HomeMy WebLinkAboutMHIDDEI-415 Contracted Services Program Monitoring1
FRANKLIN/FULTON COUNTY
MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL
DISABILITIES/EARLY INTERVENTION
425 Franklin Farm Lane
Chambersburg, PA 17202
(717) 264-5387
MH/IDD/EI PROCEDURE STATEMENT
PROCEDURE SUBJECT: Contracted Service Program Monitoring
PROCEDURE NUMBER: MHIDDEI-415
Effective Date: January 1, 2004
Date Revised: September 27, 2018
INTRODUCTION:
The monitoring of programs contracted by MH/IDD/EI will be an ongoing process of the
Franklin/Fulton MH/IDD/EI Program Office (hereafter “MH/IDD/EI”). The mission, vision, and
values of MH/IDD/EI, as stated in Procedure Statement MHIDDEI-401, as well as the State
mandated provider monitoring tools for EI and IDD, and the MH/IDD/EI contract will serve as
the basis for monitoring of contracted services.
The intent of the monitoring process is to assist providers in implementing regulations and
meeting contract requirements as well as to ensure the provision of high quality services. The
monitoring process will be the established mechanism to allow positive feedback from
MH/IDD/EI to be shared with service providers and allow for the refinement or correction of
provided services and/or contract provisions. Continued delivery of high quality services is the
responsibility of the provider and, to ensure this, the provider will have its own internal
procedures for self-evaluation. This internal procedure is also subject to monitoring review by
MH/IDD/EI.
PROCEDURE:
Provider monitoring will be done at a minimum of once a year for each provider, within
each fiscal year (July 1st – June 30th), and may be done in conjunction with a site visit,
or during the provider re-qualification process. Although most monitoring visits will be
scheduled in advance, on occasion, monitoring visits may be conducted on several hours’
notice or no notice at all. MH/IDD/EI reserves the right to conduct monitoring visits
without prior notice to the provider.
The program monitoring will be based on applicable Department of Human Services
(DHS) regulations, the provider’s contract, the work statement/checklist, quality
enhancement policies, previous monitoring reports, previous licensing inspection
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summaries, program evaluation recommendations and/or such programmatic issues as
may need to be addressed.
While all three (3) programs have their own monitoring tool, which can be obtained
through a Program Specialist, the attached universal checklist will also be used to
monitor compliance with the contract.
The monitoring visit or review may include but not be limited to a site visit, observation
of and/or conversation with individuals accessing the services and/or their family
member and staff, a review of program manuals, program files, service recipient’s files,
staff files, service recipient’s financial transactions, and program financial records.
MH/IDD/EI fiscal staff may conduct, or participate in, monitoring visits for the purpose
of fiscal monitoring.
The objective of the monitoring visits is to address all areas of compliance/
noncompliance. Any issues identified as life-threatening to anyone served and/or blatant
violations of contract provisions must be corrected immediately. An incident report will
be completed per regulations. The corrective action must be reported to the MH/IDD/EI
Administrator within 24 hours.
The results of the monitoring review will be documented in the applicable tool. The
Program Specialist may recommend strategies for program improvement.
For any provider on the Advisory Board list, the complete monitoring report will be
submitted to the MH/IDD/EI Advisory Board at a regularly scheduled or, if necessary,
emergency meeting. After the MH/IDD/EI Advisory Board’s approval, the formal
monitoring report will be submitted to the provider.
The provider is responsible for submitting the completed Plan of Correction/
Improvement Plan to MH/IDD/EI within (30) days after receipt of formal monitoring
report. After review, the Program Specialist will notify the provider if the Plan of
Correction/Improvement Plan has been approved and schedule a date for validation. If
the provider and the Program Specialist cannot reach an agreement on the Plan of
Correction/Improvement Plan, the matter will be taken to the MH/IDD/EI Administrator.
ATTACHMENT:
Universal Checklist Monitoring Tool
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Fiscal Year: ____________
UNIVERSAL CHECKLIST FOR PROVIDER MONITORING
CONTRACT
SECTION CHECKLIST ITEM YES NO N/A COMMENTS
3, F, H If applicable, does provider have current full licensure?
3, I Does provider have a policy “Protection of Client Funds
and Property”
4, E Are authorizations for services in individual case
files/ISPs?
4, J
Does provider assure that individual has no insurance
before billing the county as the payer of last resort? (view
their operating procedure)
5, A, B
Quality Assurance (refer to Appendices “D”, “E” and
“F”). Does provider comply with these standards for
your program?
16, A-C Verify all required insurances are in place as applicable:
1. Commercial General Liability $1,000,000 per
occurrence
2. Professional Liability/Errors and Omissions
$1,000,000/aggregate
3. Workman’s Compensation (PA Statutory
Coverage & Employer’s Liability at Minimum
Limits)
4. Medical Malpractice $1,000,000/occurrence,
$3,000,000/aggregate
5. Auto Insurance/combined single limit of
$500,000 per occurrence for bodily
injury/property damage
6. Key Person Life insurance as applicable
17 Statements of Disclosure and Board Member lists are in
place and up-to-date
18, A-D Does provider comply with MH/IDD/EI Record
Retention Policy?
18, E Client Records which is adequate for the following:
1. History of service to the individual
2. Planning and evaluation of individual’s program
3. Provides means of communication among all
involved staff
4. Documents individual’s progress and response to
services
5. Serves as basis for review, study and evaluation
of overall program operated by provider/provides
date for research
6. Protects legal right of individual/staff
20 Meeting Attendance. Provider attends quarterly
MH/IDD/EI provider meetings and any other requested
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ad hoc meetings
21 Training – Provider provides the following training to
their staff/volunteers:
1. Client abuse (including sexual abuse) and
behaviors associated with someone who has been
abused
2. Annual training on the following applicable
subjects occurs: ODP required trainings,
medication management, behavior support, fire
safety, abuse investigation, assistive technology,
client rights, diversity, resiliency/recovery (MH
providers), reporting of unusual incidents
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All generated public provider materials contain statement
“This facility is funded in whole or in part, through a
contract with Franklin/Fulton MH/IDD/EI Program”
26 Liabilities are collected and Room and Board Contracts
are reviewed/in place as required and applicable
27
Grievance Procedures for individuals served is in place
and is in compliance with MH/IDD/EI policy. It is
posted prominently for individuals to see and includes
address and telephone number for MH/IDD/EI
Administrator
28
Provider has written policy relating to the maintenance
and security of confidential information which complies
with MH/IDD/EI policy and contains HIPAA
compliance regulations
29
Provider has a policy pertaining to unusual
incidents/ODP/OCDEL Incident Management that
complies with MH/IDD/EI policy
31
Non-Discrimination Clause/Sexual Harassment Policy is
in place that is communicated to staff and complies with
MH/IDD/EI contract
32 Provider complies with Americans with Disabilities Act
33 Provider complies with Drug Free Workplace Act and in
doing so provides a drug free workplace
Provider has the following procedure statements in place:
1. Termination/Discharge
2. Exclusion/Disbarments
3. Safety
4. Emergency Disaster Preparedness
5. Agency Disciplinary Policy