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Quality Assurance

The Quality Assurance section of the DIDD is responsible for surveying contracted community-based providers to determine quality of services provided and performance in regard to meeting DIDD requirements.  The types of providers surveyed include day and residential, independent support coordinator agencies and clinical service providers.

The survey instruments that are used have been developed by the DIDD in conjunction with TennCare, the federal Centers for Medicare and Medicaid Services (CMS) and other stakeholders and are based on a set of quality domains, outcomes and indicators that measure performance based on DIDD requirements. Generally providers are surveyed annually with the exception of independent clinical services providers who are surveyed every three years. Regional Quality Assurance surveyors conduct the surveys. Data is collected from the survey results and used to determine the level of quality across the service system. This data is also incorporated into the DIDD quality management reports for distribution to interested persons.

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Determining Provider Performance

The purpose of the DIDD Quality Assurance (QA) survey is to evaluate the performance of service providers in meeting DIDD requirements. DIDD has developed a set of outcomes and indicators for each of ten domain areas. These outcomes and indicators are found in the checklists that DIDD uses to conduct service provider QA surveys.

QA surveys are conducted on an annual basis for most providers. Following is a brief description of each domain.

This domain measures whether or not persons and their families have access to services and supports and a choice of available qualified providers. This includes having information about how to gain access to services as well as knowing how to appeal decisions about access to, and eligibility for, services.

This domain measures whether a person's Individual Support Plan covers his or her needs, preferences and decisions. It looks at how the person and family participate in developing the plan, whether the right assessments have been used to develop the plan, and if the plan includes supports and services that meet the person's needs. It also looks at things that may create risk for the person and how these are addressed. This domain also looks at whether the plan is used to obtain services and if staff know about the plan and how to use it to work with the person. Finally, it looks at how the plan is monitored to make sure it is implemented to help the person.

This domain measures whether the person's services are provided in a safe, secure and comfortable environment. It looks at how staff are screened prior to hiring, trained in incident management policies and if providers have processes for resolving safety concerns and responding to incidents. This area also measures whether providers have a complaint resolution system that works as well as a mechanism for correcting issues found by investigations so that these things do not occur again.

This domain looks at whether the person is treated with respect and dignity, if rights are protected and if inappropriate restrictions are prohibited. It also looks at whether the person has access to his or her personal funds and is allowed to do the things that he or she wants to do, as appropriate.

This domain measures whether the person achieves or maintains the best possible health by getting the appropriate assessments and health care services. It looks at whether providers help persons receive necessary health care, if medications are given correctly, and if persons are provided nutritious meals that follow any specially prescribed diets.

This domain looks at whether the person and family are involved in making decisions about the person's services, if the person's plan includes his or her choices and if the provider supports the person to make good decisions. It also measures the provider's method of getting feedback concerning satisfaction with services and how the provider uses that information to change services.

This domain looks at whether the person has opportunities for meaningful relationships and if the provider has activities and opportunities that support the individual to have important relationships and be a valued member of his or her community.

This domain looks at how the provider gives people opportunities for paid employment or other meaningful day activities. It also measures whether the provider ensures that there are appropriate supports for employment and other meaningful day activities.

This domain measures the provider's qualifications, including licensing, training, supervision and support of staff. It also looks at how the provider evaluates itself and how its governing body works.

This domain looks at how providers show proof that they have provided services and billed for them correctly. It also looks at whether the provider has the right systems in place to oversee the management of personal funds.

In 2006, DIDD (then DMRS) began to recognize provider agencies that were performing at a high quality level by acknowledging them publicly in a listing on the web site and reducing the frequency of quality assurance surveys from annually to every other year. 

Since the inception of this program, approximately 185 organizations have attained star status at least once.  Several providers have maintained star status since the beginning of the recognition. 


CRITERIA FOR 4 STAR PROVIDER[1]

Day

Residential

PA

Clinical (Nursing, Therapy)

Behavior

ISC

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A Performance Rating of Exceptional Performance on QA surveys for two consecutive years.

A score of Substantial Compliance in Domains 2, 3, 4, 5 and 8 and 9

A score of Substantial Compliance in Domains 2, 3, 4, 5 and 9

A score of Substantial Compliance in Domains 2, 3, 4, 5 and 9

A score of Substantial Compliance in Domains 2, 3,  4, 5 and 9, if applicable

A score of Substantial Compliance in Domains 2, 3, 4 and 9, if applicable

A score of Substantial Compliance in Domains 1, 2, 3, and 9

A score of Substantial Compliance on Outcomes 3C, 4D, 5B and 10B, if applicable, and a score no less than Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D, 5B and 10B, if applicable, and a score no less than Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D,  5B and 10B, if applicable, and a score no less than Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D, and 5B, if applicable, and a score no less than Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C and 4D, if applicable, and a score no less than Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcome 3C and a score no less than Partial Compliance on all other applicable outcomes

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

All providers of Day services must provide employment

 

 

 

 

 

No preventable egregious events resulting in the death of an individual for two years

An annualized substantiated investigation rate of 10 substantiations per 100 persons served (10:100), or less, for one year

No sanctions or systemic recoupments[2] for one year

CRITERIA FOR 3 STAR PROVIDER[1]

Day

Residential

PA

Clinical (Nursing, Therapy)

Behavior

ISC

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A score of Substantial Compliance for Domain 3 and 5 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance for Domain 3 and 5 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance for Domain 3 and 5 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains; Nursing agencies must also receive a score of Substantial Compliance in Domain 5

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains

A score of Substantial Compliance on Outcomes 3C, 4D, 5B and 10B, if applicable, and a score no less that Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D, 5B and 10B, if applicable, and a score no less that Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D, 5B and 10B, if applicable, and a score no less that Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C, 4D, and 5B, if applicable, and a score no less that Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcomes 3C and 4D, if applicable, and a score no less that Partial Compliance on all other applicable outcomes

A score of Substantial Compliance on Outcome 3C and a score no less that Partial Compliance on all other applicable outcomes

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

A score of “Yes” on Indicators 9A5, 9A6, 9B2 and 9C2, if applicable

All providers of Day services must provide employment

 

 

 

 

 

No preventable egregious events resulting in the death of an individual for one year

An annualized substantiated investigation rate of 10 substantiations per 100 persons served (10:100), or less, for one year

No sanctions or systemic recoupments[2] for one year

Criteria for 2 Star Providers

Day

Residential

PA

Clinical (Nursing, Therapy)

Behavior

ISC

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A performance rating of Proficient on QA surveys for two consecutive years.

A score of Substantial Compliance for Domain 3 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance for Domain 3 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance for Domain 3 and at least Partial Compliance for all other applicable domains

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains; Nursing agencies must also receive a score of Substantial Compliance in Domain 5

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains

A score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains

All providers of Day services must provide employment

No preventable egregious events resulting in the death of an individual for one year

An annualized substantiated investigation rate of 10 substantiations per 100 persons served (10:100), or less, for one year

Agencies awarded 2 Star status will continue to have an annual DIDD Quality Assurance survey for the year(s) of the Star Award.


Quality Management survey instruments are revised annually prior to the beginning of each calendar year or when special circumstances create a need for revision.


All providers must have an ongoing self-assessment process.  Why is a self-assessment process critical to a provider’s success in the provision of services and supports?

A provider’s self-assessment ensures that an internal mechanism exists for ongoing review of the effectiveness of services provided.  Self-assessment allows a provider to identify systemic issues and initiate corrective actions.  The process also allows the provider to incorporate results of external monitoring reports into its self-assessment processes.  Each provider is responsible for completion of self-assessment activities and for evaluation of revision of self-assessment processes. 

To fulfill the requirement for a self-assessment process, a provider must include at least the following components in its self-assessment activities:

  • Review of all documentation regarding the implementation of a person’s plan and his or her progress toward meeting outcomes;
  • Review of trends related to persons supported and family satisfaction with services provided;
  • Review of incident trends, including those related to medication variances and errors and other health and safety factors;
  • Review of external monitoring reports for the previous twelve (12) month period;
  • Review of any sanctions imposed during the previous twelve (12) month period;
  • Review of personnel practices, including staff recruitment and hiring, staff training, staff retention and turnover;
  • Review of processes intended to ensure timely access to health-related interventions, such as health care appointments and follow-up activities;
  •  Review of policies to ensure continuing alignment with current DIDD requirements;
  • Application of the current DIDD QA survey tool to a sample of persons supported.

To fulfill the requirement for a self-assessment process, a provider may use the Council on quality and Leadership (CQL) Basic Assurances® Self-Assessment.


All providers must have an internal quality improvement plan.  What is the purpose of this plan?

The internal quality improvement plan picks up where the self-assessment ends.  This plan is the mechanism for addressing the issues identified during the self-assessment process.  The plan is to be focused on resolution of systemic issues at the provider level.  Systemic issues are those that affect or have the potential to affect a number of persons supported.  All provider staff should have access to the quality improvement plan.  The plan specifies how any necessary systemic improvements will be made through a process which includes:

  • Analysis of the cause of any serious issues and problems identified.  Serious issues and problems are those that impact multiple persons supported or those that have health and safety consequences requiring medical treatment of one or more person supported;
  • Development of observable and measurable quality outcomes related to resolving the causal factors;
  • Establishment of reasonable timeframes for implementation of quality initiatives;
  • Assignment of staff responsible for completion of actions and achievement of quality outcomes;
  • Modification of policies, procedures and/or the agency management plan (possibly including the quality improvement plan) to prevent recurrence of issues and problems that were resolved.

All day, residential, personal assistance and support coordination providers are required to have a management plan.  What is a management plan?

The management plan describes how the provider conducts business to ensure successful operation and compliance with applicable program requirements.  The plan describes how the provider implements policies and procedures to assure the health, safety and welfare of person using services.  The management plan includes:

  • The provider’s mission statement and philosophy of service delivery;
  • An organizational chart;
  • A description of service(s) offered by the provider;
  • Complaint resolution procedures for persons supported, family members and legal representatives;
  • Any policies that are required by DIDD;
  • For providers of transportation services or providers of services that include transportation as a component of the service, a description of the provider’s transportation system, including the person’s access to transportation, e.g., a description of how people will be provided adequate access to transportation for medical appointments and other activities that may be specified in the Individual Support Plan.

What are consultation surveys? 

For new agencies that have not yet been involved in a Quality Assurance survey, the regional QA survey team will conduct an initial consultation survey between 90 days and six months after service provision begins. Although this is considered an informal survey process, the provider must correct any serious health and safety issues identified during the consultation survey.  After the initial consultation survey, the provider with be added to the regular survey schedule.


What is the purpose of the entrance conference (initial meeting) for the quality assurance survey?

Surveys begin with a meeting between key provider staff and the survey team. During the initial meeting (sometimes called an entrance conference), participants will discuss the logistics of the survey. The provider may utilize the initial meeting to provide general information about the organization, including management and QI strategies that have been implemented since the last survey.  Following the initial meeting, survey activities begin.


What is purpose of the exit conference for the quality assurance survey?

The survey will conclude with an exit conference. During the exit conference, the survey team will review major findings and entertain questions from the provider staff about those findings.  Under some circumstances, the written survey report will be made available during the exit conference. When circumstances require further review of specific issues, the survey report will be issued when review is completed. A copy of the final report will be sent to the provider agency’s board chair or chief officer.


If a provider is dissatisfied or disagrees with the results of a quality assurance survey, what recourse is there for the provider?

Providers may request a review of findings cited during a survey and included in the written survey report. Review requests are submitted to the appropriate DIDD Regional Director of QA.

If the provider is dissatisfied with the results of the regional review, a second review may be initiated by submitting a written request to the DIDD Commissioner stating the reason a second level review is being requested. The Commissioner or designee will respond to the request as expeditiously as possible, in most cases, within 30 days. Response times will vary depending upon the number and complexity of issues presented with the review request.

All review requests must specify findings to be reviewed and must be accompanied by any documentation available to support requested changes in survey findings. For each step, the provider will have ten (10) days from the date of receiving the survey report or written notification of a determination to initiate or continue the review process.