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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    DDD Quali​​ty Mission

    DHHS Division of Developmental Disabilities (DDD) 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. DDD 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 Strate​​​gy and Initiatives​

    Quality Framework

    The Quality Team focuses on enhancing service quality through:

    • Regular 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. ​​​​

    Quality Management Strategy (QMS) Reports

    DDD gives yearly updates to the Nebraska Legislature on quality activities. These began in 2017. Reports are on the Nebraska Legislature reports page. 

    Liberty Partnership

    ​DDD 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.


    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 IDD State of the Workforce survey. An AD State of the Workforce survey was launched in 2023, and Nebraska plans to participate in the survey beginning in 2026.

    NCI Aging and Disabilities Adult Consumer Survey

    The NCI Aging and Disabilities Adult Consumer survey represents the population of older adults and people with disabilities who receive publicly funded long-term services and support.

    Reports

    Key Findings from 2023-2024 Reports

    • Nebraska scored above the national average in a number of areas, including:
      • Participants feel able to access to recreational activities outside of participant's home
      • Participants report receiving the support needed for personal care and other daily activities.
      • Participants have a backup plan for when paid care providers are unavailable
      • Participants know who to contact with a complaint about services or to change services
      • Participants feel in control of their lives.
      • Participants report being able to decorate living space and choose whether to have roommate when living in an Assisted Living Facility
      • Participants feel able to freely choose and change services
      • Participants report their services and supports help them live the lives they want
    • The survey shows opportunities to improve where Nebraska was below the national average in some areas, including:
      • Participant access to non-medical transportation
      • Participants feel services meet all current needs and goals - The primary reason given by participants who said their services are not meeting their needs is lack of access to non-medical transportation.
      • Participants' service providers working together to provide supports
      • Participants who have been hospitalized in the past year feeling comfortable and supported to return home following the hospitalization
      • Participants' choice of who provides paid supports and frequency of changes in who paid caretakers are.

    NCI Intellectual and Developmental Disabilities In-Person Survey

    The NCI Intellectual and Developmental Disabilities survey represents the population of adults with intellectual or developmental disabilities receiving at least one service in addition to case management/service coordination.

    Reports

    Key Findings from 2023-2024 Reports

    • Nebraska scored above the national average in a number of areas, including:
      • Participants with employment
      • Participants have choice in where they live and with whom
      • Participants report they chose their staff or are aware they can request to change staff
      • Participants can choose to go on dates, be married, and live with their partner if they choose
      • Participant helped make their service plan
      • Participant had a complete physical and dental exam in the past year
    • The survey shows opportunities to improve where Nebraska was below the national average in some areas, including:
      • Participants able to go out and do things as much as they want
      • Participants knew what was being talked about at last service planning meeting
      • Participants who want to learn to perform ADLs more independently that have a related goal in their service plan
      • Participants who want a paid job and don't currently have one that have a related goal in their service plan
      • Participant access to non-medical transportation
      • Use of technology in everyday life for greater independence​​​

    IDD State of the Workforce Survey

    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.

    Reports

    Key Findings from 2023-2024 Reports

    • Nebraska scored better than the national average in a number of areas, including:
      • Percent of agencies who gave DSPs bonuses within the last year
      • Percent of agencies paying DSPs a wage 40% or more greater than the state minimum wage
      • Percent of agencies offering an employer sponsored retirement plan to DSPs
    • Nebraska scored consistent with the national average in:
      • Average DSP Pay
      • Percent of agencies providing paid time off for DSPs
      • Percent of agencies offering health insurance to DSPs
      • Full-time DSP vacancy rate
    • The survey shows opportunities to improve where Nebraska was worse the national average in some areas, including:
      • ​DSP Turnover Ratio
      • DSP Tenure/Length of Employment


    ​​​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, DDD 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 DDD Quality team.​

    DD Agency Provider HLRC Requirements

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

    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

    ​DDD 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 DDD 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

    DDD 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 DDD 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 DDD for quality improvement activities and initiatives to improve waiver services and participant outcomes.

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    ​Other Quality Oversight and System Improvement Activities

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

    Technical Assistance

    Quality teammates provide training and technical assistance to providers and service coordination upon request on topics including participant rights and provider rights review committees, the HCBS Final Settings Rule, and general quality and compliance questions.​​​​

    Resources to Improve Participant Outcomes

    DDD Quality 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.