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THE STATE OF TENNESSEE
DEPARTMENT OF FINANCE AND ADMINISTRATION
BUREAU OF TENNCARE
AND
DIVISION OF INTELLECTUAL DISABLITIES SERVICES
DATA MANAGEMENT REPORT
October 22, 2010
TABLE OF CONTENTS
QUALITY MANAGEMENT DATA REPORT
October 22, 2010
Page
A. Demographics for HCBS Waiver Recipients 1
B. Transitions, Enrollment and Conversions 3
C. Waiting List Demographics 6
D. Protection From Harm 9
Complaints 9
Incidents 13
Investigations 15
E. Provider Qualifications/Monitoring 17
Day-Residential Providers 1
Personal Assistance 22
ISC Providers 24
Behavioral Providers 26
Nursing Providers 28
Therapy Providers 30
Personal Funds 33
F. Due Process/Freedom Of Choice 35
Data Management Report
October 22, 2010
A Demographics for HCBS Waiver Recipients
Data Source:
The census represents the number of waiver participants throughout the reporting month. The number of remaining slots for the Statewide HCBS, ADC, and SD Waivers is based on the unduplicated slots used this
waiver year. The number of waiver slots are determined by calendar year. The census data is not related to number of slots left in the waiver calendar year. The source of this data is CS Tracking.
DIDS Demographics Main Waiver (CS Tracking) Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
5 East 2344 2349 2353 0 0 0 0 0 0 0 0 0
6 Middle 2350 2358 2366 0 0 0 0 0 0 0 0 0
7 West 1398 1410 1413 0 0 0 0 0 0 0 0 0
8 Statewide 6092 6117 6132 0 0 0 0 0 0 0 0 0
CALENDAR YEAR FORMULAS Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
9 Approved Slots per calendar year 6300 6300 6300 6300 6300 6300 6390 6390 6390 6390 6390 6390
10 Used unduplicated slots (Jan-current mo.) 6196 6232 6256 0 0 0 0 0 0 0 0 0
11 # of slots remaining for calendar year 104 68 44 6300 6300 6300 6390 6390 6390 6390 6390 6390
DIDS Demographics Arlington Waiver (CS Tracking) Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
12 East 4 4 4 0 0 0 0 0 0 0 0 0
13 Middle 1 1 1 0 0 0 0 0 0 0 0 0
14 West 319 318 319 0 0 0 0 0 0 0 0 0
15 Statewide 324 323 324 0 0 0 0 0 0 0 0 0
CALENDAR YEAR FORMULAS Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
16 Approved Slots per calendar year 344 344 344 344 344 344 344 344 344 344 344 344
17 Used unduplicated slots (Jan-current mo.) 327 327 327 0 0 0 0 0 0 0 0 0
18 # of slots remaining for calendar year 17 17 17 344 344 344 344 344 344 344 344 344
DIDS Demographics SD Waiver (CS Tracking) Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
19 East 410 410 414 0 0 0 0 0 0 0 0 0
20 Middle 440 439 441 0 0 0 0 0 0 0 0 0
21 West 328 329 328 0 0 0 0 0 0 0 0 0
22 Statewide 1178 1178 1183 0 0 0 0 0 0 0 0 0
CALENDAR YEAR FORMULAS Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
23 Approved Slots per calendar year 2250 2250 2250 2250 2250 2250 2600 2600 2600 2600 2600 2600
24 Used unduplicated slots (Jan-current mo.) 1218 1222 1229 0 0 0 0 0 0 0 0 0
25 # of slots remaining for calendar year 1032 1028 1021 2250 2250 2250 2600 2600 2600 2600 2600 2600
DIDS Demographics State Funded (CS Tracking) Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
26 East 52 49 51 0 0 0 0 0 0 0 0 0
27 Middle 22 22 25 0 0 0 0 0 0 0 0 0
28 West 37 36 37 0 0 0 0 0 0 0 0 0
29 Statewide 111 107 113 0 0 0 0 0 0 0 0 0
3
Data Management Report
October 22, 2010
Developmental Center Census Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
30 GVDC 243 243 243 0 0 0 0 0 0 0 0 0
31 CBDC 88 78 76 0 0 0 0 0 0 0 0 0
32 HJC 9 8 8 0 0 0 0 0 0 0 0 0
33 ADC 30 26 14 0 0 0 0 0 0 0 0 0
34 Total 370 355 341 0 0 0 0 0 0 0 0 0
DIDS ICFMR Community Homes Census Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
35 East
36 Middle
37 West 23 24 33 0 0 0 0 0 0 0 0 0
38 TOTAL 23 24 33 0 0 0 0 0 0 0 0 0
DIDS Census September 2010 Total Served: 8126
State
Statewide Arlington Funded Development DID ICF
Waiver
Developmental Centers,Waiver
341 SD Waiver Srvs al Centers Homes
6132 324 1183 113 341 33 8126
DID ICF Homes, 33
State Funded Srvs, 113
SD Waiver, 1183
Arlington Waiver, 324
Statewide Waiver, 6132
Analysis:
The Division supports 8126 people: 33 reside in the West Community Homes, 341 in Developmental Centers, with 243 at GVDC, 76 at CBDC, 8 at HJC and 14 at ADC, 113 are in state funded services, 1183 are in
the SD Waiver, 324 are in the Arlington Waiver and 6132 are in the Statewide Waiver.
4
Data Management Report
October 22, 2010
B. Waiver Enrollments
Data Source:
The figures represented in this section are pulled directly from the Community Services Tracking system and the Internal Wait List data report. Enrollment figures may be updated monthly as there is a 2 month
window of time in which enrollments are entered into the CST system. Disenrollment data is also based on queries pulled from CST and may also have a window of adjustment for data entry.
Total Waiver Enrollments
Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
1 Arlington Waiver 0 0 1 0 0 0 0 0 0 0 0 0 1
2 SD Waiver 12 3 7 1 0 0 0 0 0 0 0 0 23
3 HCBS Main Waiver 30 32 30 7 0 0 0 0 0 0 0 0 99
4 Total 42 35 38 8 0 0 0 0 0 0 0 0 123
Arlington Waiver Enrollments Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
5 Arlington At Risk 0 0 0 0
6 Arlington Transition 0 0 1 1
7 Arlington Waiver Total 0 0 1 0 0 0 0 0 0 0 0 0 1
SD Waiver Enrollments
WL- Intake Commitee Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
8 East 0 2 3 5
9 Middle 0 0 3 1 4
10 West 0 0 1 1
11 Total 0 2 7 1 0 0 0 0 0 0 0 0 10
Conversions Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
12 East 0 0 0 0
13 Middle 12 0 0 12
14 West 0 0 0 0
15 Total 12 0 0 0 0 0 0 0 0 0 0 0 12
At Risk Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
16 At Risk Group Enrollments into SD 0 1 0 1
17 Total by Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
18 East 0 2 3 0 0 0 0 0 0 0 0 0 5
19 Middle 12 0 3 1 0 0 0 0 0 0 0 0 16
20 West 0 1 1 0 0 0 0 0 0 0 0 0 2
21 Grand Total SD Waiver 12 3 7 1 0 0 0 0 0 0 0 0 23
HCBS Statewide Waiver Enrollments
WL- Intake Commitee Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
22 East 6 3 6 1 16
23 Middle 1 8 7 1 17
24 West 2 1 2 1 6
25 Total 9 12 15 3 0 0 0 0 0 0 0 0 39
Conversions Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
26 East 1 0 0 1
27 Middle 0 0 0 0
28 West 2 2 0 4
29 Total 3 2 0 0 0 0 0 0 0 0 0 0 5
Transfers from SD to HCBS Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
30 East 0 0 0 0
31 Middle 1 1 2 4
32 West 0 1 2 3
33 Total 1 2 4 0 0 0 0 0 0 0 0 0 7
5
Data Management Report
October 22, 2010
DCS Placements Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
34 East 1 0 1 2
35 Middle 3 1 1 5
36 West 0 1 0 1 2
37 Total 4 2 2 1 0 0 0 0 0 0 0 0 9
PASSR/ Nursing Homes Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
38 East 1 1 0 2
39 Middle 0 2 2 4
40 West 0 0 0 0
41 Total 1 3 2 0 0 0 0 0 0 0 0 0 6
DC Completed Transitions into the Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
42 GVDC 1 0 0 1
43 CBDC 6 3 3 12
44 HJC 2 0 0 2
45 Total 9 3 3 0 0 0 0 0 0 0 0 0 15
At Risk Class Enrollments Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
46 East 0 0 0 0
47 Middle 0 0 0 0
48 West 3 8 4 3 18
49 Total 3 8 4 3 0 0 0 0 0 0 0 0 18
Total by Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
50 East 10 4 7 1 22
51 Middle 13 15 15 1 44
52 West 7 13 8 5 33
53 Grand Total Statewide Waiver 30 32 30 7 0 0 0 0 0 0 0 0 99
C. Disenrollments and Transitions
Arlington Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
1 Death 0 0 0 0 0 0 0 0 0 0 0 0 0
2 Voluntary Request by person/family 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Services no longer appropriate 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Moved 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Involuntary 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Transition to another waiver program 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Transitioned to an ICFMR 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Total Disenrolled 0 0 0 0 0 0 0 0 0 0 0 0 0
SD Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
9 Death 0 1 0 0 0 0 0 0 0 0 0 0 1
10 Voluntary Request by person/family 1 0 0 0 0 0 0 0 0 0 0 0 1
11 Services no longer appropriate 1 0 0 0 0 0 0 0 0 0 0 0 1
12 Moved 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Involuntary 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Transition to another waiver program 1 2 2 0 0 0 0 0 0 0 0 0 5
15 Transitioned to an ICFMR 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Total Disenrolled 3 3 2 0 0 0 0 0 0 0 0 0 8
HCBS Main Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
17 Death 9 5 6 0 0 0 0 0 0 0 0 0 20
18 Voluntary Request by person/family 2 3 1 0 0 0 0 0 0 0 0 0 6
19 Services no longer appropriate 1 0 1 0 0 0 0 0 0 0 0 0 2
20 Moved 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Involuntary 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Transition to another waiver program 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Transitioned to an ICFMR 0 0 1 0 0 0 0 0 0 0 0 0 1
24 Total Disenrolled 12 8 9 0 0 0 0 0 0 0 0 0 29
25 Total Waiver Disenrollments: 15 11 11 0 0 0 0 0 0 0 0 0 37
6
Data Management Report
October 22, 2010
Developmental Center Transitions
Greene Valley Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
26 Census 243 243 243
27 Admissions 0 0
Discharges
28 Death 0 0
29 Transition to another dev center 0 0
30 Transition to community state ICF 0 0
31 Transition to private ICF 0 0
32 Transition to waiver program 0 0
33 Transition to non DIDS srvs* 0 0
34 Total Discharges 0 0 0 0 0 0 0 0 0 0 0
Clover Bottom Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
35 Census 88 78 76
36 Admissions 0 0
37 Discharges
38 Death 0 0
39 Transition to another dev center 0 0
40 Transition to community state ICF 0 0
41 Transition to private ICF 2 2
42 Transition to waiver program 3 3
43 Transition to non DIDS srvs* 0 0
44 Total Discharges 5 0 0 0 0 0 0 0 0 0 5
Harold Jordan Center Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
45 Census 9 8 8
46 Admissions 0 0
Discharges
47 Death 0 0
48 Transition to another dev center 0 0
49 Transition to community state ICF 0 0
50 Transition to private ICF 0 0
51 Transition to waiver program 0 0
52 Transition to non DIDS srvs* 0 0
53 Total Discharges 0 0
Arlington Dev Center Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 FYTD
54 Census 30 26 14
55 Admissions 0 0
56 Discharges
57 Death 0 0
58 Transition to another dev center 0 0
59 Transition to community state ICF 7 7
60 Transition to private ICF 3 3
61 Transition to Arl waiver program 1 1
62 Transition to non DIDS srvs* 0 0
63 Total Discharges 11 11
Analysis:
In September 2010 there were 38 waiver enrollments. 1 person enrolled into the Arlington waiver from ADC, 7 people enrolled into the SD Waiver and 30 people enrolled into the Statewide Waiver. There were 11
disenrollments from the waiver programs- 2 people transferred out of the SD waiver and into the Statewide Waiver, and 9 people disenrolled from the Statewide Waiver. Clover Bottom had 5 discharges, 3 people
went into the Statewide Waiver and 2 people went into a private ICFMR facility. Arlington had 11 discharges: 7 people went into a state run community ICFMR home, 3 people went into a private ICFMR home and 1
person enrolled into the Arlingon Waiver. HJC awnd GVDC did not have any discharges.
7
Data Management Report
October 22, 2010
D. Waiting List Demographics
Data Source:
The Central Office Compliance Unit maintains the wait list data below. The wait list is a web based data system in which Regional Intake Units update as needed. The reported data is compiled on a monthly basis.
East Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
1 # of Crisis cases 34 33 25 0 0 0 0 0 0 0 0 0
2 # of Urgent cases 366 367 367 0 0 0 0 0 0 0 0 0
3 # of Active cases 1,422 1,421 1,425 0 0 0 0 0 0 0 0 0
4 # of Deferred cases 502 513 517 0 0 0 0 0 0 0 0 0
5 Wait List Total 2,324 2,334 2,334 0 0 0 0 0 0 0 0 0
Middle Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
6 # of Crisis cases 28 30 33 0 0 0 0 0 0 0 0 0
7 # of Urgent cases 297 298 297 0 0 0 0 0 0 0 0 0
8 # of Active cases 1,352 1,356 1,357 0 0 0 0 0 0 0 0 0
9 # of Deferred cases 332 332 334 0 0 0 0 0 0 0 0 0
10 Wait List Total 2,009 2,016 2,021 0 0 0 0 0 0 0 0 0
West Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
11 # of Crisis cases 31 36 35 0 0 0 0 0 0 0 0 0
12 # of Urgent cases 86 90 91 0 0 0 0 0 0 0 0 0
13 # of Active cases 1,695 1,679 1,684 0 0 0 0 0 0 0 0 0
14 # of Deferred cases 294 318 335 0 0 0 0 0 0 0 0 0
15 Wait List Total 2,106 2,123 2,145 0 0 0 0 0 0 0 0 0
Statewide Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
16 # of Crisis cases 93 99 93 0 0 0 0 0 0 0 0 0
17 # of Urgent cases 749 755 755 0 0 0 0 0 0 0 0 0
18 # of Active cases 4,469 4,456 4,466 0 0 0 0 0 0 0 0 0
19 # of Deferred cases 1,128 1,163 1,186 0 0 0 0 0 0 0 0 0
20 Wait List Total 6,439 6,473 6,500 0 0 0 0 0 0 0 0 0
21 Net Effect from Last Month 23 34 27 #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
Fiscal
Additions Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
22 # of Crisis cases added 10 12 7 0 0 0 0 0 0 0 0 0 22
23 # of Urgent cases added 8 15 9 0 0 0 0 0 0 0 0 0 23
24 # of Active cases added 23 24 20 0 0 0 0 0 0 0 0 0 47
25 # of Deferred cases added 22 24 27 0 0 0 0 0 0 0 0 0 46
26 Total # Added to the Wait List 63 75 63 0 0 0 0 0 0 0 0 0 138
8
Data Management Report
October 22, 2010
Fiscal
Removals Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
27 For enrollment into SD Waiver 1 4 4 0 0 0 0 0 0 0 0 0 5
28 For enrollment into HCBS Waiver 19 12 19 0 0 0 0 0 0 0 0 0 31
29 For enrollment into Arlington Waiver 0 1 0 0 0 0 0 0 0 0 0 0 1
30 Receiving Other Funded Services 0 3 1 0 0 0 0 0 0 0 0 0 3
31 Voluntarily 1 5 3 0 0 0 0 0 0 0 0 0 6
32 Due to Death 2 0 3 0 0 0 0 0 0 0 0 0 2
33 Not Eligible for Services 2 2 0 0 0 0 0 0 0 0 0 0 4
34 Moved Out of Region 5 9 4 0 0 0 0 0 0 0 0 0 14
35 Moved Out of State 8 2 2 0 0 0 0 0 0 0 0 0 10
36 Duplicate Name 0 1 0 0 0 0 0 0 0 0 0 0 1
37 Other Reasons 13 19 13 0 0 0 0 0 0 0 0 0 32
38 Total Number Removed this Month 51 58 49 0 0 0 0 0 0 0 0 0 109
Wait List by Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
39 East 2,324 2,334 2,334
40 Middle 2,009 2,016 2,021
41 West 2,106 2,123 2,145
42 Statewide 6,439 6,473 6,500
Wait List by Region Wait List by Category of Need
# of Crisis cases ,
West, 2,145, 33% 93, 1%
# of Urgent cases
# of Deferred , 755, 12%
cases , 1,186,
East, 2,334, 36% 18%
# of Active cases ,
4,466, 69%
Middle, 2,021,
31%
9
Data Management Report
October 22, 2010
E. Waiting List Populations
Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
43 School aged children (0-21, excluding DCS) 2719 2718 2713
44 DCS children (0-21) 92 92 88
45 Nursing Home Residents 35 35 34
46 Regional Mental Health Centers 22 22 22
47 DIDS State Funded Services 23 0 0
48 Adults with no Service 3548 3606 3643
49 6439 6473 6500 0 0 0 0 0 0 0 0 0
Wait List Demographic Groups
School aged children (0-21, excluding
Adults with no Service, 3643, 56% DCS), 2713, 42%
Nursing Home Residents, 34, 1%
DIDS State Funded Services, 0, 0%
Regional Mental Health Centers, 22, 0%
DCS children (0-21), 88, 1%
Analysis:
In September 2010, the Wait List had a net increase of 27 people bringing the new total to 6500. East had a total of 2334, Middle had 2021 and West had 2145. 49 people were removed: 19 of those to be enrolled in the
Statewide Waiver and 4 people to be enrolled into the SD Waiver. 63 people were added statewide. 69% of the wait list is in the Active category, 18% is in Deferred, 12 % is in the Urgent category and 1% is in the Crisis
category. 56% of the list was comprised of adults with no services, 42% was of school aged children, DCS children and Nursing Home residents made up 1% each, and there were less than 1% in Regional Mental Health
Centers.
10
Data Management Report
October 22, 2010
G Protection From Harm/ Complaint Resolution
Data Source:
Each Regional Office inputs all complaints information into COSMOS as each complaint is received. Every month a data report is generated which includes Complaint Information captured by each complaint type,
the source of each complaint and the number of complaints that are resolved within 30 days. The benchmark for resolution is 90% of all complaints resolved within 30 days. The data will be presented by waiver
instead of by region.
Complaints by Source- Self Determination Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
1 Total # of Complaints 0 0 4 4
2 # from TennCare 0 0 0 0
3 % from TennCare 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
4 # from a Concerned Citizen 0 0 2 2
5 % from a Concerned Citizen 0.0% 0.0% 50.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 50.0%
6 # from the Waiver Participant 0 0 0 0
7 % from the Waiver Participant 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
8 # from a Family Member 0 0 1 1
9 % from a Family Member 0.0% 0.0% 25.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 25.0%
10 # from Conservator 0 0 1 1
11 % from Conservator 0.0% 0.0% 25.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 25.0%
13 # Advocate (Paid) 0 0 0 0
14 % from Advocate (Paid) 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
15 # from PTP Interview 0 0 0 0
16 % from PTP Interview 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
Complaints by Source - Statewide Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
20 Total # of Complaints 15 14 22 51
21 # from TennCare 0 0 0 0
21 % from TennCare 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
22 # from a Concerned Citizen 1 0 0 1
23 % from a Concerned Citizen 7% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 2.0%
24 # from the Waiver Participant 0 0 2 2
25 % from the Waiver Participant 0% 0.0% 9.1% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 3.9%
26 # from a Family Member 3 8 11 22
27 % from a Family Member 20.0% 57.1% 50.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 43.1%
28 # from Conservator 8 6 8 22
29 % from Conservator 53% 42.9% 36.4% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 43.1%
31 # Advocate (Paid) 0 0 0 0
32 % from Advocate (Paid) 0% 0.0% 0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
33 # from PTP Interview 3 0 1 4
34 % from PTP Interview 20% 0.0% 4.5% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.8%
Complaints by Source - Arlington Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
38 Total # of Complaints 6 2 6 14
39 # from TennCare 0 0 0 0
40 % from TennCare 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
41 # from a Concerned Citizen 0 0 2 2
42 % from a Concerned Citizen 0% 0.0% 33.3% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 14.3%
43 # from the Waiver Participant 1 0 4 5
44 % from the Waiver Participant 17% 0.0% 66.7% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 35.7%
45 # from a Family Member 0 0 0 0
46 % from a Family Member 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
47 # from Conservator 4 2 0 6
48 % from Conservator 67% 100.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 42.9%
50 # Advocate (Paid) 0 0 0 0
51 % from Advocate (Paid) 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
52 # from PTP Interview 0 0 0 0
53 % from PTP Interview 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
11
Data Management Report
October 22, 2010
Complaints by Issue- Self Determination Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total Number of Complaints 0 0 4 4
# Behavior Issues 0 0 0 0
% Behavior Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Day Service Issues 0 0 0 0
% Day Service Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Environmental Issues 0 0 0 0
% Environmental Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Financial Issues 0 0 0 0
% Financial Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Health Issues 0 0 0 0
% Health Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Human Rights Issues 0 0 1 1
% Human Rights Issues 0% 0% 25.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 25.0%
# ISC Issues 0 0 0 0
% ISC Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# ISP Issues 0 0 0 0
% ISP Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Staffing Issues 0 0 2 2
% Staffing Issues 0% 0% 50.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 50.0%
# Therapy Issues 0 0 0 0
% Therapy Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Transportation Issues 0 0 0 0
% Transportation Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Case Management Issues 0 0 1 1
% Case Management Issues 0% 0% 25.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 25.0%
# Other Issues 0 0 0 0
% Other Issues 0% 0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
Complaints by Issue - Statewide Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total Number of Complaints 15 14 22 51
# Behavior Issues 0 0 0 0
% Behavior Issues 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Day Service Issues 1 1 0 2
% Day Service Issues 7% 7.1% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 3.9%
# Environmental Issues 2 0 3 5
% Environmental Issues 13% 0.0% 13.6% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 9.8%
# Financial Issues 0 0 3 3
% Financial Issues 0% 0.0% 13.6% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5.9%
# Health Issues 1 2 1 4
% Health Issues 7% 14.3% 4.5% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.8%
# Human Rights Issues 3 2 3 8
% Human Rights Issues 20% 14.3% 13.6% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 15.7%
# ISC Issues 1 2 3 6
% ISC Issues 7% 14.3% 13.6% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 11.8%
# ISP Issues 0 0 0 0
% ISP Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Staffing Issues 6 7 8 21
% Staffing Issues 40% 50.0% 36.4% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 41.2%
# Therapy Issues 0 0 0 0
% Therapy Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Transportation Issues 0 0 1 1
% Transportation Issues 0% 0.0% 4.5% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 2.0%
# Case Management Issues 0 0 0 0
% Case Management Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Other Issues 0 0 0 0
% Other Issues 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
12
Data Management Report
October 22, 2010
Complaints by Issue - Arlington Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total Number of Complaints 6 2 6 14
# Behavior Issues 0 0 0 0
% Behavior Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Day Service Issues 0 0 1 1
% Day Service Issues 0% 0.0% 16.7% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.1%
# Environmental Issues 1 0 0 1
% Environmental Issues 17% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.1%
# Financial Issues 0 0 0 0
% Financial Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Health Issues 0 1 0 1
% Health Issues 0% 50.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.1%
# Human Rights Issues 0 0 1 1
% Human Rights Issues 0% 0.0% 16.7% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.1%
# ISC Issues 1 0 0 1
% ISC Issues 17% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.1%
# ISP Issues 0 0 0 0
% ISP Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Staffing Issues 4 1 1 6
% Staffing Issues 67% 50.0% 16.7% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 42.9%
# Therapy Issues 0 0 0 0
% Therapy Issues 0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Transportation Issues 0 0 3 3
% Transportation Issues 0% 0.0% 50.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 21.4%
# Case Management Issues 0 0 0 0
% Case Management Issues 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
# Other Issues 0 0 0
% Other Issues 0.0% 0.0% 0.0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.0%
13
Data Management Report
October 22, 2010
Complaint Resolution-Self Determination Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total # of Complaints 0 0 4 4
Resolved Within 30 Days 0 0 4 4
# Pending 0 0 0 0
# Pending > than 31 to 60 days 0 0 0 0
# Resolved > than 31 to 60 days 0 0 0 0
# Pending > than 61 days 0 0 0 0
# Resolved > than 61 days 0 0 0 0
% Resolved within 30 Days N/A N/A 100% N/A #DIV/0! N/A #DIV/0! N/A #DIV/0! #DIV/0! N/A N/A 100%
Complaint Resolution-Statewide Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total # of Complaints 15 14 22 51
Resolved Within 30 Days 15 14 14 43
# Pending 0 0 7 0
# Pending > than 31 to 60 days 0 0 0 0
# Resolved > than 31 to 60 days 0 0 0 0
# Pending > than 61 days 0 0 0 0
# Resolved > than 61 days 0 0 0 0
% Resolved within 30 Days 100% 100% 64% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 84%
Complaint Resolution-Arlington Waiver Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
Total # of Complaints 6 2 6 14
Resolved Within 30 Days 6 2 6 14
# Pending 0 0 0 0
# Pending > than 31 to 60 days 0 0 0 0
# Resolved > than 31 to 60 days 0 0 0 0
# Pending > than 61 days 0 0 0 0
# Resolved > than 61 days 0 0 0 0
% Resolved within 30 Days 100% 100% 100% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 100%
Analysis:
CRS Analysis Report for September 2010
1. There were 32 statewide complaints: AW 6, SW 22, SDW 4.
2. Source:
Conservator: 9
Family: 12
Concerned Citizen: 4
PTP: 1
Recipient: 6
3. Types of Complaints:
Environmental: 3
Day service: 1
Financial: 3
Human Rights: 5
Staffing: 11
Transportation: 4
Case Management(SD) 1
ISC: 3
Most frequent complaint was staffing communication\supervision.
4. There were 24 complaints resolved satisfactorily in 30 days and
There are 8 pending to be resolved which are not due yet……….
SDW: 4\4
AW: 6\6
SW: 14\14
5. There were 26 interventions statewide.
6. Plans are being finalized to hold the annual CRS meetings in conjunction with the Regional Provider forums and have been sc heduled between now and January 2011.
14
Data Management Report
October 22, 2010
D Protection From Harm/Incident Management
Data Source:
The Incident Management information in this report is now based on the total D.I.D.S. Community Protection From Harm census, which is all D.I.D.S. service recipients in the community and all private ICF/MR
service recipients who are currently required to report incidents to D.I.D.S.
Through August 2009, only the West Region private ICF/MR providers were required to report. As of September 2009, the East Region ICF/MR providers were also required to report incidents to D.I.D.S., and the
Middle Region ICF/MR providers started reporting to D.I.D.S. in February 2010.
Incidents / East Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
1 # of Reportable Incidents 363 404 767
2 Rate of Reportable Incidents per 100 people 11.9 13.2 12.55
3 # of Serious Injuries 26 22 48
Rate of Incidents that were Serious Injuries per
4 100 people 0.85 0.72 0.79
5 # of Incidents that were Falls 32 31 63
6 Rate of Falls per 100 people 1.05 1.01 1.03
7 # of Falls resulting in serious injury 13 13 26
8 % of serious injuries due to falls 50.0% 59.1% 54.6%
Incidents / Middle Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
15 # of Reportable Incidents 412 423 835
16 Rate of Reportable Incidents per 100 people 13.5 13.9 13.7
17 # of Serious Injuries 26 29 55
Rate of Incidents that were Serious Injuries per
18 100 people 0.85 0.95 0.90
19 # of Incidents that were Falls 23 32 55
20 Rate of Falls per 100 people 0.76 1.05 0.91
21 # of Falls resulting in serious injury 8 15 23
22 % of serious injuries due to falls 30.8% 51.7% 41.3%
Incidents / West Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
29 # of Reportable Incidents 291 313 604
30 Rate of Reportable Incidents per 100 people 12.8 13.7 13.25
31 # of Serious Injuries 18 19 37
Rate of Incidents that were Serious Injuries per
33 100 people 0.79 0.83 0.81
37 # of Incidents that were Falls 19 17 36
39 Rate of Falls per 100 people 0.83 0.74 0.79
40 # of Falls resulting in serious injury 6 5 11
41 % of serious injuries due to falls 33.3% 26.3% 29.8%
D Protection From Harm/Incident Management
Incidents / Statewide Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 YTD
44 # of Reportable Incidents 1066 1140 2206
45 Rate of Reportable Incidents per 100 people 12.7 13.6 13.15
46 # of Serious Injuries 70 70 140
Rate of Incidents that were Serious Injuries per
47 100 people 0.84 0.83 0.84
48 # of Incidents that were Falls 74 80 154
49 Rate of Falls per 100 people 0.88 0.95 0.92
50 # of Falls resulting in serious injury 27 33 60
51 % of serious injuries due to falls 38.6% 47.1% 42.9%
15
Data Management Report
October 22, 2010
Monthly DIDS Reportable Incident and Serious Injury Rates
All DIDS Community and eligible Private ICF/MR Service Recipients
16.0
14.0
Rate per 100 Service Recipients
12.0
10.0
8.0
Reportable Incident Rate
Serious Injury Rate
6.0
Linear (Reportable Incident Rate)
4.0 Linear (Serious Injury Rate)
2.0
0.0
August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April 2010 May 2010 June 2010 July 2010 August 2010
Month
PFH Analysis: Incident Management
Chart: Monthly Rate: Reportable Incidents and Serious Injuries.
The monthly statewide rate of Reportable Incidents per 100 service recipients for August 2010 (the last point on the line graph at the top of the chart) shows a slight increase (7%) from the previous month.
August has historically been the month with the highest incident rate, and this year follows that pattern. The rate for this August is slightly lower than the rate for August 2009. The monthly rate of Reportable
Incidents per 100 service recipients has shown slight variation from month to month. This rate has ranged from the high of 13.6 incidents per 100 services recipients per month for August 2010 to a low of 10.7 for
February 2010.
The August 2010 statewide rate of Serious Injuries per 100 service recipients shows a comparable slight increase (1%) from the previous month.
The monthly rate of Serious Injuries per 100 service recipients, at the bottom of the chart, has shown relatively greater monthly variation than the incident rate, at least partly due to the relatively lower rate of serious
injuries. (Approximately 6% of Reportable Incidents are associated with a Serious Injury.) The Serious Injury rate ranged from a high of 0.88 Serious Injuries per 100 services recipients per month (April 2010) to a
low of 0.62 (February 2010).
Conclusions and actions taken for the reporting period:
D.I.D.S. Protection From Harm has continued to conduct quarterly training and discussion meetings in each of the three Regions with service provider Incident Management Coordinators. The most recent round of
sessions, conducted in July 2010, included two presentations on home safety. The first one, developed by the Centers for Disease Control (CDC) and the National Fire Prevention Association (NFPA),
demonstrates the relationship between fire prevention and fall prevention, and was presented by Randy Fox, Columbia Fire Department. The second presentation, by Sandra Clamp, discussed the D.I.D.S.
Supported Living Home Inspection process. A third presentation, by Eleanor Brantley, RN, D.I.D.S. Clinical Investigator, covered four years of information (2006-2009) about abuse and neglect investigations of
deaths.
D.I.D.S. Protection From Harm also continues to coordinate with other D.I.D.S. sections to develop interventions aimed at reducing abuse and neglect, injuries, and incidents such as choking. To help reduce
choking, training in awareness of swallowing difficulties is being expanded so that it will be available to family members, and training on swallowing issues is to be set up on the College of Direct Support system.
The overall Protection From Harm training curriculum will be revised in coordination with the pending policy revision and will also incorporate elements from the pre-CDS “What Is Abuse? How Do We Prevent It?”
curriculum.
DIDS Protection From Harm is also in the process of revising the policy that covers incident management and abuse investigations. Several focus group meetings were conducted with provider Incident
Management Coordinators in August.
16
Data Management Report
October 22, 2010
D Protection From Harm/Investigations
East Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
1 Census 3054 3052
2 # of Investigations 58 59
3 Rate of Investigations per 100 people 1.90 1.93
4 # of Substantiated Investigations 12 23
5 Rate of Substantiated Investigations per 100
people 0.39 0.75
6 Percentage of Investigations Substantiated 21% 39%
7 Middle Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
8 Census 3046 3052
9 # of Investigations 87 79
10 Rate of Investigations per 100 people 2.86 2.59
11 # of Substantiated Investigations 26 17
12 Rate of Substantiated Investigations per 100
people 0.85 0.56
13 Percentage of Investigations Substantiated 30% 22%
West Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
14 Census 2299 1993
15 # of Investigations 65 71
16 Rate of Investigations per 100 people 2.83 3.56
17 # of Substantiated Investigations 18 22
18 Rate of Substantiated Investigations per 100
people 0.78 1.10
19 Percentage of Investigations Substantiated 28% 31%
Statewide Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
20 Census 8399 8097
21 # of Investigations 210 209
22 Rate of Investigations per 100 people 2.50 2.58
23 # of Substantiated Investigations 56 62
24 Rate of Substantiated Investigations per 100
people 0.67 0.77
25 Percentage of Investigations Substantiated 27% 30%
17
Data Management Report
October 22, 2010
Monthly DIDS Abuse, Neglect, & Exploitation Investigation and Substantiation Rates
All DIDS Community and eligible Private ICF/MR Service Recipients
3
2.5
Rate per 100 Service Recipients per Month
2
1.5
Investigation Rate
1 Substantiated Investigation Rate
0.5
0
August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April 2010 May 2010 June 2010 July 2010 August 2010
Month
D Protection From Harm/Investigations
Analysis:
SQMC Investigation Data – August 2010
In August, 2010, the Middle Region led the other regions in the number of investigations conducted, opening a total of 79 investigations for a rate of 2.59 investigations opened per 100 people served in their region.
Only 17 (22%) of these were substantiated for abuse, neglect, or exploitation for a rate of .56 substantiated investigations per 100 people served.
The West Region conducted 71 investigations during August 2010 for a rate of 3.56 investigations conducted per 100 people served. Only 22 (31%) of these investigations were substantiated for abuse, neglect, or
exploitation for a rate of 1.10 investigations substantiated per 100 people served.
The East Region conducted the fewest number of investigations during August 2010, conducting 59 investigations for a rate of 1.93 investigations per 100 people served. 23 (39%) of these were substantiated for
abuse, neglect, or exploitation for a rate of .75 substantiated investigations per 100 people served in this region.
Statewide, there were 209 investigations conducted during the month of August 2010. 2.58 investigations were conducted per 100 people served during this reporting period. 62 (30%) of the investigations were
substantiated for abuse, neglect, or exploitation for a statewide rate of .77 substantiated investigations per 100 people served.
Conclusions and actions taken for the reporting period:
The DIDS Protection From Harm unit was very glad to be able to offer Mortality Review & Death Investigations training, conducted by Labor Relations Alternatives, to the Investigations Staff and several Regional
Office staff. Approximately 75 Regional and Central Office staff received this very valuable training. Equally beneficial was the CAARE (Committee Against Abuse in Residential Environments) meeting that was
attended by PFH staff. Present during this meeting were TBI Medicaid Fraud Agents, DOH, Licensure, and APS personnel. Discussions related to inter-agency referral processes, Service Recipients who are
familiar to each entity, and on-going investigations being conducted amongst various represented entities.
18
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.)
Data Source:
The information contained in this section comes from the Quality Assurance Teams. The numbers in each column represents the percentage of provider agencies that scored either substantial compliance, partial
compliance, minimal compliance or non-compliance.
Day and Residential Provider Statewide 9/10 Cumulative / Statewide 9/10
1 # of Day and Residential Providers Monitored this 15 87
Month
2 Total Census of Providers Surveyed 694 5286
3 # of Sample Size 114 874
4 % of Individuals Surveyed 16% 17%
# of additional Focused Files Reviewed 0 0
Substantial Partial Minimal Non- Substantial Partial Minimal Non-
Compliance % Compliance Compliance compliance Compliance Compliance Compliance compliance
5 Domain 2. Individual Planning and
Implementation
6 Outcome A. The person’s plan reflects his or her 100% 0% 0% 0% 89% 9% 1% 0%
unique needs, expressed preferences and
decisions.
7 Outcome B. Services and supports are provided 66% 33% 0% 0% 71% 24% 4% 0%
according to the person’s plan.
8 Outcome C. Individual risk is assessed and 100% 0% 0% 0% 87% 8% 1% 3%
adequate, timely intervention is provided.
9 Outcome D. The person’s plan and services are 80% 20% 0% 0% 55% 29% 9% 5%
monitored for continued appropriateness and
revised as needed.
10 Domain 3: Safety and Security
11 Outcome A. Where the person lives and works is 86% 13% 0% 0% 75% 22% 1% 0%
safe.
12 Outcome B. The person has a sanitary and 86% 13% 0% 0% 89% 10% 0% 0%
comfortable living arrangement.
13 Outcome C. Safeguards are in place to protect 20% 80% 0% 0% 31% 62% 5% 1%
the person from harm.
14 Domain 4: Rights, Respect and Dignity
15 Outcome A. The person is valued, respected and 100% 0% 0% 0% 96% 2% 1% 0%
treated with dignity.
16 Outcome B. The person has a positive image in 100% 0% 0% 0% 100% 0% 0% 0%
the community.
17 Outcome C. The person exercises his or her 93% 6% 0% 0% 95% 4% 0% 0%
rights.
18 Outcome D. Restricted interventions are imposed 64% 35% 0% 0% 68% 20% 4% 6%
only with due process.
19 Domain 5: Health
20 Outcome A. The person has the best possible 86% 13% 0% 0% 70% 20% 1% 8%
health.
21 Outcome B. The person takes medications as 60% 40% 0% 0% 44% 38% 8% 9%
prescribed.
22 Outcome C. The person's dietary and nutritional 86% 13% 0% 0% 89% 6% 2% 1%
needs are adequately met.
19
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.)
Substantial Partial Minimal Non- Substantial Partial Minimal Non-
Compliance % Compliance Compliance compliance Compliance Compliance Compliance compliance
23 Domain 6: Choice and Decision-Making
24 Outcome A. The person and family members are 86% 13% 0% 0% 95% 4% 0% 0%
involved in decision-making at all levels of the
system.
25 Outcome B. The person and family members have 100% 0% 0% 0% 100% 0% 0% 0%
information and support to make choices about
their lives.
26 Domain 7: Relationships and Community
Membership
27 Outcome A. The person has relationships with 100% 0% 0% 0% 100% 0% 0% 0%
individuals who are not paid to provide support.
28 Outcome B. The person is an active participant in 100% 0% 0% 0% 98% 1% 0% 0%
community life rather than just being present.
29 Outcome C. The person has a valued role in the 100% 0% 0% 0% 98% 1% 0% 0%
community.
30 Domain 8: Opportunities for Work
31 Outcome A. The person has a meaningful job in 92% 0% 7% 0% 90% 6% 3% 0%
the community.
32 Outcome B. The person's day service leads to 100% 0% 0% 0% 95% 4% 0% 0%
community employment or meets his or her
unique needs.
33 Domain 9: Provider Capabilities and
Qualifications
34 Outcome A. The provider meets and maintains 66% 13% 20% 0% 66% 21% 8% 3%
compliance with applicable licensure and provider
agreement requirements.
35 Indicator 9.A.1.: The provider meets and 100% 0% 97% 2%
maintains compliance with applicable licensure,
certification and contract requirements.
36 Indicator 9.A.2.: The provider complies with 100% 0% 97% 2%
requirements in the provider agreement.
37 Indicator 9.A.4.: The provider develops and 93% 6% 97% 2%
implements a written management plan describing
how the agency conducts its business and
specifying the provider's processes for protecting
the health, safety and welfare of the persons
whom it supports.
38 Outcome B. Provider staff are trained and meet 60% 40% 0% 0% 67% 25% 4% 2%
job specific qualifications.
39 Indicator 9.B.2.: Provider staff have received 53% 46% 66% 33%
appropriate training and, as needed, focused or
additional training to meet the needs of the person.
40 Outcome C. Provider staff are adequately 60% 40% 0% 0% 63% 25% 6% 4%
supported.
41 Outcome D. Organizations receive guidance from 93% 6% 0% 0% 89% 6% 2% 1%
a representative board of directors or a
community advisory board.
42 Domain 10: Administrative Authority and
Financial Accountability
43 Outcome A. Providers are accountable for DIDS 73% 13% 6% 6% 87% 9% 2% 1%
requirements related to the services and supports
that they provide.
44 Outcome B. People’s personal funds are 38% 46% 15% 0% 53% 38% 5% 2%
managed appropriately.
20
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- Day/Residential
30
25
Number of Agencies
20
Exceptional Performance
15
Proficient
10 Fair
Significant Concerns
5
Serious Deficiencies
0
East Middle West
Performance Ratings
Analysis: Note- Statewide and Cumulative / Statewide data in the table above may sometimes exceed or be just below 100% due to the numerical rounding functions during calculations.
Providers reviewed: East: East: Adult Community Training, Lakeway Achievement Center, Rhea of Sunshine; Middle- Care for Meg, Homeplace, Omni Visions, Restoration Residential Services, RHA Health
Services, Rutherford County Adult Activity Center, Starcare of Tennessee, Tennessee Family Solutions, Volunteers of America; West- Brenda Richardson Memorial Care Homes, C. S. Patterson Training and
Habilitation Center, Mosaic.
In the East Region:
Adult Community Training, Inc. - The survey resulted in an overall performance rating of Exceptional, score of 52, reflecting a slight increase from the previous 2008 survey which resulted in an overall performance
rating of Proficient, score of 50. The agency was exempt from a survey in 2009 due to achievement of Star status. Some issues pertaining medication histories, parameters for PRN medications and a need for
clarification of doctor-ordered diets were noted which resulted in PC for Domain 5, a decrease from SC on the previous survey. Improvements in the areas of service delivery covered by Domains 4 and 10 resulted
in SC, an increase from PC on the previous survey. All other applicable Domains resulted in SC.
Lakeway Achievement Center - The survey resulted in an overall performance rating of Fair, score of 42, reflecting a decrease from the previous survey which resulted in an overall performance rating of Proficient,
score of 48. For Domain 2, issues pertaining to service documentation and monthly review processes contributed to a result of PC, a decrease from SC in the previous survey. In Domain 8, individual issues
pertaining to choice and organizational issues re; oversight and processes to promote the development of supports contributed to a result of PC, a decrease from SC. Due to a few billing issues and repeat issues
regarding the management of personal funds, Domain 10 resulted in MC, a decrease from PC. Otherwise, Domains 5 and 9 were maintained at PC and Domains 3, 4, 6 and 7 were maintained at SC.
Rhea of Sunshine, Inc. - The survey resulted in an overall performance rating of Proficient, score of 50, which reflects a slight increase in score from the previous survey which also resulted in Proficient, however
the score was 48. Repeat issues pertaining to the timely completion of registry checks and medication variances resulted in a decrease in the results for Domain 3 from SC to PC. Improvements, however, were
noted in the results for Domain 5, Health, and Domain 9, Provider Capabilities and Qualifications, which improved from PC to SC. All other applicable Domains resulted in SC.timely completion of registry checks
and medication variances resulted in a decrease in the results for Domain 3 from SC to PC. Improvements, however, were noted in the results for Domain 5, Health, and Domain 9, Provider Capabilities and
Qualifications, which improved from PC to SC. All other applicable Domains resulted in SC.
In the Middle Region:
RHA- Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. Family Based services had several issues identified. One home did not have an ISP and a sanction occurred, there
were issues with the person's bedroom being on the 2nd floor and inaccessible and personal funds/financial issues noted and Internal Audit will review. Inadequate staff in the family-based home resulted in a rate
adjustment also. A complete review of Family-Based requirements was provided at the exit conference. New hires and tenured staff training had not occurred timely. Personal funds reimbursement was required of
4/4 individuals on the survey sample.
Tennessee Family Solutions- Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. A rate adjustment occurred for Family-Based 5 services for failure to provide adequate
staffing. Personal funds were reimbursement required for 2/4 persons
Starcare- Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. However, Outcome 9.A. scored Minimal Compliance due to the failure to analyze self-assessment data for
inclusion in a quality improvement process.
Omni-Visions- Scored Fair on the QA survey with no Domains scoring less than Partial Compliance. CPR was completed on-line for 3 tenured employees and First-Aid was completed on-line for 1 tenured
employee. Agency informed that these staff could not work alone with individuals until recertified correctly. Personal funds reimbursement required for 3/3 people reviewed on the sample.
Homeplace- Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. Personal funds reimbursement was required for 2/2 people on the sample. However much improvement noted
overall with the agency.
RCAAC- Scored Exceptional on the QA survey with no Domains scoring less than Partial Compliance. No concerns.
Restoration Residential-Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. Issues noted with timely personnel checks for new hires and rebilling occurred for lack of
documentation to support billing for one person.
VOA- Scored Proficient. No domains scored less than Partial Compliance. Background checks were completed early for 44/105 new staff for a compliance rating of 35.3%. Tenured staff training for CPR recerts
were late for 10/19 staff. Medication Administration issues were identified for individuals served through only the Hermitage office. No other concerns.
Care for Meg- Scored Exceptional on the QA survey with a perfect score. No concerns and the agency was closed as of October 1, 2010.
Other
BIOS-A Review of the QA survey findings was completed on 9/2/10. No changes were made to the survey report.
21
Data Management Report
October 22, 2010
In the West Region:
Mosaic – Day/Res provider scored 44 of 54/Fair; no Domains or Outcomes scored less than PC. Areas needing attention include 2 homes in need of cleaning/maintenance; background and registry checks present
with 1 exception but not timely; RIFs not fully or accurately completed; repeat finding re: not maintaining evidence of HRC review of psychotropic medications; one staff administered medications for two weeks with
lapsed medication administration certification; two people did not have appropriately maintained controlled medication counts; no evidence of mechanism to gather and use consumer/family satisfaction information;
self assessment activities were primarily focused on individuals rather than inclusive of systems/organizational processes and findings were presented nationwide but findings specific to the local organization were
not evident; quality improvement planning processes did reflect planning for correction/ change but data reflecting provider actions based on self assessment results was lacking; training competency and timeliness
issues for both new and tenured staff; no minutes presented for either national board or local advisory group so could not determine appropriate meeting frequency. Note personal funds was not reviewed this
survey due to concurrent full audit of personal funds by FAR.
Brenda Richardson Memorial Care Homes – Day/Res provider scored 50 of 54/ Proficient; no Domains scored less than PC; outcome 9A scored MC. Areas needing attention include 2B (2B5 – documentation of
outcomes/actions); 3C (3C6 – all background checks present with majority early [none late]; all registry checks present/timely except for 1 staff); 4D (4D3 – 1 of 2 people in sample taking psychotropic medications
did not have evidence of HRC review); 5B (5B3 – one staff with lapsed certification gave medications during the review period); 9A (9A5 & 6 – repeat issues re: weak self-assessment and quality improvement
planning processes); and 9C (9C2 – documentation does not reflect when the weekly supervisory visits to homes are completed unannounced)
C.S. Patterson Training & Habilitation Center – Day/Res provider scored 50 of 54/ Proficient; no Domain scored less than PC; outcome 9A scored MC. Areas needing attention include 3C (3C6 – early background
checks; 3C10 – some late reporting of incidents); 9A (9A3 & 9A4– incomplete records policy and management plan; 9A5 & 9A6 – no system-wide process for self-assessment and quality improvement planning; and
9C (9C2 – lack of documented supervisory visits to people receiving PA).
As represented in the graph, 21 (29%) Day-Residential providers have performed in the Exceptional Performance category, 32 (44%) have performed in the Proficient category, 14 (19%) are in the Fair category and
5 (7%) are in the category of Significant Concerns.
The following Outcomes are being studied by DIDS.
Domain 2, Outcome B (Services and Supports are provided according to the person’s plan.)
Of the providers surveyed in September 2010, 66% achieved Substantial Compliance with this Outcome. Cumulative performance is at 71% Substantial Compliance for the providers surveyed this year.
Domain 2, Outcome D (The person’s plan and services are monitored for continued appropriateness and revised as needed.)
Of the providers surveyed in September 2010, 80% achieved Substantial Compliance with this Outcome. Cumulative performance is at 55% Substantial Compliance for the providers surveyed this year.
The following QA Indicators are being tracked to meet requirements of CMS Special Terms and Conditions of Approval and / or TennCare.
9.A.1. (The provider meets and maintains compliance with applicable licensure, certification, and contract requirements.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 97% Substantial Compliance for the providers surveyed this year.
9.A.2. (The provider complies with requirements in the provider agreement.- relates to requirements regarding subcontracts.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 97% Substantial Compliance for the providers surveyed this year.
9.A.4. (The provider develops and implements a written management plan describing how the agency conducts its business and specifying the provider’s processes for protecting the health, safety and welfare of
persons whom it supports.) Of the providers surveyed in September 2010, 93% achieved Substantial Compliance with this Indicator. Cumulative performance is at 97% Substantial Compliance for the providers
surveyed this year.
9.B.2. (Provider staff have received appropriate training and, as needed, focused or additional training to meet the needs of the person.) Of the providers surveyed in September 2010, 53% achieved Substantial
Compliance with this Indicator. Cumulative performance is at 66% Substantial Compliance for the providers surveyed this year.
As represented in the graph, 24 (28%) Day-Residential providers have performed in the Exceptional Performance category, 41 (47%) have performed in the Proficient category, 17 (20%) are in the Fair category and
5 (6%) are in the category of Significant Concerns.
Conclusions:
DIDS is continuing close review of Domain 2, Outcomes B and D.
Follow-up on actions taken from the previous reporting periods:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
22
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.)
Personal Assistance Statewide 9/10 Cumulative / Statewide 9/10
1 # of Day and Residential Providers Monitored this 3 13
Month
2 Total Census of Providers Surveyed 29 457
3 # of Sample Size 6 77
4 % of Individuals Surveyed 21% 17%
5 # of Additional Focused Files Reviewed 0 0
Partial Minimal Non- Substantial Partial Minimal Non-
Substantial Compliance Compliance compliance Compliance Compliance Compliance compliance
Compliance % % % % % % % %
7 Domain 2. Individual Planning and
Implementation
8 Outcome A. The person’s plan reflects his or her 100% 0% 0% 0% 92% 0% 7% 0%
unique needs, expressed preferences and
decisions.
9 Outcome B. Services and supports are provided 66% 33% 0% 0% 53% 38% 7% 0%
according to the person’s plan.
10 Outcome C. Individual risk is assessed and 66% 0% 0% 33% 76% 7% 0% 15%
adequate, timely intervention is provided.
11 Outcome D. The person’s plan and services are 33% 33% 33% 0% 46% 30% 7% 15%
monitored for continued appropriateness and
revised as needed.
12 Domain 3: Safety and Security
13 Outcome A. Where the person lives and works is 100% 0% 0% 0% 92% 7% 0% 0%
safe.
15 Outcome C. Safeguards are in place to protect 33% 66% 0% 0% 15% 84% 0% 0%
the person from harm.
16 Domain 4: Rights, Respect and Dignity
17 Outcome A. The person is valued, respected and 100% 0% 0% 0% 100% 0% 0% 0%
treated with dignity.
18 Outcome B. The person has a positive image in 100% 0% 0% 0% 100% 0% 0% 0%
the community.
19 Outcome C. The person exercises his or her 66% 33% 0% 0% 92% 7% 0% 0%
rights.
20 Outcome D. Restricted interventions are imposed 100% 0% 0% 0% 100% 0% 0% 0%
only with due process.
21 Domain 5: Health
22 Outcome A. The person has the best possible 100% 0% 0% 0% 66% 25% 0% 8%
health.
23 Outcome B. The person takes medications as 66% 16% 0% 16%
prescribed.
24 Outcome C. The person's dietary and nutritional 100% 0% 0% 0% 84% 7% 7% 0%
needs are adequately met.
25 Domain 6: Choice and Decision-Making
26 Outcome A. The person and family members are 100% 0% 0% 0% 100% 0% 0% 0%
involved in decision-making at all levels of the
system.
27 Outcome B. The person and family members have 100% 0% 0% 0% 100% 0% 0% 0%
information and support to make choices about
their lives.
23
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.) Partial Minimal Non- Substantial Partial Minimal Non-
Substantial Compliance Compliance compliance Compliance Compliance Compliance compliance
Compliance % % % % % % % %
35 Domain 9: Provider Capabilities and
Qualifications
36 Outcome A. The provider meets and maintains 33% 33% 33% 0% 46% 30% 15% 7%
compliance with applicable licensure and provider
agreement requirements.
37 Indicator 9.A.1.: The provider meets and 100% 0% 100% 0%
maintains compliance with applicable licensure,
certification and contract requirements.
38 Indicator 9.A.2.: The provider complies with 100% 0% 100% 0%
requirements in the provider agreement.
39 Indicator 9.A.4.: The provider develops and 100% 0% 92% 7%
implements a written management plan describing
how the agency conducts its business and
specifying the provider's processes for protecting
the health, safety and welfare of the persons
whom it supports.
40 Outcome B. Provider staff are trained and meet 66% 33% 0% 0% 46% 46% 7% 0%
job specific qualifications.
41 Indicator 9.B.2.: Provider staff have received 66% 33% 46% 53%
appropriate training and, as needed, focused or
additional training to meet the needs of the person.
42 Outcome C. Provider staff are adequately 33% 66% 0% 0% 46% 46% 7% 0%
supported.
43 Outcome D. Organizations receive guidance from 100% 0% 0% 0% 92% 7% 0% 0%
a representative board of directors or a
community advisory board.
44 Domain 10: Administrative Authority and
Financial Accountability
45 Outcome A. Providers are accountable for DIDS 66% 33% 0% 0% 84% 15% 0% 0%
requirements related to the services and supports
that they provide.
24
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- Personal Assistance
5
4
Number of Agencies
3
Exceptional Performance
Proficient
2 Fair
Significant Concerns
1 Serious Deficiencies
0
East Middle West
Performance Ratings
Analysis:
Note- Statewide and Cumulative / Statewide data in the table above may sometimes exceed or be just below 100% due to the numerical rounding functions during calculations
Providers reviewed: Middle: Sitters and More; West: CAK, Mic’s Place.
In the Middle Region:
Sitters and More- Scored Proficient on the QA survey with no Domains scoring less than Partial Compliance. No concerns.
In the West Region:
Mic’s Place – first full survey completed for this microboard; Domain 2 and Outcomes 2C, 2D and 9A scored MC or NC; all other Domains and Outcomes scored at least PC. Areas needing attention include daily
notes did not document implementation of several ISP outcomes/action steps and at the time of their initial review did not provide time in/out of the service; staff from each shift do not write notes with one staff only
writing all notes; no RIIT presented; no formal planning to address person’s behavioral issues that have resulted in use of manual restraint at times; no evidence of formal training for staff regarding appropriate
techniques for addressing the person’s behavioral issues.
Monthly reviews did not note lack of ISP outcome/action implementation; though provider did request change to draft ISP [current final ISP reportedly is not appropriate for the person in several places], additional
communication with the ISC to initiate ISP changes was not evident; agency IMC has not completed approved DIDS training; RIFs not completed/ submitted for use of emergency manual restraint; person is
manually restrained if, in the opinion of staff, behaviors warrant this; no current evidence of any self assessment or quality improvement planning activities; 2 of 2 staff did not have current CPR training and 1 of 2
did not have current First Aid training; and no documentation reflecting implementation of the supervision plan.
CAK – PA/Day microboard scored 50 of 54/Proficient; Outcome 10B is the only Outcome or Domain scoring less than PC. Areas of concern noted include late background & registry checks and incomplete self
assessment and absent quality improvement planning processes. Compliance with personal funds management requirements was not evident the majority of the review period; at the time of the survey, parents
were almost done transferring responsibility for being rep payee and personal funds management requirements should not apply from this point forward.
The following Outcomes are being studied by DIDS.
Domain 2, Outcome B (Services and Supports are provided according to the person’s plan.)
Of the providers surveyed in September 2010, 66% achieved Substantial Compliance with this Outcome. Cumulative performance is at 53% Substantial Compliance for the providers surveyed this year.
Domain 2, Outcome D (The person’s plan and services are monitored for continued appropriateness and revised as needed.)
Of the providers surveyed in September 2010, 33% achieved Substantial Compliance with this Outcome. Cumulative performance is at 46% Substantial Compliance for the providers surveyed this year.
The following QA Indicators are being tracked to meet requirements of CMS Special Terms and Conditions of Approval and / or TennCare.
9.A.1. (The provider meets and maintains compliance with applicable licensure, certification, and contract requirements.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 100% Substantial Compliance for the providers surveyed this year.
9.A.2. (The provider complies with requirements in the provider agreement.- relates to requirements regarding subcontracts.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 100% Substantial Compliance for the providers surveyed this year.
9.A.4. (The provider develops and implements a written management plan describing how the agency conducts its business and specifying the provider’s processes for protecting the health, safety and welfare of
persons whom it supports.) The providers surveyed in September 2010 achieved Substantial Compliance with this Indicator. Cumulative performance is at 92% Substantial Compliance for the providers surveyed
this year.
9.B.2. (Provider staff have received appropriate training and, as needed, focused or additional training to meet the needs of the person.) Of the providers surveyed in September 2010, 66% achieved Substantial
Compliance with this Indicator. Cumulative performance is at 46% Substantial Compliance for the providers surveyed this year.
As represented in the graph, 3 (23%) providers have performed in the Exceptional Performance category, 7 (54%) have performed in the Proficient category, and 3 (23%) are in the Fair category.
Conclusions and actions taken for the reporting period:
DIDS is continuing close review of Domain 2, Outcomes B and D.
Follow-up on actions taken from the previous reporting periods:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
25
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.)
ISC Providers Statewide 9/10 Cumulative / Statewide 9/10
1 # of ISC Providers Monitored this Month
2 Total Census of Providers Surveyed
3 # of Sample Size
4 % of Individuals Surveyed #DIV/0! #DIV/0!
# of Additional Focused Files Reviewed
Substantial Partial Minimal Non- Substantial Partial Minimal Non-
Compliance % Compliance Compliance compliance Compliance Compliance Compliance compliance
5 Domain 1: Access and Eligibility
6 Outcome A. The person and family members are
knowledgeable about the HCBS waiver and other
services, and have access to services and choice
of available qualified providers.
7 Domain 2: Individual Planning and
Implementation
8 Outcome A. The person's plan reflects his or her
unique needs, expressed preferences and
decisions.
9 Indicator 2.A.4.: Current and appropriate
assessments of the person's abilities, needs and
desires for the future are used in developing the
plan.
10 Outcome B. Services and supports are provided
according to the person's plan.
11 Outcome C. Individual risk is assessed and
adequate timely intervention is provided.
12 Outcome D. The person's plan and services are
monitored for continued appropriateness and
revised as needed.
13 Domain 3: Safety and Security
14 Outcome A. Where the person lives and works is
safe.
15 Outcome B. The person has a sanitary and
comfortable living arrangement.
16 Outcome C. Safeguards are in place are in place
to protect the person from harm.
17 Domain 9: Provider Capabilities and
Qualifications
18 Outcome A. The provider meets and maintains
compliance with applicable licensure and provider
agreement requirements.
19 Indicator 9.A.2.: The provider complies with
requirements in the provider agreement.
20 Outcome B. Provider staff are trained and meet
job specific qualifications.
21 Indicator 9.B.2.: Provider staff have received
appropriate training and, as needed, focused or
additional training to meet the needs of the person.
22 Outcome C. Provider Staff are adequately
supported.
23 Outcome D. Organizations receive guidance from
a representative board of directors or a
community advisory board.
24 Domain 10: Administrative Authority and
Financial Accountability
25 Outcome A. Providers are accountable for DIDS
requirements related to the services and supports
that they provide.
26
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- ISC
2
Number of Agencies
1 Exceptional Performance
2 Proficient
1 3 Fair
4 Significant Concerns
5 Serious Deficiencies
0
East Middle West
Performance Ratings
Analysis:
Providers reviewed: no reviews.
Conclusions and actions taken for the reporting period:
Close monitoring of the Outcomes will continue throughout the fiscal year.
Follow-up on actions taken from previous reporting periods:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
27
Data Management Report
October 22, 2010
E Clinical Providers- Behavioral Statewide 9/10 Cumulative / Statewide 9/10
1 # of Clinical Providers Monitored for the month 9
2 Total Census of Providers Surveyed 476
3 # of Sample Size 42
4 % of Individuals Surveyed #DIV/0! 9%
# of Additional Focused Files Reviewed 0 0
Partial Minimal Non- Substantial Partial Minimal Non-
Substantial Compliance Compliance compliance Compliance Compliance Compliance compliance
Compliance % % % % % % % %
5 Domain 2: Individual Planning and
Implementation
6 Outcome A. The person's plan reflects his or her 87% 0% 12% 0%
unique needs, expressed preferences and
decisions.
7 Outcome B. Services and supports are provided 77% 11% 11% 0%
according to the person's plan.
8 Outcome C. Individual risk is assessed and 77% 11% 11% 0%
adequate, timely intervention is provided.
9 Outcome D. The person's plan and services are 100% 0% 0% 0%
monitored for continued appropriateness and
revised as needed.
10 Domain 3: Safety and Security
11 Outcome A. Where the person lives and works is 100% 0% 0% 0%
safe.
12 Outcome C. Safeguards are in place to protect 66% 22% 11% 0%
the person from harm.
13 Domain 4: Rights, Respect and Dignity
14 Outcome A. The person is valued, respected, and 100% 0% 0% 0%
treated with dignity.
15 Outcome D. Restricted interventions are imposed 100% 0% 0% 0%
only with due process.
16 Domain 6: Choice and Decision-Making
17 Outcome A. The person and family members are 88% 0% 0% 11%
involved in decision-making at all levels of the
system.
18 Domain 9: Provider Capabilities and
Qualifications
19 Outcome A. The provider meets and maintains 33% 55% 11% 0%
compliance with applicable licensure and provider
agreement requirements.
20 Indicator 9.A.1.: The provider meets and 100% 0%
maintains compliance with applicable licensure,
certification and contract requirements.
21 Indicator 9.A.2.: The provider complies with 88% 11%
requirements in the provider agreement.
22 Outcome B. Provider staff are trained and meet 100% 0% 0% 0%
job specific qualifications.
23 Indicator 9.B.2.: Provider staff have received 100% 0%
appropriate training and, as needed, focused or
additional training to meet the needs of the person.
24 Outcome C. Provider staff are adequately 100% 0% 0% 0%
supported.
25 Domain 10: Administrative Authority and
Financial Accountability
26 Outcome A. Providers are accountable for DIDS 88% 0% 11% 0%
requirements related to the services and supports
that they provide.
28
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- Clinical- Behavioral
4
3
Number of Agencies
2 1 Exceptional Performance
2 Proficient
3 Fair
1 4 Significant Concerns
5 Serious Deficiencies
0
East Middle West
Performance Ratings
Analysis:
Note- Statewide and Cumulative / Statewide data in the tables above may sometimes exceed or be just below 100% due to the numerical rounding functions during Excel calculations.
Behavioral: no reviews
In the West Region:
Quality Care Behavior Services – consultation survey completed for this independent provider who began providing BA services 7/16/10 and was serving 11 people at the time of the consult. Surveyor comments
reflected the need to ensure the BSP sections were as per updated DIDS requirements, to include dates of service provision on all CSMRs, and to ensure evidence of participation in Regional Office New Behavior
Service Provider Orientation is maintained.
As shown in the graph, the 7 (78%) of the providers reviewed thus far this year are in the Exceptional Performance category, 1 (11%) is in the Proficient category, and 1 (11%) is in the Serious Deficiencies category.
Conclusions and actions taken for the reporting period:
Close monitoring of the Outcomes will continue throughout the fiscal year.
Follow-up on actions taken from previous reporting periods:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
29
Data Management Report
October 22, 2010
E Clinical Providers- Nursing Statewide 9/10 Cumulative / Statewide 9/10
1 # of Clinical Providers Monitored for the month 5
2 Total Census of Providers Surveyed 66
3 # of Sample Size 15
4 % of Individuals Surveyed #DIV/0! 23%
# of Additional Focused Files Reviewed 0
Substantial Partial Minimal Non- Substantial Partial Minimal Non-
Compliance % Compliance Compliance compliance Compliance Compliance Compliance compliance
5 Domain 2: Individual Planning and
Implementation
6 Outcome A. The person's plan reflects or her 80% 20% 0% 0%
unique needs, expressed preferences and
decisions.
7 Outcome B. Services and supports are provided 60% 40% 0% 0%
according to the person's plan.
8 Outcome C. Individual risk is assessed and 100% 0% 0% 0%
adequate, timely intervention is provided.
9 Outcome D. The person's plan and services are 40% 40% 20% 0%
monitored for continued appropriateness and
revised as needed.
10 Domain 3: Safety and Security
11 Outcome A. Where the person lives and works is 100% 0% 0% 0%
12 safe.
Outcome C. Safeguards are in place to protect 0% 100% 0% 0%
the person from harm.
13 Domain 4: Rights, Respect and Dignity
14 Outcome A. The person is valued, respected, and 100% 0% 0% 0%
treated with dignity.
15 Outcome D. Restricted interventions are imposed 0% 100% 0% 0%
only with due process.
16 Domain 5: Health
17 Outcome A. The person has the best possible 80% 20% 0% 0%
18 health. B. The person takes medications as
Outcome 60% 20% 20% 0%
prescribed.
19 Outcome C. The person’s dietary and nutritional 100% 0% 0% 0%
needs are adequately met.
20 Domain 6: Choice and Decision-Making
21 Outcome A. The person and family members are 80% 20% 0% 0%
involved in decision-making at all levels of the
22 system. 9: Provider Capabilities and
Domain
Qualifications
23 Outcome A. The provider meets and maintains 40% 60% 0% 0%
compliance with applicable licensure and provider
agreement requirements.
24 Indicator 9.A.1.: The provider meets and 100% 0%
maintains compliance with applicable licensure,
certification and contract requirements.
25 Indicator 9.A.2.: The provider complies with 100% 0%
requirements in the provider agreement.
26 Outcome B. Provider staff are trained and meet 60% 40% 0% 0%
job specific qualifications.
27 Indicator 9.B.2.: Provider staff have received 50% 50%
appropriate training and, as needed, focused or
additional training to meet the needs of the person.
28 Outcome C. Provider staff are adequately 80% 20% 0% 0%
29 supported. Administrative Authority and
Domain 10:
Financial Accountability
30 Outcome A. Providers are accountable for DIDS 80% 20% 0% 0%
requirements related to the services and supports
that they provide.
30
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- Clinical- Nursing
2
Number of Agencies
1
1 Exceptional Performance
2 Proficient
3 Fair
4 Significant Concerns
0
5 Serious Deficiencies
East Middle West
Performance Ratings
Analysis:
Nursing: No reviews
As shown in the graph, 1 (20%) of the providers reviewed thus far this year is in the Exceptional Performance category, 2 (40%) are in the Proficient category, and 2 (40%) is performing in the Fair category.
Conclusions and actions taken for the reporting period:
Close monitoring of the Outcomes will continue throughout the fiscal year.
Follow-up on actions taken from previous reporting period:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
31
Data Management Report
October 22, 2010
E Clinical Providers- Therapy Statewide 9/10 Cumulative / Statewide 9/10
1 # of Clinical Providers Monitored for the month 2 15
2 Total Census of Providers Surveyed 86 1047
3 # of Sample Size 10 100
4 % of Individuals Surveyed 12% 10%
5 # of Additional Focused Files Reviewed 0 0
Partial Minimal Non- Substantial Partial Minimal Non-
Substantial Compliance Compliance compliance Compliance Compliance Compliance compliance
Compliance % % % % % % % %
Domain 2: Individual Planning and
6 Implementation
Outcome A. The person's plan reflects or her
unique needs, expressed preferences and
7 decisions. 100% 0% 0% 0% 86% 13% 0% 0%
Outcome B. Services and supports are provided
8 according to the person's plan. 50% 50% 0% 0% 33% 33% 26% 6%
Outcome C. Individual risk is assessed and
9 adequate, timely intervention is provided. 50% 0% 50% 0% 46% 40% 13% 0%
Outcome D. The person's plan and services are
monitored for continued appropriateness and
10 revised as needed. 50% 0% 50% 0% 33% 26% 40% 0%
11 Domain 3: Safety and Security
Outcome A. Where the person lives and works is
12 safe. 50% 50% 0% 0% 93% 6% 0% 0%
Outcome C. Safeguards are in place to protect
13 the person from harm. 100% 0% 0% 0% 93% 6% 0% 0%
14 Domain 4: Rights, Respect and Dignity
Outcome A. The person is valued, respected, and
15 treated with dignity. 100% 0% 0% 0% 100% 0% 0% 0%
Outcome D. Restricted interventions are imposed 100% 0% 0% 0% 100% 0% 0% 0%
16 only with due process.
17 Domain 6: Choice and Decision-Making
Outcome A. The person and family members are
involved in decision-making at all levels of the
18 system. 100% 0% 0% 0% 100% 0% 0% 0%
Domain 9: Provider Capabilities and
19 Qualifications
Outcome A. The provider meets and maintains
compliance with applicable licensure and provider
20 agreement requirements. 50% 50% 0% 0% 53% 40% 6% 0%
Indicator 9.A.1.: The provider meets and 100% 0% 100% 0%
maintains compliance with applicable licensure,
21 certification and contract requirements.
Indicator 9.A.2.: The provider complies with 100% 0% 100% 0%
22 requirements in the provider agreement.
Outcome B. Provider staff are trained and meet
23 job specific qualifications. 100% 0% 0% 0% 100% 0% 0% 0%
100% 0% 100% 0%
Indicator 9.B.2.: Provider staff have received
appropriate training and, as needed, focused or
24 additional training to meet the needs of the person.
Outcome C. Provider staff are adequately 100% 0% 0% 0% 90% 9% 0% 0%
25 supported.
Domain 10: Administrative Authority and
26 Financial Accountability
Outcome A. Providers are accountable for DIDS
requirements related to the services and supports
27 that they provide. 100% 0% 0% 0% 66% 26% 6% 0%
32
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions- Clinical- Therapy
6
5
Number of Agencies
4
1 Exceptional Performance
3 2 Proficient
3 Fair
2
4 Significant Concerns
1
5 Serious Deficiencies
0
East Middle West
Performance Ratings
Analysis:
Reviews: East: Dynamic Dietetics, Focus on Function; Middle: no reviews; West: no reviews.
In the East Region:
Focus on Function, Inc. - This OT provider serves people residing in both the Middle and East Regions. As the office is maintained in the Chattanooga area, the survey was conducted by the East Region with
information provided by the Middle Region for some individuals included in the sample. The survey resulted in an overall performance rating of Fair, score of 30, which reflects a decrease from the previous survey
which resulted in an overall performance rating of Proficient, score of 32. Due to issues pertaining to the procurement of needed equipment, lapses in the identification of emerging risks/interventions to address risk
issues and a lack of follow-up to address/resolve identified issues resulted in a decrease in the results for Domain 2 from PC to MC. Domain 3 was maintained at PC as the provider's system for identifying
measures to be taken when safety issues are identified needs to be strengthened. All other applicable Domains resulted in SC; 4, 6, 9 and 10.
Dynamic Dietetics, Inc. - This Nutrition provider serves people residing in both the Middle and East Regions. As the office is maintained in the Chattanooga area, the survey was conducted by the East Region with
information provided by the Middle Region for some individuals included in the sample. The survey resulted in an overall performance rating of Exceptional, score of 36, the highest possible with all applicable
Domains resulting in SC. It is also significant to note that all applicable Indicators also resulted in Y.
Summit View Health Services - East - A consultative survey was conducted in order to focus specifically on the newly added Speech Language Therapy service; the agency's provision of Nutrition services has been
well established for quite some time and the agency was designated as a Four Star agency in 2010, hence, exempt from a regular, annual, survey. Some improvements were indicated in the areas of service
delivery covered by Domain 2 pertaining to the completion of assessments, documentation, processes to assure competence in risk management and information needing to be clearly identified in discharge
summaries. The agency is encouraged to strengthen processes to more clearly show how input from family members and individuals is utilized and to maintain complete records.
In the West Region:
Lifestyle Nutrition – consultation survey completed for this independent RD who began providing services in April 2010; at the time of the visit, she was supporting 55 people. Surveyor comments reflected a need to
regularly review and, as indicated, update agency policies to ensure they continually reflect current operation. No other issues were noted.
Kimberly Musicante, OT - consultation survey completed for this independent provider who began providing OT services in July 2010 and was serving 7 people at the time of the review. Surveyor comments
reflected no systemic or individual concerns.
The following QA Indicators are being tracked to meet requirements of CMS Special Terms and Conditions of Approval and / or TennCare.
9.A.1. (The provider meets and maintains compliance with applicable licensure, certification, and contract requirements.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 100% Substantial Compliance for the providers surveyed this year.
9.A.2. (The provider complies with requirements in the provider agreement.- relates to requirements regarding subcontracts.) The providers surveyed in September 2010 achieved Substantial Compliance with this
Indicator. Cumulative performance is at 100% Substantial Compliance for the providers surveyed this year.
9.B.2. (Provider staff have received appropriate training and, as needed, focused or additional training to meet the needs of the person.) The providers surveyed in September 2010 achieved Substantial
Compliance with this Indicator. Cumulative performance is at 100% Substantial Compliance for the providers surveyed this year.
As shown in the graph, the 6 (40%) of the providers reviewed thus far this year are in the Exceptional Performance category, 2 (13%) is in the Proficient category, and 7 (47%) are performing in the Fair category.
Conclusions and actions taken for the reporting period:
Close monitoring of the Outcomes will continue throughout the fiscal year.
Follow-up in actions taken from previous reporting period:
All survey findings are reported to the RQMC for review and determination of actions to be taken. RQMC recommendations are then reviewed by the SQMC for final approval.
33
Data Management Report
October 22, 2010
Cumulative Performance Ratings Across All Regions / All Types
30
25
Number of Agencies
20
Exceptional Performance
15 Proficient
Fair
Significant Concerns
10
Serious Deficiencies
5
0
East Middle West
Performance Ratings
Graph of all Providers:
Analysis:
As represented in the graph, 41 providers (32%) have performed at the level of Exceptional Performance, 53 providers (41%) have performed at the Proficient level, 29 providers (22%) have performed in the Fair
category, 5 (4%) are in the category of Significant Concerns and one provider (1%) is in the category of Serious Deficiencies.
34
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.) Personal Funds
Data Source:
Data collected for the personal funds information is garnered from the annual QA survey. The number of Individual Personal Funds reviewed is based on the sample size for each survey, approximately 10%. Also,
personal funds are reviewed only if the provider agency is the Representative Payee. DIDS does not have authority to review personal funds managed by other entities.
Personal Funds - East Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
# of Individual Personal Funds Accounts
1 Reviewed 26 15 15
# of Individual Personal Funds Accounts Fully
2 Accounted For 26 13 7
3 # of Personal Funds Accounts Found Deficient 0 2 8
4 % of Personal Funds Fully Accounted for 100% 87% 47% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
5 % of Personal Funds Found Deficient 0% 13% 53% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Personal Funds - Middle Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
# of Individual Personal Funds Accounts
6 Reviewed 9 12 19
# of Individual Personal Funds Accounts Fully
7 Accounted For 9 11 9
8 # of Personal Funds Accounts Found Deficient 0 1 10
9 % of Personal Funds Fully Accounted for 100% 92% 47% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
10 % of Personal Funds Found Deficient 0% 8% 53% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Personal Funds - West Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
# of Individual Personal Funds Accounts
11 Reviewed 8 16 9
# of Individual Personal Funds Accounts Fully
12 Accounted For 5 9 8
13 # of Personal Funds Accounts Found Deficient 3 7 1
14 % of Personal Funds Fully Accounted for 63% NA 89% #DIV/0! NA #DIV/0! NA #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
15 % of Personal Funds Found Deficient 38% NA 11% #DIV/0! NA #DIV/0! NA #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Personal Funds - Statewide Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
# of Individual Personal Funds Accounts
16 Reviewed 43 43 43 0 0 0 0 0 0 0 0 0
# of Individual Personal Funds Accounts Fully
17 Accounted For 40 33 24 0 0 0 0 0 0 0 0 0
18 # of Personal Funds Accounts Found Deficient 3 10 19 0 0 0 0 0 0 0 0 0
19 % of Personal Funds Fully Accounted For 93% 77% 56% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
20 % of Personal Funds Found Deficient 7% 23% 44% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
E Provider Qualifications / Monitoring (II.H., II.K.) Personal Funds
21 Cumulative Funds Data Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
# of Individual Personal Funds Accounts
22 Reviewed 271 314 357
# of Individual Personal Funds Accounts Fully
23 Accounted For 230 263 287
24 # of Personal Funds Accounts Found Deficient 41 51 70
25 % Funds Accounted for, Cumulatively 85% 84% 80% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
26 % Funds Deficient, Cumulatively 15% 16% 20% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
35
Data Management Report
October 22, 2010
E Provider Qualifications / Monitoring (II.H., II.K.) Personal Funds
Analysis:
The criteria used for determining if personal funds are fully accounted for is tied to compliance with all requirements in the Personal Funds Management Policy.
In the East Region, 47% of personal funds were fully accounted for.
In the Middle Region, 47% of personal funds were fully accounted for.
In the West Region, 89% of personal funds were fully accounted for.
Statewide, 56% of funds were fully accounted for in September 2010.
Among the issues identified with personal funds management included:
East Region:
Adult Community Training (ACT): Of the 7 accounts reviewed, 5 were considered to be fully accounted for. Issues pertaining to the 2 accounts found deficient were: payments and deposits not always identified
with a check number, personal allowance in the home goes over-limit, cash logs not accurate and ending balances do not match beginning balances, community money over-limit, missing lease, payroll stubs
missing, and missing receipts.
Lakeway Achievement Center: Of the 6 accounts reviewed, 2 were considered to be fully accounted for. Issues pertaining to the 4 accounts found deficient were: Documentation missing for bank deposits,
payments to the agency that were not owed, utility bills lacked details of the service, duplicate payment for Dollywood pass, change left from checks not redeposited, personal allowance logs not accurate and not
legible, inventory not updated timely, check written and not used or voided, unclear if all food receipts were used in splitting expense, late charges, utility payment not split between roommates, check numbers not
on payments or deposits leaving no audit trail, and food and supply expense not reconciled monthly.
Rhea of Sunshine: Of the 2 accounts reviewed, both accounts were found deficient. Issues with the 2 accounts were: Documents showing source and the amount of personal funds received were lacking, person
signed for her allowance money and receipts were not maintained even though the ISP does not indicate that she can make purchases without staff assistance, allowance logs were not accurate and ending
balances did not match the beginning balance on the next log, minimal spending activity, no ledger for cash given to the workshop and personal property inventories did not always include components needed to
protect the person's property.
Middle Region:
Homeplace- Two out of two files reviewed required minimal personal funds reimbursement and much improvement noted in the fiscal overview of personal funds.
Omni-Visions- Three out of three files reviewed required reimbursement of personal funds with lack of receipts or documentation kept of personal spending.
RHA- Three out of four files reviewed required reimbursement of personal funds for lack of receipts and one family-based provider had no records of the individuals monies. This issue was referred to internal audit
for review and disposition.
Starcare- Three individuals reviewed had adequate documentation to support personal funds management.
Restoration Residential- A new agency with 1 out of 2 individuals records reviewed requiring reimbursement of personal funds with lack of adequate documentation to reconcile spending.
RCAAC- Only one out of the 5 records reviewed required reimbursement of personal funds for failure to maintain receipts appropriately.
West Region:
Brenda Richardson Memorial Care Homes - The agency’s inventory did not include P-008 3.g.5. “Inventories of personal property shall be updated in a timely manner (i.e., on the day of the occurrence or the
following morning) to indicate personal property removed from or brought into the home, as described above, and must include dated signatures of the individuals who supplied or disposed of the personal property.”
Two out of the four service recipients are due reimbursements for one missing receipt and a money order fee.
C.S. Patterson - Out of the four individuals surveyed only one and a missing receipt. One household did not have food stamps divided equally on several occasions. One lacked an adequate inventory list. One of
the personal funds log had several math errors. Three of four were receiving more personal funds cash than the ISP stated was adequate.
Mosaic - No personal funds review completed as 100% audit for entire review period being completed by FAR/IA.
Mic's Place - Personal funds requirements not applicable to this microboard
CAK - At last year's review of this microboard, the family stated their intention was that the parent who was not the Representative Payee would be the paid staff; however, this did not occur until July 5, 2010.
Conclusions and actions taken for the reporting period:
None
Follow-up action taken from previous reporting periods:
The Quality Management Committee will continue to analyze data from this area to identify other ways to address concerns.
36
Data Management Report
October 22, 2010
F Due Process / Freedom of Choice
Data Source:
Each Regional Office Appeals Director collects data regarding Grier related appeals. The DIDS Central Office Grier Coordinator maintains the statewide database regarding the specifics of the Grier related
East Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
SERVICE REQUESTS
Total Service Requests Received 2585 2283
Total Adverse Actions (Incl. Partial Approvals) 179 148
% of Service Requests Resulting in Adverse
Actions 7% 6%
Total Grier denial letters issued 104 91
APPEALS RECEIVED
DELIVERY OF SERVICE
Delay 1 0
Termination 0 0
Reduction 0 0
Suspension 0 0
Total Received 1 0
DENIAL OF SERVICE
Total Received 17 22
Total Grier Appeals Received 18 22
Total Non-Grier Appeals Received 0 0
Total appeals overturned upon reconsideration 1 4
TOTAL HEARINGS 41 29
DIRECTIVES
Directive Due to Notice Content Violation 0 0
Directive due to ALJ Ruling in Recipient's Favor 0 1
Other 5 6
Total Directives Received 5 7
Overturned Directives 0 0
MCC Directives 0 0
Cost Avoidance (Estimated) $68,525.90 $21,138
LATE RESPONSES
Total Late Responses 0 0
Total Days Late 0 0
Total Fines Accrued (Estimated) $0.00 $0.00
DEFECTIVE NOTICES
Total Defective Notices Received 0 0
Total Fines Accrued (Estimated) $0.00 $0.00
*fine amount is based on timely responses 0 0
PROVISION OF SERVICES
Delay of Service Notifications Sent (New) 1 0
Continuing Delay Issues (Unresolved) 0 1
Total days service(s) not provided per
TennCare ORR 0 0
Total Fines Accrued (Estimated) $0.00 $0.00
37
Data Management Report
October 22, 2010
Middle Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
SERVICE REQUESTS
Total Service Requests Received 2292 2747
Total Adverse Actions (Incl. Partial Approvals) 297 364
% of Service Requests Resulting in Adverse
Actions 13% 13%
Total Grier denial letters issued 194 224
APPEALS RECEIVED
DELIVERY OF SERVICE
Delay 0 0
Termination 0 0
Reduction 0 0
Suspension 0 0
Total Received 0 0
DENIAL OF SERVICE
Total Received 27 24
Total Grier Appeals Received 27 24
Total Non-Grier Appeals Received 0 0
Total appeals overturned upon reconsideration 5 9
TOTAL HEARINGS 12 21
DIRECTIVES
Directive Due to Notice Content Violation 0 0
Directive due to ALJ Ruling in Recipient's Favor 0 1
Other 1 1
Total Directives Received 1 2
Overturned Directives 0 0
MCC Directives 0 0
Cost Avoidance (Estimated) $0 $16,592
LATE RESPONSES
Total Late Responses 1 0
Total Days Late 1 0
Total Fines Accrued (Estimated) $100 $0
DEFECTIVE NOTICES
Total Defective Notices Received 0 1
Total Fines Accrued (Estimated) $0 $500
*fine amount is based on timely responses
PROVISION OF SERVICES
Delay of Service Notifications Sent (New) 0 0
Continuing Delay Issues (Unresolved) 0 0
Total days service(s) not provided per
TennCare ORR 0 0
Total Fines Accrued (Estimated) 0 0
38
Data Management Report
October 22, 2010
West Region Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
SERVICE REQUESTS
Total Service Requests Received 2201 2236
Total Adverse Actions (Incl. Partial Approvals) 168 181
% of Service Requests Resulting in Adverse
Actions 8% 8%
Total Grier denial letters issued 85 77
APPEALS RECEIVED
DELIVERY OF SERVICE
Delay 0 0
Termination 0 0
Reduction 0 0
Suspension 0 0
Total Received 0 0
DENIAL OF SERVICE
Total Received 12 10
Total Grier Appeals Received 12 10
Total Non-Grier Appeals Received 0 0
Total appeals overturned upon reconsideration 3 1
TOTAL HEARINGS 13 16
DIRECTIVES
Directive Due to Notice Content Violation 0 0
Directive due to ALJ Ruling in Recipient's Favor 0 0
Other 2 1
Total Directives Received 2 1
Overturned Directives 0 0
MCC Directives 0 0
Cost Avoidance (Estimated) $16,592 $12,384
LATE RESPONSES
Total Late Responses 1 0
Total Days Late 1 0
Total Fines Accrued (Estimated) 100 0
DEFECTIVE NOTICES
Total Defective Notices Received 0 1
Total Fines Accrued (Estimated) $0 $500
*fine amount is based on timely responses
PROVISION OF SERVICES
Delay of Service Notifications Sent (New) 3 0
Continuing Delay Issues (Unresolved) 5 5
Total days service(s) not provided per
TennCare ORR 0 0
Total Fines Accrued (Estimated) 0 0
39
Data Management Report
October 22, 2010
Statewide Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
SERVICE REQUESTS
Total Service Requests Received 7078 7266
Total Adverse Actions (Incl. Partial Approvals) 644 693
% of Service Requests Resulting in Adverse
Actions 9% 10%
Total Grier denial letters issued 383 392
APPEALS RECEIVED
DELIVERY OF SERVICE
Delay 1 0
Termination 0 0
Reduction 0 0
Suspension 0 0
Total Received 1 0
DENIAL OF SERVICE
Total Received 56 56
Total Grier Appeals Received 57 56
Total Non-Grier Appeals Received 0 0
Total appeals overturned upon reconsideration 9 14
TOTAL HEARINGS 66 66
DIRECTIVES
Directive Due to Notice Content Violation 0 0
Directive due to ALJ Ruling in Recipient's Favor 0 2
Other 8 8
Total Directives Received 8 10
Overturned Directives 0 0
MCC Directives 0 0
Cost Avoidance (Estimated) $85,117 $50,113
LATE RESPONSES
Total Late Responses 2 0
Total Days Late 2 0
Total Fines Accrued (Estimated) 200 0
Total Defective Notices Received 0 2
Total Fines Accrued (Estimated) $0 $1,000
*fine amount is based on timely responses
PROVISION OF SERVICES
Delay of Service Notifications Sent (New) 4 0
Continuing Delay Issues (Unresolved) 5 6
Total days service(s) not provided per
TennCare ORR 0 0
Total Fines Accrued (Estimated) 0 0
40
Data Management Report
October 22, 2010
Appeals:
DIDS received 56 appeals in August which is a 2% decrease in volume compared to the previous month. Statewide, 7266 service requests were submitted in August which is a 3% increase in volume compared
to the previous month. The percentage of service requests resulting in adverse actions increased 1% for August compared to th e previous month.
Directives:
A total of 10 directives were received statewide in the month of August.
The East Region received 7 directives. 1 directive regarded a request for SL6-IND for the ISP year. The region had approved SL4-IND and a SLSNADJ for the ISP year. The ALJ ruled in favor of the recipient. 2
directives were the result of TennCare overturning the region’s denial upon medical necessity review. The appeals regarded 24 ,820 units of LPN for the ISP year and 64 units per day of LPN for the ISP year. 1
directive regarded a request for 24 hrs per day in PA services where the region agreed to provide the care as requested.
A total of 10 directives were received statewide in the month of August.
The East Region received 7 directives. 1 directive regarded a request for SL6-IND for the ISP year. The region had approved SL4-IND and a SLSNADJ for the ISP year. The ALJ ruled in favor of the recipient. 2
directives were the result of TennCare overturning the region’s denial upon medical necessity review. The appeals regarded 24 ,820 units of LPN for the ISP year and 64 units per day of LPN for the ISP year. 1
directive regarded a request for 24 hrs per day in PA services where the region agreed to provide the care as requested.
1 directive regarded a request for 16 hours a day in PA services where the region agreed to provide10 hrs per day during the week, 16 hrs per day on weekends and CBDay-4 for the ISP year. This decision
resulted in a cost avoidance (see below). The remaining 2 directives were the result of the ALJ ruling in favor of the region regarding requests for SL4-2 for the ISP year where the region had approved SL3-2 as the
medically necessary alternative. This resulted in a cost avoidance (see below)
The West Region received 1 directive regarding a request for 17,788 units of PA services for the ISP year. The region approve d 14,432 units for the ISP year as the medically necessary alternative. The ALJ upheld
the region’s denial which resulted in cost avoidance (see below).
The Middle Region received 2 directives. 1 directive regarded a request for SL3-IND for the ISP year. The region approved SL3-2 for the ISP year as the medically necessary alternative. The ALJ ruled in favor of
DIDS. This resulted in a cost avoidance (see below). The remaining directive regarded a request for SL4 -IND for the ISP year where the ALJ ruled in favor of the recipient.
Cost Avoidance:
2 directives were received regarding East Region appeals where the ALJ ruled in favor of the region’s denials and another directive was received where the region partially approved the requested service.
These directives resulted in a cost avoidance of $21,137.88.
The ALJ ruled in favor of the West Region regarding an appeal which resulted in a cost avoidance of $12,383.64.
The ALJ ruled in favor of the Middle Region regarding an appeal which resulted in a cost avoidance of $16,591.50.
The Division’s estimated cost avoidance for the month of August 2010 is $167,999.06 and is $2,056,780.31 for the year.
Sanctioning/Fining Issues:
There was no delay of service issues received in this month. There are 9 ongoing delays which have carried over from the previous month.
Late Responses
Statewide, there were no late responses for this month.
Defective Notices:
Statewide, 2 defective notices were received this month. The Middle region received 1 due to listing the service amount incor rectly and the other was received by the West region due to citing incorrect legal basis
for denial. This resulted in a total fine amount of $1,000.00.
41
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