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SC Data and Compliance 2014. What Works Today?. Presenters. Michelle Sipple, Familylinks Mary Jane Fletcher, Lenape Valley Foundation Dan Sausman, CMU Joel Goldberg, Quality Progressions. Is this YOU?. What do we mean by Compliance?.

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Presentation Transcript
  • Michelle Sipple, Familylinks
  • Mary Jane Fletcher, Lenape Valley Foundation
  • Dan Sausman, CMU
  • Joel Goldberg, Quality Progressions
what do we mean by compliance
What do we mean by Compliance?
  • Compliance plans establish guidelines and policies around Standards of Conduct:
    • Quality of Care and Services
    • Coding and Billing
    • Workplace Conduct and Employment Practices
    • Adhering to Laws and Regulations
    • Potential Conflict of Interest
    • Protecting Agency Assets
    • A good compliance plan is the cornerstone of your agency and establishes a culture of accountability.
an enforced compliance plan shows
An Enforced Compliance Plan Shows:
  • The agency has a commitment to ethical business practices
  • Encourages a culture of awareness and quality
  • It is important to follow local, state, and federal regulatory standards
  • Documentation needs to be accurate
  • What we do is important and matters-we are professionals who are held to high standards
  • We have policies that reflect this message
  • We monitor ourselves
general outline of a compliance plan
General Outline of a Compliance Plan:
  • Introduction/Purpose
  • Items to consider:
      • Policies and Procedures
      • Risk
      • HIPAA
      • Security
      • Need for compliance officer/committee
      • Training and education
      • Communication
      • Disciplinary action
      • Auditing and Monitoring
      • Self-reporting
best practice procedures
Best Practice Procedures
  • Review Compliance plan and policies and have staff sign-off on acknowledgement
  • Review internal policies related to compliance
  • Review applicable laws and regulations
  • Review internal procedures for monitoring and oversight of compliance
  • The plan should be reviewed and updated at least annually
  • Be proactive-not reactive
policy checklist
Policy checklist
  • “Whistleblower” (43 Pa. Cons. Stat. §§ 1421 to 1428)
  • Work Conduct
  • Billing
  • Harassment
  • Confidentiality and HIPAA
  • Fraud, Waste, and Abuse
  • Diversity and Inclusion
  • Grievance Resolution
  • Conflict of Interest
compliance plans
Compliance Plans:
  • Show the Good, the Bad and the Ugly
  • Snapshot of Where We Are Now
  • Tools for Performance Evaluations – more objective than subjective
  • Improved Fiscal Accountability
  • Allows for a quick response when things aren’t going well
  • Shows which staff are on the mark and helps pinpoint who isn’t and what areas need improvement
sco s and compliance
SCO’s and Compliance
  • Build your plan based on ODP mandated timelines, frequencies and quality mandates.
    • Monitoring – frequency and location
    • Monitoring – 14 days
    • Service notes – content and timeframe (7 days)
    • ISP’s
        • 90, 45, 30 days out
        • Invitation letters
        • Meeting Date
    • PUNS – 364 days
    • SCO Monitoring
    • Customer Satisfaction Surveys
sco s and compliance1
SCO’s and Compliance

Balancing act between fiscal viability, quality and compliance

  • You can do all three – but it’s not easy:
    • Mandates change
    • Inconsistencies between AE’s, counties, and regions
    • Staff change
    • Policies change
    • Conflict between what Providers want and what AE’s tell SCOs to do
four agencies
Four agencies….
  • One goal…create a compliance plan
  • How each agency began and implemented their plans….
one agency two plans
One Agency-Two Plans
  • Corporate Compliance Plan
    • Created to meet the needs of the MH, ID and EI Departments globally
  • SCO Compliance plan
    • Created to meet ODP required standards and measures
    • Specific to SCO’s needs
    • Moving Target – changes as ODP changes
    • Requires intense quality management and tools
    • Quarterly and Annual QM Plan Reviews
  • Both Plans
    • Reviewed Annually and updated as needed
    • Quality stems from compliance
    • Agency culture at all levels
    • Annual training for SCs on both plans
tools for staff
Tools for Staff
  • Timeline Cheat Sheet
  • Checklist Cheat Sheet
  • ISP Timeline Spreadsheet
  • Monitoring Spreadsheet
  • Service Note Log
  • Service Note Templates
  • Productivity Calendar
  • PUNS Due Date Cheat Sheet
  • 6 Month Reviews List
tools for management
Tools for Management
  • Pre-populated Supervision Note
  • Weekly Individual SC Unit Review
  • Data Warehouse & HCSIS reports – manipulated to give individual statistics
  • Monthly “Chart” Compliance Reviews
    • Includes consumer/family satisfaction calls
  • Weekly
    • Unfinalized PUNS
    • Pending Monitors
    • Units per week by each SC
more reviews and tools
More Reviews and Tools
  • Monthly Utilization Reviews
    • Weekly during 4th quarter of FY
  • Data Extract Reviews – billable vs non-billable, units billed, zero units review
  • Quality reviews of service notes, ISP content, monitoring tools, closing the loop
  • Performance Improvement Plans
  • SC Performance Checklist – reviews all aspects of the job and scores them.
  • Corporate Compliance Plan (2005)
    • Establishes Corporate Compliance Plan Committee – Monthly meeting.
    • Promotes agency culture of “prevention, detection & resolution.”
    • Directs the operation of routine, ongoing monitoring & auditing procedures.
    • Assures training at hire and on an annual basis, at minimum, for all staff.
  • Compliance Reports
    • SC Service Compliance Reviews:
      • Provided directly to SCs & SC Supervisors.
      • Incorporated into 1:1 supervision with SCs by the SC Supervisors.
  • HCSIS Extract Reports
    • Service Notes:
      • Timeliness
      • Productivity
  • Random Customer Service/Compliance Reviews:
    • Completed by SC Supervisor -
      • Contact with individual/family.
      • Satisfaction.
      • Verification of contact.
    • Audit of supporting documentation -
      • Review of HCSIS Documentation, Quality of Service Note.
      • Crosswalk to time sheet.
      • Crosswalk to travel log.
  • Incorporate culture of compliance into all activities:
    • Routine support & supervision for SC’s.
    • Training / Staff Meetings.
    • Claims review/resolution activities.
  • Set high standards & be true to them:
    • Talk about it all the time – assure SC’s not only understand what, but also understand why.
    • Proactive: Training & counseling.
    • Reactive: Discipline/Termination.

Organizational Overview

  • Agency started in 2004.
  • Standards developed from the beginning
  • Standards and expectations have evolved as has ODP
  • Balance quality and compliance
  • Make a difference

Standards & Expectations

• Standards and expectations are trained upon hire.

• All staff members are re-trained on an annual basis.

• By all managers with different parts of orientation.

• Training is focused on integrity and compliance.

• Integrity is also discussed at all monthly staff meetings.

• Agency reputation is at stake!


QP Online Database

• ISP Compliance

• Service Notes/ Units


• Utilization

• Monitoring Compliance

• Eligibility (Physicals, Recertifications, Redeterminations)


Service Notes

• Quality - Documenting service delivery and issues

• Outcome progression and issue resolution

• Compliance - Acting as a Medicaid claim

• Productivity – Oversight and assurance of TSM productivity

standards and billing integrity

• Timeline Compliance/ weekly reconciliation of work time



• Be accurate

• Be honest

• Make a difference in the lives of consumers

familylinks plan
Familylinks Plan
  • Created in 2009
  • Annual Training for SC’s and part of our new hire orientation
  • Work with our Director of QI around accreditation and CQI
  • Has assisted in terminations/unemployment
familylinks sc sample reports that can assist in monitoring compliance
Familylinks SC Sample Reports that can assist in monitoring compliance:
  • ISP Clean up report-monthly
  • ISP Outstanding report-monthly
  • ISP Monthly report-monthly for following month due dates
  • Bi-annual compliance report
  • Service note management review-monthly to check billing status
  • SC utilization report-monthly or weekly (last quarter of fiscal year)
  • Pending Revision report-daily
  • Unit Discrepancy Report-weekly (compares DOS to units billed)
  • Waiver/Sub-category discrepancy report (compares TSM category to waiver category in HCSIS)-weekly
  • Service Note Review-weekly for quality and compliance
  • Monthly Compliance Reports-7 areas of compliance
  • Office of Inspector General
  • Health Care Compliance Association
  • Laws relevant to compliance--Federal laws identified in Section 6032(A); Pennsylvania laws imposing civil or criminal penalties for false claims and statements, and about whistleblower protections under such laws, including 62 P.S. §§ 1407 (relating to provider prohibited acts, criminal penalties and civil remedies) and 1408 (relating to other prohibited acts, criminal penalties and civil remedies), and the Pennsylvania Whistleblower Law, 43 P.S. §§ 1421-1428;
  • Questions/ Comments?