ensure the HRC has a protocol in place that includes all ODP-required elements. The HRC is to:
  1. Conduct a systemic review to ensure that the use of restraints and restrictive interventions is appropriate and necessary;
  2. Verify strategies exist and are achieved to reduce or eliminate the need for the use of a restraint or restrictive intervention;
  3. Conduct technical assistance to provider agencies in developing positive intervention or strategy alternatives to eliminate or reduce the need for restraint and restrictive procedures; and
  4. Analyze systemic concerns including a review of policies, procedures, trends and patterns, individual situations, and plans that authorize the use of interventions that have the potential to impact an individual’s rights.

Recommendations on Supporting People with Complex Needs
SCOs should continue to ensure they have processes in place to identify criteria triggers for higher frequency monitoring for individuals and plans to address individuals’ complex needs.

Recommendations on Developing and Supporting Qualified Staff

  • Providers should review their performance to ensure all staff receive all required training, including in incident management, Emergency Disaster Response plan, and CPS;
  • Providers should ensure staff receive training on the needs of individuals they support, prior to service delivery, as identified in their approved ISPs; and
  • SCOs should review their performance and ensure mandatory training requirements are met annually.

ODP is hosting a webinar to review the findings with stakeholders on Thursday, February 27, 2020 from 2:30 pm to 3:30 pm. Participants may register at the following link: Quality Assessment and Improvement (QA&I) Annual Comprehensive Statewide Report Cycle 1 Year 2 (C1Y2).

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The Office of Inspector General (OIG) has released their report after conducting a review of ODP’s Incident Management for individuals served in waiver programs. The report, entitled Pennsylvania Did Not Fully Comply With Federal and State Requirements for Reporting and Monitoring Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities, outlines findings from the review as well as PA Department of Human Services’ response to the report.

The data that was reviewed is from 2015–2016. Since that time, DHS has made many advances in incident management oversight. These improvements include the development and implementation of a more sophisticated IM system, implementation of mortality reviews for all participant deaths, clarification of the types of incidents to be reported, strengthened collaboration with law enforcement, and strengthened protocols for referrals to law enforcement.

The following are excerpts from the report:

What OIG Found
Pennsylvania did not fully comply with Federal Medicaid waiver and State requirements for reporting and monitoring 24-hour reportable incidents involving Medicaid beneficiaries with developmental disabilities who resided in community-based settings. Specifically, Pennsylvania did not (1) ensure that community-based providers reported thousands of 24-hour reportable incidents within required timeframes, (2) ensure that community-based providers and county and regional investigators analyzed and investigated all beneficiary deaths, and (3) ensure that community-based providers referred all suspicious deaths to law enforcement. Pennsylvania did not have adequate controls to detect unreported 24-hour reportable incidents and did not have controls in place to ensure that all beneficiary deaths were investigated and that all suspicious deaths were referred to law enforcement. Therefore, Pennsylvania did not fulfill participant safeguard assurances it gave to CMS to ensure the health, welfare, and safety of the 18,770 Medicaid beneficiaries with developmental disabilities covered by the Medicaid waiver in their audit.

What OIG Recommends and Pennsylvania Comments
OIG recommends that Pennsylvania improve its controls regarding the reporting and monitoring of 24-hour reportable incidents involving Medicaid beneficiaries with developmental disabilities residing in community-based settings. Specific recommendations were made for these controls. Pennsylvania concurred with six of the seven recommendations and described corrective actions that it plans to take or has already taken, but it did not concur with the recommendation that it record the 24-hour reportable incidents noted in the report. Instead, Pennsylvania stated that it plans to focus on recording unreported emergency room visits and hospital stays that contain diagnoses indicative of high risk for suspected abuse or neglect and take remedial action as appropriate. OIG agrees that Pennsylvania should prioritize recording unreported incidents that contain diagnoses indicative of high risk for suspected abuse or neglect but maintains that all unreported 24-hour reportable incidents must be reported.

The full report can be found here, including the response from DHS.

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The Office of Developmental Programs (ODP) has issued the new Provider Agreement. Effective January 1, 2020, the Provider Agreement must be filled out and submitted by the legal entity of each waiver provider. Only one agreement should be submitted per provider, regardless of the number of service locations or services provided by the agency. Instructions for completing and returning the agreement are included within the document. Questions may be directed to the ODP Provider Enrollment Unit.

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Senate Bill 906 SB 906, calling for a state center closure moratorium, has passed the House by a vote of 139–55. The bill amends the Mental Health and Intellectual Disability Act, in preliminary provisions, further providing for definitions; and, in responsibilities of the State, providing for a state center closure moratorium. The amendment sponsored by state Representative Lee James passed Tuesday, January 14, 2020. The measure eradicates previous wording on the bill that placed a moratorium on the closure of state centers until all Medicaid waiver-eligible individuals on the waiting list (of over 13,000) received funding for home or community-based care. The moratorium would now have a five-year limit.

The bill calls for the creation of a task force on the closure of state centers. The task force would convene within 60 days and be comprised of the Secretary of Department of Human Services, one representative from each state center, one representative from the Governor’s office, the chair and minority chair of the Senate Health and Human Services Committee and House Human Services Committee, two family members of residents of state centers, and one representative of a nonprofit organization that serves as an advocate for those with intellectual disabilities. The bill now goes back to the Senate as the bill was amended on the floor yesterday.

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