Quality Management (QM) Program. A. The Contractor’s QM Program shall improve Contractor’s established treatment outcomes through structural and operational processes and activities that are consistent with current standards of practice. B. The Contractor shall have a written description of the QM Program which clearly defines the QM Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement. C. Annually, each Contractor must: 1) Measure and report to DHCS its performance using standard measures required by DHCS including those that incorporate the requirements of section 438.204(c) and 438.240(a)(2); 2) Submit to DHCS data specified by DHCS that enables DHCS to measure the Contractor’s performance; or 3) Perform a combination of the activities described above. D. The QM Program shall be evaluated annually and updated by the Contractor as necessary per 42 CFR 438.240(e). E. Triennial Review 1) During the triennial reviews, DHCS shall review the status of the Quality Improvement Plan and the Contractor’s monitoring activities. a) This review shall include the counties service delivery system, beneficiary protections, access to services, authorization for services, compliance with regulatory and contractual requirements of the waiver, and a beneficiary records review. b) This triennial review shall provide DHCS with information as to whether the counties are complying with their responsibility to monitor their service delivery capacity. c) The counties shall receive a final report summarizing the findings of the triennial review and if out of compliance, the Contractor must submit a plan of correction (POC) within 60 days of receipt of the final report. DHCS shall follow-up with the POC to ensure compliance. F. The QM Program shall conduct performance monitoring activities throughout the Contractor’s operations. These activities shall include, but not be limited to, beneficiary and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of beneficiary grievances. G. The Contractor shall ensure continuity and coordination of care with physical health care providers. The Contractor shall coordinate with other human services agencies used by its beneficiaries. The Contractor shall assess the effectiveness of any MOU with a physical health care plan. H. The Contractor shall have mechanisms to detect both underutilization of services and overutilization of services, as required by 42 CFR 438.240(b)(3). I. The Contractor shall implement mechanisms to assess beneficiary/family satisfaction. The Contractor shall assess beneficiary/family satisfaction by: 1) Surveying beneficiary/family satisfaction with the Contractor’s services at least annually; 2) Evaluating beneficiary grievances, appeals and fair hearings at least annually; 3) Evaluating requests to change persons providing services at least annually; and 4) The Contractor shall inform providers of the results of beneficiary/family satisfaction activities. J. The Contractor shall implement mechanisms to monitor the safety and effectiveness of medication practices. The monitoring mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs. Monitoring shall occur at least annually. K. The Contractor shall implement mechanisms to address meaningful clinical issues affecting beneficiaries system-wide. L. The Contractor shall implement mechanisms to monitor appropriate and timely intervention of occurrences that raise quality of care concerns. The Contractor shall take appropriate follow-up action when such an occurrence is identified. The results of the intervention shall be evaluated by the Contractor at least annually. M. The Contractor shall have a QM Work Plan covering the current Intergovernmental Agreement cycle with documented annual evaluations and documented revisions as needed. The Contractor’s QM Work Plan shall evaluate the impact and effectiveness of its quality assessment and performance improvement program. The QM Work Plan shall include: 1) Evidence of the monitoring activities including, but not limited to, review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review as required by 42 CFR 438.240 and 42 CFR 438.416; 2) Evidence that QM activities, including performance improvement projects, have contributed to meaningful improvement in clinical care and beneficiary service; 3) A description of completed and in-process QM activities, including performance improvement projects. The description shall include: a) Monitoring efforts for previously identified issues, including tracking issues over time; b) Objectives, scope, and planned QM activities for each year; and c) Targeted areas of improvement or change in service delivery or program design. 4) A description of mechanisms the Contractor has implemented to assess the accessibility of services within its service delivery area. This shall include goals for responsiveness for the Contractor’s 24-hour toll-free telephone number, timeliness for scheduling of routine appointments, timeliness of services for urgent conditions, and access to after-hours care; and 5) Evidence of compliance with the requirements for cultural competence and linguistic competence specified in 42 CFR 438.10 and 42 CFR 438.206.
Appears in 8 contracts
Samples: Standard Agreement, Standard Agreement, Intergovernmental Agreement
Quality Management (QM) Program.
A. The Contractor’s QM Program shall improve Contractor’s established treatment outcomes through structural and operational processes and activities that are consistent with current standards of practice.practice.
B. The Contractor shall have a written description of the QM Program which clearly defines the QM Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement.improvement.
C. Annually, each Contractor must:must:
1) Measure and report to DHCS its performance using standard measures required by DHCS including those that incorporate the requirements of section 438.204(c) and 438.240(a)(2);438.240(a)(2);
2) Submit to DHCS data specified by DHCS that enables DHCS to measure the Contractor’s performance; oror
3) Perform a combination of the activities described above.above.
D. The QM Program shall be evaluated annually and updated by the Contractor as necessary per 42 CFR 438.240(e).438.240(e).
E. Triennial ReviewReview
1) During the triennial reviews, DHCS shall review the status of the Quality Improvement Plan and the Contractor’s monitoring activities.activities.
a) This review shall include the counties service delivery system, beneficiary beneficiary protections, access to services, authorization for services, compliance with regulatory and contractual requirements of the waiver, and a beneficiary records review.
b) This triennial review shall provide DHCS with information as to whether the counties are complying with their responsibility to monitor their service delivery capacity.
c) The counties shall receive a final report summarizing the findings of the triennial review and if out of compliance, the Contractor must submit a plan of correction (POC) within 60 days of receipt of the final report. DHCS shall follow-up with the POC to ensure compliance.
F. The QM Program shall conduct performance monitoring activities throughout the Contractor’s operations. These activities shall include, but not be limited to, beneficiary and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of beneficiary grievances.grievances.
G. The Contractor shall ensure continuity and coordination of care with physical health care providers. The Contractor shall coordinate with other human services agencies used by its beneficiaries. The Contractor shall assess the effectiveness of any MOU with a physical health care plan.plan.
H. The Contractor shall have mechanisms to detect both underutilization of services and overutilization of services, as required by 42 CFR 438.240(b)(3).438.240(b)(3).
I. The Contractor shall implement mechanisms to assess beneficiary/family satisfaction. The Contractor shall assess beneficiary/family satisfaction by:by:
1) Surveying beneficiary/family satisfaction with the Contractor’s services at least annually;annually;
2) Evaluating beneficiary grievances, appeals and fair hearings at least annually;annually;
3) Evaluating requests to change persons providing services at least annually; and
4) The Contractor shall inform providers of the results of beneficiary/family satisfaction activities.activities.
J. The Contractor shall implement mechanisms to monitor the safety and effectiveness of medication practices. The monitoring mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs. Monitoring shall occur at least annually.annually.
K. The Contractor shall implement mechanisms to address meaningful clinical issues affecting beneficiaries system-wide.wide.
L. The Contractor shall implement mechanisms to monitor appropriate and timely intervention of occurrences that raise quality of care concerns. The Contractor shall shall take appropriate follow-up action when such an occurrence is identified. The results of the intervention shall be evaluated by the Contractor at least annually.
M. The Contractor shall have a QM Work Plan covering the current Intergovernmental Agreement cycle with documented annual evaluations and documented revisions as needed. The Contractor’s QM Work Plan shall evaluate the impact and effectiveness of its quality assessment and performance improvement program. The QM Work Plan shall include:include:
1) Evidence of the monitoring activities including, but not limited to, review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review as required by 42 CFR 438.240 and 42 CFR 438.416;CFR
2) Evidence that QM activities, including performance improvement projects, have contributed to meaningful improvement in clinical care and beneficiary service;service;
3) A description of completed and in-process QM activities, including performance improvement projects. The description shall include:include:
a) Monitoring efforts for previously identified issues, including tracking issues over time;time;
b) Objectives, scope, and planned QM activities for each year; andand
c) Targeted areas of improvement or change in service delivery or program design.design.
4) A description of mechanisms the Contractor has implemented to assess the accessibility of services within its service delivery area. This shall include goals for responsiveness for the Contractor’s 24-hour toll-free telephone number, timeliness for scheduling of routine appointments, timeliness of services for urgent conditions, and access to after-hours care; andand
5) Evidence of compliance with the requirements for cultural competence and linguistic competence specified in 42 CFR 438.10 and 42 CFR 438.206.438.206.
Appears in 1 contract
Samples: Intergovernmental Agreement
Quality Management (QM) Program. A. The Contractor’s QM Quality Management (QM) Program shall improve Contractor’s established treatment outcomes through structural and operational processes and activities that are consistent with current standards of practice.
B. The Contractor shall have a written description of the QM Program which clearly defines the QM Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement.
C. Annually, each Contractor must:
1) Measure and report to DHCS its performance using standard measures required by DHCS including those that incorporate the requirements of section 438.204(c) and 438.240(a)(2);
2) Submit to DHCS data specified by DHCS that enables DHCS to measure the Contractor’s performance; or
3) Perform a combination of the activities described above.
D. . The QM Program shall be evaluated annually and updated by the Contractor as necessary per 42 CFR Title 9, CCR, Section 1810.440(a)(6) and Title 42, CFR, Section 438.240(e).
E. Triennial Review
1) During the triennial reviews, DHCS shall review the status of the Quality Improvement Plan and the Contractor’s monitoring activities.
a) This review shall include the counties service delivery system, beneficiary protections, access to services, authorization for services, compliance with regulatory and contractual requirements of the waiver, and a beneficiary records review.
b) This triennial review shall provide DHCS with information as to whether the counties are complying with their responsibility to monitor their service delivery capacity.
c) The counties shall receive a final report summarizing the findings of the triennial review and if out of compliance, the Contractor must submit a plan of correction (POC) within 60 days of receipt of the final report. DHCS shall follow-up with the POC to ensure compliance.
F. C. The QM Program shall conduct performance monitoring activities throughout the Contractor’s operations. These activities shall include, include but not be limited to, beneficiary client and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of beneficiary grievances.
G. D. The Contractor shall ensure continuity and coordination of care with physical health care providers. The Contractor shall coordinate with other human services agencies used by its beneficiaries. The Contractor shall assess the effectiveness of any MOU with a physical health care plan.
H. E. The Contractor shall have mechanisms to detect both underutilization of services and overutilization of services, as required by 42 CFR Title 42, CCR, Section 438.240(b)(3).
I. F. The Contractor shall implement mechanisms to assess beneficiary/family satisfaction. The Contractor shall assess beneficiary/family satisfaction by:
1) Surveying beneficiary/family satisfaction with the Contractor’s services at least annually;
2) Evaluating beneficiary grievances, appeals and fair hearings at least annually;; and
3) Evaluating requests to change persons providing services at least annually; and
4) . The Contractor shall inform providers of the results of beneficiary/family satisfaction activities.
J. G. The Contractor shall implement mechanisms to monitor the safety and effectiveness of medication practices. The monitoring mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs. Monitoring shall occur at least annually.
K. H. The Contractor shall implement mechanisms to address meaningful clinical issues affecting beneficiaries system-wide.
L. I. The Contractor shall implement mechanisms to monitor appropriate and timely intervention of occurrences that raise quality of care concerns. The Contractor shall take appropriate follow-up action when such an occurrence is identified. The results of the intervention shall be evaluated by the Contractor at least annually.
M. J. The Contractor shall have a QM Work Plan covering the current Intergovernmental Agreement contract cycle with documented annual evaluations and documented revisions as needed. The Contractor’s QM Work Plan shall evaluate the impact and effectiveness of its quality assessment and performance improvement program. The QM Work Plan shall include:
1) Evidence of the monitoring activities including, but not limited to, review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review as required by 42 CFR 438.240 Title 9, CCR, Section 1810.440(a)(5) and 42 CFR Title 42, CFR, section 438.416;
2) Evidence that QM activities, including performance improvement projects, have contributed to meaningful improvement in clinical care and beneficiary service;
3) A description of completed and in-process QM activities, including performance improvement projects. The description shall include:
a) Monitoring efforts for previously identified issues, including tracking issues over time;
b) Objectives, scope, and planned QM activities for each year; and,
c) Targeted areas of improvement or change in service delivery or program design.
4) A description of mechanisms the Contractor has implemented to assess the accessibility of services within its service delivery area. This shall include goals for responsiveness for the Contractor’s 24-24- hour toll-free telephone number, timeliness for scheduling of routine appointments, timeliness of services for urgent conditions, and access to after-hours care; and.
5) Evidence of compliance with the requirements for cultural competence and linguistic competence specified in 42 CFR 438.10 and 42 CFR 438.206Title 9, CCR, Section 1810.410.
Appears in 1 contract
Samples: Standard Agreement
