Quality Management Bureau (QMB)
(DDW) Service Provider Self-Assessment
QMB Provider Survey Process
Who is the Quality Management Bureau and how are we connected to your loved one(s) and/or any individual receiving Developmental Disabilities (DD) Waiver Services?
We are the Department of Health, Division of Health Improvement, Quality Management Bureau (DD Waiver Survey Unit). Our primary responsibility is to ensure the health, safety and welfare of your loved one receiving Developmentally Disabled Waiver Services. We do this in several different ways: First and foremost, is by monitoring all DD Waiver provider agencies statewide to ensure compliance with federal and state regulations and second by working closely with other divisions in the Department of Health and other state agencies to assure accountability, compliance and quality from DD Waiver provider agencies.
Our process is only used to determine if the services being provided by an agency meet the fundamental regulations and is not used in any way to cause intimidation or to scare people away from services or close agencies down. We want to work in collaboration with the community to ensure that people with Developmental Disabilities are getting the highest quality services possible.
We too strive to improve the quality of the work we do, by using a continuous quality improvement cycle. In order to do this, we are constantly looking at the work done by our group. Over the past years we have been able to improve our process with feedback from our surveyors, other state agencies, providers, families and individuals. Because of those changes, now that process includes sharing the information gained from our surveys with the public. By doing so we hope that you will be able to make a more informed choice on selecting an Agency to serve your loved one. So with that said, let’s go over some of the basics of our process:
First, How do we choose what agencies are surveyed and what individuals will be seen during that time?
- Agencies are surveyed based on the certification approvals given by QMB, which fall into several categories, the higher the rating the less we need to be on site:
- “Quality Approval Rating”
- “Merit Approval Rating”
- “Standard Approval Rating”
- “Provisional Approval Rating”
- “Probationary Approval Rating”
Prior to a survey being completed we have a preparation period where we begin to collect data to determine our sample. Our sample size is based on several factors, which include the following:
- The size of the Agency (number of Individuals served)
- Services Provided by the Agency (Supported Living, Family Living, Independent Living, Adult Habilitation, Community Access & Supported Employment). Note: Individuals selected in the sample are seen across all services they receive from the Agency.
- A percentage of Individuals with a Health Assessment Tool (HAT) score of 5 or 6.
Secondly, we gather information on the individuals in the sample, such as the Individual Service Plan (ISP).
We do this in order to adequately determine what services the Agency is to be providing for the individual.
Thirdly, we conduct an on-site unannounced survey. During that time our survey teams complete the following:
- An interview with the Agency’s Executive Director
- An interview with Direct Service Personnel
- An interview with the Individual receiving services (when possible)
- An interview with Case Managers (if needed)
- An interview with Parents/Guardian (if needed)
- An interview with other Agency personnel
- A complete review of the Individual’s Agency Record
- A complete review of the Individual’s Residential Record (for those receiving Supported Living or Family Living)
- A review of the Agency’s Policies & Procedures
- A review of the Agency’s Quality Improvement Plan
Once the above items above are reviewed the information gathered is then analyzed by our survey team and Team Leader to determine the compliance level of the agency and what approval rating will be given to the agency. The approval rating is based on all the deficiencies (areas lacking full compliance). As you begin to read our survey reports you will see that each regulation is given what is called a “tag number” which identifies which regulation the agency is out of compliance with. To the right of that you will see what is called “scope and severity rating” that means, the level of non-compliance with the particular regulation. Each scope and severity rating ranges from “A” through “L” as follows:
- Scope and severity ratings which rank in the A through C category are considered “Low Impact” and have a minimal potential for harm.
- Scope and severity ratings which are ranked D through F are considered to be, “Medium impact,” no actual harm, but there may be a potential for more than minimal harm.”
- Scope and severity ratings which are ranked G through I are considered “High Impact” and have caused actual harm and finally ranking of J through L, which means an individual or individuals was at immediate risk regarding their health or safety.
Below is a copy of what we call the “QMB Scope and Severity Matrix of Survey Results,” which will give you a better understanding of the ranking and whether or not the problem is an isolated issue or if it is a widespread issue throughout the agency.
In final, we hope this will give you a clear picture of where an Agency falls when it come to determining compliance with regulations under the DD Waiver program.
Scope and Severity Definitions:
Key to Scope scale:
Isolated:
A deficiency that is limited to 1% to 15% of the sample, usually impacting no more than one or two individuals in the sample.
Pattern:
A deficiency that impacts a number or group of individuals from 16% to 79% of the sample is defined as a pattern finding. Pattern findings suggest the need for system wide corrective actions.
Widespread:
A deficiency that impacts most or all (80% to 100%) of the individuals in the sample is defined as widespread or pervasive. Widespread findings suggest the need for system wide corrective actions as well as the need to implement a Continuous Quality Improvement process to improve or build infrastructure. Widespread findings must be referred to the Internal Review Committee for review and possible actions or sanctions.
Key to Severity scale
Low Impact Severity: (Blue)
Low level findings have no or minimal potential for harm to an individual. Providers that have no findings above a “C” level may receive a “Quality” Certification approval rating from QMB.
Medium Impact Severity: (Tan)
Medium level findings have a potential for harm to an individual. Providers that have no findings above a “F” level and/or no more than two F level findings and no F level Conditions of Participation may receive a “Merit” Certification approval rating from QMB.
High Impact Severity: (Green or Yellow)
High level findings are when harm to an individual has occurred. Providers that have no findings above “I” level may only receive a “Standard” Approval rating from QMB and will be referred to the IRC.
High Impact Severity: (Yellow)
“J, K, and L” Level findings:
This is a finding of Immediate Jeopardy. If a provider is found to have “I” level findings or higher, with an outcome of Immediate Jeopardy, including repeat findings or Conditions of Participation they will be referred to the Internal Review Committee.
