On page 3, #3, the guidance reads "As DBHDS requires statewide performance measures, it will provide information to providers."  Providers request that they be allowed to review draft statewide performance measures and to post public comments about them before they are finalized and implemented.  Providers also request that they be allowed to share information with DBHDS about estimated costs of collecting and sharing performance measure data, before this requirement is finalized and implemented.

Public comment on statewide performance measures should be included if providers are required to report on them. 

The cost of creating, implementing, and reviewing data collection systems to meet this requirement must be taken into consideration.  Low reimbursement rates for waiver services are already creating a staffing crisis, additional administrative costs only add to this critical shortage by absorbing funds that could go towards increasing DSP wages and benefits.

General Overview Comment:

The DBHDS Guidance Document addressing the Quality Improvement Program appears to be written in a manner that is geared towards smaller organizations and focuses more heavily on the program level. The semantics utilized in this guidance would benefit from a greater level of flexibility.

12VAC35-105-620. Monitoring and evaluating service quality.

A. The provider shall develop and implement written policies and procedures for a quality

improvement program sufficient to identify, monitor, and evaluate clinical and service

quality and effectiveness on a systematic and ongoing basis.

Guidance:

A quality improvement (QI) program is the structure used to implement quality improvement

efforts. The structure of the program shall be documented in the provider’s policies.

[Note: If you are a provider of group home, sponsored residential, supervised living

residential, or day support services offered in the Developmental Disability (DD) waivers,

and your agency is currently engaged in efforts to come into compliance with the Home and

Community Based Services (HCBS) settings requirements (42 CFR § 441.301), consider

including those efforts into your QI program.]

When developing a quality improvement program, providers may consider resources and

tools available on the department’s Office of Community Quality Management page.

Comment:

This section of the guidance document that focuses on the quality improvement plan structure impacts agencies specifically by being DBHDS Licensure focused and program based rather than being broader focused on the overall quality improvement of the agency. This component would be more beneficial if it was edited in a manner that made it more scalable and applicable agency wide.

C. The quality improvement plan shall:

1. Be reviewed and updated at least annually;

Guidance:

There is no specific template required for creating a quality improvement plan;

however, staff responsible for implementation of the quality improvement plan must

review and update the plan at least annually (every 365 days).

o If needed, the provider must also update the plan more frequently based on

defined goals and the occurrence of relevant events, such as the issuance of

a corrective action plan (CAP). As providers experience changes in systems

or programs, the quality improvement plan should be reviewed to ensure that

it continues to be relevant.

o Annual and other reviews of the quality improvement plan should include

evaluation of the components of the program, efficacy of the plan, and

whether any updates are needed to accomplish the plan’s goals.

o The quality improvement plan should be dated and signed to indicate when

it is implemented and when any updates occur.

Comments:

The guidance document is requiring that the agency edit the Quality Improve Plan each time a CAP is received as a way to revise the Quality Improvement Plan. This expectation is not realistic due to the frequency that CAPs are received from DBHDS. An effective alternative would be to sign the Quality Improvement Plan Annually with all effective edits.

3. Include and report on statewide performance measures, if applicable, as required by

DBHDS;

Guidance:

As DBHDS requires statewide performance measures, it will provide information to

providers.

Comments:

The state performance measures needs to have clearer information a regarding the timeframes related to when communications from DBHDS will occur, What DBHDS representative will be updating the agency and the amount of time to make and enact the changes.

4. Monitor implementation and effectiveness of approved corrective action plans pursuant

to 12VAC35-105-170; and

Guidance:

The provider should identify any systematic actions that may be taken to address

deficiencies identified by citations or CAPs and incorporate these into their quality

improvement program.

This may include establishing measurable objectives that are related to the corrective

actions and evaluating the degree to which these objectives have been achieved.

o For example, if a provider was cited for errors in medication administration, they

may develop a CAP to reduce errors, and then establish a specific objective for X

number of errors in the next quarter. This could be measured through chart

review and reported as part of the quality improvement program

Comments:

The definition of systemic needs to be specific to each agency based on variable that include but are not limited to the size of the agency and number of programs. This may be opportunity to allow for the agency to establish what systemic as defined within their policies and regulations.

D. The provider’s policies and procedures shall include the criteria the provider will use to:

1. Establish measurable goals and objectives;

2. Update the provider’s quality improvement plan; and

3. Submit revised corrective action plans to the department for approval or continue

implementing the corrective action plan and put into place additional measures to

prevent the recurrence of the cited violation and address identified systemic

deficiencies when reviews determine that a corrective action was fully implemented but

did not prevent the recurrence of the cited regulatory violation or correct a systemic

deficiency pursuant to 12VAC35-105-170.

Guidance:

Provider policies and procedures must include the processes by which the provider will

develop, implement, and update its quality improvement plan, and thereby demonstrate an

ongoing, constant process.

The provider’s policies and procedures must address the steps that the provider will take

when the provider determines that an approved CAP was fully implemented, but did not

resolve the underlying issue (e.g., even though the CAP was fully implemented, the

regulatory violation that the CAP was adopted to prevent still recurred, or an underlying

systemic deficiency was not resolved). In this scenario, the provider may:

o Continue to implement the CAP, but adopt additional corrective measures and

incorporate those additional measures into the quality improvement plan, or

o If the provider wishes to revise the CAP, the provider must submit a revised CAP to

the department for approval.

For additional information related to 12VAC35-105-620.D.2. and 12VAC35-105-170 please

see the DBHDS Office of Licensing’s Guidance on Corrective Action Plans (CAPs).

Comments:

The requirement for monitoring and adding CAPs to the Quality Improvement Plan is a burden to agencies due to the resource requirements and inhibits the ability to focus on additional areas of quality improvement within the agency. Additionally, adding certain CAPs may not be appropriate for the Quality Improvement Plan.

E. Input from individuals receiving services and their authorized representatives, if applicable,

about services used and satisfaction level of participation in the direction of service planning

shall be part of the provider’s quality improvement plan. The provider shall implement

improvements, when indicated.

Guidance:

Provider quality improvement programs must incorporate input from individuals and their

authorized representatives, when applicable, including input related to the level of

satisfaction with the level of participation for individuals related to service planning; and,

when improvements are indicated based on this input, such improvements shall be

implemented.

Comments:

The DBHDS Guidance is requiring that input from individuals and/or authorized representatives, if applicable. The statement “As Applicable” or When Applicable” needs to be clearly defined in section of the guidance documents.

General Comment:

Final Regulations are effective 8/1/20 and will begin to be enforced 11/1/20. However, adequate training has not been provided to assist providers with becoming compliant with these regulations. It is reasonable to expect that training would be provided in a timely manner to support providers in gaining proficiency, allow for development of a meaningful QI program plan, training staff, etc. well before the enforcement date of regulations and certainly at a minimum prior to the regulations becoming effective.   

Hope House Foundation agrees with Andie Plumley's comment:

Public comment on statewide performance measures should be included if providers are required to report on them. 

Regarding the guidance regarding C.1. be reviewed and updated annually. The guidance section states that it should update the QI plan based on the issuance of CAPs.  Due to the significant number of corrective action citations now being issued this may become an onerous activity of constant revision, especially for large organization that are providing a wide range of services.  The department should clearly indicate that having a goal that states that the agency will implement CAPs, monitor their success, and if not successful identify different strategies without re-writing the QI plan is sufficient for meeting this expectation.

RE: Item 3 Include and report on statewide performance measures.  I believe that most organizations are attempting to do this outside of the QI plan.  It would be a more meaningful activity for agencies if there was a way to clearly see how the state is calculating measures so we could duplicate their results.  This would give us clarity as to what the issues are and give us greater opportunity to improve our results.