DIDD Awarded Chattanooga, TN. Three Star Status
State of Tennessee
Department of Intellectual and Developmental Disabilities
Andrew Jackson building, 15th floor
500 Deaderick street
Nashville, Tennessee 37243
November 21, 2012
Garth Platt, Director
Community Options, Inc.-East
5751 Uptain Road, Suite 407
Chattanooga, TN 37411
Dear Mr. Platt:
For several years, the Department of Intellectual and Developmental Disabilities (DIDD) has worked to establish a comprehensive quality management system which includes numerous mechanisms to measure the quality of services and supports provided by community-based providers. The foundation of the quality management system is a set of outcome-based quality assurance survey tools that were designed with assistance from consultants provided by the Center for Medicare and Medicaid Services (CMS).
In addition to the foundational tools, we have also developed mechanisms for the review and trending of data related to incidents and investigations for each provider, as well as other quality-related data that are available within our system. For example, we review the status, where applicable, of each day and residential provider with the Court Monitor’s Quality Tier system. We also review the status as to resolution of all complaints regarding a provider.
All of this information generates a portrait as relates too the level of performance of each provider.
During the development of the quality management system, DIDD made a commitment to examine the frequency with which we were monitoring providers and attempt to make some adjustments in that frequency, based on provider performance. We have worked to develop specific criteria to utilize in making decisions about the number of monitoring visits by DIDD. A document discussing those criteria is attached for your information.
Based on these criteria, I am pleased to notify you that Community Options, Inc. has been designated a ***Agency for 2013. You, your staff and others associated with the operation of Community Options, Inc. should feel a much deserved sense of accomplishment because of your achievement.
Community Options, Inc. is exempt from the requirement of having a quality assurance survey during 2013. Additional information about the monitoring schedule is included in the criteria document. Please review this closely for a specific understanding of the designation and its implications for your agency in the future.
Congratulations on attaining the *** designation.
Sincerely,
James M. Henry
Commissioner
JMH:pna
Attachment
CC: Debbie Payne, Deputy Commissioner, Program Operations
Thomas Cheetham, Director, Office of Health Services
Jordan Allen, Director of Provider Support
Lee Vestal, Director of Risk Management and Licensure
Pat Nichols, Assistant Commissioner, Office of Quality Management
John Craven, East TN Regional Director
Kenneth D. Guthrie, East TN Regional QA Director
Department of Intellectual and Developmental Disabilities
Monitoring Frequency based on Agency Performance REVISED
All final decisions for reduced monitoring and increased monitoring will be made by the Statewide Quality Management Committee (SQMC), following receipt of recommendations from the Regional Quality Management Committee (RQMC).
The following are criteria for decreasing the number of monitoring visits by the Department of Intellectual and Developmental Disabilities (DIDD) based on agency performance.
1. Minimum requirements for **** Agencies:
- For all service providers and agencies providing support coordination, achievement of a Performance Rating of Exceptional Performance on QA surveys for two consecutive years. For Day, Residential, Personal Assistance and Clinical providers, this includes the requirement for a score of Substantial Compliance in Domains 2, 3, 5 and 9, if applicable. For ISC agencies, this includes the requirement for a score of Substantial Compliance in Domains 1, 2, 3 and 9;
- No preventable egregious events resulting in the death of an individual for one year;
- An annualized substantiated investigation rate of 10 substantiations per 100 persons served (10:100), or less, for one year;
- Quality Tier designation from Court Monitor, if applicable.
2. Monitoring schedule for **** Agencies:
- Every other year full Quality Assurance Survey;
- Additional monitoring, as deemed necessary by the RQMC, during the off survey year with focus on quality improvement planning, including the agency’s Quality Improvement Plan (QIO) and self-assessment;
- Review(s) of other areas(s) of performance, as deemed necessary by the RQMC, such as review of compliance with training requirements, recoupment or sanction issues, et cetera;
- Quality Tier designation from Court Monitor, if applicable;
- For agencies providing day, residential and/or personal assistance, the agency to submit to the Regional Office Protection from Hart Unit an annual trend analysis of incidents and investigations with evidence of proactive efforts for improvement.
3. Minimum requirements for *** Agencies:
- For all service providers and support coordination agencies, achievement of a performance rating of Proficient on QA surveys for two consecutive years. For Day, Residential, Personal Assistance and Clinical providers, this includes the requirement for a score of Substantial Compliance for Domain 3 and at least Partial Compliance for all other applicable domains. For ISC agencies, this includes the requirement for a score of Substantial Compliance in Domains 2 and 3 and a score of at least Partial Compliance in all other applicable domains;
- No preventable egregious events resulting in the death of an individual for one year;
- An annualized substantiated investigation rate of 10 substantiations per 100 persons served (10:100), or less, for one year;
- Quality Tier designation from Court Monitor, if applicable.
4. Monitoring schedule for *** Agencies:
- Every other year full Quality Assurance Survey;
- Individual Record Reviews, as may be applicable, as determined by a statewide random sample, to assess waiver compliance with established performance measures;
- Additional monitoring, as deemed necessary by the RQMC, during the off survey year with focus on quality improvement planning, including the agency’s QIP and self-assessment;
- Review(s) of other area(s) of performance, as deemed necessary by the RQMC, such as review of compliance with training requirements, recoupment or sanction issues, et cetera;
- Quality Tier designation from Court Monitor, if applicable;
- For agencies providing day, residential and/or personal assistance, the agency to submit to the Regional Office Protection from Harm Unit annual trend analysis of incidents and investigations with evidence of proactive efforts for improvement.
5. In the event that there is evidence that the performance level of a **** Agency or *** Agency may have decreased, the RQMC will examine the need to increase monitoring activity, utilizing appropriate methodology as available to the Regional Office. Indicators for consideration of increased monitoring include:
- Pattern of egregious or immediate jeopardy events;
- Increase in agency investigation substantiation rate or indicators of under-reporting of incidents;
- Other performance issues as identified by the RQMC.
6. The specific increased monitoring schedule will be determined by the RQMC.