Quality Assurance Committee G-01

PURPOSE:

This policy outlines the membership and procedures for the Sedgwick County Developmental Disability Organization (SCDDO) Quality Assurance Committee (QAC) consistent with K.A.R. 30-64-27.

POLICY:

Community service providers (CSP) delivering targeted case management (TCM) services shall develop an on-site monitoring team to work in collaboration with members of the QAC. The members will ensure that quality services are being provided to individuals served by any CSP as required by the provisions of K.A.R 30-64-27.

PROCEDURES:

1. The QAC members will be comprised of the SCDDO QA Coordinator, TCM representatives, on-site monitoring teams, and Community Council members representing the following categories: individuals receiving services, their family members and/or guardians, and interested citizens.
2. Each CSP delivering TCM services will designate a representative from their organization to participate in the local quality review This individual shall be the individual who maintains oversight of the agency’s quality assurance and/or TCM department.
3. The representative is responsible for the following:
   1. Establish and maintain an on-site monitoring team to complete on-site reviews. The team may include individuals receiving services, their family members and/or guardians, and interested citizens.
   2. Provide training to the on-site review committee on the SCDDO QAC manual and review tools.
   3. Collect, assess, and submit review packets to SCDDO designated QA staff by the due date assigned.
   4. Provide copies of completed review tools to the reviewed
4. SCDDO will assign a sample, quarterly, of individuals randomly selected for QAC review as defined in the QAC manual, available upon request.
5. The on-site review will consist of the following activities:
   1. Review of the Person Centered Support Plan (PCSP), Behavior Support Plan (BSP), and Psychotropic Medication Plan (PMP) for quality.
   2. Evaluate the delivery of each service as defined in the above mentioned documents.
   3. Complete site visit with the individual and their paid staff which may include family at the location of service.
   4. Complete the review tools specified in the QAC manual and include additional documentation of comments, questions, or concerns identified by the review team.
6. The representative or their designee and at least one other member, not paid by the agency, will be involved throughout the entire review process for the individual assigned to that team. In lieu of the representative or designee, the TCM may assist the non-paid team member during the site visit at the request of the family.
7. The representative will submit all QAC review tools and corresponding documentation to SCDDO designated QA staff by the due date assigned. Submitting late QAC reviews may result in a request for an agency continuous quality improvement plan.
8. SCDDO will evaluate each QAC review using a standardized tool and provide feedback to the CSP whose performance was reviewed during the quarter.
   1. If concerns are identified regarding an individual’s services, the CSP will receive notification requesting improvement. The CSP is responsible for assuring improvements are made to address the deficiencies through the agency’s internal quality assurance policy and procedures. The CSP is responsible for submitting within 30 days documentation of service modifications based on the review.
   2. If systemic quality concerns are identified, the CSP will receive written notification identifying the deficient area. The CSP is responsible for submitting a continuous quality improvement plan. The written plan shall be submitted within 30 days for review and agreement by SCDDO.
9. Upon review, SCDDO may request additional information which will be due no later than 15 days or as specified by SCDDO staff.
10. SCDDO will meet quarterly with all designated representatives to review local trend data including, but not limited to the following:
    1. Services that are paid for are delivered;
    2. Services that are delivered are paid for in accordance with the terms of any agreement or contract in force;
    3. Services are provided consistent with Article 63;
    4. The CSP is affording the individual being served all of the individual’s legally protected rights;
    5. The CSP is reporting any suspicions of abuse, neglect or exploitation and taking corrective action when needed;
    6. Services are provided consistent with the PCSP;
    7. Services are provided in a manner that offers opportunities of choice to the individual being served.
11. The Community Council will review quarterly trend data, consider CSP recommendations and provide additional observations to ensure that any identified concerns are addressed through follow up by SCDDO QA staff.