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Kevin S. Settlement

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The Health Care Authority’s mission is: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

Quality Management Bureau

The Quality Management Bureau (QMB) works in close coordination with other divisions of the Department of Health and with other state agencies to ensure accountability and compliance of community based waiver providers with state and federal regulations, contractual or program requirements, and quality standards.

Survey Units

QMB conducts compliance surveys of agencies who have a provider agreement with the Developmental Disabilities Supports Division (DDSD) to provide Medicaid home and community-based waiver services including; the Developmental Disabilities Waiver (DDW) providers, Medically Fragile Waiver (MFW), the Mi Via Waiver consultant agencies and Supports Waiver (SW) Community Support Coordination and Customized Community Supports providers

A QMB survey team conducts a thorough review of each provider’s services to determine if they are in compliance with required standards, rules and statutes and to ensure the health, safety and welfare of individuals receiving services.

Customer Satisfaction Survey

Has your community program recently been surveyed by the Division of Health Improvement? We would like to know. How did we do?

Take our Community-Based Waiver Provider Customer Satisfaction Survey today!

Your anonymous response will help QMB evaluate our customer service and performance and identify opportunities on how we can improve the quality of the survey process.

Developmentally Disabled Waiver Survey Unit

A DDW survey team conducts on-site, systems-based surveys and other quality improvement activities related to the health, welfare and safety of individuals receiving supports through case management services, living care arrangements, community inclusion services (i.e. customized community supports and employment services).

Visit the Developmental Disabilities Waiver Survey Unit page to learn more.

Medically Fragile Waiver Survey Unit

This unit conducts on-site, systems-based surveys and other quality improvement activities related to the health, welfare and safety of individuals receiving supports through the medically fragile waiver.

Visit the Medically Fragile Waiver Survey Unit page to learn more.

Mi Via Self-Directed Waiver Survey Unit

This unit conducts surveys of agencies who have a provider agreement with the DDSD to provide mi via self-directed consultant services. The survey consists of on-site, systems-based surveys and other quality improvement activities related to the health, welfare and safety of Individuals receiving supports through the mi via consultant agency locations.

Visit the Mi Via Self-Directed Waiver Survey Unit page to learn more.

Supports Waiver Survey Unit

This unit conducts on-site, systems-based surveys and other quality improvement activities related to the health, welfare and safety of individuals receiving supports through community support coordination and customized community support services (Agency-Based Service Delivery Model and Participant Directed Service Delivery Model).

Visit the Supports Waiver Unit page to learn more.

Survey Process, and Conditions of Participation

ImageQMB conducts unannounced surveys of community based waiver providers.

QMB surveys determine compliance with the DDW standards and state and federal regulations. QMB has grouped the Centers for Medicare and Medicaid Services waiver assurances into five service domains.

  1. Level of Care
  2. Plan of Care
  3. Qualified Providers
  4. Health, Welfare and Safety
  5. Administrative Oversight

 

NOTE: Administrative oversight listed in this document is not the same as the Centers for Medicare and Medicaid Services assurance of Administrative Authority. Used in this context it is related to the agency’s operational policies and procedures, Quality Management system and Medicaid billing and reimbursement processes.

Within these five service domains there is focus on seven fundamental regulations, standards, or policies with which a provider must be in essential compliance in order to ensure the health and welfare of individuals served and are known as Conditions of Participation (COPS). A provider must be in compliance with COPS to participate as a waiver provider. The DHI and the DDSD collaborate to revise and update the current COPS as needed.

There are seven categories of COPS in which providers must be in compliance.

Case Management Supports

Level of Care

  1. The case manager shall complete all required elements of the Long Term Care Assessment Abstract (LTCAA) to ensure ongoing eligibility for waiver services.

Service Plans

  1. Individual Service Plan (ISP) Creation and Development — Each individual shall have an ISP. The ISP shall be developed in accordance with DDSD regulations and standards and is updated at least annually or when warranted by changes in the individual’s needs.
  2. ISP Monitoring and Evaluation — The Case Manager shall ensure the health and welfare of the individual through monitoring the implementation of ISP desired outcomes.

All Service Providers

Qualified Providers

  1. Qualified Providers — Agencies shall ensure support staff has completed criminal background screening and all mandated trainings as required by the DDSD.

Living Supports and Community Supports

Service Plans

  1. ISP Implementation — Services provided shall be consistent with the components of the ISP and implemented to achieve desired outcomes.

Health, Welfare and Safety

  1. Individual Health, Safety & Welfare (Safety) — Individuals have the right to live and work in a safe environment.
  2. Individual Health, Safety and Welfare (Healthcare Oversight) — The provider shall support individuals to access needed healthcare services in a timely manner. Nursing, healthcare services and healthcare oversight shall be available and provided as needed to address individuals’ health, safety and welfare.

The QMB Determination of Compliance process is based on provider compliance or non-compliance with standards and regulations. All deficiencies (non-compliance with standards and regulations) are identified and cited as either a standard level deficiency or a condition of participation level deficiency in the QMB reports of findings.

Reports of Findings and Plan of Correction Process

ImageUpon completion of a QMB survey the provider agency is sent the report of findings via email. All deficiencies require corrective action when non-compliance is identified. Each provider must develop and implement a Plan of Correction (POC) that identifies specific quality assurance and quality improvement activities the agency will implement to correct deficiencies and prevent continued deficiencies and non-compliance.

Agencies must submit their POC within ten (10) business days from the date the QMB report of finding is received.

NOTE: Providers who do not submit a POC within 10 business days may be referred to the Internal Review Committee (IRC) for possible actions or sanctions.

Agencies must fully implement their approved POC within 45 business days (10 business days to submit your POC for approval and 35 days to implement your approved POC) from the date they receive the QMB Report of Findings.

NOTE: Providers who fail to complete a POC within the 45 business days allowed will be referred to the IRC for possible actions or sanctions.

If you have questions about the POC process, see our Plan of Correction Process (Attachment A) document, or contact the POC Coordinators Monica Valdez at 505-273-1930 or Marie Passaglia at 505-819-7344.

On rare occasions, it may be necessary to request a time extension to complete a component of a POC. A written request for a time extension must be submitted to the POC coordinator with an explanation as to why the addition time is needed and when it will be completed. QMB will review the request for the extension and notify the provider if approved or not approved.

Requests for technical assistance must be requested through your regional DDSD office.

To view completed QMB surveys of providers and their past performance, please visit the Developmental Disabilities Waiver Survey Unit, Medically Fragile Waiver Survey Unit, Mi Via Self-Directed Waiver Survey Unit and Supports Waiver Unit sections of our website.

Informal Reconsideration of Findings

Providers who wish to dispute the specific finding(s) of a QMB survey may do so by requesting an Informal Reconsideration of Findings (IRF).

Please visit the Informal Reconsideration of Findings section of our website to learn more.

Quality Improvement Resources

Quality Improvement Tool Box

Assessment

Planning

Decision-Making

Template

Additional Resources

Diagram of the process improvement process that describes the relationship between disvocery, remidiation, and improvement.

  • National Center for Patient Safety (NCPS) — The Department of Veterans Affairs National Center for Patient Safety was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. We are part of the VA Office of Quality, Safety and Value. Our goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care.
  • Root Cause Analysis (RCA) — The goal of the root cause analysis process is to find out what happened, why it happened, and how to prevent it from happening again. Because our culture of safety is based on prevention, not punishment, teams investigate how well patient care systems function. We focus on the “how” and the “why” not on the “who”. Through the application of Human Factors Engineering approaches, we aim to support human performance.
  • Results-Based Accountability (RBA) — Established in 1996 to help communities, cities, counties, states and nations working to measurably improve the well-being of their citizens.
  • Lean Six Sigma — A methodology that relies on a collaborative team effort to improve performance by systematically removing waste, combining lean manufacturing/lean enterprise and Six Sigma to eliminate the eight kinds of waste: transportation, inventory, motion, waiting, over production, over processing, defects, and skills.
  • Define, Measure, Analyze, Improve and Control (DMAIC) — A data-driven improvement cycle used for improving, optimizing and stabilizing business processes and designs. The improvement cycle is the core tool used to drive Six Sigma projects. However, it is not exclusive to Six Sigma and can be used as the framework for other improvement applications.

Field Tools

Please visit the Field Tools page to explore the various field tools such as Case Management, Living Care and Arrangements, and Community Inclusion.