KMAP BULLETIN: UPDATED - HCBS Quality Assurance Policy

Date: 09/19/24

Effective August 1, 2024, Home and Community-Based Services (HCBS) Quality Assurance (QA) Policy provides quality assurance oversight for Medicaid 1915(c) HCBS in the State of Kansas. This policy serves as a basis for the State’s QA Unit’s review of the HCBS Waiver Programs based on HCBS Performance Measures, Program Policies, and Waiver Requirements per waiver type.

Quality Reviews:

The Kansas Department for Aging and Disability Services (KDADS) shall conduct quality reviews on Level of Care (LOC) assessments and Managed Care Organization (MCO) records for participants receiving HCBS Programs to determine:

· KanCare Quality Performance Measure Outcomes

o The Performance Measures are included in all current/approved HCBS waivers.

· KDADS HCBS Waiver Program Requirement Outcomes

o May include, but are not limited to, State Plan requirements and HCBS waiver requirements.

UPDATED Septemter 19, 2024: As a condition of Centers for Medicaid and Medicare Services (CMS) waiver approval of each HCBS waiver program, the State of Kansas shall have and comply with defined and approved QA policies and procedures contained in this policy.

The following sub-assurances of the State’s HCBS waiver shall have defined and approved QA requirements:
- Administrative Authority.
- Evaluation/Reevaluation Level of Care.
- Qualified Providers;
- Service Plan;
- Health and Welfare; and
- Financial Accountability
KDADS shall conduct QA checks through staff designated as Quality Management Specialists (QMS).
- KDADS may conduct QA checks through, but not limited to, any of the following methods and data sources:
- LOC Assessor file reviews
- MCO file reviews
- Participant’s survey feedback
- Provider’s Credentialing, Training, and Background Checks
- Data found in the following systems:
  - Kansas Aging Management Information System (KAMIS)
  - Kansas Modular Medicaid System (KMMS)
  - Medicaid Management Information System (MMIS)
  - Quality Review Tracker (QRT)
  - Kansas Adverse Incident Reporting and Management System (AIRS)

Quality Assurance Procedures:

A. KDADS Financial and Information Services Commission (FISC) will select and assign a representative sample of HCBS waiver participants' case files to the Quality Management System (QMS) Unit for quarterly review.

B. Documentation Required.

1. Documentation required for each waiver can be found in the Documentation section of this bulletin.

C. Authorized Signature

1. Signatures must be original handwritten, including digital signatures, and dated by the recipient and/or their representative.

a) A signature on file and/or a signature that converts to a “typed” signature is unacceptable.

b) If a recipient has a legal guardian, representative, or activated durable power of attorney (DPOA), the legal guardian or DPOA must sign all required document(s).

i. In the event of representation through a DPOA, supporting documentation showing DPOA activation is required.

ii. If an electronic signature is used, it must comply with the Kansas Department of Health and Environment (KDHE) Kansas Medical Assistance Program (KMAP) Provider Bulletin Number 782: Electronic Documentation. This policy must be documented to the KDADS HCBS Director, Policy Program Oversight Manager, and QA Manager.

2. In the event a participant is unable to manually/hand sign their own name due to physical or other limitations, one or more of the following methods may be utilized:

a) The use of a distinct mark representing the participant’s signature;

b) The use of the participant’s signature stamp and/or;

c) The use of an identified designated signatory.

3. If a participant utilizes any of the three options in Quality Assurance Procedures C.2 listed above, documentation supporting the method selected must be uploaded with the QA review.

4. Each “authorized signature” must be dated.

D. Procedure for conducting quality reviews shall be as follows:

1. File Reviews:

a) KDADS shall review documentation uploaded in the Quality Review Tracker (QRT) by the MCOs and/or assessing entities using the established KDADs protocols.

i. KDADS QMS shall record findings from file reviews in the QRT for the MCO’s/assessor’s remediation.

E. Record Submission

1. MCO files are to be uploaded to the QRT database.

2. LOC assessing entity must upload documents for all HCBS waivers.

a) LOC Assessment documentation for all HCBS waivers, unless an exception is granted for a specific waiver, may be found in the Kansas Assessment Management Information Systems (KAMIS) or QRT.

3. Case file documentation must be:

a) Properly labeled with document name and the completion date (month and year); and

b) Documentation must be legible.

4. At the beginning of each upload period, KDADS will send out specific information regarding documentation that must be uploaded for the audit.

5. When documentation is uploaded to QRT, the MCO/assessing entity must mark the upload as “complete.”

6. Documentation uploaded after the deadline will not be considered for the quality review.

F. Deadline for Record Submission

1. Case files for review shall be listed in the QRT for the review period.

a) KDADS QA Manager shall notify the MCOs and assessing entity of the required upload.

b) MCOs and the assessing entity shall have 15 calendar days from upload notification to upload the required documentation.

G. An example of the timeline for a Quality Review is outlined in the following chart:

Review Period (look back period)	*Samples Pulled Posted to QRT**	Notification to MCO/Assessing Entity Samples Posted	*MCO/Assessing Entity Upload Period (15 days)**	*Review of Data (60 days)**
01/01 – 03/31	04/01 – 04/15	04/16	04/16 – 04/30	05/01 – 07/01
04/01 – 06/30	07/01 – 07/15	07/16	07/16 – 07/31	08/01 – 10/01
07/01 – 09/30	10/01 – 10/15	10/16	10/16 – 10/31	11/01 – 01/01
10/01 – 12/31	01/01 – 01/15	01/16	01/16 – 01/31	02/01 – 04/01

H. Findings and Remediation

1. Protocol Scoring Options:

a) “Compliant” documentation is provided and meets compliance requirements.

b) “Non-compliant” documentation was not provided or was not correct or complete.

i. Missing Document (Document/documentation not provided for review);

ii. No Valid Signature and/or Date (“Valid signature” means by the individual and/or representative/guardian or Care Coordinator/Case Manager. Must have both signature and date);

iii. Incomplete (Form was not completed in its entirety);

iv. Inaccurate (Scoring or eligibility is not correct, or services listed are not being received as outlined in the PCSP, or the process for developing a PCSP was not followed); or

v. Timeline not met.

c) “N/A” when not applicable to the protocol question.

2. Findings from file reviews will be recorded in QRT.

I. Remediation and Response Process

1. KDADS FISC shall generate and provide reports regarding findings to HCBS Program Managers for review and remediation as necessary.

2. Centers for Medicare and Medicaid Services (CMS) requires states to submit remediation language and a Quality Improvement Plan for any HCBS Performance Measure when the statewide average for a waiver is less than 86%. Therefore, KDADS shall complete data analysis to ensure that each quality assurance or sub- assurance of less than 86% is remediated. Further, CMS also requires the state to remediate any “non-compliant internally” (less than 100%) for a performance measure even though it may not be below the 86% threshold requiring the data analysis:

a) KDADS shall notify the MCO and assessing entity of quality assurance or sub-assurance below 86% with details of each finding.

b) KDADS shall notify the provider of each non- compliance with a performance measure.

c) Upon notification of the remediation requirement for quality assurance sub-assurance, or performance measures, providers must respond within 10 business days with a detailed plan for correction/remediation strategies and a timeline for completion.

d) KDADS staff shall review the received remediation plan for approval. If a remediation plan is not approved, KDADS shall notify the provider and request that acceptable remediation be resubmitted.

e) Once a remediation plan is approved with a timeline for compliance, KDADS will monitor for compliance.

3. KDADS shall immediately forward/report Abuse, Neglect, or Exploitation (ANE) issues to the designated state reporting agency.

4. KDADS FISC shall generate and provide reports regarding findings to HCBS Program Managers for review and remediation as necessary.

5. If QMS finds issues or concerns on a specific case during a review:

a) The issues or concerns shall be entered in QRT.

b) The QRT system will send an alert to the HCBS Program Manager for the Program Manager’s review. Issues that may cause an alert to the HCBS Program Manager include, but are not limited to, the following:

i. The participant being served could not be located or no longer resides at the address provided in the case record;

ii. Case should be reviewed for potential closure;

iii. Assessment is not current;

iv. Participant being served stated they would like their Care Coordinator to contact them;

v. There is a protective service concern;

vi. Spouse cannot serve as a Personal Care Service Worker or in any other paid capacity without a “Spousal Exception;”

vii. Activated DPOAs/legal guardians are not allowed to provide any direct services without court documentation approving them to do so;

viii. The assessor is not on the qualified assessor list.

J. Quality reviews of credentialing; background checks; provider’s training:

1. Refer to policies posted on the KDADS website at HCBS Policies.

2. Credentials such as provider specifications applicable to each HCBS waiver, background checks, and training are to be provided per the direction of KDADS.

3. Provider qualification audit review process per the direction of KDADS and waiver standards.

Documentation:

A. Forms

1. All forms and templates will be sent to the appropriate assessing entity or MCO at the beginning of the upload period via secure email. Specific required documentation for the audit will be listed in the following documents:

a) HCBS LOC review: Required documentation for QA Reviews (Frail Elderly (FE), Physical Disability (PD), Brain Injury (BI));

b) HCBS LOC Review: Required Documentation for QA Reviews (Autism (AU));

c) HCBS LOC Review: Required Documentation for QA Reviews (Intellectual/Developmental Disability (IDD));

d) HCBS LOC Review: Required Documentation for QA Reviews (Technology Assisted (TA));

e) HCBS LOC Review: Required Documentation for QA Reviews (Severe Emotional Disability (SED));

f) HCBS MCO Record Review: Required Documentation for QA Reviews (Except SED);

g) HCBS MCO LOC and Record Review: Required Documentation for SED QA Reviews;

h) QMS' official case review record and findings are in QRT.

2. Required documentation is subject to change and will be updated on the specific record review document sent out via email at the beginning of every upload period.

3. For the required documentation, assessing entities/MCOs must provide all current and prior documentation that demonstrates compliance with CFR Regulations, performance measures, applicable policies, and program mandates for every day of the review period.

B. LOC Performance Measure Documentation

1. The LOC assessing entity is responsible for providing appropriate documentation for this section of the audit review.

2. Requests for LOC documentation may include, but is not limited to:

a) Specific waiver eligibility assessment, applicable re-assessments, and any medical documentation if required for eligibility;

b) Initial Intake/Referral Form;

c) 3160 approval/Functional Eligibility Assessment request from the specific waiver program manager – if coming off a waitlist or is a crisis/exception, when the initial assessment has expired and will need a new assessment to be eligible for the waiver.

C. Service Plan and Health and Welfare Performance Measure Documentation

1. The MCOs are responsible for providing the appropriate documentation for this section of the audit review.

2. Requests for Service Plan and Health and Welfare Documentation may include, but are not limited to:

a) 3160 and 3161 – include the initial notification from the eligibility worker of a new member;

b) Person-Centered Service Plan (PCSP) for current and prior PCSP to determine timeliness. The following is considered part of the individual’s PCSP and is subject to review:

i. Documentation of participant choice, as directed by the waiver;

ii. Physical, Functional, and Behavioral Assessment;

iii. Back up plan;

iv. Evidence of information provided on reporting suspected abuse, neglect, and exploitation; and

v. Goals

c) Physician/Registered Nurse (RN) Statement (if applicable);

d) Legal representative, DPOA, and/or guardianship paperwork

e) Physical exam;

f) Evidence of rights and responsibilities discussed with participant and/or representative/guardian;

g) Evidence of appeal and grievance rights/processes discussed with participant and/or representative/guardian;

h) Notice of Actions (for any updates or changes in Service Plans, including annual reviews and/or adverse actions);

i) Log or case notes (inclusive of verification of services being received in the type, scope, amount, duration, and frequency specified in the Service Plan);

j) BI Waiver only - Progress notes for Transitional Living Skills and/or Therapies.

k) SED Only: Documentation on Critical Incidents/APS/CPS reports regarding restraints, seclusion, or other restrictive interventions and/or anything in the Adverse Incident Reporting (AIR) system.

Note: The effective date of the policy is August 1, 2024. The implementation of State policy by the KanCare MCOs may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates, once the policy is implemented.