Part 2: Post-Audit Activities · ★Share post-audit experiences ★Walk through post-audit phase...
Transcript of Part 2: Post-Audit Activities · ★Share post-audit experiences ★Walk through post-audit phase...
Part 2: Post-Audit ActivitiesBy:
Maria Lane, Florida PACE – FloridaEmmanuel Cheo, Mercy LIFE – Massachusetts
Objectives
★Share post-audit experiences
★Walk through post-audit phase – Case examples of activities Preparing and fulfilling document requests: CAR, ICAR,
CAP Responding to findings: Brief references to RCAs and
IAs
★Forecast based on CMS PACE Audit Updates as of April 2018? Health Plan Management System
Definitions
★CAP: Corrective Action Plan★CAR: Corrective Action Required★HPMS: Health Plan Management System★ICAR: Immediate Corrective Action Required★IA: Impact Analysis★RCA: Root Cause Analysis
Some Activities
Activity Time Frame Focus
Root Cause Analysis
(RCA)
24-48 business
hours
• Systems• What systemic processes led to the outcomes related to
the finding?• Document activity using RCA Templates as instructed• Provide supporting evidence (documentation)
illustrating compliance, or progress toward compliance
Impact Analysis
(IA)
10 business days
• Participants affected or impacted by finding• Actions taken in each case to remedy or mitigate
impact• Supporting evidence (documentation)
Corrective Action Plan
(CAP)
30 calendar days from
draft report date
• Systems and participants impacted. • Actions taken to “cure the non-compliance”• Upload into HPMS using Data Upload tab: “CAP File”
Findings
Type CMS Definition Related Activities Points
CAR
Corrective Action Required:“A systemic deficiency that must be corrected,
but the correction can wait until the [draft] audit report is issued.”
• RCA• IA• QI initiatives
1
ICARImmediate Corrective Action Required:
“A systemic deficiency that is so severe that it requires immediate correction.”
• RCA• IA• QI initiatives
2
ObservationsObservations:
“Conditions of non-compliance that are not systemic, or represent a ‘one-off issue’.”
• Provide supporting evidence to show that issues are/were:
• Not systemic or ongoing
• Did not impact safety or access to care
0
Logistics & Considerations
★Make it easy for the reviewers! Respond timely Simplify: Evidence, evidence, evidence Organize, track and upload documents requested Upload supporting documentation: medical records,
staff/participant education materials, policy and process changes, etc. Use file naming convention(s) and formats as
instructed May cross reference previously uploaded files
Preparation of RCAs
★Florida PACE Centers conducted 5 RCAs post audit for the following:
Florida Appeals in Denial Notice Denial Notice In-person Assessments Service Notifications Competencies Immunizations
Preparation of RCAs
★Florida PACE Centers conducted IAs post audit for the following:
Denial Notice Appeals Process Competencies Immunizations
CAPs
★Key Points Deadline: 30 calendar days after issuance of draft
report of findings Methods used to identify participants
affected/impacted Corrective actions taken, and outcomes, in each
case Supporting documentation: Evidence showing
results/outcomes Upload documents using naming convention Sample
CAR – CAP – Case Example
★Placeholder for Sample
ICAR – CAP – Case Example
★Placeholder for Sample
Response to Draft Report
★Key Points Deadline: 14 business days after issuance of draft
report of findings Upload: HPMS
★Case Example
Response to Draft Audit Report• Draft report was
received 30 days after the survey with preliminary results.
• Draft Report stated cause for each finding that the surveyors identified during the reviewed period.
• After receiving the draft report. All CAPs for CAR conditions needed to be submitted in HPMS within 30 calendar days from the issuance of the finalreport.
QI Initiatives & Outcomes
★SDR In-person assessments Timeliness of IDT decisions Outcomes communicated to AM: Quarterly HPMS
calls
★Appeals Compliance with timeframes
★Grievances Extracting and processing embedded SDR
Tips
★Prepare and Organize Documents
CAR / ICAR
Finding1-2 business days
RCA10 business days
IA
Final Report
Final report was received within 8 days after receiving the draft report. Florida PACE did not object to any of the findings in the draft report.
Corrective Actions
Florida PACE submitted all corrective actions via HPMS website and developed a Monthly Dashboard to show compliance of the findings.
Closing
It is always a great to read words such as:
CMS has accepted and released all CAPs that were submitted by______. The ____ PACE audit is now closed.
Post-Audit QI Implementations
Monthly Dashboard created Formal correspondence createdPolicies were created and updatedEMR updated to track SDRMonthly audits to ensure complianceAdded staff to the Quality Department
Thank you – Questions?
★Updates Fieldwork extended to 2 weeks
• Week 1: Desk review including SDAG element• Week 2: In-person review of onsite element, etc.
State audits may be conducted during CMS audit, or separately
★Resources NPA Audit Prep Guide, and Risk Assessment Package NPA Quality Directors Handbook HPMS Integrated Audit Module User Guide PACE Audit Updates: HPMS Memo dated 04/23/2018