A 1915( (ADHC) & H (HBHS)

ANNUAL STATEWIDE 1915(i) HOME & COMMUNITY BASED SERVICES STATE PLAN ADULT DAY HEALTH CARE (ADHC) & HOME BASE HABILITATION SERVICES (HBHS) REVIEW FINAL

REPORT 2018

Home and Community Based Services (HCBS) Serving Individuals enrolled in Adult Day Health Cares and Home-Based Habilitation Services Quality Assurance review to ensure the service continues to meet essential Federal statutory assurances and effectively meet the

recipient's needs.

State of Nevada Division of Health Care Financing and Policy Managed Care & Quality Assurance Unit April 2020 Review Year: 2018

Table of Contents

Background/Introduction........................................................................................ 2 Aims & Objectives ................................................................................................. 3 Methodology........................................................................................................... 3 Results 2018 Case File Review ADHC/HBHS/Combined..................................... 6 Quality Improvement Strategy ................................................................................10 Results 2018 Financial Review ADHC/HBHS/Combined......................................12 Providers ..................................................................................................................15 Participant Experience Surveys (PES).....................................................................15 QI Project Performance ...........................................................................................17 Additional Recommendations .................................................................................23 Observations ............................................................................................................23 Best Practices...........................................................................................................23 Requirements .......................................................................................................... 24 Acronyms & Definitions ........................................................................................ 53 Appendices ............................................................................................................. 59

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ANNUAL STATEWIDE 1915(i) HOME & COMMUNITY BASED SERVICES STATE PLAN ADULT DAY HEALTH CARE (ADHC) & HOME BASE HABILITATION SERVICES (HBHS) REVIEW FINAL REPORT

2018

Background/Introduction

The State Plan Amendment (SPA) renewal of the ADHC and HBHS are contingent on the Centers for Medicare and Medicaid Services (CMS) determining that the state has effectively assured the health and welfare of state plan recipients during the period the SPA has been in effect.

The State is required under 1915(i)(1)(H) to ensure that the provision of state plan home and community-based services (HCBS) meets Federal and State guidelines for quality assurance. In addition, under 42 CFR ?441.745: "States must develop and implement an HCBS quality improvement strategy that includes a continuous improvement process and measures of program performance and experience of care. The strategy must be proportionate to the scope of services in the state plan HCBS benefit and the number of individuals to be served." CMS must assess each state plan HCBS benefit to determine that the state requirements are met. The assessment also serves to inform CMS in its review of the state's request for renewal of these services.

CMS conducts quality reviews, requiring states to demonstrate their use of performance measures to collect HCBS data and address how they conduct discovery, remediation, and quality improvement activities.

A state must demonstrate oversight through performance measures included in its ?1915(i) state plan HCBS benefit. When a performance measure falls below the threshold, further analysis is required to determine the cause and the Quality Management Activities implemented unless the state provides acceptable justification clarifying why system improvement is not necessary.

Performance Measures

CMS evaluates the state's oversight and monitoring systems according to outcome-based evidence in the form of performance measures. Well-crafted performance measures indicate whether the state is meeting the Federal requirements for the approved SPA benefit. The performance measures drive the state's Quality Improvement Strategy (QIS) and form the basis of the evidence provided to CMS.

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The state's performance measures are assessed by CMS based on the following seven criteria:

1. The performance measure is stated as a metric (e.g., number or percent), and specifies a numerator and denominator (i.e., is the performance measure measurable?).

2. The performance measure has face validity (i.e., Does the performance measure truly measure the requirement?).

3. The performance measure data is based on the correct unit of analysis (e.g., participants, providers, claims, etc.). The unit of analysis should be linked to the requirement measured.

4. The performance measure data is based on a representative sample of the population. The performance measure data should have at least a 95 percent confidence level with a +/- 5 percent margin of error. If the state chooses to stratify a sample to allow for a representative sample of subgroups, the state must "re-weight" the data in order to make estimates for the population as a whole.

5. The performance measure must provide data specific to the state plan benefit undergoing evaluation.

6. The performance measure data demonstrates the degree of compliance for each period of data collection.

7. The performance measure measures the health of the system, (e.g. does the performance measure evaluate the anticipated outcome of the requirement as opposed to measuring a beginning step in the process).

Aims & Objectives

The annual review monitoring activities provide the foundation for quality improvement by generating information regarding compliance, potential problems and individual corrective actions. The results can be aggregated and analyzed to measure the overall system performance in meeting the service assurances.

Methodology

The CMS quality requirements are founded on an evidence-based approach. The CMS requests evidence from the state that it meets the assurances and applies a continuous quality improvement approach to the assurances. Effective October 2017, the Division of Health Care Financing and Policy (DHCFP) Quality Assurance (QA) unit implemented a monthly process to allow the state to achieve higher administrative efficiency, a natural process of current and continuous quality improvement, and prevent duplication. The DHCFP QA uses a representative sample producing a probability of a 95 percent confidence level with a +/- 5 confidence interval (95/5) to determine the statewide total of recipient files to be reviewed by the operating agency and the DHCFP QA.

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A 95/10 representative sample is used f o r financials and Participant Experience Surveys (PES). The annual review for the HCBS State Plans ADHC and HBHS for the State of Nevada was conducted from October 1, 2018 through September 30, 2019 with reviews covering 2017-2019. The DHCFP QA reviewed a random sample of eightysix (86) case files for ADHC, 100 percent of the twenty-two (22) case files for HBHC, one hundred eleven (111) financial claims were reviewed for one hundred eleven (111) unique recipients and two-hundred seventy eight (278) recipients were selected for PES interviews (both on-site and by mailings) for the 2018 service plan year.

To assist the DHCFP Long Term Services and Supports (LTSS) unit, the DHCFP QA conducted all the provider reviews for the 2018 Federal Fiscal Year.

The following areas were evaluated during this year's annual review:

Case File Review: 1. State Plan Eligibility 2. State Plan Services Received 3. Universal Needs Assessment (UNA) 4. Health Assessment (ADHC) or Initial Evaluation & Continued Stay Documentation (HBHS) 5. Service Plan (SP) 6. Prior Authorization (PA) 7. Provider and DHCFP Plan of Care (POC)

Financial Review: 1. Recipient Eligibility 2. PA 3. Claim 4. Daily Record 5. Payment 6. Provider

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Provider Review: 1. Provider Qualifications 2. Recipient Eligibility 3. Service Plan/Plan of Care 4. Recipient Safeguards 5. Records Retention 6. Attendance and Daily Record 7. Completion and Documentation of Training

Participant Experience Surveys (PES): 1. Choice and Control 2. Respect and Dignity 3. Access to Care 4. Community Integration and Inclusion

Listed below are the specific 1915(i) ADHC and HBHS, Medicaid Services Manual (MSM) used in the implementation of this annual review:

MSM Chapter 1800 Adult Day Health Care (Effective 11/14/2013)

MSM Chapter 1800 Adult Day Health Care (Effective 01/08/2015) MSM Chapter 2400 Home Based Habilitation Services (Effective 03/09/2008) MSM Chapter 2400 Home Based Habilitation Services (Effective 02/14/2012) State Plan: 1915(i) HCBS State Plan Services CFR- 441-540/CFR- 441.720/CFR-441.725 Final Rule CMS 2249-F & CMS 2296-F NAC 449.4087/NAC 449.4088

The following results identify the areas and percentages of compliance with performance measures and requirements outlined in the above documents.

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Results

ADHC Eligibility Provider Service Plan (SP)

Provider Plan of Care (POC) DHCFP Plan of Care (POC)

Results

2018 Statewide Case File Review Results ADHC

Meets needs-based criteria with ADLs (CSHA) Meets needs-based criteria completed annually or more frequently as needed UNA was completed per policy Meets criteria on UNA or recipient on waiver UNA face-to-face annually or more frequently as needed Health Assessment completed timely by the ADHC nurse Services on the SP have a current Prior Authorization SP submitted as part of the Prior Authorization SP updated annually or more frequently as needed SP addresses assessed needs identified on the UNA Frequency/Duration/Scope of each service was identified on SP SP signed by ADHC nurse SP signed by recipient/LRI Documented on SP if recipient was unable to sign SP was completed using Person Centered Planning SP documents choice of services and providers POC addresses needs identified on SP POC addresses assessed needs identified on UNA POC addresses assessed needs identified on the Health Assessment POC identifies the objectives/goals of the POC POC reflects all services and supports that will assist the individual to achieve identified goals POC updated annually or more frequently as needed POC developed within 30 days Frequency/Duration/Scope of each service was identified POC signed by recipient/LRI POC signed by ADHC nurse Documented on POC if recipient was unable to sign POC was completed using Person Centered Planning POC addresses needs identified on the SP POC addresses assessed needs identified on the UNA POC addresses assessed needs identified on the CSHA POC identified the objectives/goals of the POC POC reflects all services & supports that will assist the individual to achieve identified goals POC updated annually or more frequently as needed POC developed within 30 days Frequency/Duration/Scope of each service was identified

68.6% 67.4% 98.8% 98.8% 79.1% 40.7% 95.3% 87.2% 82.6% 25.6% 5.8% 69.8% 68.6% 93.0% 52.3% 45.3% 26.7% 19.8% 40.7% 45.3% 50.0% 43.0% 43.0% 14.0% 33.7% 50.0% 50.0% 18.6% 46.5% 46.5% 44.2% 80.2% 81.4% 59.3% 30.2% 18.6%

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ADHC Eligibility Provider Service Plan (SP) Provider Plan of Care (POC)

POC signed by recipient/LRI POC signed by DHCFP case manager Documented on POC if recipient was unable to sign POC was completed using Person Centered Planning POC documents choice of services and providers

2018 Statewide Case File Review Results HBHS

Meets needs-based criteria with ADLs (CSHA) Meets needs-based criteria completed annually or more frequently as needed UNA was completed per policy Meets criteria on UNA or recipient on waiver UNA completed face-to-face annually or more frequently as needed Initial Evaluation completed (new enrollees) Continued Stay Criteria completed Processes & instructions for determining eligibility satisfied for Initial Evaluation and/or Continued Stay Medically verifiable TBI/ABI &/or unable to return to independent or re-integration document Services on the SP have a current Prior Authorization SP, UNA & statement recipient offered choice of providers submitted for Prior Authorization SP was updated annually or more frequently as needed SP addresses assessed needs identified UNA Frequency/Duration/Scope/Title of Staff for each service was identified on the SP SP signed by all individuals & providers responsible SP signed by recipient/LRI with legal documents Documented on SP recipient was unable to sign SP was completed using Person Centered Planning SP documents choice of HBHS providers POC addresses needs identified on SP POC addresses assessed needs identified on UNA

POC addresses assessed needs identified on the Initial Evaluation or Continued Stay POC identifies specific goals, how achieved and duration of achievement with barriers Assessment of needs in POC conducted every 3 months POC was updated annually or more frequently as needed POC initiated on day of admission Frequency/Duration/Scope for each service POC signed by recipient/LRI POC signed by licensed professional Documented on POC if recipient was unable to sign POC was completed using Person Centered Planning

31.4% 26.7% 79.1% 36.0% 87.2%

18.2% 45.5% 40.9% 36.4% 45.5% 90.9% 68.2% 0.0% 9.1% 68.2% 0.0% 54.5% 5.3% 4.5% 18.2% 0.0% 63.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 4.5% 4.5% 0.0%

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