Chapter 7: Quality Assurance

7.1 Overview

A provider participates in monitoring activities as explained in this chapter, per CRS policy and the provider’s contract. Program monitoring applies to a provider of post-acute residential and non-residential rehabilitation services and inpatient comprehensive rehabilitation services.

7.2 Quality Reviews

Designated CRS program staff members continuously monitor the services provided to CRS participants and make regular on-site visits to a provider’s facility. The tasks completed during the visits may include the review of case files.

The quality review process focuses on how well the provider complies with the contract to provide and deliver services.

Ongoing quality reviews of the providers include ensuring that:

  • the services identified by the interdisciplinary team are necessary and appropriate;
  • the services are provided in accordance with the respective service array and other needed services and interventions are provided, as appropriate;
  • participants are free from abuse, neglect or exploitation;
  • participants, families, and guardians participate in identifying and selecting services;
  • services are provided based on assessed need;
  • services are continued, based on their efficacy and promote greater independence;
  • services are billed and paid correctly based on services provided and contracted rate;
  • the staff members interact appropriately and effectively with participants; and
  • all the participant’s identified needs are being addressed.

7.3 On-Site Quality Reviews

 A provider is subject to periodic administrative, programmatic, and financial monitoring by CRS program staff members. Each fiscal year, state and regional offices assess providers to identify which will be monitored on-site during a 12-month period.

If a provider’s facility is selected for an announced quality review, the lead monitor sends a letter announcing the review, provides information about the scope of the review, and provides instructions about how to prepare for the review.

If the CRS program determines the need, a provider that is not identified on the risk assessment may also be monitored. Agency staff members may conduct an unannounced quality review, if the CRS program determines it is necessary.

The unannounced quality review or reviews may consist of:

  • an entrance conference;
  • a records review;
  • interviews;
  • observation;
  • tours of the provider’s facility and grounds; and
  • an exit conference.

7.4 Notification of Quality Review Results

The lead monitor sends the provider a report about the results of the quality review after it is completed. This report includes findings of noncompliance with program or financial standards, if any.

The provider is responsible for providing further documentation to help resolve the findings or completes a correction action plan.

7.5 Corrective Action Plan

Within 28 calendar days after the date on the initial report of findings, the provider must submit:

  • an acceptable written corrective action plan that addresses all the findings that require a written response;
  • financial restitution for overpayments or questioned costs; or
  • a rebuttal of the findings (financial or otherwise), including documentation to substantiate the rebuttal.

The written corrective action plan may include corrective actions other than those recommended in the initial report, if the provider identifies additional ways of correcting the findings. The monitoring team reviews the corrective action plan and may accept it or recommend changes to it. If the provider does not submit an acceptable corrective action plan or make financial restitution when required, the agency may take adverse action against the provider, in accordance with the terms of the contract.

7.6 Quality Review Closeout

If there are no findings, or when the monitoring team accepts the corrective action plan, the monitoring review is closed. A letter is sent to the provider documenting this result.