Common use of Compliance Rating Partial Compliance Clause in Contracts

Compliance Rating Partial Compliance. Assessment, as with other services, needs to have clear standards regarding timeliness for that service. For example, a CSED Waiver assessment versus a CMCR assessment would have different timeliness standards to access assessment. Specific timeliness standards and related oversight and monitoring are not available for all services. Chapter 502, the CSED manual, notes that “The BMS contracts with a MECA to determine initial and re-determination eligibility of prospective and active persons and to recruit and train licensed clinicians to participate in the Independent Evaluator Network (IEN). The ASO and the MECA work together to process initial applications and re-determination packets.” The Achieving Safety, Permanency and Well Being For West Virginia’s Children, A Knowledge and Skills-Based Curriculum includes information that children must be independently evaluated but does not include timeliness for the assessment itself. The State of West Virginia Department of Health and Human Resources (DHHR) Bureau for Behavioral Health (BBH) Pathway to Children’s Mental Health Services Phase 1 Reference Guide notes that for the CSED Waiver, “KEPRO will then review the application, contact the child, family, BSS worker, or other legal guardian to complete the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business-day period, and notify BBH at xxxxxxxxxxxxxxxxxxxx@xx.xxx within three business days whether the individual will be further evaluated for the CSED Waiver, based on the CAFAS score. If the CAFAS score is 90 or above, KEPRO will assign an evaluator to complete the CSED Waiver evaluation process to determine eligibility, which typically takes 21-45 days.” The CMCRS Draft Manual notes that “MCRS services will be provided up to eight weeks; will take place in family homes, schools, group care, and other settings that are natural to the youth and family; and will include such services as: crisis intervention, crisis assessment, the development of a crisis plan which will include presumptive eligibility for crisis services (i.e., the family and youth determine whether it is a crisis), engagement, de-escalation, assessment, planning, and the coordination of supports and other services as needed” [emphasis added]. The Children’s Crisis and Referral Line Data Update January – December 2021 notes that as of January 2022, “staff are trained to incorporate the Assessment Pathway screening into calls when appropriate to help individuals further connect to key services to meet their needs.” The Bureau of Juvenile Services (BJS) Detention Referrals to Children with Serious Emotional Disorder (CSED) Waiver Standard Operating Procedure (SOP) details the steps needed to refer children to the assessment pathway but does not include explicit timelines. In that document the State notes “DHHR is in the process of designing a data plan template for all related data tracking, such as for referrals for youth involved in BJS, to include indicators such as data source, frequency, owner, and any guidance on reviewing data. In the interim, BJS will track data manually with spreadsheets, which can then be compared with KEPRO data, as an example of tracking youth who applied for CSED Waiver enrollment.” The SME expects to review this data in the next report cycle. The Pathway to Children’s Mental Health Services Bureau for Social Service specifies that “When a child is placed immediately in an emergency shelter or directly into a residential mental health treatment facility (RMHTF) prior to the completion of the FAST/Ongoing Assessment or any screening for mental health needs, the child welfare worker will immediately complete a CSED Waiver Application for the child (within 24 to 48 hours of placement) and submit to KEPRO for a thorough assessment of needs.” The same document requires an Aetna managed care coordinator “[to] ensure the child welfare worker has access to all relevant data to be reviewed and will schedule a meeting to occur within seven business days with the Aetna managed care coordinator, the child welfare worker, and the residential provider. The Aetna managed care coordinator and the child welfare worker will review the results of the CANS, CAFAS/PECFAS, Monthly Progress Report, treatment plan, and any other relevant data.” The SME requests documentation of how the State is monitoring these timelines, as well as any CQI plans or corrective processes it uses to correct deficiencies. Timeliness indicators are noted above in Agreement Number 24. In addition, the Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) also includes measures related to mobile crisis services (see Table 6) but lacks information on frequency of review, who is responsible for review, and guidance for review. As the KPIs have not yet been finalized, no data has been provided to the SME to review. Training must also reflect the expectation that assessment is provided to address urgent needs, including initial and continuing education; coaching; curricula, including seat-time and competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific as to deliver the services in a manner that is likely to accomplish the Agreement goals. AGREEMENT REQUIREMENT 28.1 Aforementioned mental health services [assessment] will be provided in consultation with the child and family.

Compliance Rating Partial Compliance. Assessment, as with other services, needs to have clear standards regarding timeliness for that service. For example, a CSED Waiver assessment versus a CMCR assessment would have different timeliness standards to access assessment. Specific timeliness standards and related oversight and monitoring are not available for all services. Chapter 502, the CSED manual, notes that “The BMS contracts with a MECA to determine initial and re-determination eligibility Accessibility of prospective and active persons and to recruit and train licensed clinicians to participate assessments is addressed in the Independent Evaluator Network (IEN). The ASO and the MECA work together to process initial applications and re-determination packets.” The Achieving Safety, Permanency and Well Being For West Virginia’s Children, A Knowledge and Skills-Based Curriculum includes information that children must be independently evaluated but does not include timeliness for the assessment itselfpreceding requirements. The State of West Virginia Department of Health amended its CSED waiver to expand who may conduct an independent evaluation (IE) from licensed psychologists to supervised psychologists, licensed independent clinical social workers, and Human Resources (DHHR) Bureau for Behavioral Health (BBH) Pathway to Children’s Mental Health Services Phase 1 Reference Guide notes that for licensed professional counselors. This expansion improves accessibility statewide by widening the potential independent evaluation network. The WV CSED WaiverWaiver Frequently Asked Questions Updated 1/1/2022 document includes a question regarding accessibility: “There are no Independent providers listed in my area, “KEPRO will then review the application, contact closest one is over an hour away! How can I get my child evaluated? OR The provider in my area can’t evaluate my child within the child, family, BSS worker, or other legal guardian to complete the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business14-day periodtimeline, and notify BBH now what?” with the response “Please contact PC&A [Psychological Consultation & Assessment, Inc.] to assist you to find a provider in their network at xxxxxxxxxxxxxxxxxxxx@xx.xxx within three business days whether the individual will be further evaluated for the CSED Waiver, based on the CAFAS score. If the CAFAS score is 90 or above, KEPRO will assign an evaluator to complete the CSED Waiver evaluation process to determine eligibility, which typically takes 21-45 days304.776.7230.” The CMCRS Draft Manual notes that “MCRS services will be provided up to eight weeks; will take place in family homesHowever, schools, group care, and other settings that are natural to the youth and family; and will include such services as: crisis intervention, crisis assessment, the development of a crisis plan which will include presumptive eligibility for crisis services (i.e., the family and youth determine whether it is a crisis), engagement, de-escalation, assessment, planning, and the coordination of supports and other services as needed” [emphasis added]. The Children’s Crisis and Referral Line Data Update January – December 2021 notes that as of January 2022, “staff are trained to incorporate the Assessment Pathway screening into calls when appropriate to help individuals further connect to key services to meet their needs.” The Bureau of Juvenile Services (BJS) Detention Referrals to Children with Serious Emotional Disorder (CSED) Waiver Standard Operating Procedure (SOP) details the steps needed to refer children to the assessment pathway but does not include explicit timelines. In that document the State notes “DHHR is in the process of designing a data plan template for all related data tracking, such as for referrals for youth involved in BJS, to include indicators such as data source, frequency, owner, and any guidance on reviewing data. In the interim, BJS will track data manually with spreadsheets, which can then be compared with KEPRO data, as an example of tracking youth who applied for CSED Waiver enrollment.” The SME expects to review this data in the next report cycle. The Pathway to Children’s Mental Health Services Bureau for Social Service specifies that “When a child is placed immediately in an emergency shelter or directly into a residential mental health treatment facility (RMHTF) prior to the completion of the FAST/Ongoing Assessment or any screening for mental health needs, the child welfare worker will immediately complete a CSED Waiver Application for the child (within 24 to 48 hours of placement) and submit to KEPRO for a thorough assessment of needs.” The same document requires an Aetna managed care coordinator “[to] ensure the child welfare worker has access to all relevant data to be reviewed and will schedule a meeting to occur within seven business days with the Aetna managed care coordinator, the child welfare worker, and the residential provider. The Aetna managed care coordinator and the child welfare worker will review the results of the CANS, CAFAS/PECFAS, Monthly Progress Report, treatment plan, and any other relevant data.” The SME requests documentation of unclear how the State monitors and oversees calls to PC&A to ensure that families seeking an independent evaluation are being assisted such as quality reviews, call tracking, complaints, etc. It is monitoring these timelinesalso unclear how this information is conveyed to families; the FAQ does not appear on the CSED website (xxxxx://xxxx.xx.xxx/bms/Programs/WaiverPrograms/CSEDW/Pages/SED.aspx) which is linked to from the WV Child Welfare Collaborative website (xxxxx://xxxxxxxxxxxx.xx.xxx/initiatives/Pages/WV-Wraparound.aspx). Chapter 502 states, “At times, the ASO, in collaboration with BMS, will provide answers to policy questions, which will serve as well as any policy clarifications. These policy clarifications will be posted on the CSEDW website” but no such policy clarification have yet been posted. To fully comply with this requirement, the State will need to provide additional documentation regarding how it ensures statewide accessibility to assessment. Such documentation could take the form of a list and map of IEs locations; operating hours of IEs, including those that offer evening and/or weekend hours or transportation assistance; methodologies for measuring and ensuring time and distance by region or county; recruitment and retention efforts of IEs; provider contracts; SOPs; family surveys of accessibility; and CQI processes and/or corrective action plans or corrective processes it uses to correct deficiencies. Timeliness indicators are noted above in Agreement Number 24. In addition, the Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) also includes measures related to mobile crisis services (see Table 6) but lacks information on frequency of review, who is responsible for review, and guidance for review. As the KPIs have not yet been finalized, no data has been provided to the SME to review. Training must also reflect the expectation that assessment is provided to address urgent needs, including initial and continuing education; coaching; curricula, including seat-time and competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific deficiencies as to deliver the services in a manner that is likely to accomplish the Agreement goalsthey may arise. AGREEMENT REQUIREMENT 28.1 Aforementioned mental health 40.3 Provide families and children with accurate, timely, and accessible information regarding in-home and community-based services available in their communities. [assessment] will be provided in consultation with the child and familyAssessment].

Compliance Rating Partial Compliance. Assessment, as Wraparound for children with other services, needs to have clear standards regarding timeliness for that service. For example, a CSED Waiver assessment versus a CMCR assessment would have different timeliness standards to access assessment. Specific timeliness standards and related oversight and monitoring are not SED is available for all services. Chapter 502, statewide through the CSED manualWaiver, notes that “The BMS contracts with and BBH; and through Safe at Home only as an interim service while a MECA to determine initial and re-determination child completes their eligibility of prospective and active persons and to recruit and train licensed clinicians to participate in the Independent Evaluator Network (IEN). The ASO and the MECA work together to process initial applications and re-determination packets.” The Achieving Safety, Permanency and Well Being For West Virginia’s Children, A Knowledge and Skills-Based Curriculum includes information that children must be independently evaluated but does not include timeliness for the assessment itself. The State of West Virginia Department of Health and Human Resources (DHHR) Bureau for Behavioral Health (BBH) Pathway to Children’s Mental Health Services Phase 1 Reference Guide notes that for the CSED Waiver. Provider lists in WF Capacity Deployed Across BBH CSED and SAH (March 2022) show statewide coverage. The SME notes that for children enrolled in the CSED waiver, the West Virginia Wraparound/Assessment Pathway Frequently Asked Questions (FAQ) from Wraparound Providers Question 23 states there is a single Wraparound provider available to children and families in the eastern panhandle (Homebase) (Question 26 says three providers have signed contracts with Aetna but only one is providing services). During the review period of a draft of this report, DHHR verbally indicated that a second provider, KVC, became available in the Eastern Panhandle as of April 1, 2022, but the SME has not yet received documentation related to this provider. Chapter 502 notes that “KEPRO In order to facilitate coordination of care, the ASO will then review notify the application, contact MCO administering the child, family, BSS worker, or other legal guardian to complete CSEDW when a new waiver member is determined eligible so that the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business-day period, and notify BBH at xxxxxxxxxxxxxxxxxxxx@xx.xxx member may begin receiving services within three business days whether of the individual will be further evaluated eligibility determination for waiver enrollment as long as there is not a waitlist for services.” The manual requires the CSED Waiver, based on the CAFAS score. If the CAFAS score is 90 or above, KEPRO will assign an independent evaluator to complete the evaluation within 14 days of the kept appointment and for the contracted agency to make a final medical eligibility determination within seven days of the completed independent evaluation. Appendix A required the Initial Plan of Care to be developed within seven days of intake. The CSED Waiver evaluation process to determine eligibility, which typically takes Enrollment Updated Stats July 21-45 Dec. 21 shows that average (mean) days from the time an application was received to determination (approved, closed, or denied) is 34.5 days.” The CMCRS Draft Manual notes that “MCRS services will be provided up to eight weeks; will take place in family homes, schools, group care, and other settings that are natural to the youth and family; and will include such services as: crisis intervention, crisis assessment, the development of a crisis plan which will include presumptive eligibility for crisis services (i.e., the family and youth determine whether it is a crisis), engagement, de-escalation, assessment, planning, and the coordination of supports and other services as needed” [emphasis added]. The Children’s Crisis and Referral Line Data Update January – December 2021 SME notes that as of January 2022, “staff are trained to incorporate the Assessment Pathway screening into calls when appropriate to help individuals further connect to key services to meet their needs.” The Bureau of Juvenile Services (BJS) Detention Referrals to Children with Serious Emotional Disorder (CSED) Waiver Standard Operating Procedure (SOP) details the steps needed to refer children to the assessment pathway but does not include explicit timelinessignificant improvement in this timeline. In that document the State notes “DHHR is in the process of designing a data plan template for all related data tracking, such as for referrals for youth involved in BJS, to include indicators such as data source, frequency, owner, and any guidance on reviewing data. In the interim, BJS will track data manually with spreadsheets, which can then be compared with KEPRO data, as an example of tracking youth who applied for CSED Waiver enrollment.” The SME expects to review this data in the next report cycle. The Pathway to Children’s Mental Health Services Bureau for Social Service specifies that “When a child is placed immediately in an emergency shelter or directly into a residential mental health treatment facility (RMHTF) prior to the completion of the FAST/Ongoing Assessment or any screening for mental health needs, the child welfare worker will immediately complete a CSED Waiver Application for the child (within 24 to 48 hours of placement) and submit to KEPRO for a thorough assessment of needs.” The same document requires an Aetna managed care coordinator “[to] ensure the child welfare worker has access to all relevant data to be reviewed and will schedule a meeting to occur within seven business days with the Aetna managed care coordinator, the child welfare worker, and the residential provider. The Aetna managed care coordinator and the child welfare worker will review the results of the CANS, CAFAS/PECFAS, Monthly Progress Report, treatment plan, and any other relevant data.” The SME requests documentation of how the State is monitoring these timelines, as well as any CQI plans or corrective processes it uses to correct deficiencies. Timeliness indicators are noted above in Agreement Number 24. In addition, While the Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) also includes measures indicators related to mobile crisis services timeliness (see Table 62) but lacks information and provider capacity (which is inextricably linked to timeliness), many of those indicators lack details on the frequency of review, who is responsible for review, and guidance for review. As The Quality Assessment and Performance Improvement (QAPI) Update notes that monthly reviews data are set to begin later this spring. The SME anticipates receiving data related to indicators for provider capacity and timeliness in the KPIs have not yet been finalizednext report cycle. DHHR has also began tracking wraparound facilitators in a multi-tab Excel spreadsheet (WF Capacity Deployed Across BBH CSED and SAH (March 2022)) that over time can be paired with youth access data to inform sufficiency of the provider network and regions where expanded capacity is needed. To fully comply with this requirement, no data has been provided the State will need to provide additional documentation such as the SME to review. Training must also reflect the expectation that assessment is provided to address urgent needsfinalized West Virginia Wraparound manual and/or other provider manuals, including initial SOPs, training curriculum, bulletins and continuing educationother transmittals; coaching; curricula, including seat-time and competency-based staffing requirements; billing and training evaluation practices reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to ensure the training is sufficiently robust providers and specific as to deliver the stakeholders. AGREEMENT REQUIREMENT 24.1 & 24.2 Aforementioned services will be provided in a manner that is likely to accomplish the Agreement goals. AGREEMENT REQUIREMENT 28.1 Aforementioned mental health services [assessment] will be provided in consultation with enable the child to remain with or return to the family (or xxxxxx/kin/independent living where applicable) whenever possible to prevent crises and familypromote family stability.

Compliance Rating Partial Compliance. Assessment, as with other services, needs Ensuring timely access to have HCBS requires a clear standards regarding timeliness for that service. For example, a CSED Waiver assessment versus a CMCR assessment would have different timeliness standards pathway to access assessment. Specific timeliness standards and related oversight and monitoring are not available for all services. Chapter 502, the CSED manual, notes that “The BMS contracts with a MECA to determine initial and re-determination eligibility of prospective and active persons and to recruit and train licensed clinicians to participate in the Independent Evaluator Network (IEN)care. The ASO and the MECA work together to process initial applications and re-determination packets.” The Achieving Safety, Permanency and Well Being For West Virginia’s Children, A Knowledge and Skills-Based Curriculum includes information that children must be independently evaluated but does not include timeliness for the assessment itself. The State of West Virginia Department of Health and Human Resources (DHHR) Bureau for Behavioral Health (BBH) Pathway to Children’s Mental Health Services Phase 1 Reference Guide notes includes information on how children and families may be connected with the Assessment Pathway directly or via their primary care provider, children’s crisis line, or Children’s Mobile Crisis Response and Stabilization team. The SME wishes to acknowledge the State’s extensive efforts to define the pathway, and that for the State began its roll-out in late January 2022. Families with behavioral health concerns are directed to complete the CSED WaiverWaiver application and email or mail it to KEPRO. Upon receiving a CSED Waiver application, “KEPRO will email BBH at xxxxxxxxxxxxxxxxxxxx@xx.xxx to notify BBH the application was received within one business day of application receipt. KEPRO will then review the application, contact the child, family, BSS worker, or other legal guardian to complete the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business-day period, and notify BBH at xxxxxxxxxxxxxxxxxxxx@xx.xxx within three business days whether the individual will be further evaluated for the CSED Waiver, based on the CAFAS score. As per Chapter 502, if a child meets initial criteria, KEPRO asks the family to select a provider from the independent evaluation network and contact the independent evaluator [IE] to schedule an evaluation. If the IE is unable to schedule and complete the evaluation within 14 days, KEPRO will assist the family in choosing an alternative IE. The final determination of eligibility must be made within seven (7) days of receipt of the completed independent evaluation using the CAFAS or PECFAS. Eligibility determinations are communicated to the family who chooses a Wraparound provider. If the CAFAS score is 90 or above, KEPRO will assign an evaluator to complete the CSED Waiver evaluation process to determine eligibility, which typically takes 21-45 days. The State has not yet provided a count of the number of independent evaluators available to conduct CAFAS/PECFAS assessments. A search of the PC&A website (the State’s contractor) did not produce a list of those specific to the CSED waiver. It appears there is a temporary list on KEPRO’s website but it notes it was last updated March 2021 (see xxxxx://xxx.xxxxx.xxxxx.xxx/media/3021/temp-ipn-list-updated-march-2021.docx); separately, KEPRO’s website was inaccessible for periods during this review. DHHR has indicated data will be available for future compliance evaluations regarding the independent evaluations. In addition to access to independent evaluators to determine CSED Waiver eligibility, DHHR has indicated that behavioral health assessments include use of the CANS tool. The State has not yet provided a list of CANS-trained individuals and their locations or the total number of CANS assessments to date. The preliminary CANS data plan (Utilizing Child and Adolescent Needs and Strengths (CANS) Data to Assess Outcomes and Functional Improvement in Children Receiving Mental Health Services, undated) reports “an outline of how CANS data will be used to evaluate functional outcomes and be incorporated into quality improvement efforts is anticipated to be developed by August 2022. Efforts are still underway to integrate all CANS data scores into the CANS Automated System. Data is expected to be reviewed quarterly both at the program and quality committee level as part of the indicators reviewed through CQI related processes for mental health services.” The CMCRS Draft Manual notes that “MCRS services will be provided up State has expended considerable effort in creating assessment pathways to eight weeks; will take place in family homes, schools, group care, and other settings that are natural to the youth and family; and will include such services as: crisis intervention, crisis assessment, the development of a crisis plan which will include presumptive eligibility for crisis services (i.e., the family direct children and youth determine whether it is a crisis), engagement, de-escalation, assessment, planning, and the coordination of supports and other services as needed” [emphasis added]into these services. The Children’s Crisis and Referral Line Data Update January – December 2021 notes that as of January 2022, “staff are trained to incorporate the Assessment Pathway screening into calls when appropriate to help individuals further connect to key services to meet State shared their needs.” The Bureau of Juvenile Services (BJS) Detention Referrals to Children with Serious Emotional Disorder (CSED) Waiver Standard Operating Procedure (SOP) details the steps needed to refer children to the assessment pathway but does not include explicit timelines. In that document the State notes “DHHR is in the process of designing a data plan template for all related data tracking, such as for referrals for youth involved in BJS, to include indicators such as data source, frequency, owner, and any guidance on reviewing data. In the interim, BJS will track data manually with spreadsheets, which can then be compared with KEPRO data, as an example of tracking youth who applied for CSED Waiver enrollment.” The SME expects to review this data in the next report cycle. The Pathway to Children’s Mental Health Services Bureau for Social Service specifies that Assessment Pathway - Data Collection and Analysis Plan which includes measures related to referral source and timeliness (e.g., “When a child is placed immediately timeliness of first family contact by BBH”). That document notes data collection began in an emergency shelter or directly into a residential mental health treatment facility (RMHTF) prior to the completion of the FAST/Ongoing Assessment or any screening for mental health needsJanuary 2022 and will continue monthly through July 2022. Preliminary data from November and December 2021 did not include timeliness. However, the child welfare worker State has messaged that data will immediately complete a CSED Waiver Application be available for the child (within 24 to 48 hours of placement) and submit to KEPRO for a thorough assessment of needs.” The same document requires an Aetna managed care coordinator “[to] ensure the child welfare worker has access to all relevant data to be reviewed and will schedule a meeting to occur within seven business days with the Aetna managed care coordinator, the child welfare worker, and the residential providerfuture compliance evaluations. The Aetna managed care coordinator and the child welfare worker will review the results of the CANS, CAFAS/PECFAS, Monthly Progress Report, treatment plan, and any other relevant data.” The SME requests documentation of how the State is monitoring these timelines, as well as any CQI plans or corrective processes it uses to correct deficiencies. Timeliness indicators are noted above in Agreement Number 24. In addition, the Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) also includes measures related to mobile crisis services timeliness (see Table 6“timeliness of referral to Assessment Pathway”; “timeliness of completion of the CAFAS/PECFAS”; “timeliness of completion of the CANS”; “number of referrals to BBH Assessment Pathway for Wrap Facilitator Assignment”; etc.). However, the majority are missing the following information in the table (1) but lacks information on frequency of review, ; (2) who is responsible for review, ; and (3) guidance for review. The State notes this document will be updated in the future. As the KPIs have not yet been finalized, no data has been provided to the SME to review. The link to the CSED waiver application on the State’s website includes the following: “If you have not heard back from KEPRO within 5 business days, please call (304) 343-9663 ext. 4483 or 4418.” DHHR will need to provide information and documentation on how it is tracking the number of applications that report difficulty after submission and any corrective actions it is taking to ensure children are timely assessed. The SME notes that families are advised to contact KEPRO if they had not heard back within 5 days, but it is unclear how the State is monitoring and overseeing the number of families contacting KEPRO and the timeliness of resolution, as well as any corrective action plans. Additionally, as noted under Agreement Requirements 24 and 28 “KEPRO will then review the application, contact the child, family, BSS worker, or other legal guardian to complete the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business-day period….” KEPRO has three business days to respond to families. The SME recognizes the distinction between calendar days and business days in the referenced time periods but raises that waiting five days before a second attempt adds delay, and both time periods should be the same. To fully comply with this requirement, the State will need to provide additional documentation for the SME to review such as the West Virginia Wraparound manual and/or other provider manuals, SOPs, training curriculum, bulletins and other transmittals; staffing requirements; billing and reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to providers and stakeholders. Training must also reflect the expectation that timely assessment is provided to address urgent needsstatewide, including initial and continuing education; coaching; curricula, including seat-time and competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific as to deliver the services in a manner that is likely to accomplish the Agreement goals. AGREEMENT REQUIREMENT 28.1 26 Aforementioned mental health services [assessment] will be provided in consultation with delivered at times and locations mutually agreed upon by the provider and the child and family to assist in practicing skill development in the context of daily living. Compliance Rating Partial Compliance The BBH Pathway to Children’s Mental Health Services Phase 1 Reference Guide does not provide details on completing the CAFAS such as language regarding how an assessment with the independent evaluator will be completed at times and locations mutually agreed upon by the providers and family. Chapter 502 includes some language regarding family choice (“the ASO helps the applicant child/family select an IE [independent evaluator] within the applicant’s geographical area or otherwise convenient for the member and their family”) but there are no policy or operational documents outlining how the State is monitoring this requirement such as family satisfaction surveys, random auditing, or regular reporting. The materials do not specify how the CAFAS and CANS are introduced and explained to families along with their different purposes and frequency of completion. Families should receive this information in an accessible manner to ensure they understand what is happening throughout the assessment process. The Children’s Mental Health Assessment Pathway - Data Collection and Analysis Plan includes timeliness measures but nothing specific to measure and evaluate whether initial and ongoing assessment (e.g., CANS) is delivered at mutually agreeable times and locations, such as surveys or interviews with families to determine if families felt that the assessments were completed in collaboration with the family at a time and location that was convenient to them. To fully comply with this requirement, the State will need to provide additional documentation for the SME to review such as SOPs and/or other documentation such as that mentioned above regarding how it monitors and measures this requirement, as well as any CQI plans or corrective processes it uses to correct deficiencies; the West Virginia Wraparound manual and/or other provider manuals, SOPs, training curriculum, bulletins and other transmittals; staffing requirements; billing and reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to providers and stakeholders. Training must also reflect the expectation that assessment is provided in a mutually agreeable manner, including initial and continuing education; coaching; curricula, including seat-time and competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific as to deliver the services in a manner that is likely to accomplish the Agreement goals. Note: Assessment does not assist in skill development in the context of daily living. AGREEMENT REQUIREMENT 28 Ensure timely provision of mental health services to address any urgent need for services.