DDSN conducts Contract Compliance Review (CCR) activities that provide a more in-depth look at the overall functioning of the provider. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/family still want and need them, and that they comply with contract and/or funding requirements and best practices.
SC DDSN contracts with a Quality Improvement Organization, Alliant ASO, to conduct annual assessments of service providers by making on-site visits in its Contract Compliance Review (CCR) process. During this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to make sure that services are being implemented as planned and based on the consumer’s need, that the consumer/family still wants and needs them, and that they comply with contract and/or funding requirements and best practices. In addition, the service provider’s administrative capabilities are reviewed annually to ensure compliance with DDSN standards, contracts, policies, and procedures.
As another cornerstone in the foundation of Quality Management, DDSN maintains a program of performing contract compliance reviews. DDSN conducts these annual assessments of service providers by making on-sight visits under its Contract Compliance Review (CCR) process. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/family still wants and needs them, and that they comply with contractual and/or funding requirements and best practices. In addition to health and safety, the CCR process assesses the provider's basic administrative strengths and weaknesses, and where necessary, may refer a provider to receive special technical assistance or to undergo a more extended financial and managerial audit. These activities are very important to assure a foundation of quality service delivery. In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
Review Instruments: In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
- What is the criteria for a 12 month verses an 18-month Contract Compliance Review?
The FY18 Review Cycle will be determined by your FY17 (or FY16) Review Scores. If a provider scored at or above 75% Compliance on all areas (Administrative Indicators and Services Indicators), then they will be on an 18 month review cycle. Providers with one or more scores falling below 74.9% Compliance will be on a 12-month review cycle.
Beginning July 1, 2017, DDSN Providers will have a new threshold for qualifying for the 18-month review. For FY18, Providers must score at or above 85% Compliance in all service areas in order to qualify for an 18 month review. Providers scoring below 84.9% Compliance in one or more areas will be on a 12-month review cycle.
- How do I determine whether I am on a 12 month or 18 month CCR?
A provider should review their last Contract Compliance Review Score to determine whether they are on a 12 or 18-month Review Cycle. Please note, the time frames are approximate.
- When can I anticipate my report from the CCR review?
The Report of Findings will be posted on the QIO Portal within 30 days of the completion of the Contract Compliance Review.
Key Indicators for Contract Compliance Reviews
- Are there new Key Indicators for FY18?
Providers should refer to the FY18 Key Indicators Crosswalk for new indicators and/or changes to prior indicators. The Key Indicators are based on DDSN Service Standards and Directives or Medicaid Policies/requirements and may changes from year to year.
- Which Key Indicators are applicable to my organization?
The Key Indicators are based on DDSN Service Standards, Directives, and Medicaid Policy/Requirements. Each of these documents will state the applicability for different types of providers. In general, Administrative Indicators apply to all providers, although there may be some indicators that only apply to particular service types.
For FY18, the Key Indicators have been separated for different provider types. On the DDSN Website, there is a set of Key Indicators for Direct Service Providers (Day, Residential, In-Home Support, and HASCI Rehabilitation Supports), a set of Key Indicators for Case Management, Intake, Waiver Administration, and Early Intervention, and a set for Early Intensive Behavior Intervention Providers. There is also a master set of Key Indicators that includes all Administrative and Service Specific Indicators.
- What are the required training requirements that are measured in the CCR process?
Providers should ensure that all training requirements outlined in DDSN Directive 567-01-DD: Employee Orientation, Pre-Service and Annual Training Requirements are met, in addition to other requirements listed in individual service standards.
- What are the employee qualifications requirements that are measured in the CCR process?
Providers should ensure that all pre-employment background check and reference requirements outlined in DDSN Directive 406-04-DD: Criminal Record Checks and Reference Checks of Direct Caregivers are met, in addition to other requirements listed in individual service standards.
- When is a SLED Background Check required versus a Federal Background Check?
A direct care applicant who is unable to verify South Carolina residency for the past 12 months and/or will be expected to work directly with children, newborn to 18 years old, shall submit to a Federal Criminal Record Check conducted by the Federal Bureau of Investigation (FBI) prior to employment. The results will include any applicable state law enforcement agency results and the FBI database information. The Federal Criminal Record Check shall be conducted via an electronic fingerprint scan. No other type of criminal background check can be substituted for an FBI database check when a Federal background check is required. Federal Background Checks must be requested as outlined in DDSN Directive 406-04-DD: Criminal Record Checks and Reference Checks of Direct Caregivers.
- What are the requirements for Human Rights Committees?
The requirements for Human Rights Committees are outlined in DDSN Directive 535-02-DD: Human Rights Committees.
- Are small providers required to have a Human Rights Committee? Yes.
All DDSN contracted providers must have a Human Rights Committee, or they must have a contractual relationship with another provider to utilize their Human Rights Committee.
- Are small providers required to have a Risk Management Committee? Yes.
All providers must have a system in place to track, trend and analyze their organization’s data and compare it to statewide data.
Review Notification/Samples for Contract Compliance Reviews
- Will I receive prior notification of my review?
The Provider will receive a 48-hour notice for their Administrative Indicator review. This can be an on-site review or a desk review with the provider uploading required information (provider choice). This process will apply to the 12/18 month reviews and the Follow-up Reviews.
Individual Record Reviews will begin without prior notice to the Provider Agency for Case Management, Residential and Day Services. The QIO will begin the record review utilizing information available through the electronic record, including Therap and CDSS. Alliant will set up a time to go on-site to review any information that is not required in an electronic format, or the provider may choose to upload the documentation required for review. Early Intervention will have a one week prior notice for review of individual records to avoid conflicts with family training. This process will be the same for 12/18 month reviews and Follow-up Reviews.
- Do all my service records/files need to be available?
Providers should be “Review Ready” at all times and the records should be accessible for a review. The QIO will review a sample of files from each service type offered by the provider.
- What if there is a specific time period that I would like to avoid a review?
On a case-by-case basis, the QIO may determine the need to exempt a provider from having a review during a specific time period. For example, a small provider may have a training retreat scheduled for two (2) days and request (in advance) that their organization would be excluded from any review for that two (2) day period. Generally speaking, if a provider is open for business, they may be subject to a review.
- How is a sample determined for the Individual Record Review?
DDSN will select a representative sample for each provider. The sample will be statistically significant and generally represent about 5% of the service population. Larger providers may have a smaller sample and smaller providers may have a larger sample than 5% in order to meet minimum review requirements.
- When will the provider receive the sample?
The provider will continue to receive the sample for staff files (Administrative Review) and individual files (Individual Record Reviews) on the morning of the scheduled review. If the Individual Record Review will take more than one (1) day, the provider will receive the sample for each day on the morning of the review.
- What information is needed to begin the Administrative Review?
To prepare for the Administrative Review, the Provider will assemble documentation verifying compliance with standards, manuals and policies for each of the Administrative Review sections. This information should be available at the conclusion of the entrance conference and may include, but not be limited, to the following:
- Identification of Human Rights Committee members with their start dates, as well as identification of member composition
- Verification of Human Rights Committee initial training (for new members during review period) and tabbed ongoing training for all corrective actions
- Human Rights Committee Minutes
- Risk Management/Safety Committee Meeting Minutes
- Verification of analysis of ANE, Critical Incident, and Death/impending death data and actions taken to prevent future ANE and Critical Incident and Death as applicable
- Database of recorded/tracked, analyzed, trended medication errors including corrective actions
- Database of recorded/tracked, analyzed, trended use of restraints
- Documentation of follow-up for consumers referred for GERD/Dysphagia Consultation
- Verification of quarterly visits to all homes by upper-level management (tabbed by home)
- A list of homes with names of their designated coordinators (staff responsible for the development and monitoring of residential plans)
- Statements of Financial Rights for all residential admissions during the period in review
- Verification that employees are made aware of False Claims Recovery Act and Whistleblower laws annually (verification will be reviewed for the personnel files selected for review)
- Outlier Contracts including:
- Approved staffing grids,
- Master schedule and corresponding verification/confirmation of staff coverage, and
- Logs, etc.
- System for 24/7 access to assistance (Service Coordination providers only)
*The Administrative Indicator Review may be subject to the request of additional information.
- How is a sample determined for the Administrative Indicators/personnel files to be reviewed?
Upon notification of the Administrative Review, the Service Provider must submit a listing of all employees to the QIO within 24 hours. This list will include all staff employed during the review period, even staff that are no longer working for the provider. From this list, the QIO will determine the personnel files to be reviewed. The Provider will be notified of the names in the sample on the morning of the Administrative Review start date.
- What is the time frame that the files must be available during a CCR?
Most files should be available for the QIO to review within two (2) hours of receiving the sample. Typically, providers will receive their sample information when the QIO Review Team is in transit and the files should be available upon the team’s arrival.
- Will DSN Boards have direct services (Day, Residential, In-Home Supports, and HASCI Rehabilitation Supports) reviewed at the same time as Case Management or Early Intervention Services? No.
Based on provider feedback, it was determined that most providers needed prior notification for Early Intervention services due to pre-arranged family training appointments with families. In response, DDSN has restructured the review process by separating Case Management, Intake, Waiver Administration, and Early Intervention from other Direct Services. This model will also support the transition to Conflict-Free Case Management and provide a balanced approach to reporting Administrative Indicator scores for DSN Boards and Qualified Providers that have a smaller number of indicators reviewed. Administrative Indicators will be reviewed and scored for the respective service types at the time of the designated review.
- Will Early Intervention Service Providers receive prior notice for reviews? Yes.
Early Intervention providers will receive a 48-hour notice for the Administrative Indicator section of their review and a seven (7)-day notice for the Individual Record Review.
Reconsideration/Appeal- Contract Compliance Reviews
- Are DDSN staff available to assist with questions during a review?
DDSN staff will not intervene during a provider review. If the provider does not agree with a citation, they may have an opportunity to resolve it during the reconsideration period immediately following the review or by submitting an appeal after the report of findings has been posted to the portal. DDSN staff are not able to see the same documentation available to the review staff while they are completing a review and they cannot provide a response without consideration of all available information.
- Will the provider have an opportunity to discuss potential citations and provide additional documentation if needed? Yes.
There is an opportunity for dialogue between the QIO and the Provider each day. In addition, the provider will receive a brief, written summary of findings immediately following their review. The provider will have an opportunity to provide additional documentation for consideration during a 48-hour window, following receipt of the summary.
- What if I am not in agreement with the citation?
If a provider is not in agreement with a citation noted in the Report of Findings they may choose to appeal the citation.
- What is the appeal process and how do I appeal?
From the POC template on the QIO Portal, the provider must indicate their intent to appeal the designated citation. There is a check box within the format for this purpose. In addition, the provider must complete the Appeal form (available on the QIO Portal) and upload this document along with any supporting documentation they would like to be considered. Once the Appeal documentation has been uploaded, the QIO will provide documentation of their findings and DDSN program staff for the specific service area will review all available documentation in order to make a determination. Providers will be notified of the Appeal decision within 30 days.
- Once a determination has been made by DDSN regarding my appeal, is there another reconsideration process if I am not in agreement with DDSN’s determination?
The Appeal decision is determined by DDSN Program Staff working in the specific service area. These staff are likely the same staff that are responsible for the development and monitoring of the service standards and/or the applicable directives and in the best position to determine if the requirements for the standard/directive was, in fact, met. The decision is final. The DDSN Appeal process does not provide any process for a secondary review after the appropriate program staff have made a determination on the citation.
Plans of Correction-Contract Compliance Reviews
- Do I have to provide a Plan of Correction for each citation? Yes.
A Plan of Correction will be required for each citation. The action plan should address both the individual citation and systemic corrections.
- What is the time frame to submit a Plan of Correction?
A Plan of Correction will be due within 30 days of the provider’s receipt of the Report of Findings for Contract Compliance Reviews. The due date is noted on the Report of Findings and on the Plan of Correction format on the QIO portal.
- What if my Plan of Correction is late? Will it affect the follow-up review?
Providers will be notified if their Plan of Correction is not submitted by the due date. Failure to submit a timely Plan of Correction will not affect the follow-up review.
- When can I anticipate a follow-up review?
The purpose of the follow-up review is to ensure remediation of the citation. Typically, this is after the Plan of Correction has been submitted and the targeted action plans have been implemented. Most Follow-up Reviews occur four (4) to six (6) months after the prior review date.
- Will I receive notification of my follow-up review?
Providers will receive notice on the date their follow-up review begins. Since the follow-up is specifically targeted towards the prior citations, the follow-up review is limited in scope and size. Most follow-up reviews are desk reviews and the providers may upload documentation of their remediation as it happens. For additional samples or other information needed, the QIO will give the provider 24 hours’ notice to upload the documentation.
- What will the QIO review during my follow-up review?
The QIO will look for documentation that verifies any citations from the prior review were corrected and that the provider took steps to prevent similar citations in the future.
A follow-up review is limited in size and scope. The only indicators reviewed are those with prior citations. An equal number of new records will also be reviewed to ensure systemic remediation.
- Will the QIO come on-site for a follow-up review or will they be limited to desk reviews?
Most follow-up reviews will be completed as desk reviews. On-site follow-up reviews may be coordinated with the QIO on a case-by-case basis.
- What happens if I continue to have the same citations after my follow-up review?
If the citations are not resolved during the follow-up visit, the provider will complete another Plan of Correction and then be scheduled for a second follow-up visit. In addition, the provider may receive technical assistance from the District Office to assist with the remediation.
Recoupment-Contract Compliance Reviews
- Will my organization automatically be charged for any recoupable indicators found out of compliance?
Before the provider is charged back for any paid claims, DDSN Waiver Coordinators and Finance staff review the citation to ensure the claims reversal is warranted. There may be citations that do not result in recoupment.
DDSN Finance staff also verify the services billed through Medicaid fall within the dates the noted indicator is cited for non-compliance. Upon completion of a secondary review, the provider is notified of any reversal of claims for delivered services. DHHS will recoup the amount of the services billed by DDSN. DDSN will then seek payment from the provider of services billed while the indicator was out of compliance.