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2017 Audit Guidance: Preparation, Experiences, and Lessons LearnedNPA Quality Symposium
Friday, June 9th
Objectives
Discuss preparing for the audit
Review and discuss the work of the Audit Task Force Record Layout (Universe) templates
Risk Assessments
Operational Guide
Discuss the tracer methodology and how it applies to the CMS audit
Discuss two audit experiences
2
CMS PACE Conference July 8, 2016
Goal in restructuring PACE audit: Make PACE audits more outcomes-based
Focus on access and the participant experience
Reduce the administrative burden of PACE organizations
Drive improvements in the quality of care for participants
3
Outcome Focused Audits
Measuring a clinical outcome against well-defined standards set on the principles of evidence-based medicine in order to identify the changes needed to improve the quality of care.
Purpose is to highlight the discrepancies between actual practice and standard in order to identify the changes needed to improve the quality of care.
Determine Audit Focus
Set Criteria and Standards
Data CollectionData Analysis and Implementation
of Changes
Improvements –Monitor and Maintenance
4
Audit Elements
Audit Elements (with Naming Conventions)
Service Delivery Requests, Appeals and Grievances (SDAG) Did the PO appropriately process service delivery requests, appeals and
grievances?
Clinical Appropriateness and Care Planning (CPAP) Did the PO develop and document an appropriate plan of care for the
participants?
Personnel Records (PER) Do personnel have appropriate licensure, were OIG exclusions checks
performed, were background checks completed, evidence of competency evaluation, health records.
Onsite Review (ON) Observe 3 to 5 participants (1 who receives care from home and one who
receives care at the center), transportation vehicle and emergency equipment.
Quality Assessment (QA) Did the PO develop and/ or implement an effective, data driven quality
assessment and performance improvement program? Did the PO ensure that the appropriate staff were involved in the
development and implementation of QAPI activities?
5The PACE Audit Process and Data Request Document and all Attachments can be found: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/PACE_Audits.html
Pre-Audit Document Submissions
Pre-Audit Disclosed Issues of Non-Compliance PO to provide a list of all disclosed issues of non-compliance that are
relevant to the audit elements.
Use Excel template (Pre-Audit Issue Summary) provided by CMS
Attachment III included with Audit Process and Data Request protocol sent 4/11/2017
Disclosed issue: one that is disclosed to CMS prior to the receipt of the audit engagement letter.
6
Pre-Audit Document Submissions
Pre-Audit Universe uploads to HPMS
Requires specific naming conventions of documents as specified in Appendix N (sent to PO through HPMS after audit engagement letter)
SDAG (Service Delivery Requests, Appeal, and Grievance)1. [PO Name]-[SDAG]-[SDR]--[Universe]-[Version Number]
(e.g. OnLok-SDAG-SDR—Universe-Version 1)
2. [PO Name]-[SDAG]-[AR]-[Universe]-[Version Number]
3. [PO Name]-[SDAG]-[GR]-[Universe]-[Version Number]
CPAP (Clinical Appropriateness and Care Planning)1. [PO Name]-[CPAP]-[LOPMR]-[Universe]-[Version Number]
2. [PO Name]-[CPAP]-[OCU]-[Universe]-[Version Number]
PER (Personnel Records)1. [PO Name]-[PER]-[LOP]-[Universe]-[Version Number]
ON (Onsite Element) No universes will be submitted for this element. Participants will be selected from the CACP list
of participants.
QA (Quality Assessment)1. [PO Name]-[QA]-[QAIR]-[Universe]-[Version Number]
7
Pre-Audit Document Submissions
Pre-Audit Universe Questions Grid Upload to HPMS
Use Excel template provided by CMS (PO Questions for CMS)
Appendix V sent to PO through HPMS after audit engagement letter
Naming convention required [PO Name]-[Questions for
CMS]-[Date]
(e.g. OnLok-Questions for CMS-04112017.xlsx)
Question # Element
Universe/Table/
Record Layout
(ifapplicable)
PACE
Organization (PO)
Questions
CMS'
Response
1
2
8
Pre-Audit Document Submissions
PACE Supplemental Questions Attachment II provided with Audit Process and Data Request
protocol sent 4/11/2017
Grievance information
Emergency medications readily available
Emergency and disaster preparedness training
Staff vaccinations
Driver communication
EMR information (access remotely?)
Service delivery request definition and policy
9
Responding to Documentation Requests
During the Audit
Sample Case Supporting Documentation Uploads to HPMS PO must upload all sample case supporting documentation
requested during the audit to HPMS by selecting:
Naming conventions and instructions detailed in Appendix N
10
Audit Findings and Corrective Action
CMS will determine if each condition cited is: An Observation – 0 points
Corrective Action Required (CAR) – 1 point
Immediate Corrective Action Required (ICAR) – 2 points
All points related to CARs and ICARs will be added then divided by the number of audit elements (5 audit elements) tested to determine the PO’s overall PACE audit score.
11
Development of the NPA Audit Materials
Began with an initiative involving MI PACE programs.
Through the NPA Regulatory Compliance Quality Subcommittee, an Audit Task Force was developed with participants from each of the CMS regions.
Purpose of developing the audit materials: Assist POs in collecting and submitting data universes required for
revised CMS audits beginning 2017;
Support POs’ compliance efforts and ability to identify compliance issues in real time and in advance of audits;
Support POs’ efforts in identifying opportunities for system improvements resulting from analyses of the data universes;
Identify where the data universe elements overlap with HPMS PACE Quality Data Level I reporting requirement;
Assist EHR vendors to understand the audit process and related data requirements; and
Support CMS’ efforts to assure consistency in audit practices.
NPA Operational Guide should be used concurrently with CMS's Programs of All-Inclusive Care for the Elderly (PACE) Audit Process and Data Request document issued April 11, 2017
Although CMS has responded to specific questions related to the templates for the audit data universes, the templates, risk assessment tools and the operational guide referenced in this presentation have not been reviewed or approved by CMS. NPA disclaims all liability with respect to these materials. Members use them at their discretion.
Audit Data Universe Record Layout Templates
The 7 data universes are related to the 5 audit elements:1. Service Delivery Requests, Appeals and Grievances;
2. Clinical Appropriateness and Care Planning;
3. Quality Assessment;
4. Personnel Records; and
5. Onsite Review
7 record layouts to be used in providing the data universes to CMS:1. Service Delivery Requests (SDR);
2. Appeal Requests (AR);
3. Grievance Requests (GR);
4. List of Personnel (LOP);
5. List of Participant Medical Records (LOPMR);
6. Quality Assessment Initiatives Records (QAIR); and
7. On-call Universe (OCU)
13The NPA Record Layouts, Risk Assessment, Opertaional Guide, and recent recorded webinar may be found: http://www.npaonline.org/member-resources/compliance
Audit Data Universe Record Layout Templates
The 7 record layout templates have the following features: For ease of use, the templates include the description of each data
element and the number of characters allowed within each field.
Additional reference information for POs’ consideration (e.g. definitions for subjective data, list of dementia diagnoses that correspond with HCC51 and HCC52, etc.).
Dropdown responses for many data fields to facilitate data entry.
The Service Delivery Requests, Appeal Requests, and Grievance Requests templates include an “analytics” function that identifies potential compliance problems.
The Appeal and Grievance Requests templates include HPMS PACE Quality Data Level I to avoid maintaining similar data in multiple places.
Data integrity functions provided by CMS to ensure the data entered are consistent with CMS specifications.
Password: 2017Audit
14
Risk Assessment Tools
To assure ongoing compliance with critical PACE regulatory requirements and to assist POs in assessing their compliance in the 5 audit areas, the following 5 Risk Assessment tools were created:
Service Delivery Requests Risk Assessment
Appeal Requests Risk Assessment
Grievance Requests Risk Assessment
Clinical Appropriateness and Care Planning Risk Assessment
Personnel Records Risk Assessment
15
Risk Assessment Tools
Each Risk Assessment exists within an Excel workbook consisting of an “Audit Totals” worksheet and 20 numbered spreadsheets.
Each of the 20 numbered spreadsheets refers to an individual audit observation (i.e. a service delivery request, an appeal, a grievance, a participant medical record, or a personnel record).
After completing a workbook for a probe sample of 20 observations (random or targeted), the “Audit Totals” worksheet will help to identify areas of overall compliance/noncompliance.
Each risk assessment tool contains a set of compliance standards with a corresponding reference to the applicable PACE regulation.
Each audit observation requires a scoring mechanism and provides a space to make comments specific to noncompliance observed.
16
Impact Analysis
Impact Analysis: identifies who was subjected to and in what ways an issue of non-compliance effected the outcome (i.e. identifying the consequences of non-compliance).
15 CMS templates provided with Audit Process and Data Request protocol sent 4/11/2017
Appeal template
Grievance template
Personnel template
Root cause template
Service delivery template
10 Clinical appropriateness templates
PO must upload all IAs requested during the audit through HPMS
Naming conventions and instructions provided in Appendix N (sent to PO through HPMS after audit engagement letter)
17
Tracer Methodology
Tracer methodology uses organizational information to follow the experience of care, treatment, or services.
Allows for the identification of performance issues in one or more steps of a process or interfaces between processes.
Individual Tracers (participant focused) Designed to trace the care experience of a participant in the PACE
program.
Analyzes the PO’s system of providing care, treatment or services using actual participants to assess compliance to standards.
Participants selected are typically high risk or medically complex
System Tracers (process focused) Trace a process or system within the PO (use individual tracer
information).
Evaluates the system or process, integration of processes, coordination and communication among disciplines and departments within the system/process.
Relies upon the use of quality data in performance improvement.
18
Tracer Methodology
Involves talking with multiple staff, the participant, and caregivers to learn details about the individual experience.
Identify gaps or risk points that could affect quality or safety of care.
Learn from individuals directly involved in providing or receiving services about how the process actually works.
Evaluate the following: Compliance with standards and evidence based principles.
Consistent adherence to policy and implementation of procedures.
Communication within and between departments, disciplines, and services/providers.
Staff competency for assignments and workload capacity.
The physical environment.
19
Purpose of Tracers
Retrospective Learn more about why a process didn’t work or was successful.
Prospective Evaluate a process identified as problematic, determine current
practice around new regulatory standards, evaluate high risk participants or processes with poor outcomes.
20
How to Apply a Tracer
What would you like to know more about in your program?
What worries you?
What keeps you awake at night?
What does your data show as potentially problematic? Clinical outcomes
Grievances
PAC feedback
Contracted provider feedback
21
Planning Tracers
Assemble the team – determine who should be on the team related to skills, experience, expertise, etc.
Assure objectivity.
Identify a team leader to manage the process.
Provide the necessary guidance and training for tracer team.
Communicate with leadership and personnel.
Determine the goal of the tracer: Is it driven by a level II or significant event?
Confirm practices of key policies and systems?
Identify key practices that increase the success or effectiveness of a process?
Preparing for strategic program growth or development?
Evaluating outcome of recent performance improvement efforts?
22
Performing the Tracer
Identify the pool of applicable participants and select participants for tracer
Random or targeted selection
Trace processes of care not clinical appropriateness
Review applicable policies and procedures
Review applicable standards, regulations, evidence based practices, etc.
Create tracer tool to ensure interrater reliability and standard application of observations and interviews –similar to the audit risk assessments.
Provides a means of documenting the process.
23
Creating a Tracer Tool
Participant Name
Date grievance was made
Date grievance was resolved
Universe Compliance Standard
Grievance RequestsA PO must determine the timeframe for resolving grievances in their internal policies and procedures. §460.120
Scoring Key 0 = Noncompliant 1 = Partial Compliance 2 = Full Compliance Blank = Not Applicable
Score Comments (Required for any score of 1 or0):Possible Actual
A §460.120(b) Upon enrollment, was the participant given written information regarding the grievance process? 0
B §460.120(b)Was the participant given written information regarding the grievance process annually after enrollment? 0
C§460.120(c)(
3)
Is there documentation showing that the grievance was resolved timely and consistent with the program's policy? (If the response is "2", skip question D. 0
D N/A If no, was the root cause determined and addressed? 0
E§460.120(c)(
2)Is the participant's grievance documented and does documentation show that all issues were addressed? 0
F §460.120(e) Is there documentation showing that the participant was notified of the grievance outcome? 0
G §460.120(d) Is there documentation showing that the program continued to furnish all required services to the participant during the grievance process? 0
Total 0 0
24
Performing the Tracer
Interview staff involved in the process you are tracing Maintain an open tone
Listen attentively
Restate and clarify responses
Ask open ended questions
Interview staff directly involved in the process – not the manager
All interview questions and responses should be documented
All interviewees should be asked the same questions
Interview applicable participants
Review medical records
Debrief as a tracer team and review findings
Organize and analyze and summarize findings
Communicate findings to leadership and staff
Develop and implement improvement plans
25
Questions Questions before we transition to the discussion of audit experience and lessons?
26