State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT EDMUND G. BROWN JR. DIRECTOR GOVERNOR
Managed Care Quality and Monitoring Division 1501 Capitol Avenue, P.O. Box 997413, MS 4400
Sacramento, CA 95899-7413 Phone (916) 449-5000 Fax (916) 449-5005
www.dhcs.ca.gov
November 2, 2016
Matt Levin, Chief Compliance officer & Legal Counsel Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502
RE: Department of Managed Health Care 1115 Waiver Seniors and Persons with Disabilities Survey
Dear Mr. Levin:
The Department of Managed Health Care conducted an on-site 1115 Waiver Senior and Persons with Disabilities (SPD) Survey of Alameda Alliance for Health, a Managed Care Plan (MCP), from June 8, 2015 through June 12, 2015. The survey covered the period of April 1, 2014 through March 31, 2015.
On November 2, 2016, the MCP provided DHCS with additional information regarding its Corrective Action Plan (CAP) in response to the report originally issued on March 18, 2016.
All items have been reviewed and found to be in compliance. The CAP is hereby closed. The enclosed report will serve as DHCS’ final response to the MCP’s CAP.
Please be advised that in accordance with Health & Safety Code Section 1380(h) and the Public Records Act, the final report will become a public document and will be made available on the DHCS website and to the public upon request.
If you have any questions, feel free to contact me at (916) 552-8946 or Lyubov Poonka at (916) 552-8797.
Sincerely,
Page 2
Jeanette Fong, Chief Compliance Unit
Enclosures: Attachment A CAP Response Form
cc: Stephanie Issertell, Contract Manager Department of Health Care Services Medi-Cal Managed Care Division P.O. Box 997413, MS 4408 Sacramento, CA 95899-7413
ATTACHMENT A Corrective Action Plan Response Form
Plan Name: Alameda Alliance For Health
Review/Audit Type: SPD Survey Review Period: April 1, 2014 – March 31, 2015
MCPs are required to provide a CAP and respond to all documented deficiencies within 30 calendar days, unless an alternative timeframe is indicated in the letter. MCPs are required to submit the CAP via email in word format which will reduce turnaround time for DHCS to complete its review.
The CAP submission must include a written statement identifying the deficiency and describing the plan of action taken to correct the deficiency, and the operational results of that action. For deficiencies that require long term corrective action or a period of time longer than 30 days to remedy or operationalize, the MCP must demonstrate it has taken remedial action and is making progress toward achieving an acceptable level of compliance. The MCP will be required to include the date when full compliance is expected to be achieved.
DHCS will maintain close communication with the MCP throughout the CAP process and provide technical assistance to ensure the MCP provides sufficient documentation to correct deficiencies. Depending on the volume and complexity of deficiencies identified, DHCS may require the MCP to provide weekly updates, as applicable.
CORRECTIVE ACTION PLAN FORMAT
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
Utilization Management 1. The Plan does not
consistently make
decisions in a timely
manner, based on
medical necessity
determinations, to
approve, modify, or
AAH updated its UM Policy of
Authorization Process to include
the correct timeframe
requirements. Implemented daily
aging monitoring reports that are
reviewed by the UM supervisor to
monitor staff’s open authorization
1.A- MED-UM-
0001 UM Auth
Process Policy
10_22_15
1.B- UM
Authorization Daily
4/21/2016 04/21/16 – MCP submitted:
- “UM Authorization Process
Policy” (10/22/15). This updated
policy includes a table with the
correct authorization processing
timeframes that complies with
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
deny requests by
providers.
cases and ensure they are
processed timely. UM daily audits
are conducted by the UM
supervisor to ensure authorizations
are processed within appropriate
timeframes and that appropriate
notices with required elements are
sent timely. Internal audits are
conducted by AAH’s Compliance
department to monitor compliance
of medical authorization
turnaround timeframes.
Audit Sample
Report
1.C- UM
Authorization Daily
Aging Sample report
1.D- Compliance
Monthly UM TAT
Monitoring Report
Oct 2015
1.E- Compliance
Monthly UM Auth
Audit Reports
1.F- AAH Board
Meeting UM
Internal Audit
Results 10_9_15
1.G- AAH Board
Meeting UM
Internal Audit
Results 3_11_16
compliance and statutory
requirements (p.6)
- “UM Authorization Daily
Aging Report” sample report
which provides a snap shot of
unprocessed authorizations using
the TrueCare tool.
- “UM Authorization Daily Audit
Report” sample that tracks all PA
timeliness milestones (e.g.,
receipt date, processing date,
extension date, notification dates,
etc.).
- “Compliance Monthly UM
TAT Monitoring Report” (Oct
2015) as evidence that the MCP
tracks PA TATs on a monthly
basis. The percentage of
compliance has improved.
- “Compliance Monthly UM
Auth Audit Reports” as evidence
that the MCP conducts an
internal audit on a monthly basis.
It shows an increase in
compliance rate for PA TATs
- 3 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
from October 2014 through
August 2015.
- A Compliance Report (March
11, 2016) that was presented to
the Governing Board. The report
provides an update on the DHCS
CAP status on improving UM
TATs, including the results of the
MCP’s internal audit (page 3).
This deficiency is closed.
2. For decisions to
deny, delay, or
modify health care
service requests by
providers based in
whole or in part on
medical necessity, the
Plan does not
consistently include in
its written response:
A clear and concise
explanation of the
reasons for the
decision;
AAH’s UM department
implemented daily quality audit
review for monitoring staff prior
authorization cases for complete
and sufficient medical review.
2.A- UM
Authorization Daily
Audit Sample
Report
10/18/16
UM Audit Results
April 2016
UM Audit Results
May 2016
UM Audit Results
June 2016
4/21/2016 10/18/16 – MCP submitted:
-Three audit samples, “UM
Authorization Internal Audit”
(April, May, June, 2016) that
show review of PAs for 3
required components (clear &
concise, criteria/guideline,
clinical reason). The template
requires the reviewed to input all
three requirements. Audits are
conducted monthly.
This finding is closed.
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
A description of the
criteria or guidelines
used; and
The clinical reasons
for the decision.
3. The Plan does not
consistently make
decisions in a timely
manner, based on
medical necessity
determinations, to
approve, modify or deny
requests by providers for
pharmaceutical
treatments.
Starting 1/1/2015, a 24 hours’
turnaround time (TAT) has been
implemented for all pharmacy
authorizations. TAT compliance
is measured and monitored every
month. In 2015, the overall 24
hours TAT compliance rate was
99%.
3.A- 2015 Pharmacy
Prior Authorization
Summary MCAL
3.B- 2015 Pharmacy
Prior Authorization
Summary IHSS
4/21/2016 4/21/16 –The MCP submitted
“PerformRx Prior Authorization
Summary - 2015” as evidence
that the MCP monitors pharmacy
TAT on a monthly basis. This
summary report (January 2015
through December 2015) yielded
a 100% compliance rate average.
This finding is closed.
4. The Plan does not
have adequate
mechanisms to detect
for under- and over-
utilization of out-of-
network specialty
referrals and behavioral
health services.
AAH regularly monitors requests
for out-of-network (OON)
specialty referrals using the OON
specialty referrals report. The
monitoring occurs at least
quarterly. AAH will be reporting
under-over utilization data at the
internal UM Subcommittee.
MCP’s Response 10/17/16: Our
internal UM sub-committee meets
to discuss various internal and
delegation reporting. Attached are
4A- Alliance OON
Specialist Referrals
4B- Behavioral
Health OON Report
09-14-16
8/31/2016
9/14/2016
4/21/16 – MCP submitted
“Alliance OON Specialist
Referrals” report which tracks the
number of OON requests and
approvals for the MCP and its
provider groups (Q3 2015).
9/14/16 – MCP’s written
response indicated that the OON
specialty referrals are discussed
quarterly and will be discussed at
the UM Sub-committee in
October 2016 and March 2017.
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
the minutes and reports discussed
which includes Beacon’s data with
behavioral health utilization.
10/14/16 – MCP submitted
“Behavioral Health OON Report”
(09-14-16) as evidence of
monitoring of OON referrals for
Behavioral Health.
- “Monthly Utilization
Management Sub-Committee”
minutes and corresponding
attachments including several
Beacon utilization reports (01-27-
16). The minutes document
review, discussion, and follow up
of behavioral health utilization.
(Item V)
This finding is closed.
Continuity of Care 5. The Plan does not
monitor or ensure the
timely provision of an
Initial Health
Assessment for each
new member.
AAH revised its IHA policy to
include a procedure for monitoring
the completion of all new member
IHAs within the required
timeframe. AAH’s IHA
workgroup meets quarterly to
review IHA completion reports,
discuss improvements,
interventions, and activities.
Targeted interventions
implemented in the past 6 months
5.A- MED-QM-
0041 Initial Health
Assessment
12_17_15
5.B- AAH IHA
Work Flow 9_24_15
5.C- IHA Work
Group Minutes
7_7_14
4/21/2016 4/21/16 –MCP submitted:
- “MED-QM-0041 Initial Health
Assessment” policy and
procedure (revised 12/17/15) that
demonstrates alignment with the
contractual requirements
regarding timely completion of
IHAs (p.1).
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
include:
Included an IHA
requirement in P4P for
direct-contract providers;
Added IHA education in
provider orientation
packets for Q1 2016; and
Added new member flag in
provider portal. Providers
can download list of new
members in Excel format
from AAH’s portal.
AAH will be conducting quarterly
outreach to providers in the lowest
quartile beginning in Q4 2016.
5.D- IHA Work
Group Minutes
8_14_15
5.E- IHA Work
Group Minutes
10_28_15
5.F- IHA Work
Group Minutes
2_10_16
5.G- New Members
IHA Report July
2015
5.H- New Members
IHA Report Oct
2015
5.I- New Members
IHA Report Feb
2016
5.J- Kaiser IHA
Report 2015
5.K- AAH P4P
Program
5.L- P4P Program
Guide Presentation
5.M- AAH Member
ID Card IHA
Reminder
This P&P also addresses IHA
monitoring. The MCP indicates
that Current Procedural
Terminology (CPT) codes that
represent IHA completion will be
queried to retrieve and track IHA
completion (p.2).
- “New Members IHA Report”
(Oct 2015 & Feb 2016) as
evidence that the MCP is
monitoring IHA completion
based on CPT codes.
- “IHA Work Group Minutes”
for 7/7/14, 8/14/15, 10/28/15,
2/10/16 committee meetings
document review of the above
mentioning reports, discussion,
and follow-up.
- “IHA For Medi-Cal New
Members” provider education
material that reiterates the
requirement and directs PCPs to
the Plan’s web-site for available
resources. These resources
include:
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
5.N- Medi-Cal EOC
Health Exam New
Members
5.O- Provider IHA
Education
5.P- MCAL Member
Welcome Letter
SHA forms, SHA provider
training power point presentation,
Attestation form and handouts
that are available for use when
providing counseling and
guidance on topics covered by
the SHA.
- “AAH Pay For Performance
(P4P)” spreadsheet that shows
the MCP’s point base incentive
system for different measures,
one of which is IHA.
- “Program Guide – MY 2015 &
2016. Pay for Performance
Program – Directly Contracted
PCPs” which educates providers
on the point based incentive
system.
- “Welcome to AAH” welcome
letter that encourages the new
member to schedule a well exam.
- “AAH Member ID Card IHA
Reminder” – a sample of ID Card
mailed to the member which
includes another IHA reminder.
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
This finding is closed.
6. The Plan does not
consistently ensure the
provision of complex
case management
services.
AAH expanded its criteria of
members who qualify for
Complex Case Management. AAH
is currently in the process of hiring
additional Nurse Case Managers
to build the program and increase
the number of members receiving
Complex Case Management
services.
6.A- AAH 2015
Case Management
Program Description
6.B- 2015 Complex
Case Management
Program Evaluation
6.C- AAH Complex
Case Management
Criteria
6.D- AAH Case
Management
Referral Form
6.E- AAH Case
Management
Website
12/31/2016 04/21/16
MCP submitted the following
supporting documents:
- “Comprehensive Case
Management Program
Description” (2015) which
describes the MCP’s Complex
Case Management Program
including criteria for
identification (pages 16-17).
- “Complex Case Management
Measures of Effectiveness
Report” (2015) which evaluates
the effectiveness of the MCP’s
CCM program.
- “Alliance Complex Case
Management Criteria” which
specifies criteria for CCM
eligibility.
-Screenshot of the MCP’s “Case
and Disease Management
Program” webpage which
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
provides providers with
accessibility to referral forms.
08/23/16
MCP provided two case
examples that demonstrated care
plans which address all of the
members' needs identified in the
assessment (“Referral for
Complex Case Management”
p.3,5-14). age 3).
This finding is closed.
Availability & Accessibility 7. The Plan does not
implement prompt
investigation and
corrective action when
compliance monitoring
discloses that the Plan’s
provider network is not
sufficient to ensure
timely access to
appointments.
AAH revised its Timely Access
policies. AAH’s Access
Subcommittee monitors providers’
compliance with timely access
standards on a quarterly basis
through various monitoring
reports such as out-of-network
authorizations, grievances and
appeals related to access, provider
capacity levels, geographic access
reports, and annual appointment
access & availability provider
survey results. The Access
Subcommittee reports all
monitoring activities to the Health
7.A- AAH-CMP-
0024 Monitoring of
Access &
Availability
Standards
7.B- MED-DEL-
0025 Appointment
Access &
Availability
7.C- MED-DEL-
0024 Access to
Behavioral Health
Services
7.D- AAH-CMP-
0028 Access &
4/21/2016 4/21/16 –MCP submitted:
-Minutes from two Access
Committee meetings (9-17-15 &
11-19-15) showing that timely
access and monitoring reports are
being reviewed.
- The Plan submitted examples
of three corrective action plans
(AHS Timely Access CAP 8-21-
15, Beacon Timely Access CAP
2-18-15 & CHCN Timely Access
CAP 4-16-15) issued to delegates
that were out of compliance with
- 10 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
Care Quality Committee (HCQC).
AAH issued three Access
Corrective Action Plans (CAPs) in
2015.
Availability
Committee Policy
7.E- MED-QM-
0023 Provider
Access and
Availability Survey
7.F- 2015 ICE
DMHC
Appointment
Availability Survey
Tool
7.G- AAH Access
Committee Minutes
9_17_15
7.H- AAH Access
Committee Minutes
11_19_15
7.I- AHS Timely
Access CAP
8_21_15
7.J- Beacon Timely
Access CAP
2_18_15
7.K- CHCN Timely
Access CAP
4_16_15
7.L- HCQC Minutes
11_23_15
timely access standards. The
CAPs were discussed in the
Access Committee meetings.
This finding is closed.
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
7.M- HCQC Packet
12_17_15
8. The Plan does not
ensure that during
normal business hours,
the waiting time for a
member to speak by
telephone with a Plan
customer service
representative does not
exceed ten minutes.
AAH revised its policy for Quality
Monitoring Member/Plan
Interactions. Monthly Member
Services Performance Dashboards
are reported to Senior Leadership
and the Governing Board.
Member Services staff routinely
monitors call performance
measures and call center
timeliness. Since November 2015,
90% or more of AAH’s member
services calls are answered within
30 seconds.
8.A- MEM GEN
003 Quality Monitor
Member Plan
Interaction Dec
2015
8.B- AAH Member
Services Staff
Performance
Evaluation Tool
8.C- AAH Board
Report Call
Statistics 1_22_16
8.D- AAH Board
Report Call
Statistics 4_8_16
8.E- Member
Services
Performance
Dashboard 2015
4/21/2016 4/21/16 –MCP submitted:
- P&P MEM GEN 003: “Quality
Monitoring of Member/Plan
Interactions and Electronic
Communications” (revised
12/2015) which establishes the
MCP’s standard of answering
80% of calls within 30 secs with
an abandonment rate less than or
equal to 5%.
- “Member Services Dashboard”
(2015) as evidence that the MCP
is monitoring call center activity
(e.g., incoming calls,
abandonment rate, calls answered
in 30 secs). The results show an
improved rate of compliance
from January to December 2015.
- “Board of Governors Report”
(1-22-16 and 4-8-16) as evidence
that call center data including
abandonment rates and calls
answered in 30 seconds is
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
reported to the Board of
Governors.
This finding is closed.
Members’ Rights
9. The Plan’s grievance
system does not
consistently ensure that
all expressions of
dissatisfaction are
captured as grievances
and that a written record
is made for each
grievance received.
AAH has revised its Exempt
Grievance policy. Staff trainings
were conducted on the exempt
grievance process and
documentation standards.
9.A- MEM-GEN-
0024 Exempt
Grievances Policy
9.B- Member
Services Exempt
Grievances Report
9.C- Member
Services
Documentation
Training 3_31_16
9.D- Member
Services Training
4_13_16
9.E- Member
Services Exempt
Grievance Training
4_20_16
4/21/2016 4/21/16 –MCP submitted:
- “MEM-GEN-0024 Exempt
Grievances” (revised 04-13-15)
policy that demonstrates
alignment with the requirements
of Section 1368(a)(4)(B) and
Rule 1300.68(d)(8) regarding
process of receiving, identifying,
documenting and monitoring of
exempt grievances.
- “Member Services Dashboard
2015
Informal Complaint Reasons for
Member Services” as evidence
that the MCP is tracking and
trending exempt grievances.
- Evidence of the staff trainings
conducted on documenting calls.
“Elements of Good
documentation” (A tip sheet for
documenting Member Service
delivery).
- 13 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
- “MSD Bi-Monthly
Meeting/Training” (04/13/16 and
04/20/16) agenda/minutes and
attendees sign in sheet. “Informal
Complaints
MSR Documentation Guidelines”
are included as part of the
training materials (04/13/16,
pages 5-7) and gives instruction
on how to utilize Health Suite to
properly enter Informal
Complaints. Informal complaints
(exempt), formal grievance and
appeals, timely filing, definitions,
and documentation standards are
discussed.
This finding is closed.
10. The Plan’s grievance
system does not
consistently ensure
adequate consideration
of exempt grievances
and rectification when
appropriate.
AAH has revised its Exempt
Grievance Policy. Staff trainings
were conducted on the exempt
grievance process and
documentation standards.
9.A- MEM-GEN-
0024 Exempt
Grievances Policy
9.B- Member
Services Exempt
Grievances Report
9.C- 9.C- Member
Services
Documentation
Training 3_31_16
4/21/2016 10/14/16 – MCP submitted:
MCP’s response (10/14/16)
indicating that they have had staff
trainings focusing on exempt
grievances and how to adequately
resolve the complaint.
- “Member Services Department
Stand-Up/Training Meetings”
sign-in sheets (September 8-9,
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
9.D- Member
Services Training
4_13_16
9.E- Member
Services Exempt
Grievance Training
4_20_16
2016) and Power Point training
as evidence that member services
representatives were trained on
how to fully resolve exempt
grievances.
- “Agent Scored Evaluation”
three samples of call evaluation
form results as evidence that the
member services representative is
evaluated on how well he/she
solved the problem.
This finding is closed.
11. The Plan does not
consistently ensure that
Limited English
Proficient members
receive coordinated
interpreter services at
the time of scheduled
appointments.
AAH distributed “Point to Your
Language" signage and contact
information for AAH interpreter
services to all providers in Q3
2015 and Q4 2015 provider office
visits. Grievances and any issues
related to interpreter services are
reported to the Language
Assistance Subcommittee.
11.A- MED-CL-
0003 Language
Assistance Services
11.B- MED-CL-
0010-Cultural and
Linguistic Services
Program Staff
Training
11.C- Point to Your
Language Signage
11.D- Interpreter
Services Quick
Guide
11.E- Language
Assistance
4/21/2016 4/21/16 –MCP submitted:
-Policy & Procedure “MED-CL-
0010, Cultural and Linguistic
Services Program: Staff
Training” (02/13/15) indicates
that the Plan ensures that all staff,
providers and subcontractors are
compliant with the Cultural and
Linguistic Services Program
through cultural competency
training that is provided on an
annual basis.
Additionally, Bilingual staff that
is hired receives bilingual
- 15 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
Committee Minutes
10_21_15
11.F- Language
Assistance
Committee Minutes
1_20_16
proficiency assessments upon
becoming employed with the
Plan. (p.1)
- “Point to Your Language We
Will Get You an Interpreter”
signage that informs the
beneficiaries of the availability of
free language assistance services,
as well as in the EOC, welcome
packet and member newsletters.
(MED-CL-0010 p.3)
- “Alameda Alliance for Health
Interpreter Services Quick
Reference Guide” informs
providers of the availability of
free language assistance services
for members as well as the new
provider orientation, provider
bulletins, through their contract
and in the provider manual.
(MED-CL-0010 p.3)
- “Quarterly Language Assistance
Program Sub-Committee October
21, 2015” The minutes indicate
that the common theme in the G
& A trending report and Member
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
Services informal complaints was
interpreter no shows and
members not being informed.
All complaints, informal and
formal should be reported to IEC
and follow-up documented.
Grievance data re: C & L is now
communicated to appropriate
departments and documented.
(p.2)
- “Language Assistance Services
Sub-Committee January 20,
2016” sub-committee minutes
show evidence that issues such as
language capacity of providers,
consideration of a change in
interpretation vendors, tracking
of threshold languages were
discussed. Minutes document that
a report documenting
unfulfilled/cancelled interpreter
requests (Oct-Dec 2015) was
reviewed and no significant
trends were noted.
This finding is closed.
Quality Management
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
12. The Plan does not
conduct adequate review
of potential quality
issues to ensure that all
problems are being
identified and that
grievances related to
medical quality issues
are consistently referred
to the Plan’s medical
director.
Policies & Procedures, the Work
Plan and the Potential Quality
Issues (PQI) Tracking System
were revised:
To require Medical
Director review of all
PQIs, both administrative
& quality related; and
To create an interrater
reliability process.
A Monthly Monitoring Report was
created for the Quality
Management Subcommittee and
HCQC.
12.A- MED-QM-
0002 Potential
Quality Issues (PQI)
12.B- PQI
Workflow
12.C- 2016 PQI
Master Log
Redacted
12.D- PQI Report to
Committee
8/31/2016 8/31/16 –MCP submitted:
-Revised policy and procedure
“MED-QM-0002, Potential
Quality Issues (PQI)” (4/13/15)
requires Medical Director to
review all PQI cases, both
administrative and clinical. (§10
(3))
- “PQI Referral log 2016 De-
identified” as evidence that the
MCP is required to capture a
number of elements, including
the date of MD review. The new
process was developed and
initiated Spring 2016 and
approved/finalized by QI
Committee (HCQC) in June
2016. All new PQI cases now
have MD review prior to closing
the case.
- “PQI Report to Quality
Management Committee” as
evidence that the MCP has
implemented its process for
providing updates to the QIC. All
PQI case statuses, required
CAPs, and inter-rater reliability
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Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
reviews are captured in this
monthly report.
This finding is closed.
13. The Plan does not
have effective oversight
procedures in place to
ensure that providers are
continuously fulfilling
all delegated
responsibilities.
AAH revised its delegation
oversight policies. AAH’s
Compliance Department
conducted all annual delegation
audits for 2015. Delegation
reporting is monitored routinely
and CAPs were issued in response
to reporting of non-compliance.
Delegation oversight activities and
CAPs are reported quarterly to the
Compliance Committee.
13.A- CMP-0042
Delegation
Oversight Policy
13.B- MED-QM-
0040 Delegation of
Quality
Management
13.C- AAH
Delegation Grid_
June 2015
13.D- 2015
Delegation Audit
Schedule 10_1_15
13.E- Compliance
Committee Minutes
8_4_15
13.F- Compliance
Committee Minutes
11_24_15
13.G- Compliance
Committee Agenda
3_22_16
13.H- Beacon Audit
Report
4/21/2016 4/21/16 –MCP submitted:
- “CMP-0042 Delegation
Oversight” policy, which
commits MCP to pre-delegation
review, annual delegation review,
delegation oversight meetings
and contractual and regulatory
reporting. (p.2)
- “MED-QM-0040 Delegation of
Quality Management”
(rev.12/17/15) policy and
procedure requires audits of each
delegate prior to contracting to
evaluate the delegate capacity
meets DHCS requirements. (§
A.) The MCP performs annual
delegation oversight audit to
verify compliance. If needed
MCP will issue a CAP. (§ D.)
- “Compliance Committee
Meeting Minutes” (06/03/15 &
11/24/15) shows review and
discussion of delegation activities
- 19 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
13.I- CFMG Audit
Report
13.J- CHCN Audit
Report
13.K- CHME Audit
Report
13.L- EviCore Audit
Report
13.M- Kaiser Audit
Report
13.N- March Vision
Audit Report
13.O- PerformRx
PBM Audit Report
13.P- LPCH Audit
Report
13.Q- UCSF Audit
Report
13.R- AAH
Delegation CAP
Report 11_24_15
13.S- AAH Board
Compliance Report
1_22_16
13.T- AAH Board
Compliance Report
2_12_16
(e.g., audit schedule, audits,
CAPs, etc.) (agenda item # 5)
- MCP submitted 10 delegated
entity reports and subsequent
Corrective Action Plans as
evidence of ongoing monitoring.
- “Board of Governors Regular
Meeting” (01/22/16 & 02/12/16)
memo as evidence that the
Compliance Department provides
updates on delegated audits and
issued CAPs to the Board.
This finding is closed.
- 20 -
Deficiency Number and Finding
Action Taken Implementation Documentation
Completion/ Expected
Completion Date
DHCS Comments
14. The Plan does not
maintain a system of
accountability for its
Quality Improvement
System by ensuring that
reports to the governing
body are sufficiently
detailed to identify
significant or chronic
quality of care issues.
Components of the Quality
Improvement System were
discussed during December 2015
and January 2016 Board of
Governor’s meeting.
14.A- AAH Board
Meeting Minutes
12_11_15
14.B- AAH Board
Meeting Minutes
1_22_16
4/21/2016 10/28/16 – MCP submitted:
- “BOG Regular Meeting”
packet (06/10/16; 07/08/16;
09/09/16; 10/14/16) which
includes evidence of the Board
receives and reviews monitoring
reports including the “Medical
Services Report.”
-Evidence of review and approval
of the QI program, work plan,
and evaluation in the 07/08/16
Board meeting packet (page 65).
11/02/16 – MCP submitted:
-An e-mail indicating, “We are
planning to include the HCQC
minutes in the Board packets for
reporting activities, findings, and
recommendations. The HCQC
minutes will be in the Board
packets beginning January 2017.”
This finding is closed.
Submitted by: Matt Levin, Esq. Date: 4/21/2016 Title: Chief Compliance Officer/General Counsel
Scott Coffin, CEO Matt Levin, Chief Compliance Officer/General Counsel
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