Medicaid Managed Care - U.S. Senate Special Committee on Aging

More Development of
Promising Quality
Assurance
Approaches Needed
to Reduce Potential
Risks
=
States Continue to Use
Traditional Mechanisms to
Assure Adequate Quality
B20
435
To increase quality for recipients and families, states are introducing
promising quality assurance innovations while simultaneously building in
more flexibility in traditional quality assurance mechanism These
changes are intended to provide recipients and families with a greater
choice of services within appropriate budget and safety limits. However,
until states more comprehensively develop and test these approaches,
some recipients may face health and safety risks and others may not have
access to the range of choices state programs seek to provide.
One of the most important mechanisms that states use to assure adequate
quality is service standards. Each state, as required by HCFA guidelines,
adopts or develops standards for each waiver service. Waiver standards
are specified in state and local laws, regulations, or operating guidelines
and are enforced by specific agencies. As a result waiver standards reflect
specific state processes and choices in how states assure quality, and are
not uniform across the nation as are ICF/nM standards. (For example, see
app. IV for a summary of how Florida meets HCFA requirements for
speciying waiver standards.) Waiver standards may include professional
licensing standards, minimum training requirements for staff and criminal
background checks for providers. The standards may also include
requirements for certification of group home or other facilities and
compliance with local building codes and fire and safety requirements.
States review providers and services on an ongoing basis and have abuse
and neglect reporting procedures in place. Florida, Michigan, and Rhode
Island, for example, conduct routine and unannounced reviews of
providers. As a result of these reviews, providers can be required to
provide plans of correction for identified problems and implement
improvements. In some cases, providers have lost their certification to
participate in the program. These states also have formal grievance
procedures and a grievance unit, such as a state agency or human rights
committee, to investigate complaints on a statewide, regional, or agency
basis. Through these processes, the states have also identified problems in
quality and taken steps to ensure corrective action.
In addition to state quality assurance efforts, HcFA regional staff conduct a
compliance review of each state's waiver program before its renewal. HCFA
uses a compliance review document for this process. HCFA reviews involve
random selections of recipients for interviews and visits to their homes.
The reviews also involve interviews with and visits to service providera
P.e 17
GAP 1Mo9&2.0-s W.1- P a0- A. D.1-sUsy DIsad