Post on 11-Aug-2020
transcript
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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