Training Agenda

bull Welcome and Introductionsbull Presentation from KDADSbull Presentation from WSU CEIbull Questions from Youbull Introduction to Upcoming Provider Learning Collaboratives bull Breakout Room Scenarios

Provider Remediation

Next Steps on the Road to Compliance for Final Rule in Kansas

PresentersLaTonia Wright KDADSRussell Bowles KDADS

This training will addresshellip

bull The remediation process and expectationsbull Remediation strategiesbull Accessing the remediation tab and submitting a remediation planbull Technical supports and resources

Review of Key Phases

bull Systemic Assessment bull Provider Self Assessment bull Heightened Scrutiny bull Transition bull Ongoing Monitoring bull New ProvidersSites

Timeline Review

bull 03142014 ndash CMS published HCBS Settings Final Rulebull 09152019 ndash Provider Self-Assessment opened in Kansasbull 02292020 ndash Provider Self-Assessment closed in Kansasbull 07012020 ndash Heightened Scrutiny Categories 1 and 2 must be

submitted to CMSbull 10302020 ndash Heightened Scrutiny Category 3 must be submitted to

CMSbull 07012021 ndash All setting(s) remediation evidence must be submitted to

community connections (KDADS)bull 03172022 ndash All settings must be in compliance with the Final Rule (CMS)

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Provider Remediation

Next Steps on the Road to Compliance for Final Rule in Kansas

PresentersLaTonia Wright KDADSRussell Bowles KDADS

This training will addresshellip

bull The remediation process and expectationsbull Remediation strategiesbull Accessing the remediation tab and submitting a remediation planbull Technical supports and resources

Review of Key Phases

bull Systemic Assessment bull Provider Self Assessment bull Heightened Scrutiny bull Transition bull Ongoing Monitoring bull New ProvidersSites

Timeline Review

bull 03142014 ndash CMS published HCBS Settings Final Rulebull 09152019 ndash Provider Self-Assessment opened in Kansasbull 02292020 ndash Provider Self-Assessment closed in Kansasbull 07012020 ndash Heightened Scrutiny Categories 1 and 2 must be

submitted to CMSbull 10302020 ndash Heightened Scrutiny Category 3 must be submitted to

CMSbull 07012021 ndash All setting(s) remediation evidence must be submitted to

community connections (KDADS)bull 03172022 ndash All settings must be in compliance with the Final Rule (CMS)

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

This training will addresshellip

bull The remediation process and expectationsbull Remediation strategiesbull Accessing the remediation tab and submitting a remediation planbull Technical supports and resources

Review of Key Phases

bull Systemic Assessment bull Provider Self Assessment bull Heightened Scrutiny bull Transition bull Ongoing Monitoring bull New ProvidersSites

Timeline Review

bull 03142014 ndash CMS published HCBS Settings Final Rulebull 09152019 ndash Provider Self-Assessment opened in Kansasbull 02292020 ndash Provider Self-Assessment closed in Kansasbull 07012020 ndash Heightened Scrutiny Categories 1 and 2 must be

submitted to CMSbull 10302020 ndash Heightened Scrutiny Category 3 must be submitted to

CMSbull 07012021 ndash All setting(s) remediation evidence must be submitted to

community connections (KDADS)bull 03172022 ndash All settings must be in compliance with the Final Rule (CMS)

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Review of Key Phases

bull Systemic Assessment bull Provider Self Assessment bull Heightened Scrutiny bull Transition bull Ongoing Monitoring bull New ProvidersSites

Timeline Review

bull 03142014 ndash CMS published HCBS Settings Final Rulebull 09152019 ndash Provider Self-Assessment opened in Kansasbull 02292020 ndash Provider Self-Assessment closed in Kansasbull 07012020 ndash Heightened Scrutiny Categories 1 and 2 must be

submitted to CMSbull 10302020 ndash Heightened Scrutiny Category 3 must be submitted to

CMSbull 07012021 ndash All setting(s) remediation evidence must be submitted to

community connections (KDADS)bull 03172022 ndash All settings must be in compliance with the Final Rule (CMS)

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Timeline Review

bull 03142014 ndash CMS published HCBS Settings Final Rulebull 09152019 ndash Provider Self-Assessment opened in Kansasbull 02292020 ndash Provider Self-Assessment closed in Kansasbull 07012020 ndash Heightened Scrutiny Categories 1 and 2 must be

submitted to CMSbull 10302020 ndash Heightened Scrutiny Category 3 must be submitted to

CMSbull 07012021 ndash All setting(s) remediation evidence must be submitted to

community connections (KDADS)bull 03172022 ndash All settings must be in compliance with the Final Rule (CMS)

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Systemic Assessment

bull Kansas has and continues working to modify systemic documents to come into compliance with the Final Rule which includes a review of statutes regulations policies procedures and contracts

bull There will be opportunities for stakeholders to review and provide feedback on changes during public comment periods

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Provider Self-Assessment

bull This phase has been completed for those in attendance (YesNo) bull KDADS continues to review assessments to determine what areas

providers need to remediatebull Remediation for Kansas is based on the idea that all providers and

settings willing to come into compliance - will be able to do so bull Remediation notifications are being processed for provider

notifications

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Heightened Scrutiny

bull HS is triggered by the provider self-assessmentbull Heightened Scrutiny (HS) has 3 categories

bull Category 1 Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment

bull Category 2 Settings that are in a building located on the grounds of or immediately adjacent to a public institution

bull Category 3 Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Heightened Scrutiny

bull Due to triggered flags during the self-assessment regarding location andor physical characteristics of the setting an on-site visit by KDADS must be completed to determine if the setting is HCBS compliant

bull Heightened Scrutiny notifications to schedule a site visit will come from the Heightened Scrutiny Director or team This will be a second notification from the remediation notification

bull A provider must have overcome HS and be willing to collaborate with KDADS during the process in a timely manner in order to meet federal deadlines for implementation of the Final Rule

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Transition

bull Settings choosing not to come into compliance or unable to come into compliance with Final Rule will not receive HCBS Medicaid funding after March 17 2022

bull HCBS clients must transition to a compliant setting before March 18 2022 to continue receiving HCBS funding

bull All remediation evidence must be submitted to communityconnectionsksorg by July 1 2021

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Transition

bull The July 1 2021 date will allow time for KDADS desk review of submitted evidence and to work with the provider to come into compliance before March 17 2022

bull Please note that if submitted evidence shows a setting is unable to meet final rule requirements by March 17 2022 it will no longer receive HCBS funding beginning March 18 2022

bull Transition notifications to persons served must begin no later than October 1 2021

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Ongoing Monitoring

bull After a setting comes into full compliance with the Final Rule ongoing monitoring will ensure it remains in compliance

bull The ongoing monitoring process is still being reviewed at KDADS to determine who will complete these ongoing tasks

bull State regulations are in the process of being updated

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

New and Closed Settings

bull New settings will have an onboarding process at a later date in 2020bull KDADS is currently working on IT supports to enhance the database

system bull New Setting After 22920

bull Provider should use toolbox documents found at communityconnectionsksorg under the ldquoSupport Tabrdquo to assess setting(s) for HCBS compliance characteristics

bull Use missed deadline form located at communityconnectionsksorg to notify KDADS of a new setting or closed setting

bull KDADS will follow-up with provider once onboarding process is availablebull All HCBS settings will be tracked in the database system including closed

settings Closed settings are not deemed compliant A new assessment will be required for a closed setting if it reopens in the future and is seeking to utilize HCBS funding

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Road to ComplianceComing into compliance -bull Provider ndash review and consider each settingrsquos physical location

policies procedures and practices when identifying strategies to come into compliance with the Final Rule The requirements are to not have institutional like characteristics in HCBS settings

bull It is okay as a provider to have blanket policies procedures and practices across multiple settings if possible

bull Most providers are not yet fully compliant and that is okaybull Wyoming ndash 462 of settings in full compliance after initial assessmentbull Tennessee ndash 14 of settings in full compliance after initial assessment

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Remediation Notification

bull Once the Self-AssessmentValidationDesk Review Phases Concludes bull An email and letter is sent to the provider (for each setting)

describing what needs to be remediated bull If there is nothing to be remediated the provider will get a letter

of compliance (for each setting) bull The email and letter describes the remediation process and

instructs providers toward a timeline of plan submission for the setting

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Remediation Plan

bull For each self-assessment question that needs to be remediated the provider will select a remediation strategy and a timeframe for when the strategy will be completed Timeframes are required as part of the remediation plan

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

What Can Be Used As Evidence

bull Photographs- These can be from internet map sources andor photos taken by the agency

bull PolicyProcedures- These are agency documents that explain how an agency provides guidance in different areas

bull Handbooks- This is a document that supports or clarifies agency policiesprocedures

bull Manuals- This is a document that supports or clarifies agency policiesprocedures

bull Other Documentation (ie agency forms agency brochures agency pamphlets rental agreements support plans etc - If these documents are used they should provide support or clarification to policies procedures handbooks or manuals Providers please do not submit PHI on any evidence

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Remediation Strategies ndash Guidance On

bull Writing Policy and Procedure bull What policy should look likebull What procedure should like

bull Handbooks and Manualsbull What handbooksmanual should look like bull What policies support the handbookmanual

bull Staff and Volunteer Trainingbull What constitutes ldquogoodrdquo trainingbull What policies support the training manual

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Writing Policies and Procedures

bull Policies andor procedures are the preferred documents for setting evidence bull Policies andor procedures should have the following qualities at a minimum

bull Organization Identificationbull Policy Title andor Policy Number (what is this policy about)bull Policy effective date (revised date is acceptable)bull Regularly review for updates as needed

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Handbooks

bull Handbooks should support andor clarify a policy andor procedure

bull Handbooks should have the following qualities at a minimumbull Organization Identificationbull Purpose of Handbook (can be seen in the title or stated in a

purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (can be on document or as evidenced by a

signaturedate page or initialsdate)bull Does the handbook answer the question

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Manuals

bull Manuals should support andor clarify a policy andor procedurebull Manuals should have the following qualities as a minimum

bull Organization Identificationbull Purpose of Manual (can be seen in the title or stated in a purpose statement)bull What policy andor procedure does the handbook supportbull Is it a handbook for persons served or staffbull Effective Date (revised date is acceptable)bull Does the manual answer the questionbull Review and update as needed

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Other Documentation

bull Other documentation submitted as evidence must support or link back to a policy procedure handbook or manual (these might include residential agreements rental agreements person centered plans behavioral support plans agency forms etc)

bull Keep in mind there can be exceptions and a document can be used as stand alone evidence if it can validate andor answer the question

Other Documentation

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Staff and Volunteer Training

bull What constitutes ldquogoodrdquo trainingbull Regularly making staff and volunteers aware of

policies procedures and practicesbull Clear correlation between staff and volunteer

training policies procedures and practicesbull Regular reviews to update as needed

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Clarification and Tips

bull It is possible that questions marked as compliant by the provider on the self-assessment had evidence attached that did not meet validation criteria These questions will be seen in remediation and may need clarification

bull If a question is in bold red on a remediation plan it needs to be addressed first as these relate to heightened scrutiny The Provider should ensure that their resubmission evidence addresses what is asked in the question

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Clarification and Tips continuedhellip

bull If there are multiple sites to remediate keep a log of what has changed this can make remediation for sites governed by the same policies much faster

bull Before picking the ldquootherrdquo box carefully look at the listed options Can what is envisioned for the setting remediation fit into one of the strategies already listed If so this can save time

bull Check and double check evidence for adherence to the specific question Example - does staff training policies also extend to volunteers Can people come and go ldquowhenever they pleaserdquo and so on

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Remediation Technical Guidance

A Walk Down the Road to Compliance

Presenter Percy Turner

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Remediation From the Tophellip

bull Logging back in (Communityconnectionsksorg)bull Forgot password (I told you to remember ithellip) bull Technical Tips

bull Do not use Internet explorer yes - still bull Uploading videos will exceed the maximum file size They are usually too big bull One requested change might cover multiple points of remediation However

evidence still must be uploaded for each remediation section bull Remediation plans are per site only Approval of a plan does not mean it can

extend to all sites automatically

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

Accessing the Remediation Tab

bull Once a provider receives remediation notification they should navigate with their internet browser (do not use Internet Explorer) to wwwcommunityconnectionsksorg

bull Log-in with the same information the provider used to create and complete the self-assessment(s)

bull After logging in the dashboard should look like this for the remediation tab

The DashboardThe Remediation Tab

Dashboard Part 2

The Remediation Tab

bull Click on the tab the red arrow pointed at bull Now you should see something that looks like this

Remediation Tab

bull Click on name of the site to be taken to the next page This page will have all questions in need of remediation and will look like this

Remediation Tab

bull Click on the specific question to access the remediation strategies Should look like this

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Dashboard Part 2

The Remediation Tab

bull Click on the tab the red arrow pointed at bull Now you should see something that looks like this

Remediation Tab

bull Click on name of the site to be taken to the next page This page will have all questions in need of remediation and will look like this

Remediation Tab

bull Click on the specific question to access the remediation strategies Should look like this

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

The Remediation Tab

bull Click on the tab the red arrow pointed at bull Now you should see something that looks like this

Remediation Tab

bull Click on name of the site to be taken to the next page This page will have all questions in need of remediation and will look like this

Remediation Tab

bull Click on the specific question to access the remediation strategies Should look like this

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Remediation Tab

bull Click on name of the site to be taken to the next page This page will have all questions in need of remediation and will look like this

Remediation Tab

bull Click on the specific question to access the remediation strategies Should look like this

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Remediation Tab

bull Click on the specific question to access the remediation strategies Should look like this

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Selecting a strategy

bull Select (click the check box) a remediation strategy that fits the needs of your site You will be prompted to enter a date representative of when the proposed changes will be made

bull This date cannot be set past July 1 2021 to allow time for remediation activities to be reviewed by KDADS or time for transition of persons served if needed

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Remediation The ldquoOtherrdquo Box

bull Each question on a providerrsquos remediation table for each setting will have pre-populated suggested remediation steps

bull A provider might or might not feel a suggestion is right for the setting bull A provider is able to choose not to follow the suggested action(s) There is

a field marked ldquootherrdquo that can be chosen bull If a provider marks the ldquootherrdquo box KDADS will have to review and accept

the suggested remediation bull KDADS is advising that a provider wait for their feedback on the

submitted remediation plan listed under the ldquootherrdquo section of a question

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Evidence

bull Once a remediation strategy has been selected alongside a timeline (before July 1 2021) the remediation tab will accept evidence Submission of evidence represents the provider following through on a selected strategy

bull All evidence must be submitted by July 1 2021

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Remediation Evidence continued

bull Evidence must be uploaded for each item listed on a remediation plan

bull Evidence will be validated in the same manner as the self-assessment It will be first reviewed by the Validation Team and then by KDADS Desk Review Team

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

The Activity Log

bull The activity log is an active document that will show your progress through Remediation

bull While the system is designed to give the provider an email notification each time the status of a question changes on a remediation plan it is important that the provider is diligent on checking each site through the process

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937

Supports and Resources

bull Toolbox at httpscommunityconnectionsksorg

bull One-on-one support Call 1-800-445-0116

bull There is a ldquoLive Chatrdquo box and ldquoContactrdquo tab at httpscommunityconnectionsksorg

bull You can sign up for email updates at httpscommunityconnectionsksorg

bull Stakeholder Calls take place the 3rd Wednesday of every month from 12-1 pm and 530-630 pmbull Phone Line (866)620-7326bull Code 989 114 3937