DCS Comprehensive Health Plan

Quality of Care

Policy Statement

Quality of care is a critical component of the DCS Comprehensive Health Plan (DCS CHP) Department of Quality Improvement and Performance Management (QM/PI) Program. Concerns, complaints and potential quality of care (QOC) issues are identified and systematically examined to ensure that health care services meet acceptable standards of care and comply with state and federal regulations.

Definitions

Adverse Action: Any type of restriction placed on a provider’s practice by CHP such as, but not limited to, contract termination, suspension, limitation, continuing education requirement, monitoring or supervision.

Corrective Action Plan (CAP): A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/tasks to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish CAP goals and objectives, and staff responsible to carry out the CAP within established timelines. CAPs are generally used to improve performance of the Contractor and/or its providers, to enhance Quality Management/Process Improvement activities and the outcomes of the activities, or to resolve a deficiency.

Final QOC Determination: Upon completion of systematic examination the following determinations are made regarding the Quality of Care concern cases:

• Non QOC: not a QOC issue (no clinical investigation required);

• Substantiated: QOC issues confirmed (following clinical investigation);

• Unsubstantiated: no QOC issues (following clinical investigation);

• Unable to Substantiate: unable to substantiate a QOC (following clinical investigation).

Health Care Acquired Conditions (HCACs): A condition which occurs in any inpatient hospital setting and is not present on admission. (Refer to the current Centers for Medicare and Medicaid Services (CMS) list of Hospital Acquired Conditions).

Incident, Accident or Death (IAD): A report entered into the AHCCCS Quality Management (QM) Portal by a provider to document an occurrence that caused harm or may have caused harm to a member and or to report the death of a member

Internal Referral (IRF): A report entered into the AHCCCS QM Portal by an employee of a health plan to document an occurrence that caused harm or may have caused harm to a member and or to report the death of a member.

National Committee Quality Assurance (NCQA): is a private, 501 (c)(3) not-for profit organization dedicated to improving health care quality.

Other Provider Preventable Conditions (OPPCs): A condition occurring in the inpatient or outpatient health care setting which is a direct result of provider error; such as surgery on wrong member, or wrong site surgery.

Overall Case Finding/Determination: Substantiated - Quality of care issue(s) confirmed (following clinical investigation). Unsubstantiated - No quality of care issue(s) (following clinical investigation) Unable to substantiate - Unable to substantiate a quality of care issue (following clinical investigation)

Quality of Care (QOC): The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professionally recognized standards of care and service provision.

Quality of care Concern: A concern or allegation that a provider or facility did not meet the professionally recognized standards of health care, or suspected deviation of care that caused or could have caused an acute medical or psychiatric condition or an exacerbation of a chronic condition and may ultimately cause the risk of harm to the member.

Sentinel Event: A patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitation to both patients and health care providers involved in the event. AHCCCS defines sentinel event as outlined in AMPM 961(A)(2) as:

• Member death or serious injury associated with a missing person,

• Member suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting,

• Member death or serious injury associated with a medication error,

• Member death or serious injury associated with a fall while being cared for in a healthcare setting,

• Any stage 3, stage 4, and any unstageable pressure ulcers acquired after admission or presentation to a healthcare setting,

• Member death or serious injury associated with the use of seclusion and/or restraints while being cared for in a healthcare setting,

• Sexual abuse/assault on a member during the provision of services.

• Death or serious injury of a member resulting from a physical assault that occurs during the provision of services, and

• Homicide committed by or allegedly committed by a member.

Severity Level: All QOC case categories receive leveling which indicates the severity of the findings:

• Severity Level 0: no quality issue finding;

• Severity Level 1: quality issue exists with minimal potential for significant adverse effects to the member/recipient;

• Severity Level 2: quality issue exists with significant potential for adverse effects to the member/recipient if not resolved timely;

• Severity Level 3: quality issue exists with significant adverse effects to the member/recipient; dangerous and/or life threatening; and

• Severity Level 4: quality issue exists with the most severe effects to the member/recipient; no longer impacts the member/recipient with the potential to cause harm to others.

Systematic Examination: The word investigation is used by DCS in their investigation of child abuse and neglect. CHP uses the phrase “systematic examination” to convey the same meaning. Systematic examination is the activity that is conducted by the CHP Quality Management (QM) department to thoroughly and systematically examine all aspects of a case for QOC issue determination.

Policy

DCS CHP in partnership with its contracted Managed Care Organization (MCO) systematically examines Quality of Care (QOC) complaints and potential QOC concerns that are identified through a variety internal or external of sources to ensure that the quality of medical services delivered to members meets acceptable standards of care.

DCS CHP requires compliance with all State and Federal requirements.

The majority of DCS CHP’s member population are children placed in out-of-home care who have potential history of abuse and neglect. DCS CHP and its contracted MCO does not investigate incidents that bring members into DCS custody and is careful not to impede DCS investigations. However, if a member is already in DCS care and there are allegations of abuse, neglect, exploitation, suicide attempts, opioid-related concerns, alleged human rights violations, and unexpected deaths, DCS CHP and its contracted MCO examine those allegations for potential QOC concerns while abiding by the DCS investigation jurisdiction constraints. All of these allegations are referred to DCS and the appropriate regulatory agency or reporting bodies, as soon as possible and no later than 24 hours of being made aware of the concern.

Allegations of Health Care Acquired Conditions (HCACs), Other Provider Preventable Conditions (OPPCs), and unexpected deaths are reviewed as QOC concerns. The availability of autopsy results does not impede or delay the systematic evaluation of any cases involving the death of a member.

Systematic examinations of QOC complaints and potential QOC concerns are kept confidential in accordance with ARS§36-2401 through 2404, ARS§36-441, ARS§36-445, and ARS§36-2917 and ARS§41-1959(C) (5).

DCS CHP and its contracted MCO acknowledge receipt of the QOC complaints and potential QOC concerns and provides written explanations to members and/or providers of the process to resolve issues. If the complaint or concern is not appropriate for the QM department, the information is transferred to the appropriate unit for resolution.

The QOC process provides a mechanism to assess the severity of occurrences of substandard care to identify trends in service for an individual or an organization. Those trends are reported to the DCS CHP QM/PI Committee.

DCS CHP and its contracted MCO reports QOC concerns and supporting documentation to AHCCCS through the AHCCCS QM portal as appropriate.

DCS CHP requires its contracted MCO to conduct QOC activities, reviews, investigations, tracking and trending in compliance with AMPM 900 and 960.

The QOC process is a standalone process completed through the QM departments of DCS CHP and its contracted MCO. Areas outside of the QM departments do not conduct QOC evaluations, but may serve as Subject Matter Experts throughout the QOC process.

The QOC process is conducted by appropriately trained individuals, and methods are applied consistently by all staff. Inter-rater activities are required to ensure consistent evaluation of QOCs by staff.

The regulatory agencies are notified of initial concerns, as well as adverse determinations as appropriate. These agencies may include, but are not limited to:

• Department of Child Safety (DCS)

• Adult Protective Services (APS)

• Attorney General Office (AGO)

• Law Enforcement

• AHCCCS Office of Inspector General (OIG)

• AHCCCS Division of Health Care Management (DHCM)

DCS CHP and its contracted MCO comply with the National Committee for Quality Assurance (NCQA) Standards.

Procedure

In collaboration with its contracted MCO, the DCS CHP QM department conducts the QOC review process which includes:

• Identification;

• Triage;

• Collection of information;

• Systematic examination;

• Final determination;

• Interventions and resolution; and

• Conclusion.

The QM departments review reported concerns with Chief Medical Officers (CMO) or designees. The CMO, or designee, provides guidance through triage, information collection, systematic examination, final substantiation, interventions, and case resolution.

Urgent concerns are assigned and completed, within 30 calendar days of opening the case, in the QM portal. Non- Urgent concerns are assigned and completed within 60 calendar days of opening in the QM poral. Concerns that are over 60 days are tracked and an action plan is created to address the case.

If the contracted MCO is unable to complete a QOC in 60 days, an extension request is submitted to AHCCCS and DCS CHP outlining the reasons for the delay. The extension request includes the current status of the member, the status of the investigation, and the barriers to completion.

All pertinent information regarding incidents of abuse, neglect exploitation, serious incident (including suicide attempts), and unexpected death (including transplant) are submitted to AHCCCS via the QM portal.

1. Identification of a QOC Concern

Potential QOC concerns are identified from internal and external sources at DCS CHP or its contracted MCO that include, but are not limited to:

• Members and/or out-of-home caregivers/health care decision makers;

• Custodial agency representatives;

• Health care providers;

• CHP staff;

• Community service agencies;

• Licensing agencies; and/or

• Governmental agencies, including Arizona Health Care Cost Containment System (AHCCCS).

Potential QOC concerns are also identified during routine clinical reviews of members’ care, including but not limited to:

• Concurrent, prospective, and retrospective utilization reviews;

• Care coordination activities;

• Facility site reviews;

• Claims and encounter data;

• Pharmacy utilization data;

• Medical record audits; and

• Complaints/Grievances and Appeals.

All potential QOC concerns are reported to the contracted MCO Quality Management department. If the concern is received outside of the QM portal, it is entered into the portal within two business days.

Sentinel events are entered in to the QM portal within in one business day of discovery, for triage, systematic review and determination.

DCS CHP and its contracted MCO acknowledge receipt of the issue and provide written explanation to the member or provider of the process to be followed to resolve the issue through written correspondence.

2. Triage

DCS CHP and its contracted MCO review all potential QOC concerns upon receipt and initiate a triage process, which may include:

• Identification of immediate safety needs;

• Need for relocation of a member to another facility;

• Determination of the concern as a QOC or non-QOC concern;

• Determination of initial severity levels, allegation categories, and other evaluations;

• Notification of appropriate agencies, and immediate action determinations (i.e. need for on-site review when a Health and Safety concern or Immediate Jeopardy situation is identified);

• Identification of any member needs.

Identified QOC concerns and initial findings are documented in the AHCCCS QM Portal within one business day of determination, as applicable. Systemic concerns and initial findings are reported via secure email to the AHCCCS QM manager, supervisor and assigned QM coordinator. Non-QOC concerns are documented internally and referred to the appropriate unit if applicable (i.e. Grievance, Claims etc.). The grievance and QOC process can occur concurrently if necessary. QOC categories include:

• Abuse;

• Availability, Accessibility, Adequacy;

• Denial, Decrease and Discontinuance of Benefits;

• Effectiveness Appropriateness of Care;

• Exploitation;

• Fraud;

• Health Care Acquired Condition;

• Members Rights Respect and Caring;

• Neglect;

• Other Provider Preventable Condition;

• Safety Risk Management;

• Attempted Suicide;

• Suicide due to Opioid or Polypharmacy Toxicity; and

• Suicide Due to Other Cause.

DCS CHP requires the contracted MCO to notify to DCS CHP and AHCCCS via secure email of any high-profile cases and RED files (sentinel events/ media cases) no later than 24 hours of receipt of the case, followed by an initial finding report within seven business days.

The QOC concern investigation and documentation process is completed within the QM Portal and includes a summary of all applicable research, evaluation, intervention, and resolution details for each case. The QM Portal is updated throughout the case as critical information is discovered.

An initial part of the triage process involves the determination of the need for immediate action, which may include:

• On-site visits conducted by QM clinical and/or MCO staff to address health and safety concerns in collaboration with DCS, visits may be initiated when the health plan is notified of a setting or service site that has reported allegations of deficiencies that may affect the health and safety of a member(s);

• Referral to DCS CHP teams;

• Referral to DCS;

• Referral to external agencies;

• Collaboration with DCS Specialists (custodial agency representatives).

If additional allegations are discovered during the course of the QOC triage subsequent process, they are added to the existing case and systematically evaluated

3. Collection of Information

DCS CHP requires the completion of a QOC opening letter including a detailed records request from the health care provider as indicated by the QOC concern.

Health care providers are expected to make records, policies and procedures available for review and staff and administrators available for interviews.

Review of the Arizona State Board of Pharmacy, Controlled Substances Prescription Monitoring Program (SCAMP) and issues related to opioid use or other controlled substances is required as part of the QOC review.

Information may also be obtained from the guardian, member or caregiver as appropriate.

4. Systematic Examination

DCS CHP requires that the evaluation of the information obtained for Final QOC Determination be conducted by appropriately qualified individuals, who then identify severity and determine/recommend corrective action and resolution. Findings are completed and submitted for secondary review by the DCS CHP CMO or for final review/final determination on level four findings.

5. Final Determination

Second level review process is conducted by DCS CHP’s and/or the MCO’s quality designee within the QOC File/AHCCCS QM portal. Final severity level, allegation(s), substantiation and corrective action plan are completed within the QOC File/AHCCCS QM Portal by CHP’s Quality designee.

Final determination QOCs that are level four are sent to the DCS CHP CMO for second level review and submission to AHCCCS.

Final Determinations are communicated to the provider in writing.

6. Interventions and Resolution

DCS CHP requires the contracted MCO to conduct member and system resolution for all substantiated allegations which may include but are not limited to:

• Peer Committee Review of QOC concerns;

• Corrective Action Plans (CAPs) or actions taken to resolve the concern or gaps in care which may include:

  • Attestation of education/training and sign-in sheets;

  • Implementation of new interventions/approaches;

  • New or changed policies and/or procedures;

• Adverse determinations.

Final Determinations as well as any adverse determination or CAP requirements are communicated to the provider in writing and include findings and required timelines for submission if applicable.

Written resolution correspondence is made available to the member, provider, or caregiver as applicable.

Adverse determinations (suspension, termination etc.) resulting from a QOC concern are reported to the appropriate regulatory agency or law enforcement for further research and/or action as required by law.

All adverse actions are reported to AHCCCS QM Unit and the National Practitioner Data Bank within one business day of final determination.

CAPs are monitored and subsequent actions including CAP approval, periodic updates, monitoring updates, success of interventions, provider technical assistance or training are documented in the QOC file. If the provider is non-responsive to a CAP request or there is a lack of progress toward the desired outcome the issue will be elevated to QM QOC Management and ultimately the QM Medical Director or designee.

7. Conclusion

Closure of the QOC concern may include, but is not limited to:

• A description of the allegation, including any new allegations identified;

• Substantiation and severity level for each allegation as well as the case overall;

• Written response from or summary of the documents received from referrals made to outside agencies (accrediting boards, Medical Examiner, DCS, APS, ADHS, AGs office, law enforcement, AHCCCS/OIG etc.);

• Interventions imposed as part of the investigation;

• Completed Corrective Action Plan including reporting of provider interventions; and

• Any additional information connected with the QOC process, including referrals to regulatory or reporting bodies.

DCS CHP requires that all information is stored according to Health Insurance Portability and Accountability Act (HIPPA) guidelines and HIPAA Privacy Policy.

DCS CHP and/or its contracted MCO notifies AHCCCS Quality Management Unit of any findings of physician failure to follow the Arizona State Board of Pharmacy, Controlled Substances Prescription Monitoring Program (CSPMP) protocol, such as prescribing issues or failure of the provider to check the CSPMP, failure to coordinate care with other prescribers, or referral for substance use treatment or pain management.

DCS CHP reports all actions taken with the provider including suspension or Corrective Action Plans and submits referrals to the appropriate regulatory boards including the Arizona State Board of Pharmacy.

Case findings are reviewed at Peer Review Committee.

QOC Training

All DCS CHP staff are trained within 30 days of hire on QOC, Grievance and Appeals and annually thereafter. Records of training with course content, name of member, department, title, and date are kept and are retrievable for review. This is also the requirement for the contracted MCO.

Tracking and Trending

DCS CHP conducts routine reviews of all documented potential QOC concerns conducted by the contracted MCO to review compliance with the process and procedures required by AHCCCS.

The contracted MCO is required to review cases to determine possible trends related to members, providers, facilities, services, allegation types, severity and substantiation. Proactive care coordination is provided for members who have multiple complaints regarding services or the AHCCCS program.

Tracking of third-party reporting and regulatory agency referrals are completed as needed. All referrals made to third party agencies are tracked and reported.

Documentation and Reporting

New and active QOCs are reported through the AHCCCS QM Portal.

All QOC final resolution reports are redacted in accordance with AMPM to remove all Personally Identifiable Information (PII) and submitted to an Independent Oversight Committee through the AHCCCS QM Portal within three business days of completion of the QOC systematic evaluation.

QOC outcomes and trends are reviewed quarterly at the QM/PI Committee meetings. Trend specifications include provider, facilities, services and allegation types.

The contracted MCO documents and tracts any actions taken in the provider file regarding the QOC concern. Provider trends are reported to DCS CHP. Peer review and credentialing processes are updated as appropriate.

Peer Review referrals and high-level summary documentation of the Peer Review committee decisions are documented in the members QOC file in the QM portal and should include documentation of the credentials of the involved committee members who attended as subject matter experts.

Any adverse action taken with a provider for any reason including QOC are required to be reported to DCS CHP and the National Provider Data Bank (NPDB).

The contracted MCO follows their established protocols for potential QOCs with DCS CHP oversight. Health and safety Onsite Reviews are reported to AHCCCS within 24 hours of completion of the review.