Quality Assurance for HCBS Waivers

 
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Disabilities Assistance
Developmental Disabilities
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What you need to know

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Sections on this page
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    Quali​​ty Mission, Strategy, and Init​​iatives

    DHHS is dedicated to continuous quality improvement within its Medicaid Home and Community-Based Services (HCBS) programs. By focusing on enhancing service delivery, we aim to ensure beneficiaries receive optimal care and support. The Division actively engages in evaluating program performance, seeking stakeholder input, and implementing best practices. This commitment involves ongoing assessment and refinement of processes to align with evolving healthcare standards and the needs of the community. Through these efforts Nebraska strives to provide efficient, effective, and participant-centered services and supports.​​​​​

    Quality Framework

    The Quality Team focuses on enhancing service quality through:

    • Audits and Evaluations: Conducting scheduled reviews of services and providers to ensure compliance with standards and identify areas for improvement.
    • Performance Metrics: Tracking specific indicators related to service delivery and outcomes, providing measurable data on quality
    • Feedback Mechanisms: Collecting input from service recipients, families and stakeholders to understand their experiences and identify areas for improvement.
    • Stakeholder Engagement: Collaborating with community partners, advocacy groups, and service providers to maintain transparent communication and shared goals.
    • Quality Improvement Initiatives: Implementing targeted projects aimed at addressing identified opportunities for improvement and enhancing overall service delivery.
    • Training and Support: Offering educational resources to providers and caregivers to ensure they possess the skills necessary to deliver high quality services and supports. ​​​​

    Liberty Partnership

    ​DHHS contracts with Liberty Healthcare Corporation to help plan and enact changes to improve services. Liberty is a Quality Improvement Organization-Like Entity certified by the Centers for Medicare and Medicaid Services (CMS) to provide technical assistance and guide decision-making using data insights that align goals, objectives, and initiatives each year to ensure that participants are at the center of their services and expectations around safety and compliance are being met.

    An important part of continuous quality improvement (CQI) is eliciting and responding to feedback from a variety of stakeholders. Stakeholders are encouraged to deliver feedback directly to those it relates to; however, when a more formal process is needed, you can contact Liberty. 

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    National Core Indicators (NCI) - A​​ssessments to Improve Services

    The National Core Indicators (NCI) is a national effort to measure and improve the quality of services for aged and disabled people and individuals with intellectual and developmental disabilities and their families. It is a collaborative project between the National Association of State Directors of Developmental Disability Services (NASDDDS) and the Human Services Research Institute. The survey assesses various aspects of quality of life, including employment, human and civil rights, service planning, community inclusion, choice, health, and safety. 

    In Nebraska, we participate in the Aging and Disabilities Adult Consumer survey, the Intellectual and Developmental Disabilities In-Person survey, and the State of the Workforce survey. 

    NCI Aging and Disabilities Adult Consumer Survey (AD ACS)

    The Division's Quality Assurance (QA) Team administers the Adult In-Person Survey, which evaluates the daily lives and service experiences of adults (18+) receiving state waiver services. The survey cycle runs from October through June, with data submitted to the NCI National Office by June 30. External review and analysis occur with the NCI National Team during August and September. NCI completes its multi‑state review in the spring, and reports are typically published in June or July.

    Key Sampling Highlights

    • Administered by the Division's QA Team under the NCI framework.
    • Survey cycle: October–June.
    • National review: August–September; reports published June/July.
    • Participants randomly selected from the state database.
    • Includes adults receiving at least one publicly funded service beyond case management.
    • Core sample size of 400 provides statistically reliable comparisons, ensuring a 95% confidence level with a margin of error of ±5%.
    • Approximately 1,000 individuals selected to accommodate refusals and invalid surveys.

    NCI Website

    Nebraska Dashboard

    A resource for individuals, families, providers, and policymakers working to create more inclusive, person-centered supports. Presents key findings from statewide surveys and data collections, offering a transparent look at how people experience services and how providers are performing. Promotes transparency, accountability, and continuous improvement in Nebraska's human services system.

    Reports

    NCI Intellectual and Developmental Disabilities In-Person Survey (IDD IPS)

    The Division's Quality Assurance (QA) Team administers the Adult Consumer Survey (ACS), which assesses the daily lives and service experiences of adults receiving state waiver services. The survey cycle begins in January and concludes with submission to the NCI National Office by June 30. External review and analysis take place during August and September. NCI finalizes its multi‑state review in the spring, with reports generally published in June or July.

    Key Sampling Highlights

    • Administered by the Division's QA Team under the NCI framework.
    • Survey cycle: January–June.
    • National review: August–September; reports published June/July.
    • Participants randomly selected from the state database.
    • Includes adults receiving at least one publicly funded service beyond case management
    • Core sample size of 400 provides statistically reliable comparisons, ensuring a 95% confidence level with a margin of error of ±5%.
    • More than 1,000 individuals selected to address refusals and invalid surveys.

    NCI Website

    Nebraska Dashboards

    A resource for individuals, families, providers, and policymakers working to create more inclusive, person-centered supports. Presents key findings from statewide surveys and data collections, offering a transparent look at how people experience services and how providers are performing. Promotes transparency, accountability, and continuous improvement in Nebraska's human services system.

    Reports

    IDD State of the Workforce Survey (SoTW)

    The State of the Workforce Survey collects comprehensive data on the Direct Support Professional workforce providing direct supports to adults with intellectual and developmental disabilities, to help states examine workforce challenges, identify areas for investigation or improvement, and measure the success of improvement initiatives.

    Dashboard

    A resource for individuals, families, providers, and policymakers working to create more inclusive, person-centered supports. Presents key findings from statewide surveys and data collections, offering a transparent look at how people experience services and how providers are performing. Promotes transparency, accountability, and continuous improvement in Nebraska's human services system.

    Reports

    ​AD SoTW
    		​DD SoTW
    ​2024 AD-SoTW National
    		​2024 DD-SoTW ​National
    ​2024 AD-SoTW National At-a-Glance​
    		​2024 DD-SoTW National At-a-Glance
    ​

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    NCI Dashboard Video


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    Frequently Asked Questions (FAQs)

    Who conducts the surveys?

    The Division's Quality Assurance (QA) Team administers both the Adult In-Person Survey (DD) and the Adult Consumer Survey (AD) as part of the National Core Indicators (NCI) program.

    Why are these surveys conducted?
    Surveys help measure the quality of life, satisfaction, and service outcomes for adults receiving waiver services. The results support program improvement and statewide planning.

    How are survey participants selected?
    Individuals are randomly chosen from the state's database of adults receiving at least one publicly-funded service, in addition to case management.

    Why is the sample size so large?
    A core sample of 400 respondents is needed for statistically valid reporting. To ensure enough completed surveys, a larger group (around or over 1,000 individuals) is selected to compensate for refusals or invalid responses.

    When are survey results released?
    NCI publishes final reports in June or July each year, following national review and analysis in the spring.

    Is participation required?
    No. Participation is voluntary, and individuals may decline without any impact on their services.

    How is my information protected?
    All survey responses are confidential and are reported only in combined, anonymous formats for statewide analysis.

    Nebraska NCI Contacts

    For questions about NCI surveys, contact the Quality Assurance Team by emailing dhhs.nci@nebraska.gov. The team has an office in Lincoln, Nebraska.

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    ​​​Access Rule 

    ​​​The HCBS Access Rule is a federal regulation finalizing a broad set of requirements related to ensuring access to Medicaid services. The Centers for Medicare and Medicaid Services (CMS) published the Access Rule in the Federal Register in May of 2024, and it became effective on July 9, 2024. For more information on Nebraska's compliance, visit our Access Rule Page​.​


    Final Settings Rule

    ​The HCBS Final Settings Rule is federal regulation promulgated in 2014 aimed at improving Home and Community-Based Services. The Quality Team oversees compliance in Nebraska. For more information, visit our Final Settings Page. 


    ​​Rights Review Oversight and HLRAC

    ​In March 2024, the Division partnered with Liberty Healthcare to implement oversight of DD Agency Provider rights review committees and to start Human and Legal Rights Advisory Committee (HLRAC). The partnership with Liberty Healthcare on this project ended in April 2025, but the oversight and committee continue, led by the Quality team.​

    DD Agency Provider HLRC Requirements

    DD Agency Providers are required to submit documentation of their rights review committee reviews to DHHS.

    HLRAC Advisory Committee

    The committee is a multi-disciplinary committee that reviews referred participant files and offers insights and recommendations to improve quality of supports, improve participant quality of life, and reduce the need for rights restrictions in the long term.

    The committee is advisory in nature and does not approv​e or deny rights restrictions.

    Cases can be referred by a participant's person-centered planning team and referrals can be submitted via Therap​SCOMM to HLRCReferrals.​

    Rights Resources and Training


    Mortality Reviews

    ​DHHS partners with Liberty Healthcare to perform reviews of any death of an HCBS waiver participant and to lead a Mortality Review Committee. ​

    Individual Reviews

    When a participant dies, a review is completed to identify others at risk, factors that may have contributed to the participant's death, whether the death could have been prevented and concerns with quality of care and services.

    • DD Waiver Providers are required to submit a Notice of Death form to Liberty Healthcare within 10 days of a DD waiver participant death. This form can be found in the Forms section of the DD Provider webpage.
    • AD Waiver Service Coordinators are required to submit a Notice of Death form to Liberty Healthcare upon learning of the death of an AD/TBI waiver participant. The form can be found on the AD/TBI Service Coordination Partners site.​

    Mortality Review Committee (MRC)

    ​The MRC reviews participant deaths referred by Liberty Healthcare and makes recommendations to the Division for quality improvement activities and initiatives to reduce preventable deaths and improve participant outcomes in waiver services.


    ​​Critical Incident Management Process and Root Cause Analysis

    DHHS partners with Liberty Healthcare to implement a Critical Incident Management Process (CIMP) to perform oversight of critical incidents and incident follow-up, engage service providers in Root Cause Analysis (RCA), and to lead an Incident Management Committee. ​​​​

    Oversight of Incident Reporting and Follow-Up

    Liberty Healthcare to review incident reports, also called General Event Reports (GERs), to ensure incident reporting and follow-up are being done in compliance with DHHS policy, with the goal of reducing the frequency and severity of incidents over time.

    • Incident reporting and follow-up requirements and guidelines for DD Waiver Providers can be found on the DD Providers webpage.
    • Incident reporting requirements and guidelines for AD and TBI waiver providers and Service Coordination can be found on the AD and TBI Waiver Providers webpage​.​

    Root Cause Analysis

    Root Cause Analysis (RCA) is one of the basic quality tools used for quality improvement. It is a systematic process to discover the root cause of issues to identify appropriate solutions and prevent recurrences of the issues or problems. It relies on data to inform the process of analysis, and it focuses on the HOW and WHY something happened rather than WHO is responsible.

    During RCA, the Person-Centered Planning (PCP) team will be assigned an Incident Review Specialist who will complete discovery activities. The assigned specialist will request documents and interviews during this process, and providers will provide the documents and facilitate the interviews with employees, participants, or other parties. Occasionally, an onsite review will be conducted, requiring approximately two hours of the PCP team's time to develop a plan.​

    Incident Management Committee

    The Incident Management Committee (IMC) reviews critical incidents referred by Liberty Healthcare. They make recommendations to the Division for quality improvement activities and initiatives to improve waiver services and participant outcomes.​


    ​Other Quality Oversight and System Improvement Activities

    ​​​The Quality Improvement team performs various forms of oversight of all aspects of the HCBS Waiver Programs. ​​

    Service Plan Reviews

    Samples of participants' Person-Centered Plans are reviewed for compliance with division policies, waiver requirements, and best practices. ​

    Claim Reviews

    Samples of claims paid for HCBS Waiver services are reviewed to ensure that services were delivered and billed in compliance with DHHS policy and to monitor for fraud, waste, and abuse.​

    Waiver Performance Measure Reporting

    Annually, the Division reports to the federal Centers for Medicaid Services (CMS) on compliance metrics for various aspects of each waiver.​

    Resources to Improve Participant Outcomes

    DHHS partnered with Liberty Healthcare to develop and collect resources to improve participant outcomes by mitigating identified risks. These resources can be found on the main Provider page​ for all HCBS providers.