orientation to the revised licensure and certification system department of developmental services...
TRANSCRIPT
ORIENTATION TOORIENTATION TOTHETHE
REVISED LICENSURE AND REVISED LICENSURE AND CERTIFICATION SYSTEMCERTIFICATION SYSTEM
Department of Developmental ServicesDepartment of Developmental ServicesOFFICE OF QUALITY MANAGEMENTOFFICE OF QUALITY MANAGEMENT
GAIL GROSSMAN, DOREET GOLDHABER, GAIL GROSSMAN, DOREET GOLDHABER, CONNIE LEHRCONNIE LEHR
JUNE, 2010JUNE, 2010
WHAT WILL BE COVEREDWHAT WILL BE COVERED
RATIONALE FOR CHANGESRATIONALE FOR CHANGES
OVERVIEW OF PROCESS USEDOVERVIEW OF PROCESS USED
EXPLANATION OF CHANGES (COMPARISON EXPLANATION OF CHANGES (COMPARISON OF CURRENT AND NEW)OF CURRENT AND NEW)
QUESTIONS AND ANSWERSQUESTIONS AND ANSWERS
NEXT STEPSNEXT STEPS
OVERVIEW AND RATIONALE FOR CHANGES TO THE OVERVIEW AND RATIONALE FOR CHANGES TO THE DDS LICENSURE AND CERTIFICATION SYSTEMDDS LICENSURE AND CERTIFICATION SYSTEM
SYSTEM 15 YEARS OLDSYSTEM 15 YEARS OLD
IMPORTANT TO EVALUATE PERIODICALLYIMPORTANT TO EVALUATE PERIODICALLY
NEED TO ALIGN WITH NEW WAIVER SERVICE NEED TO ALIGN WITH NEW WAIVER SERVICE DEFINITIONSDEFINITIONS
NEED TO ALIGN WITH NEW RFR’S FOR NEED TO ALIGN WITH NEW RFR’S FOR DAY/EMPLOYMENT SERVICESDAY/EMPLOYMENT SERVICES
CONCERNS RAISED BY PROVIDERS, DDS CONCERNS RAISED BY PROVIDERS, DDS OPERATIONS AND QE STAFF, FAMILIES AND OPERATIONS AND QE STAFF, FAMILIES AND INDIVIDUALSINDIVIDUALS
ISSUES RAISEDISSUES RAISED
TRANSPARENCYTRANSPARENCY WHAT WE RATEWHAT WE RATE HOW WE RATEHOW WE RATE SCORING SYSTEMSCORING SYSTEM
CONSISTENCY AND OBJECTIVITYCONSISTENCY AND OBJECTIVITY REDUCING SUBJECTIVITYREDUCING SUBJECTIVITY QUANTIFIABLE MEASURESQUANTIFIABLE MEASURES
ISSUES RAISED ISSUES RAISED (CONT:)(CONT:)
EFFICIENCY EFFICIENCY TIME – ON SITETIME – ON SITE USE OF AVAILABLE INFORMATIONUSE OF AVAILABLE INFORMATION MINIMIZING DUPLICATIONMINIMIZING DUPLICATION SAMPLING APPROACHSAMPLING APPROACH REPORT FORMATREPORT FORMAT
COLLABORATION BETWEEN PROVIDERS COLLABORATION BETWEEN PROVIDERS AND DDS STAFFAND DDS STAFF
PROCESS USEDPROCESS USED
DEVELOPED WORKGROUP OF ADDP PROVIDER DEVELOPED WORKGROUP OF ADDP PROVIDER REPRESENTATIVES, DDS OPERATIONS STAFF AND OQM REPRESENTATIVES, DDS OPERATIONS STAFF AND OQM STAFFSTAFF
SOLICITED INPUT FROM SELF-ADVOCATES, FAMILIES, CABS, SOLICITED INPUT FROM SELF-ADVOCATES, FAMILIES, CABS, SAC, QUALITY COUNCILS, DDS STAFF, QE STAFFSAC, QUALITY COUNCILS, DDS STAFF, QE STAFF
INCORPORATED INPUT INTO WORKGROUP REVIEWINCORPORATED INPUT INTO WORKGROUP REVIEW
MADE RECOMMENDATIONS TO COMMISSIONERMADE RECOMMENDATIONS TO COMMISSIONER
PILOTED IN FEBRUARY WITH FOUR PROVIDERSPILOTED IN FEBRUARY WITH FOUR PROVIDERS
MADE MODIFICATIONS BASED ON PILOT RESULTSMADE MODIFICATIONS BASED ON PILOT RESULTS JOINT TRAININGSJOINT TRAININGS
““GO LIVE” WITH SURVEYS SCHEDULED FOR JULYGO LIVE” WITH SURVEYS SCHEDULED FOR JULY
FEEDBACK FROM STAKEHOLDERS ON FEEDBACK FROM STAKEHOLDERS ON IMPORTANT INDICATORS OF QUALITYIMPORTANT INDICATORS OF QUALITY
CARING, COMPETENT, COMMITTED CARING, COMPETENT, COMMITTED STAFFSTAFF
SAFETYSAFETY
HEALTH AND WELLNESSHEALTH AND WELLNESS
MEANINGFUL ACTIVITIESMEANINGFUL ACTIVITIES
RELATIONSHIPSRELATIONSHIPS
COMMUNITY INCLUSIONCOMMUNITY INCLUSION
CHOICECHOICE
RESPECTRESPECT
NICE ENVIRONMENTNICE ENVIRONMENT
““INTANGIBLES”INTANGIBLES”
OVERVIEW OF CHANGESOVERVIEW OF CHANGES
SERVICES SUBJECT TO LICENSURESERVICES SUBJECT TO LICENSURE
REVIEW PROCESSESREVIEW PROCESSES
TOOLSTOOLS
SURVEY METHODOLOGYSURVEY METHODOLOGY
SURVEY FLOW AND TIMELINESSURVEY FLOW AND TIMELINES
OVERVIEW OF CHANGES (cont:)OVERVIEW OF CHANGES (cont:)
SAMPLING APPROACHSAMPLING APPROACH
RATING SYSTEMRATING SYSTEM
LEVELS OF LICENSURE AND LEVELS OF LICENSURE AND CERTIFICATIONCERTIFICATION
FEEDBACK AND REPORTFEEDBACK AND REPORT
FOLLOW-UP AND TARGETED REVIEWSFOLLOW-UP AND TARGETED REVIEWS
SERVICES SUBJECT TO LICENSURESERVICES SUBJECT TO LICENSURE
CURRENTCURRENT:: 24 HOUR RESIDENTIAL24 HOUR RESIDENTIAL LESS THAN 24 HOUR RESIDENTIALLESS THAN 24 HOUR RESIDENTIAL PLACEMENTPLACEMENT SITE BASED RESPITESITE BASED RESPITE EMPLOYMENTEMPLOYMENT COMMUNITY BASED DAYCOMMUNITY BASED DAY
NEWNEW:: SAME, WITH ADDITION OFSAME, WITH ADDITION OF INDIVIDUAL SUPPORT SERVICES (MORE THAN 7 HRS.)INDIVIDUAL SUPPORT SERVICES (MORE THAN 7 HRS.)
(INDIVIDUALIZED HOME SUPPORTS)(INDIVIDUALIZED HOME SUPPORTS) OUT OF HOME RESPITE (PLACEMENT SERVICE)OUT OF HOME RESPITE (PLACEMENT SERVICE)
REVIEW PROCESSESREVIEW PROCESSES
CURRENTCURRENT:: FULL LICENSURE/CERTIFICATION REVIEWS FOR SELECTED FULL LICENSURE/CERTIFICATION REVIEWS FOR SELECTED
SAMPLESAMPLE SAFEGUARD SYSTEMS REVIEWS FOR 50% OF 24 HOUR SAFEGUARD SYSTEMS REVIEWS FOR 50% OF 24 HOUR
LOCATIONS NOT IN SAMPLELOCATIONS NOT IN SAMPLE SEPARATE PROCESS FOR REVIEW OF SITE-BASED RESPITESEPARATE PROCESS FOR REVIEW OF SITE-BASED RESPITE SEPARATE CERTIFICATION REVIEW FOR INDIVIDUAL SUPPORT SEPARATE CERTIFICATION REVIEW FOR INDIVIDUAL SUPPORT
SERVICESSERVICES
NEWNEW:: ONE INTEGRATED PROCESS FOR ALL SERVICESONE INTEGRATED PROCESS FOR ALL SERVICES INDICATORS REVIEWED TAILORED TO REQUIREMENTS OF INDICATORS REVIEWED TAILORED TO REQUIREMENTS OF
SPECIFIC SERVICE TYPESSPECIFIC SERVICE TYPES
DESCRIPTION OF TOOLSDESCRIPTION OF TOOLS
CurrentCurrent:: BASED ON BROAD QUALITY OF LIFE BASED ON BROAD QUALITY OF LIFE
AREASAREAS
FURTHER DIVIDED INTO OUTCOMES AND FURTHER DIVIDED INTO OUTCOMES AND INDICATORSINDICATORS
EXAMPLES OF INTENT OF OUTCOME EXAMPLES OF INTENT OF OUTCOME NOTEDNOTED
DESCRIPTION OF TOOLSDESCRIPTION OF TOOLSNEWNEW::
LICENSURE INDICATORSLICENSURE INDICATORS:: ENVIRONMENTAL SAFETYENVIRONMENTAL SAFETY PERSONAL SAFETYPERSONAL SAFETY HEALTHHEALTH HUMAN RIGHTSHUMAN RIGHTS COMPETENT STAFFCOMPETENT STAFF SKILL DEVELOPMENT/ISP GOALSSKILL DEVELOPMENT/ISP GOALS
INCLUDES 8 CRITICAL INDICATORSINCLUDES 8 CRITICAL INDICATORS
CERTIFICATION INDICATORSCERTIFICATION INDICATORS::
BASED ON SERVICE EXPECTATIONS FOR EACH DISCRETE SERVICE BASED ON SERVICE EXPECTATIONS FOR EACH DISCRETE SERVICE TYPE (E.G., CAREER EXPLORATION ACTIVITIES; SUPPORT FOR TYPE (E.G., CAREER EXPLORATION ACTIVITIES; SUPPORT FOR PARTICIPATION IN CHOICES AT HOME)PARTICIPATION IN CHOICES AT HOME)
BOTH LICENSURE AND CERTIFICATION STANDARDS CONCRETE BOTH LICENSURE AND CERTIFICATION STANDARDS CONCRETE AND QUANTIFIABLEAND QUANTIFIABLE
DESCRIPTION OF TOOLS (cont:)DESCRIPTION OF TOOLS (cont:)
ALL STANDARDS CONTAIN:ALL STANDARDS CONTAIN: REGULATORY REFERENCEREGULATORY REFERENCE INTERPRETIVE GUIDELINESINTERPRETIVE GUIDELINES INFORMATION SOURCEINFORMATION SOURCE HOW STANDARD IS MEASUREDHOW STANDARD IS MEASURED CRITERIA FOR:CRITERIA FOR:
STANDARD METSTANDARD MET STANDARD NOT METSTANDARD NOT MET
SURVEY METHODOLOGYSURVEY METHODOLOGY
CURRENTCURRENT:: BASED ON FOLLOWING A SAMPLE OF BASED ON FOLLOWING A SAMPLE OF
INDIVIDUALS ACROSS ALL MEASURED INDIVIDUALS ACROSS ALL MEASURED INDICATORSINDICATORS
UTILIZES INTERVIEW, OBSERVATION UTILIZES INTERVIEW, OBSERVATION AND REVIEW OF DOCUMENTATIONAND REVIEW OF DOCUMENTATION
NEWNEW:: ““AUDIT” METHODOLOGYAUDIT” METHODOLOGY INFORMATION GATHERED FROM A VARIETY OF INFORMATION GATHERED FROM A VARIETY OF
DIFFERENT INDIVIDUALSDIFFERENT INDIVIDUALS DIFFERENT INDIVIDUALS SELECTED TO RATE DIFFERENT INDIVIDUALS SELECTED TO RATE
DIFFERENT INDICATORSDIFFERENT INDICATORS HEAVIER FOCUS ON ELECTRONIC DATA TO HEAVIER FOCUS ON ELECTRONIC DATA TO
INFORM CERTAIN INDICATORSINFORM CERTAIN INDICATORS INCREASED FOCUS ON PROVIDERS’ INTERNAL INCREASED FOCUS ON PROVIDERS’ INTERNAL
SYSTEMS WITH VALIDATION ON SITESYSTEMS WITH VALIDATION ON SITE CONTINUES TO UTILIZE INTERVIEW, CONTINUES TO UTILIZE INTERVIEW,
OBSERVATION AND REVIEW OF OBSERVATION AND REVIEW OF DOCUMENTATIONDOCUMENTATION
SURVEY FLOW AND TIMELINESSURVEY FLOW AND TIMELINES
CURRENTCURRENT:: PROVIDER SUBMITS APPLICATION 120-150 PROVIDER SUBMITS APPLICATION 120-150
DAYS PRIOR TO EXPIRATION OF LICENSEDAYS PRIOR TO EXPIRATION OF LICENSE
PROVIDER NOTIFIED 45 DAYS IN ADVANCE PROVIDER NOTIFIED 45 DAYS IN ADVANCE OF SURVEY DATES AND TEAM MEMBERSOF SURVEY DATES AND TEAM MEMBERS
PROVIDER NOTIFIED 21 DAYS IN ADVANCE PROVIDER NOTIFIED 21 DAYS IN ADVANCE OF SURVEY OF INDIVIDUALS AND OF SURVEY OF INDIVIDUALS AND LOCATIONS SELECTED IN SAMPLELOCATIONS SELECTED IN SAMPLE
SURVEY AVERAGES BETWEEN 7-10 DAYS SURVEY AVERAGES BETWEEN 7-10 DAYS ON-SITEON-SITE
SURVEY FLOW AND TIMELINES SURVEY FLOW AND TIMELINES (CONT:)(CONT:)
NEWNEW:: SAME WITH FOLLOWING CHANGES:SAME WITH FOLLOWING CHANGES:
PROVIDER NOTIFIED OF SITES TO BE VISITED AND PROVIDER NOTIFIED OF SITES TO BE VISITED AND INDIVIDUALS REVIEWED FOR SITE-LESS SERVICES ON INDIVIDUALS REVIEWED FOR SITE-LESS SERVICES ON THE FIRST DAY (AT ADMINISTRATIVE REVIEW)THE FIRST DAY (AT ADMINISTRATIVE REVIEW)
PROVIDER NOTIFIED OF INDIVIDUALS TO BE PROVIDER NOTIFIED OF INDIVIDUALS TO BE REVIEWED AT SITES WHEN SURVEYOR ARRIVES AT REVIEWED AT SITES WHEN SURVEYOR ARRIVES AT LOCATIONLOCATION
GOAL IS TO COMPLETE ON-SITE SURVEY WITHIN 5 GOAL IS TO COMPLETE ON-SITE SURVEY WITHIN 5 WORKING DAYSWORKING DAYS
ADMINISTRATIVE REVIEWADMINISTRATIVE REVIEW
CURRENTCURRENT:: PROCESS INCLUDES EXECUTIVE DIRECTOR PROCESS INCLUDES EXECUTIVE DIRECTOR
PRESENTATION/INTERVIEW AND DOCUMENTATIONPRESENTATION/INTERVIEW AND DOCUMENTATION BASED ON BROAD ORGANIZATIONAL AREAS AND OUTCOMESBASED ON BROAD ORGANIZATIONAL AREAS AND OUTCOMES OPPORTUNITY TO HEAR ABOUT NEW INTIATIVES AND BEST OPPORTUNITY TO HEAR ABOUT NEW INTIATIVES AND BEST
PRACTICESPRACTICES
NEWNEW:: INFORMATION EXCHANGE AND ADVANCE PREPARATION PRIOR INFORMATION EXCHANGE AND ADVANCE PREPARATION PRIOR
TO ADMINISTRATIVE REVIEWTO ADMINISTRATIVE REVIEW PROCESS INCLUDES INTERVIEW/DISCUSSION WITH EXECUTIVE PROCESS INCLUDES INTERVIEW/DISCUSSION WITH EXECUTIVE
DIRECTOR AND KEY PERSONNEL AND DOCUMENTATIONDIRECTOR AND KEY PERSONNEL AND DOCUMENTATION BASED ON SPECIFIC INDICATORS WHICH ARE VALIDATED ON-BASED ON SPECIFIC INDICATORS WHICH ARE VALIDATED ON-
SITESITE OPPORTUNITY TO HEAR ABOUT BEST PRACTICESOPPORTUNITY TO HEAR ABOUT BEST PRACTICES MORE EVIDENCE-BASED AND STRUCTURED MORE EVIDENCE-BASED AND STRUCTURED
SURVEY VISITS/ON-SITE AUDITSSURVEY VISITS/ON-SITE AUDITS
CURRENTCURRENT:: REVIEW OF QUALITY OF LIFE OUTCOMES FOR INDIVIDUALS IN REVIEW OF QUALITY OF LIFE OUTCOMES FOR INDIVIDUALS IN
SAMPLESAMPLE OBSERVATION AND INTERVIEW OF INDIVIDUALS SELECTEDOBSERVATION AND INTERVIEW OF INDIVIDUALS SELECTED REVIEW OF DOCUMENTATION AND ENVIRONMENT PRIOR TO REVIEW OF DOCUMENTATION AND ENVIRONMENT PRIOR TO
MEETING WITH INDIVIDUALMEETING WITH INDIVIDUAL
NEWNEW:: REVIEW OF INDICATORS THROUGH AUDITS AT EACH LOCATIONREVIEW OF INDICATORS THROUGH AUDITS AT EACH LOCATION INFORMATION COLLECTED FROM MULTIPLE INDIVIDUALSINFORMATION COLLECTED FROM MULTIPLE INDIVIDUALS INTERVIEWS MAY INVOLVE CONVERSATIONS WITH MORE THAN INTERVIEWS MAY INVOLVE CONVERSATIONS WITH MORE THAN
ONE INDIVIDUAL SUPPORTED AT LOCATIONONE INDIVIDUAL SUPPORTED AT LOCATION OBSERVATION MORE FOCUSED ON ALL INDIVIDUALS SERVED AT OBSERVATION MORE FOCUSED ON ALL INDIVIDUALS SERVED AT
THAT LOCATIONTHAT LOCATION REVIEW OF DOCUMENTATION AND ENVIRONMENT PRIOR TO REVIEW OF DOCUMENTATION AND ENVIRONMENT PRIOR TO
MEETING WITH INDIVIDUALMEETING WITH INDIVIDUAL
SAMPLING APPROACHSAMPLING APPROACH
CURRENTCURRENT INDIVIDUALS SERVED BY THE AGENCY SELECTED INDIVIDUALS SERVED BY THE AGENCY SELECTED
RANDOMLY AND RATED ACROSS RANDOMLY AND RATED ACROSS ALLALL INDICATORS INDICATORS
NUMBER OF INDIVIDUALS SAMPLED IS DETERMINED BY A NUMBER OF INDIVIDUALS SAMPLED IS DETERMINED BY A PERCENTAGE RANGE BASED ON TOTAL NUMBER OF PERCENTAGE RANGE BASED ON TOTAL NUMBER OF PEOPLE SERVEDPEOPLE SERVED
SAMPLE PROPORTIONAL TO NUMBERS IN EACH SERVICESAMPLE PROPORTIONAL TO NUMBERS IN EACH SERVICE
ADDITIONAL SAFEGUARD SYSTEMS REVIEWS FOR 50% ADDITIONAL SAFEGUARD SYSTEMS REVIEWS FOR 50% OF 24 HOUR HOMES NOT IN ORIGINAL SAMPLEOF 24 HOUR HOMES NOT IN ORIGINAL SAMPLE
SAMPLING APPROACH SAMPLING APPROACH (CONT:)(CONT:)
NEWNEW:: NUMBER OF AUDITS IS PROPORTIONAL TO NUMBERS IN NUMBER OF AUDITS IS PROPORTIONAL TO NUMBERS IN
EACH SERVICEEACH SERVICE SAMPLE ADJUSTED TO ADDRESS VARIANCE WITHIN SAMPLE ADJUSTED TO ADDRESS VARIANCE WITHIN
DIFFERENT SERVICE TYPESDIFFERENT SERVICE TYPES PROVIDERS WITH MANY SERVICE TYPES WILL HAVE PROVIDERS WITH MANY SERVICE TYPES WILL HAVE
SAMPLES DRAWN FROM EACHSAMPLES DRAWN FROM EACH 25% OF SERVICE LOCATIONS SELECTED RANDOMLY25% OF SERVICE LOCATIONS SELECTED RANDOMLY NUMBER OF INDIVIDUAL AUDITS WILL BE SPLIT ACROSS NUMBER OF INDIVIDUAL AUDITS WILL BE SPLIT ACROSS
SITESSITES INFORMATION WILL BE COLLECTED FROM MULTIPLE INFORMATION WILL BE COLLECTED FROM MULTIPLE
INDIVIDUALS TO INFORM EACH AUDITINDIVIDUALS TO INFORM EACH AUDIT MOST PROVIDERS WILL EXPERIENCE FEWER LOCATIONS MOST PROVIDERS WILL EXPERIENCE FEWER LOCATIONS
VISITEDVISITED
RATING SYSTEMRATING SYSTEM
CURRENTCURRENT:: QUALITY OF LIFE AREAS ARE DIVIDED INTO OUTCOMESQUALITY OF LIFE AREAS ARE DIVIDED INTO OUTCOMES OUTCOMES FURTHER DIVIDED INTO 2-4 INDICATORS PER OUTCOMES FURTHER DIVIDED INTO 2-4 INDICATORS PER
OUTCOMEOUTCOME FOR EACH INDIVIDUAL SAMPLED, EACH INDICATOR IS RATED YES FOR EACH INDIVIDUAL SAMPLED, EACH INDICATOR IS RATED YES
OR NO OR NO EACH OUTCOME ALSO RATED EXCEEDS, ACHIEVED, PARTIALLY EACH OUTCOME ALSO RATED EXCEEDS, ACHIEVED, PARTIALLY
ACHIEVED, NOT ACHIEVEDACHIEVED, NOT ACHIEVED PROVIDER’S RATING BASED ON THE CUMULATIVE OUTCOME PROVIDER’S RATING BASED ON THE CUMULATIVE OUTCOME
RATINGS OF INDIVIDUALS SAMPLEDRATINGS OF INDIVIDUALS SAMPLED
NEWNEW:: EACH INDICATOR IS RATED SEPARATELYEACH INDICATOR IS RATED SEPARATELY RATING IS EITHER STANDARD MET OR STANDARD NOT METRATING IS EITHER STANDARD MET OR STANDARD NOT MET THE PROVIDER’S RATING ON EACH INDICATOR IS COMPUTED BY THE PROVIDER’S RATING ON EACH INDICATOR IS COMPUTED BY
TALLYING THE NUMBER OF LOCATIONS/INDIVIDUALS WHERE TALLYING THE NUMBER OF LOCATIONS/INDIVIDUALS WHERE STANDARD WAS MET OVER THE NUMBER RATEDSTANDARD WAS MET OVER THE NUMBER RATED
LEVELS OF LICENSURE/CERTIFICATIONLEVELS OF LICENSURE/CERTIFICATION
CURRENT PROCESSCURRENT PROCESS:: ONE LEVEL OF LICENSURE FOR ENTIRE ONE LEVEL OF LICENSURE FOR ENTIRE
PROVIDER FOR ALL SERVICESPROVIDER FOR ALL SERVICES
CERTIFICATION LEVEL REPORTED BY NUMBER CERTIFICATION LEVEL REPORTED BY NUMBER OF QUALITY OF LIFE AREAS ACHIEVEDOF QUALITY OF LIFE AREAS ACHIEVED
CERTIFICATION APPLIES TO AGENCY AS A CERTIFICATION APPLIES TO AGENCY AS A WHOLE (COMBINES ALL RESIDENTIAL AND DAY WHOLE (COMBINES ALL RESIDENTIAL AND DAY SERVICES)SERVICES)
LEVELS OF LICENSURE/CERTIFICATION LEVELS OF LICENSURE/CERTIFICATION (cont:)(cont:)
NEWNEW:: SEPARATE LICENSURE GRANTED FOR EACH OF TWO SEPARATE LICENSURE GRANTED FOR EACH OF TWO
MAJOR SERVICE CATEGORIES:MAJOR SERVICE CATEGORIES: RESIDENTIAL/HOME SUPPORTS INCLUDINGRESIDENTIAL/HOME SUPPORTS INCLUDING::
24 AND LESS THAN 24 HOUR SUPPORTS24 AND LESS THAN 24 HOUR SUPPORTS PLACEMENT SERVICESPLACEMENT SERVICES INDIVIDUALIZED HOME SUPPORTSINDIVIDUALIZED HOME SUPPORTS SITE-BASED RESPITESITE-BASED RESPITE
EMPLOYMENT/DAY SUPPORTS INCLUDINGEMPLOYMENT/DAY SUPPORTS INCLUDING:: COMPETITIVE INTEGRATED EMPLOYMENTCOMPETITIVE INTEGRATED EMPLOYMENT INDIVIDUAL/GROUP SUPPORTED EMPLOYMENTINDIVIDUAL/GROUP SUPPORTED EMPLOYMENT CENTER-BASED WORKCENTER-BASED WORK COMMUNITY-BASED DAYCOMMUNITY-BASED DAY
LEVELS OF LICENSURE/CERTIFICATION cont:LEVELS OF LICENSURE/CERTIFICATION cont:
CERTIFICATION:CERTIFICATION:
SEPARATE REPORTING OF RESULTS SEPARATE REPORTING OF RESULTS FOR EACH DISCRETE SERVICE TYPEFOR EACH DISCRETE SERVICE TYPE
LICENSURE AND CERTIFICATION LICENSURE AND CERTIFICATION RESULTS RESULTS NOTNOT COMBINED COMBINED
LEVELS OF LICENSURE/CERTIFICATIONLEVELS OF LICENSURE/CERTIFICATION
CURRENTCURRENT:: LICENSURE LEVELSLICENSURE LEVELS::
TWO YEAR LICENSETWO YEAR LICENSE ONE YEAR CONDITIONALONE YEAR CONDITIONAL RECOMMENDATION FOR NON-LICENSURERECOMMENDATION FOR NON-LICENSURE
CERTIFICATION LEVELSCERTIFICATION LEVELS:: COMBINES BOTH LICENSURE AND COMBINES BOTH LICENSURE AND
CERTIFICATION QUALITY OF LIFE AREASCERTIFICATION QUALITY OF LIFE AREAS CAN RESULT IN CERTIFICATION WITH CAN RESULT IN CERTIFICATION WITH
DISTINCTION (ALL OUTCOMES MET) ORDISTINCTION (ALL OUTCOMES MET) OR NUMBER OF QUALITY OF LIFE AREAS NUMBER OF QUALITY OF LIFE AREAS
ACHIEVEDACHIEVED
LEVELS OF LICENSURE/CERTIFICATIONLEVELS OF LICENSURE/CERTIFICATION (CONT:) (CONT:)
NEW:NEW:
LEVELS OF LICENSURELEVELS OF LICENSURE:: TWO YEARTWO YEAR TWO YEAR WITH MID-CYCLE REVIEWTWO YEAR WITH MID-CYCLE REVIEW DEFERRED STATUSDEFERRED STATUS RECOMMENDATION FOR NON-LICENSURERECOMMENDATION FOR NON-LICENSURE
CERTIFICATION FINDINGSCERTIFICATION FINDINGS NUMBER OF STANDARDS MET FOR EACH NUMBER OF STANDARDS MET FOR EACH
DISCRETE SERVICE TYPEDISCRETE SERVICE TYPE
LEVELS OF LICENSURE/CERTIFICATION LEVELS OF LICENSURE/CERTIFICATION (CONT:)(CONT:)
TWO YEAR LICENSETWO YEAR LICENSE:: 80% OR MORE OF STANDARDS MET80% OR MORE OF STANDARDS MET ALL 8 CRITICAL INDICATORS METALL 8 CRITICAL INDICATORS MET
TWO YEAR WITH MID-CYCLE REVIEWTWO YEAR WITH MID-CYCLE REVIEW:: 60-79% OF STANDARDS MET60-79% OF STANDARDS MET ALL 8 CRITICAL INDICATORS METALL 8 CRITICAL INDICATORS MET
DEFERRED LICENSEDEFERRED LICENSE:: 60% OR MORE OF STANDARDS MET60% OR MORE OF STANDARDS MET ANY ONE OF THE 8 CRITICAL INDICATORS NOT METANY ONE OF THE 8 CRITICAL INDICATORS NOT MET
RECOMMENDATION FOR NON-LICENSURERECOMMENDATION FOR NON-LICENSURE:: 59% OR LESS OF THE INDICATORS MET59% OR LESS OF THE INDICATORS MET
FEEDBACK AND REPORTFEEDBACK AND REPORT
CURRENTCURRENT:: DRAFT REPORT SENT TWO DAYS IN ADVANCE OF DRAFT REPORT SENT TWO DAYS IN ADVANCE OF
SERVICE ENHANCEMENT MEETINGSERVICE ENHANCEMENT MEETING
SERVICE ENHANCEMENT MEETING HELDSERVICE ENHANCEMENT MEETING HELD
FINAL REPORT SENTFINAL REPORT SENT
REPORT FORMAT:REPORT FORMAT: VERY LENGTHYVERY LENGTHY EXECUTIVE SUMMARYEXECUTIVE SUMMARY DETAILED NARRATIVE FOR EACH QUALITY OF LIFE AREADETAILED NARRATIVE FOR EACH QUALITY OF LIFE AREA COMMENDATIONS, AREAS NEEDING COMMENDATIONS, AREAS NEEDING
IMPROVEMENT/SUGGESTIONSIMPROVEMENT/SUGGESTIONS SAFEGUARD SUMMARY REVIEWSSAFEGUARD SUMMARY REVIEWS
FEEDBACK AND REPORTFEEDBACK AND REPORT (CONT:) (CONT:)
NEWNEW:: SAME AS CURRENT PROCESSSAME AS CURRENT PROCESS REPORT FORMATREPORT FORMAT::
MUCH SHORTER; MINIMAL NARRATIVEMUCH SHORTER; MINIMAL NARRATIVE EXECUTIVE SUMMARY, INCLUDING BEST PRACTICESEXECUTIVE SUMMARY, INCLUDING BEST PRACTICES LIST OF AREAS NEEDING IMPROVEMENT AND LIST OF AREAS NEEDING IMPROVEMENT AND
COMMENDATIONS FOR PROVIDER AS A WHOLECOMMENDATIONS FOR PROVIDER AS A WHOLE DETAIL OF LOCATIONS, INDIVIDUALS WHERE STANDARD DETAIL OF LOCATIONS, INDIVIDUALS WHERE STANDARD
WAS NOT MET (FOR PROVIDER AND DDS ONLY)WAS NOT MET (FOR PROVIDER AND DDS ONLY) MASTER RATING SHEET WITH SCORES FOR EACH DISCRETE MASTER RATING SHEET WITH SCORES FOR EACH DISCRETE
SERVICE TYPE SERVICE TYPE ADDENDUM FOR ISSUES BEYOND PROVIDER’S CONTROL ADDENDUM FOR ISSUES BEYOND PROVIDER’S CONTROL
(FOR PROVIDER/DDS ONLY)(FOR PROVIDER/DDS ONLY) ADDENDUM FOR FAMILY COMMENTS (FOR PROVIDER/DDS ADDENDUM FOR FAMILY COMMENTS (FOR PROVIDER/DDS
ONLY)ONLY)
FOLLOW-UP AND TARGETED REVIEWSFOLLOW-UP AND TARGETED REVIEWS
CURRENTCURRENT:: FOLLOW-UP ON “ACTIONS REQUIRED”FOLLOW-UP ON “ACTIONS REQUIRED”
FOLLOW-UP ON QUALITY OF LIFE AREAS FOLLOW-UP ON QUALITY OF LIFE AREAS RECEIVING A PARTIALLY ACHIEVED OR RECEIVING A PARTIALLY ACHIEVED OR LOWERLOWER
FOLLOW-UP WITHIN 60 DAYS WHEN FOLLOW-UP WITHIN 60 DAYS WHEN THERE IS A RECOMMENDATION FOR THERE IS A RECOMMENDATION FOR NON-LICENSURENON-LICENSURE
FOLLOW-UP AND TARGETED REVIEWS FOLLOW-UP AND TARGETED REVIEWS (CONT:)(CONT:)
NEWNEW:: FOLLOW-UP ON “ACTIONS REQUIRED”FOLLOW-UP ON “ACTIONS REQUIRED”
FOLLOW-UP ON ALL INDICATORS WHERE THE FOLLOW-UP ON ALL INDICATORS WHERE THE STANDARD WAS NOT MET REGARDLESS OF STANDARD WAS NOT MET REGARDLESS OF LEVEL OF LICENSURELEVEL OF LICENSURE
FOLLOW-UP ON CRITICAL INDICATORS NOT FOLLOW-UP ON CRITICAL INDICATORS NOT MET WHEN PROVIDER IS IN DEFERRED STATUSMET WHEN PROVIDER IS IN DEFERRED STATUS
FOLLOW-UP ON RESULTS OF WORK PLANS FOLLOW-UP ON RESULTS OF WORK PLANS WHEN THERE IS A RECOMMENDATION FOR WHEN THERE IS A RECOMMENDATION FOR NON-LICENSURENON-LICENSURE
TARGETED REVIEWSTARGETED REVIEWS
PROVIDERS RECEIVING A FULL 2 YEAR PROVIDERS RECEIVING A FULL 2 YEAR LICENSE WILL RECEIVE A TARGETED LICENSE WILL RECEIVE A TARGETED REVIEW OF INDICATORS NOT MET IN REVIEW OF INDICATORS NOT MET IN PREVIOUS SURVEY AND WILL DO A SELF-PREVIOUS SURVEY AND WILL DO A SELF-ASSESSMENT OF REMAINING INDICATORSASSESSMENT OF REMAINING INDICATORS
PROCESS AND CONTENT UNDER PROCESS AND CONTENT UNDER DEVELOPMENTDEVELOPMENT
PRACTICES THAT REMAIN THE SAMEPRACTICES THAT REMAIN THE SAME
USE OF OBSERVATION, INTERVIEW AND USE OF OBSERVATION, INTERVIEW AND DOCUMENTATION AS SOURCES OF DOCUMENTATION AS SOURCES OF INFORMATIONINFORMATION
OPEN COMMUNICATION DURING SURVEYOPEN COMMUNICATION DURING SURVEY
RECONSIDERATION PROCESSRECONSIDERATION PROCESS
DEEMING OF CARF AND THE COUNCIL FOR DEEMING OF CARF AND THE COUNCIL FOR PROVIDERS WITH TWO YEAR LICENSEPROVIDERS WITH TWO YEAR LICENSE
ISSUANCE OF “ACTIONS REQUIRED”ISSUANCE OF “ACTIONS REQUIRED”
NEXT STEPSNEXT STEPS REVIEW MANUAL FOR MORE SPECIFIC REVIEW MANUAL FOR MORE SPECIFIC
INFORMATIONINFORMATION
REGIONAL QE STAFF ALREADY MEETING WITH REGIONAL QE STAFF ALREADY MEETING WITH PROVIDER WHOSE SURVEYS WILL OCCUR IN PROVIDER WHOSE SURVEYS WILL OCCUR IN JULY, AUGUSTJULY, AUGUST
ADDITIONAL ORIENTATIONS FOR OTHER ADDITIONAL ORIENTATIONS FOR OTHER PROVIDERS WILL OCCURPROVIDERS WILL OCCUR
FULL IMPLEMENTATION BEGINNING IN JULYFULL IMPLEMENTATION BEGINNING IN JULY
ALL PROVIDERS WILL HAVE FULL REVIEWS IN ALL PROVIDERS WILL HAVE FULL REVIEWS IN ORDER TO OBTAIN BASELINE INFORMATIONORDER TO OBTAIN BASELINE INFORMATION
ON-GOING PLANSON-GOING PLANS
FEEDBACK WILL BE SOLICITED FEEDBACK WILL BE SOLICITED AFTER EVERY SURVEYAFTER EVERY SURVEY
REVIEW OF PROCESS AFTER YEAR REVIEW OF PROCESS AFTER YEAR ONEONE
MODIFICATIONS, IF NEEDEDMODIFICATIONS, IF NEEDED
JOINT PROVIDER, QE TRAININGJOINT PROVIDER, QE TRAINING