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Review Protocol

Overview

This evaluation process uses a comprehensive, multiple-method approach, much of which is gathered during a multi-day site visit at the lead agency’s location. These methods provide a full picture of compliance, context, and practices within each lead agency, and further explain how people benefit from these programs. 

The fifth round of reviews will take place from May 2024 through the end of 2027. In this round, reviews will have a hybrid protocol with a combination of remote and on-site activities. Enhancements to the review process for this round include an increased focus on each lead agency’s:

  • Equity practices and aspects
  • Community Inclusion, Access, & Integration
  • Program Capacity

Within this section is a brief description of the HCBS Lead Agency Review site visit activities.

Important information to prepare for your review.

Outline Activities and Data Sources

Pre-site visit

Kick-off video conference 

An introductory conversation between the lead agency and members of the Lead Agency Review (LAR) team that will be on the review. It will take place approximately 3 months prior to the site visit (see Round 5 Schedule). The LAR team will provide an overview of the purpose and activities of Lead Agency Review, gather information on the lead agency structure, and address technical items.

Lead Agency Review Survey 

Sent to all program staff and leadership to collect information about key organizational factors influencing how the programs operate. The results are shared during the site visit and drive conversations.

Planning video meeting

Approximately 2 to 4 weeks before the site visit and case file review, the lead agency and LAR team will finalize coordination tasks and answer outstanding questions about the review. This may include follow-up on case file review preparation and survey completion.

On-site visit

Entry meeting

Conducted with lead agency directors, managers, and supervisors to gather information on major issues, strengths, and challenges the lead agency is currently experiencing in the management of HCBS programs. An operational performance summary using various measures and data comparisons will be shared.

Case manager and assessor focus group

To gather staff feedback and insights into the operation of the lead agency’s HCBS programs. The results of the Lead Agency Review Survey and program data will be shared. 

Supervisor meeting

The supervisor meeting will be conducted on site with lead agency managers and/or supervisors to dig deeper into the agency’s practices and policies. This meeting will also include a review of the HCBS Lead Agency Review Survey. 

Remote Case file review

This activity is concurrent with the site visit. A random sample of case files for each HCBS program will be remotely reviewed by our team. At least one month prior to the site visit a list of case files will be sent to the lead agency. The lead agency will transfer case file documents to the LAR team via a secured file share program. Please reference “List of Items Reviewed” for the specific documents to be reviewed. 

The purpose of the case file review is to identify practices and tools used by your agency which contribute to strong technical compliance and improved outcomes for individuals. Areas of non-compliance with technical requirements will require remediation.

Post site visit and case file review activities

Exit meeting

Conducted with directors, managers, and supervisors at the completion of all site visit activities and case file review. Preliminary themes and findings gathered from various sources throughout the site visit will be shared. During the meeting the remediation, reporting and corrective action processes will also be outlined. 

Remediation

All non-compliant items found during the review must to be remediated within 60 days of the site visit. The lead agency will correct each non-compliant item, then return the Compliance Worksheet to the LAR team, dating when each item was corrected. 

Corrective action planning

Corrective action(s) are issued when the case file review process determines a pattern of noncompliance exists in one or more HCBS program requirement. Once the review report is finalized, the lead agency has 10 business days to develop and submit a corrective action plan to DHS. The plan must outline how the lead agency will address each corrective action issued and bring all items into full compliance.

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