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 improvement plan used to improve performance of the Contractor and/or its providers, enhance QM/PI activities and the outcomes of those activities, or resolve a deficiency. The improvement plan includes the root cause(s) of a deficiency, goals and objectives, actions to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish the goals and objectives, and staff responsible to carry out the activities within established timelines.

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. It does so through the administration of evidence-based standards, measures, programs and accreditation.

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:An allegation that any aspect of care, or treatment, utilization of behavioral health services or utilization of physical health care services that caused or could have caused an acute medical or psychiatric condition or an exacerbation of a chronic medical or psychiatric condition and may ultimately cause the risk of harm to an AHCCCS member.

Quality of Care (QOC) Review Processes: Evaluation of IADs, IRFs, SARs, Grievance and Appeals for QOCs are all considered QOC review processes.

Incident of Seclusion and/or Restraint: An incident of seclusion and/or restraint:

• Begins at the time a behavior necessitating seclusion or restraint begins, and

• Ends when the behavior has resolved for more than ten minutes.

All interventions used during each incident should be documented in a single individual report including all required components of each type of intervention used to manage the behavior.

Seclusion: The restriction of a member to a room or area through the use of locked doors or any other device or method which precludes a member from freely exiting the room or area or which a member reasonably believes precludes their unrestricted exit as specified in AAC R9-21-101(B).

In the case of an inpatient facility, confining a client to the facility, the grounds of the facility, or a ward of the facility does not constitute seclusion. In the case of a community residence, restricting a client to the residential site, according to specific provisions of a service plan or court order, does not constitute seclusion, as specified in AAC R9-21-101(B).

Seclusion and Restraint Reports (SAR): A report entered into the AHCCCS Quality Management (QM) Portal by the health plan upon receipt of provider documentation of an incident of seclusion and/or restraint. The documentation includes information provided by the health care provider that includes the details of the incident, and all the required components of the interventions used during each incident to manage the behavior in a single report.

Restraint: Personal restraint, mechanical restraint or drug used as a restraint and is the following as specified in 42 CFR 482.13(e)(1):

Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a behavioral health recipient to move his or her arms, legs, body, or head freely.

• A drug or medication when it is used as a restriction to manage the behavioral health recipient’s behavior or restrict the behavioral health recipient’s freedom of movement and is not a standard treatment or dosage for the behavioral health recipient’s condition.

• A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a behavioral health recipient for the purpose of conducting routine physical examinations or tests, or to protect the behavioral health recipient from falling out of bed, or to permit the behavioral health recipient to participate in activities without the risk of physical harm (this does not include a physical escort).

Chemical Restraint: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Refer to 42 CFR 482.13 (e)(1)(I)(B). Chemical Restraints shall be interpreted and applied in compliance with the Center for Medicaid Services (CMS) State Operations Manual, for further Regulations and Interpretive Guidelines for Hospitals.

Mechanical Restraint: Any device, article, or garment attached or adjacent to a member’s body that the member cannot easily remove and that restricts the member’s freedom of movement or normal access to the member’s body, but does not include a device, article, or garment:

• Used for orthopedic or surgical reasons, or

• Necessary to allow a member to heal from a medical condition or to participate in a treatment program for a medical condition.

Personal Restraint: The application of physical force without the use of any device, for the purpose of restricting the free movement of a member’s body. For Behavioral Health Inpatient Facility (BHIF) or outpatient treatment centers licensed to provide behavioral health observation/stabilization services (Crisis Facility), personal restraint does not include:

• Holding a member for no longer than five minutes, without undue force, in order to calm or comfort the member.

• Holding a member’s hand to escort the member from one area to another.

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. DCS CHP uses the phrase “systematic examination” to convey the same meaning. Systematic examination is the activity that is conducted by the DCS 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 of internal or external sources/processes to ensure that the quality of medical services delivered to members meets acceptable standards of care.

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 do 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.

Providers are required to enter Incident Accidents or Deaths (IADs) into the AHCCCS QM Portal. If the health plan identifies any potential quality issues, the health plan enters them into the portal as Internal Referrals (IRFs). Providers are also required to report Seclusion and Restraints (SARs) to the health plan, who then enters them into the AHCCCS QM Portal. These are all part of the quality-of-care review system to identify, track and evaluate issues for quality of care. Complaints, Grievance and Appeals are also reviewed for potential quality of care issues. The grievance resolution process is independent of the quality-of-care review processes and may occur concurrently.

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 examination 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 during a quality-of-care review process to members and/or providers of the process to resolve issues, as appropriate. If the complaint or concern is not appropriate for the Quality Management (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. These 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 reliability activities are required to ensure consistent evaluation of QOCs by staff.

DCS CHP and its contracted MCO review all concerns to identify all suspected cases of abuse, neglect, and exploitation of a member, to verify that these concerns are reported to all appropriate authorities, by the provider directly or by DCS CHP or its contracted MCO, if not completed by the provider. 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.

Evaluation of IADs, IRFs, SARs, Complaints/Grievance and Appeals for QOCs are all part of the QOC review process and can be initiation points for QOC systematic examinations.

Seclusion and Restraint Reports

BHIFs and Mental Health Agencies, which are authorized to use Seclusion and Restraints (SAR) as specified in A.A.C. R9-21-101, A.A.C. R9-10-225, A.A.C. R9-10-316, and R9-10-1012 follow the reporting requirements.

• Each BHIF or Mental Health Agency shall submit individual reports of incidents of SAR involving AHCCCS members, directly to the health plan within five business days of the incident utilizing AMPM 962 Attachment A or the agency’s electronic medical record that includes all elements listed on AMPM 962 Attachment A which includes:

  • Member demographics

  • Current diagnoses

  • Medication details

  • Event information

  • De-escalation methods and all less restrictive measures attempted

  • Information on personal, mechanical restraints, medications used as restraint, and/or seclusion, as well as reasons for the restraint/seclusion

  • Information on face-to-face assessment

  • Clinical justification to discontinue seclusion or restraint

  • Information on any physical injuries

• Follow up actions (notifications, need for other interventions, treatment plan changes).

• In the event that the use of SAR requires face-to-face monitoring as specified in A.A.C. R9-21-204, the provider is required to submit a supplemental report as an attachment to the individual report.

• BHIFs and Mental Health Agencies shall report incidents of SAR whichthat result in an injury or complication requiring medical attention to the health plan within 24 hours.

• When out of state facilities to provide services to AHCCCS members in any state other than Arizona, the contracted MCO ensures that each facility agrees to and follows all reporting requirements as specified by AHCCCS as a part of the contracted single case agreement.

When providers do not adhere to the requirements for reporting SARs, the appropriate provider outreach and education is provided to address incomplete or inaccurate documentation or documentation that is not provided timely.

The health plan enters information submitted by the provider into the AHCCCS QM Portal. Within 3 business days of the provider submission. The provider submission is attached to the SAR record with in the AHCCCS QM Portal. QuickStart SAR

In evaluation of the SAR, the health plan reviews the provider SAR submission and links the SAR report to any connected Incident Accident or Death (IAD), Internal Referral (IRF), or Quality of Care Concern (QOC) process within the AHCCCS QM Portal at QMportal.azahcccs.gov as specified in AMPM Policy 960 and AMPM Policy 961.

Incident Accident and Death (IAD) & Internal Referrals (IRFs)

All high profile, media, and sentinel events can be reported to the health plan by individual and organizational providers, members, or family members at any time of day including evenings, weekends, and holidays. The health plan then enters these events as Internal Referrals (IRFs) into the AHCCCS QM Portal. Healthcare providers are required to report IADs into the AHCCCS QM Portal.

IADs and IRFs are then evaluated by the QM unit for quality of care issues.

A reportable IAD includes:

• Allegations of abuse, neglect, or exploitation of a member,

• Death of a member,

• Delays or difficulties in accessing care (e.g., outside of the timeline specified in ACOM Policy 417),

• Healthcare acquired conditions and other provider preventable conditions (refer to AMPM Policy 960 and AMPM Policy 1020),

• Serious injury,

• Injury resulting from the use of a personal, physical, chemical, or mechanical restraint or seclusion (refer to AMPM Policy 962),

• Medication error occurring at a licensed residential Provider site including:

• Behavioral Health Residential Facility (BHRF),

  • DDD Group Home, DDD Adult Developmental Home, DDD Child Developmental,

  • Assisted Living Facility (ALF),

  • Skilled Nursing Facility (SNF),

  • Adult Behavioral Health Therapeutic Home (ABHTH),

  • Therapeutic Foster Care Home (TFC), and

  • any other alternative Home and Community Based Service (HCBS) setting as specified in AMPM Policy 1230-A and AMPM Policy 1240-B.

• Missing person from a licensed Behavioral Health Inpatient Facility (BHIF), BHRF, DDD Group Home, ALF, SNF, ABHTH, or TFC,

• Member suicide attempt,

• Suspected or alleged criminal activity, and

• Any other incident that causes harm or has the potential to cause harm to a member.

Sentinel IADs include:

• 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 upon presentation to a healthcare setting,

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

• Sexual abuse/assault on a member during the provision of services regardless of the perpetrator,

• 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.

Submissions of IADs and IRFs into the AHCCCS QM portal must meet timeliness requirements in accordance with AMPM 960, 961 and 962. IRFs must also include reporting sources and the date the health plan was made aware of the incident.

All IADs and IRFs are submitted into the AHCCCS QM Portal within two business days of the occurrence or within two business days of notification to the health plan or provider of the occurrence.

• Sentinel IADs shall be submitted by the Contractor or provider into the AHCCCS QM Portal within one business day of the occurrence or within one business day of becoming aware of the occurrence.

AHCCCS is notified of all sentinel events via email at CQM@azahcccs.gov immediately, but within 24 hours of notification of the occurrence.

All IADs and IRFs are reviewed within one business day of entry into the AHCCCS QM Portal. The initial review includes:

• Identification of any immediate health and safety concerns and ensure the safety of the individuals involved in the incident, which may include provision of immediate care and recovery needs,

• Determination if the IAD report needs to be returned to the provider for additional information (e.g., report is assigned to the wrong Contractor, enrollment category is not selected, incident type is not correct or not selected, information is missing or incorrect),

  • IADs returned to the provider require health plan follow up within one business day to ensure the provider is aware that the report has been returned and is working on the corrections.

• Determination if the IAD report requires further investigation through a Quality of Care (QOC) systematic examination (refer to AMPM Policy 960),

• Determination if the IAD needs to be linked to a corresponding Seclusion and Restraint (SAR) Individual Reporting Form (refer to AMPM Policy 962), or

• Determination if the IAD report does not need further documentation or review and closure of the report.

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

Incomplete and/or unreviewed IADs and SARs in the AHCCCS QM Portal as required are reviewed and addressed with regular cadence to address any needed provider education and determine the need for completion or cancellation due to duplication.

Urgent QOC concerns are assigned and completed within 30 calendar days of opening the case in the QM portal, as set forth in AMPM 960. Non- Urgent QOC concerns are assigned and completed within 60 calendar days of opening the case in the QM portal. 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/processes 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;

• DCS CHP staff;

• Community service agencies;

• Licensing agencies; and/or

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

• Evaluation of IADs, IRFs, SARs, Complaints/Grievance and Appeals for QOCs.

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; and

• Medical record audits.

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.

During the quality-of-care review process 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 as needed.

2. Triage

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

• Identification of immediate action/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 DCS 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 notify 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.

These Case findings are reviewed at Peer Review Committee.

Member Engagement and Communication

Quality Management (QM) staff may engage members and stakeholders during Quality of Care (QOC) review process, in accordance with Arizona AHCCCS AMPM Policy 960.

Engagement may entail:

• Direct interviews of members, family members/HCDMs, direct care staff, and other witness(es) to a reportable event, when applicable and appropriate,

  • Member interviews may include children and their Heath Care Decision Makers (HCDMs) as applicable and appropriate,

  • Any interview must factor any legal/police or forensic interviews that may need to occur and must avoid tainting the investigation,

  • For children in foster care- interviews of the child should be cleared with the guardian if there is any concern about a forensic or criminal investigation.

• Written Acknowledgement/Resolution- All QM Department correspondence to communicate with members during a quality-of-care review process adheres to the confidentiality requirements. All information of a case is for Quality Management purposes only and is strictly confidential under one or more of the following: 42 USC 1320c-9; 42 U.S.C. 11101 et seq.; A.R.S. § 8-542; ARS § 36-441; ARS § 36-445; A.R.S. §§ 36-2401 through 2404; A.R.S. § 36-2917; ARS § 41-1959(C)(5); AHCCCS/MCO Contracts, and AHCCCS Medical Policy Manual (AMPM) Chapter 900, and any other applicable confidentiality laws, rules and/or regulations that are not outlined above.

  • During the quality -of- care review process DCS CHP and its contracted MCO acknowledge receipt of the issue and provide providing explanation to the member or provider of the process that will be followed to resolve the reported concern through written correspondence, when applicable.

  • For Internal Referral Forms (IRFs) from Grievances and Appeals that evaluated through the quality-of-care review process, letters may be issued of acknowledgment, followed by a response letter upon conclusion of the investigation, as applicable and in compliance with confidentiality requirements outlined above.

  • When a Quality of Care (QOC) or Health and Safety concern is generated by AHCCCS, regulatory bodies, or through an internal referral, the acknowledgment and resolution are reported through the portal.

  • For concerns that are determined to not be a QOC concern, the submitter of concern is notified of the process to be used to resolve the concern. The instructions/ explanation to the submitter clearly document the rationale for the determination and the appropriate process that will be followed to address the concern.

Member engagement documentation may be captured in the quality-of-care review resolution report and include the content and details of any verbal communication.

Redaction and submission to IOC

As DCS CHP is a pediatric only health plan all SARs, IADs, IRFs and QOCs and attachments are to be submitted to the IOC. The health plan follows all requirements needed to complete this activity as outlined in AMPM 960, including the removal of all Personally Identifiable Information (PII) prior to submission as specified in A.R.S. §41-3804. Disclosure of protected health information (PHI) must be in accordance with state and federal laws.

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 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

All IADs, IRFs, SARs, Complaints/Grievance and Appeals and QOC reviews are tracked and trended to identify and address systemic concerns or issues within the provider network.

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, systemic QOCs are submitted via secure email, to the AHCCCS QM Manger, Supervisor and assigned QM Coordinator when applicable.

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 Quality Management/Performance Improvement (QM/PI)Committee meetings. Trend specifications include provider, facilities, services and allegation types.

The contracted MCO documents and reviews 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 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 via the AMPM attachment 960C.

Oversight and Training of Subcontractor

DCS CHP maintains oversight and training of its subcontractor to ensure compliance with the objectives of its policies. Part of this oversight and training may include but not be limited to review of SAR reports, IADs IRFs and QOCs for timeliness and completeness of documentation, audits to address compliance with requirements, performance reviews, review of deliverables collected on DCS CHP’s behalf, and requiring documented training of the subcontracted staff. DCS CHP QM Department holds annual and ad hoc meetings with its subcontractor to review findings which may include, but not be limited to, policy changes, performance, compliance issues, and discuss any necessary improvements. Any subcontractor deviations or non-compliance may be addressed through a corrective action plan.