Quality Assurance

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 DDA requirements;
• Application of the current DDA 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 DDA;
• 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? 

Within six (6) months of a provider initiating services, but no sooner than three (3) months from the initiation of services, the Regional QA team will initiate the Consultative Survey process. The Consultative Survey report and results should be utilized by the provider agency and the DDA Provider Support Team to identify any areas where the provider may need supports. Resources have been developed by the Quality Management unit that are available on the DDA website. The Consultative Survey report and score will not be publicly published and will not be considered for the purpose of recredentialing, DDA licensing, etc.

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?

The on-site Survey will begin with an Entrance conference facilitated by DDA, the Survey Week typically begins on Monday morning (except in the instance of a State Holiday and/or extenuating circumstances approved by DDA Central Office Quality Management). All on-site survey activities, such as interviews and service observations, will occur the calendar week of the Survey Entrance.  At the Survey Entrance, providers will be encouraged to share accomplishments, challenges (including those they have overcome and those they are still facing) and other information they deem relevant to the review period. They will also use this time to detail their processes for meeting the indicators in the QM Tool. Surveyors will make note of relevant information shared during the opening conference to use during the survey and/or when preparing the final report where applicable. Any changes to the interview/service observation schedule necessitated by individual or provider circumstance will be made at that time. As a part of the Survey Entrance, DDA surveyors will ask for guidance regarding building a relationship and communicating with the people in the sample, and if there have been any changes to the sample information.

The on-site survey process consists of three main components: provider systems and records review, interviews, and observation of service delivery.  

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

The Survey Exit is a meeting between the provider, DDA, and the MCO(s) that contract with the provider to review and discuss the results of the survey. This meeting can occur virtually or in-person. An in-person Exit Meeting may be required if the provider agency had significant concerns identified during the Survey Review.  Exit Meetings will occur within thirty (30) business days of the Survey Entrance. MCO staff from each MCO contracted with that provider must attend the Exit Meeting.  

During the exit meeting, DDA survey staff will discuss agency strengths related to quality and opportunities to build on those strengths to further improve quality. DDA survey staff will emphasize the purpose and goals of indicators and share the provider’s Achievement Levels.

If during the exit meeting the provider indicates disagreement with one or more findings, they will be given the opportunity to explain what may have been missed during the Survey Review. There will be no new evidence or documentation accepted after the last day of the Survey week.

Following the Exit Meeting, within two (2) weeks (14 calendar days), DDA survey staff will distribute the final Quality Monitoring Survey Report to the provider and MCOs.

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 DDA 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 DDA 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. There will be no new evidence or documentation accepted that was not presented to the QM team during the survey week.  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.

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