CMS Waiver Assurances
Through the dynamic QMP, New York State will be able to continuously ensure the waiver assurances and other federal requirements are met.
This section explains the waiver assurances required by CMS and the NHTD activities related to Discovery, Remediation and Improvement, including performance measures and the entity(s) responsible for each activity.
A. Level of Care (LOC) - Nursing Home Eligibility
1. Waiver applicants for whom there is reasonable indication that waiver services may be needed in the future are provided an individual LOC evaluation.
- The RRDS is responsible for assuring individuals are informed about the waiver application process including the need for a LOC evaluation, using the PRI and SCREEN.
- As part of the application process, the SC assures a current PRI and SCREEN has been completed and that the individual meets the LOC requirement.
- The SC submits the Application Packet, including the PRI and SCREEN, to the RRDS who reviews 100% of all applications received to assure compliance with waiver eligibility criteria, including LOC.
- If the finding of a LOC evaluation poses any concerns or questions for the RRDS, the NE reviews the PRI and SCREEN and/or completes a new PRI and SCREEN for LOC determination.
- If the individual does not meet the nursing home level of care criteria, the RRDS assures that the individual is referred to other community resources and tracks all referrals.
- The QMS monitors for regional trends and suggests any additional training to the RRDS regarding the LOC process and waiver eligibility.
- During an annual random retrospective record review of at least five-percent (5%) in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three, QMS and DOH WMS evaluate the LOC evaluations.
- The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS evaluates the need to change and/or improve policies/procedures.
2. The LOC of enrolled participants are reevaluated at least annuallyor as specified in the approved waiver.
- Waiver participants are reevaluated at least annually for LOC through completion of the PRI and SCREEN. This is done from the anniversary date of the last LOC determination. The RRDS reviews 100% of all Revised Service Plans (RSP) (refer to Appendix C – form C.13) to assure ongoing compliance with waiver standards regarding LOC determinations.
- The SC creates and maintains a tracking system to assure timely LOC reevaluations.
- At a minimum of every six months, with the waiver participant present, the SC conducts a Team Meeting to review the SP for revision. If the team has concerns about the LOC, a new LOC evaluation must be completed.
- During review of an RSP, the RRDS informs the Service Coordinator if an updated PRI and SCREEN is needed or if the PRI and SCREEN indicate an inappropriate LOC. The RRDS maintains a system to track all LOC reevaluations to assure timeliness of submission.
- The NE who must be a certified assessor completes an updated PRI and SCREEN for LOC determination if the validity of the PRI and SCREEN is in question.
- The RRDS tracks data regarding all LOC reevaluations to monitor this assurance is being met.
- The QMS monitors for regional trends and suggest any additional training to the RRDS regarding the LOC process and waiver eligibility.
- The QMS and DOH WMS conducts an annual random retrospective record review of at least five-percent (5%) of all LOC reevaluations in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three. Findings are evaluated for trends warranting any individual, regional or systemic changes or improvements.
- DOH conducts record reviews during surveys of Service Coordination agencies to assure LOC determinations were timely and appropriate.
- The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS will evaluate the need to change and/or improve policies/procedures.
3. The processes and instruments described in the approved waiver are applied to determine LOC.
- The NYS PRI and SCREEN are designated tools for documenting LOC and can only be completed by individuals properly trained and certified by the NYS DOH. The completed PRI and SCREEN must be signed by the assessor, attesting to the validity of the assessment. If necessary, DOH WMS has the ability to verify the credentials of the qualified assessor completing the PRI and SCREEN.
- The RRDS reviews 100% of all initial and subsequent PRI and SCREENS for timeliness and to be sure the instrument indicates the waiver participant meets the LOC requirement.
- Each RRDC maintains a system to track the timeliness and appropriateness of all LOC evaluations/reevaluations.
- The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS.
- That staff, in consultation with the QMS and RRDS evaluates the need to change and/or improve policies/procedures.
4. The state monitors LOC decisions and takes action to address inappropriate LOC determinations.
- The RRDS reviews 100% of all initial and subsequent PRI and SCREENS to be sure the instruments indicate the waiver participant does meet the LOC requirement.
- When the accuracy of LOC data is questioned by the waiver participant, RRDS or SC, the NE reviews the data and, if necessary, completes a new PRI and SCREEN.
- The RRDS asks the NE to review all LOC denials when the denial is based on PRI and SCREEN results that do not meet the nursing home level of care requirement. The NE will evaluate the circumstances of the denial, the appropriateness and will assist the RRDS in monitoring regional trends.
- RRDC staff and DOH WMS takes action when inappropriate denials have been made e.g. reinforce RRDS training on the policies and protocols for LOC determinations.
- The RRDS may request technical assistance from DOH WMS when a problem or trend regarding LOC evaluations and decisions is noted.
- If a re-evaluation for LOC determines the waiver participant is no longer eligible for the waiver because he/she no longer meets the nursing home level of care requirement, and the participant disagrees with this decision, the NE may be asked to review the LOC evaluation. If the NE review confirms ineligibility, the RRDS, through a Notice of Decision informs the waiver participant of his/her right to a Conference and/or a Fair Hearing and Aid to Continue if he/she disagrees with the determination. The SC works with the waiver participant to ensure he/she understands his/her rights. If the NE review determines the original LOC decision to be incorrect, the NE will complete a new LOC assessment providing the assessment and determination to the RRDS and the SC.
- Before a participant is discontinued from the waiver, the SC assists the participant with referrals for other services, if needed.
- The RRDS notifies DOH WMS of any Fair Hearings initiated due to LOC denials.
- The RRDS tracks all LOC denials.
- The QMS analyzes data received from the RRDS for regional trends and addresses issues with the RRDS accordingly.
- The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS evaluates the need to change and/or improve in policies/procedures.