Nevada’s APS Quality Assurance Program Process

Steve SisolakGovernorRichard WhitleyDirectorState of NevadaDepartment of Health and Human ServicesNevada’s APS Quality Assurance Program ProcessAging and Disability Services DivisionDena Schmidt, ADSD AdministratorFriday, October 16, 2020Helping People. It’s who we are and what we do.

NAPSA 2020Nevada’s APS Quality Assurance Program ProcessRobin TejadaStephanie SchneiderSocial Service Program Specialist 3Social Service Program Specialist 2Quality Assurance, Adult RightsQuality Assurance, Adult RightsAging and Disability ServicesAging and Disability Tammy SeverSocial Services Chief 2Adult Protective ServicesAging and Disability Servicestsever@adsd.nv.govHelping People. It’s who we are and what we do.2

Mission StatementOur mission is to provide quality assurance oversight of AdultProtective Services and Long-Term Care Ombudsman Program byidentifying areas of program improvement and to assist withdeveloping solutions to ensure the highest level of services areprovided to Nevadans.Helping People. It’s who we are and what we do.3

Learning Objectives› How did Nevada get here? Understanding thesteps of developing a QA process.› Utilizing ACL Voluntary Consensus Guidelinesfor the State Adult Protective Services systemin the creation of the Case File Review Formand Instructions.› Data to Action! How to turn data obtainedfrom the Case File Review (CFR) forms intomeaningful statistics.› Understanding potential drawbacks todeveloping a QA process.Helping People. It’s who we are and what we do.4

Nevada’s Adult Protective Services ProgramOverview› July 1st, 2019 Nevada expanded to a full APS program.› Added protective services for vulnerable adults from the ages of 18-59along with services for those 60 years and older.› Nevada’s APS program is administered through Aging and DisabilityServices Division (ADSD).› Statewide program› Office locations: Las Vegas, Reno, Carson City, and Elko› Providing services to urban, rural, and frontier areasHelping People. It’s who we are and what we do.5

History of Nevada’s Elder Protective Services toAdult Protective Services1981Nevada’sEPSprogramstartedand washousedwithin theState ofNevada’sMedicaidProgram.Nevada’s EPSprovidedprotection servicesfor those 60- yearsand over; exceptfor Clark County(Las Vegas area)which onlyprovidedprotection servicesto those 60 yearsand over whoreceived Medicaidbenefits.July 1, 1999July 1, 2010EPS programwastransferred tothe Divisionfor AgingServices(currentlyknown as theDivision forAging andDisabilityservicesADSD).Clark County SeniorProtection Servicesturned their programover to ADSD. Thetransition expanded theEPS program in LasVegas from 1 supervisor,4 social workers, and 3intake workers to 5supervisors, 20 socialworkers, and acentralized intake unitwith 9 intake workers.Helping People. It’s who we are and what we do.July 1, 2019Nevada’s EPSprogramexpanded toAdult ProtectiveServices (APS)for vulnerableadults from theages of 18-59along withservices forthose 60 yearsand older.6

ACL Grants2016 Nevada EPS was awarded the ACL State Grant toEnhance Adult Protective Services2018 Nevada received ACL State Grant to Enhance AdultProtective Services2020 Nevada received ACL State Grant to Enhance AdultProtective Services related to Opioid MisuseHelping People. It’s who we are and what we do.7

NAMRS Data UtilizedHelping People. It’s who we are and what we do.8

Improving Data Through NAMRS1. New information available with addition of the following Case Components (added 10/1/2019): ADL Score, IADLScore, Schooling Level2. Expansion of Services options based on feedback from supervisors: Services at start \ Services at Close: Education, employment and training services (added 4/1/20) APS Ancillary Services: APS Food Pantry (added 10/1/20); Transportation Assistance (added 10/1/2019) APS Interagency Collaboration and\or Referral: Developmental Services (added 1/3/20); OCHA (added1/3/20); VOCA Compensation Application (1/3/20)3. Identified differences in trends between younger population (18 - 59) and older population (over 60): Marital Status Benefits Mental Health Diagnosis Substitute Decision Maker at Start Substitute Decision Maker at Close Allegations Cohabitation at StartHelping People. It’s who we are and what we do.9

Understanding the Steps of Developing aQA Process› STEPS› Commitment to quality assurance› Create process› Execute the process› Integrate the process in the workflow› Measure results and interpret findings› Share the results with findings andrecommendations› Request feedback and be open torevisionsHelping People. It’s who we are and what we do.10

Commitment to Quality Assurance› WHY COMMITMENT?› Improve services for client’s served.› Accountability for staff andprogram› Policy and program improvements› Identify service gaps and trainingneedsHelping People. It’s who we are and what we do.11

Create the Process› Define standards andgoals› Set policies andprocedures› Involve program staff› Create QA toolsHelping People. It’s who we are and what we do.12

Execute the ProcessTHE PROCESSNEXT STEPS› Utilize ACT Voluntary ConsensusGuidelines› Identify elements to use› Choose how to implement› Clearly state expectation of ACLGuidelines› Case Review-Supervisory Process› QA uses the Case File Review (CFR)form as a tool to address areas ofneeded improvement and to ensurequality services are provided acrossthe state.› Case Worker Initial and Ongoing Training› CFR form is used as a tool forsupervisors to train new and ongoingstaff.Helping People. It’s who we are and what we do.13

Integrate the Process› Integrate the process into theworks flow› Integrate the process in steps› Organize strategically short andlong-term goals› Clear timeline of QA process› Ensure consistencyHelping People. It’s who we are and what we do.14

Measure results and interpret findings What tracking system will beused? What is available? Does measurement toolneed to be created? Document the steps totracking results. How do you want topresent the data?Helping People. It’s who we are and what we do.15

Share the results with findings andrecommendations› Time frames for sharing results› Mode of sharing results› Email› Standing meeting› Who receives the results› Management› Supervisors› All program staff› How and where to save resultsHelping People. It’s who we are and what we do.16

Requestfeedback and beopen to revisions17Helping People. It’s who we are and what we do.

Understanding thePotential Drawbacks inPresenting Data Time consuming Difficultly with commitment End result vs. process Being accountable for thediscovery Push back from staff regardingQA processHelping People. It’s who we are and what we do.18

Nevada’s QA ProcessHelping People. It’s who we are and what we do.19

Case File Review FormHelping People. It’s who we are and what we do.20

Case File Review InstructionsHelping People. It’s who we are and what we do.21

Fiscal Year (FY) Quarterly AnalysisQuarterly Case File Review (CFR) Meeting ProcessPROCESS› QA will present ONE Shoutoutand FOUR questions to ThinkAbout› Each CFR question will havereview of:› Policy› How to review the CFRquestion and how thequestion is answeredPOLICY REVIEW› Each CFR question isdirected towards policyand/or best practices.DATABASELOCATIONHOW TOANSWER?› The Quality AssuranceTeam created CFRInstructions.› The purpose of theinstructions:› To ensure questions areinterpreted and answeredconsistently statewide.› Each CFR questionreviewed will have:› Written instructionson where to find theanswer within theAPS Database.› A screenshot ofwhere information isavailable in the APSDatabase.› Where the informationis in APS DatabaseDATA› Findings chartsreflects thepercentage of ‘Yes’answers for ALLApplicable cases.› Data listed to theright of each chartcontains the monthlytotals of casesreviewed, applicablecases, and cases thatdid not apply› and of course . Thedata!Helping People. It’s who we are and what we do.22

FY Quarterly AnalysisCFR Question Example: Investigator made efforts to speak with client privately?EX.Increasein CaseOversightCONGRATSEX. ClearerExpectationsprovided toSWResultsSuggestImprovement!(Provide datahere)EX. Increasein PersonCenteredApproachHelping People. It’s who we are and what we do.Person Centered Planning is anapproach that places the person at thecenter of their investigation.For vulnerable adults who aresubjected to abuse, neglect, isolation,abandonment, or financial exploitationas well as those who are selfneglecting, protections must be madeavailable.Providing person centered servicesallows for considerations of an adult’sneeds, goals, preferences, culturaltraditions, family situations, and values.23

FY Quarterly AnalysisTOP 4 Questions to THINK aboutQuestion # 29: Excluding closurequestion, is the Missing DataReport free of errors?Question # 34: Release ofinformation (ROI) note enteredinto Harmony?Question # 31:Documentation/case notescompleted within 3 working days?Question # 38: Monthly face-toface visits conducted?Helping People. It’s who we are and what we do.24

How to ReviewCFR Question Shoutout Example: Investigator made efforts to speak with client privately?BEST PRACTICES/POLICYQUESTION INSTRUCTIONSDATABASE LOCATIONBest practice for APS staff while conducting investigations is to interview the client in private (whenappropriate). This safeguards and assures the privacy of the client, allowing the client to have thechoice and control of who is present during interviews. This choice and control gives clientsopportunity to speak freely, potentially creating rapport with the client, and increases the ability ofthe client to speak about alleged abuse.Response Options on CFR Form should be answered as such:“Yes”, the investigator documented efforts to speak to the client privately. (OR)“No”, the investigator did not document efforts to speak to the client privately, i.e. documentationshows that investigator spoke in front of the POI without requesting privacy. (OR)“N/A”, the investigator has not met with the client at the time of the case review or the clientrefused services.Review in APS Database, under the ‘Documentation’ section. A Face-to-Face should beconducted that states in the summary if investigator made efforts to speak with the clientprivately. See example listed on next slide.Helping People. It’s who we are and what we do.25

Database LocationQuestion: Investigator made efforts to speak with client privately?Helping People. It’s who we are and what we do.26

Interpret Findings ExampleQuestion: Investigator made efforts to speak with client 77%Total CasesReviewedTotalApplicableCasesTotal TOTAL FY 20Helping People. It’s who we are and what we do.27

QA Share the ResultsESTABLISHKEY FINDINGS› Time frames sharing results› No current privacy policy available› Mode of sharing results› Email› Standing meeting› Missing Data Report Errors› Who receives the results› SupervisorsSTRATEGY RECOMMENDATIONS› All program staff› How and where to save results› Need for policy› Data to Action› Continue to monitor› Continue to utilize› Update CFR Instructions to provide clarification onHelping People. It’s who we are and what we do.28