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372 Report Maintenance - Quality
Summary
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OHR Control Number: 0938-0272
Expiration
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Quality
in as QI_TEST_STATE_MEO_OIR(State
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State:
zz
Waiver Base:
Report Status:
12345
UNSUBMITTED
Quality Report Begin and End Date:
!04/11/2018
T
Quality Report Period Year:
Date Selector fields that automatically format the date
!04/11/2019
2019
Quality Report Waiver Year:
@ Year 1
0
Year 2
0
Year 3
0
Year 4
0
Year 5
Documentation:
Provide a brief description of the process for monitoring the safeguards and standards under the waiver:
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PRA Disclosure
Statement
All State Medicaid agencies administering or supervising the administration of 1915(c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915(c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is estimated
to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FAQ:;
Contact I Centers for Medicare & Medicaid Services
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logged in as QI_TEST_STATE_MEO_OIR(State
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372 Report Maintenance - Assurances
Summary
Data
Quality
._
Overview
Assurances
State
Renewal Number
Quality Report Status O
Quality Waiver Year Begin and End Dates
zz
ZZ.12345.R02
Completed
Apr 11, 2018 - Apr 11, 2019
A
B.a
B.b
Assurances
B.c
Complete Report
Button to "Complete Report" which navigates to
summary page where report can be submitted.
Button is disabled if any sub-assurances or
deficiencies are incomplete
C.a
Sub-assurancell
C.b
Statusf!
Deficiencyf!
O Sample Universe - No Deficiency Sub-assurance Status
Not Detected
Sub-assurance B.a
Complete
Not Detected
Sub-assurance B.b
Complete
Detected
Sub-assurance B.c
Complete
Not Detected
Sub-assurance c.a
Complete
Detected
Sub-assurance C.b
Complete
Not Detected
Sub-assurance c.c
Complete
Not Detected
Sub-assurance D.a
Complete
Not Detected
Sub-assurance D.b
Complete
Not Detected
Sub-assurance D.c
Complete
Not Detected
C.c
Sub-assurance Label
Assurance A
D.a
D.b
D.c
D.d
Sub-assurance deficiency indicator
D.e
G.a
G.b
G.c
G.d
I.a
I.b
Deficiencies
T
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915( c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915( c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type. amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is estimated
to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FA~
Contact
I Centers for Medicare & Medicaid Services
CJt,TS/
7
logged in as QI_TEST_STATE_MEO_OIR(State
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372 Report Maintenance - Assurances
Summary
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._
Overview
Assurances
State
Renewal Number
Quality Report Status O
Quality Waiver Year Begin and End Dates
zz
ZZ.12345.R02
Completed
Apr 11, 2018 - Apr 11, 2019
A
B.a
B.b
Assurances
B.c
Complete Report
C.a
C.b
Sub-assurancell
Statustl
Deficiency'fl
Sub-assurance D.d
Complete
Not Detected
Sub-assurance D.e
Complete
Not Detected
Sub-assurance G.a
Complete
Not Detected
Sub-assurance G.b
No Performance Measures Example status for when a sub-assurance does not contain any performance measures
Sub-assurance G.c
No Performance Measures
Sub-assurance G.d
No Performance Measures
Sub-assurance I.a
Complete
Sub-assurance I.b
No Performance Measures
C.c
D.a
D.b
D.c
D.d
D.e
G.a
G.b
G.c
G.d
I.a
I.b
Deficiencies
...,
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915( c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915( c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type. amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is estimated
to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FA~
contact
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372 Report Maintenance - Assurances
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._
Overview
Assurances
State
Renewal Number
zz
ZZ.12345.R02
"Complete Report" button is enabled when
this field is "Completed", when all subassurances and deficiencies are completed
Quality Report Status O
Quality Waiver Year Begin and End Dates
In Progress
Apr 11, 2018 - Apr 11, 2019
A
B.a
B.b
Assurances
B.c
Comp ete Report
Example of disabled "Complete Report"
button when a sub-assurance is
incomplete
C.a
C.b
Sub-assurancell
Statusf!
Deficiencyf!
Assurance A
O Sample Universe - No Deficiency
Not Detected
Sub-assurance B.a
Not Started
Sub-assurance B.b
In Progress
Sub-assurance B.c
Complete
Not Detected
Sub-assurance c.a
Complete
Detected
Sub-assurance C.b
Complete
Not Detected
Sub-assurance c.c
Complete
Not Detected
Sub-assurance D.a
Complete
Not Detected
Sub-assurance D.b
Complete
Not Detected
Sub-assurance D.c
Complete
Not Detected
C.c
D.a
D.b
D.c
D.d
D.e
G.a
G.b
G.c
G.d
I.a
I.b
Deficiencies
T
Items per page: 10
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1 - 10 of 18 items
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915( c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915( c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type. amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is estimated
to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FA~
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372 Report Maintenance - Assurance A
Summary
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Report State
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State
Renewal Number
Quality Report Status
Quality Report Status O
zz
ZZ.12345.R02
In Progress
Quality Waiver Year Begin and End Dates
Quality Waiver Year Begin and End Dates
Apr 11, 2018 - Apr 11, 2019
B.a
Assurance 1 of 18
B.b
Currently on the detail page for the first of eighteen assurances present in the current 372 report
B.c
Assurance - A
C.a
C.b
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the
performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
C.c
D.a
D.b
Performance Measures Reporting On:
V
Expand All
D.c
D.d
Performance
measure "complete"
indicator
D.e
G.a
0
A 1:
PM: PRIOR AUTHORIAZATION OF WAIVER SERVICES: Number and percent of prior-authorization requests
processed timely by the PAC Waiver Disease Management provider.
Performance measure description
V
0
A 2:
PM: LEVELOF CARE Evaluation: Number and percent of participants' Level of Care determinations processed by
the Department of Elder Affairs (DOEA), CARES Unit within the required timeframes.
V
0
A 3:
PM: PARTICIPANTWAIVER ENROLLMENT: #and% of participants who were enrolled by case management agency
(CMA) following a completed, signed, and dated waiver application in accordance with the Medicaid Agency
V
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G.b
G.c
G.d
I.a
I.b
Deficiencies
,..
agreement.
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A Files:
Measurements
V
Were individual instances of substantiated abuse, neglect, or explotiation identified?
Reference
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Continue to B.a
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915(c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915(c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is
estimated to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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l...C
performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
D.a
D.b
Performance Measures Reporting On:
V
Expand All
D.c
D.d
D.e
0
Al:
PM: PRIOR AUTHORIAZATION OF WAIVER SERVICES: Number and percent of prior-authorization
processed timely by the PAC Waiver Disease Management provider.
0
A2:
PM: LEVELOF CARE Evaluation: Number and percent of participants' Level of Care determinations processed by
the Department of Elder Affairs (DOEA), CARES Unit within the required timeframes.
G.a
V
requests
G.b
G.c
G.d
Performance
measure "complete"
indicator
I.a
I.b
Deficiencies
,..
Report Year:
2019
Report year drop down input field
• Numerator: Number of PAC participants' level of care determinations processed within the required
timeframes.
• Denominator: Number of PAC participants' level of care determinations processed.
Expanding
navigation menu
Arrow to expand or collapse related content box
Performance measure numerator and
denominator descriptions
Sample size
The number of items selected to determine compliance (e.g., total number of records selected for review)
lo
Sample size field to input the total number of records selected for review
Sample universe
Total number of items available for selection ( e.g., total number of records available for review)
lo
Sample Universe field to input the total number of records available for review
Numerator
Number of items reviewed in compliance
lo
Numerator field to input the number of items reviewed in compliance
Denominator
Total number of items reviewed
lo
Denominator field to input the total number of items reviewed
Threshold
I would like to provide a custom threshold
□
Threshold Percentage
Special "Zero sample universe" status when all
performance measurement fields are marked zero and
the zero sample universe checkbox is checked with an
explanation accompanying it
Custom Threshold checkbox to indicate that you would like to use a custom threshold
value when considering this performance measure deficient
Custom threshold percentage input field to enter what value should be used to
determine deficiency
Percent Compliance:
Deficiency:
0 Sample Universe - No Deficiency
Not Detected
0 I will be reporting partial data for this performance measure.
0 I will not be reporting on this performance measure.
l!3 The Sample Universe for this performance measure is O, [Enter
Whether or not a deficiency is detected with the given values
Checkbox to indicate partial data is being reported
Checkbox to indicate that this performance measure is not being reported on
O for all fields]
Checkbox to indicate that this performance measure has no sample universe
Provide details about why the Sample Universe is O, you are not reporting on the performance
measure, or partial data was reported on this performance measure."'
Zero sample universe
Text area to include an explanation for any of the special cases indicated by the previous checkboxes
20 / 1000
0
A3:
PM: PARTICIPANTWAIVER ENROLLMENT:#and%
;ciof'nrv ( C:MA) follnwinn
c1rnmnlf'tf'rl.
sinnf'rl.
of participants who were enrolled by case management
c1nrl rlc1tf'rl w;iivf'r
;innlir;itinn
in c1rrnrrl;inrf'
with thf' Mf'rlirc1irl
V
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372 Report Maintenance - Sub-assurance B.a
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A
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Report State
...
Related Waiver's Renewal Number
State
zz
Renewal Number
Quality Report Status O
Quality Waiver Year Begin and End Dates
ZZ.12345.R02
In Progress
Apr 11, 2018 - Apr 11, 2019
Sub-assurance 2 of 18
B.b
B.c
Quality Waiver Year Begin and End Dates
Quality Report Status
Currently on the detail page for the second of eighteen assurances present in the current 372 report
Sub-assurance - B.a
C.a
C.b
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the
performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
C.c
D.a
D.b
Performance Measures Reporting On:
D.c
D.d
Performance
measure
incomplete
indicator
D.e
G.a
G.b
G.c
G.d
I.a
I.b
Deficiencies
,..
Expanding
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0
0
V
B.a 1:
PM: Number and percent of participants' who have a current level of care based on the 701B Department of Elder
Affairs assessment form.
Performance measure description
B.a 2:
PM: Number and percent of applicants receiving ...
B.a Files:
Expand All
V
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V
V
Were individual instances of substantiated abuse, neglect, or explotiation identified?
Measurements Reference
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Continue to B.b
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915(c) home and community-based services (HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915(c)(2)(E) of the Social Security Act requires states to annually
provide CMS with information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is
estimated to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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D.e
Performance Measures Reporting On:
G.a
G.b
Performance
measure "complete"
indicator
G.c
G.d
I.a
I.b
Deficiencies
•
Expanding
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0
Q)
Al:
A2:
V
PM: PRIOR AUTHORIAZATION OF WAIVER SERVICES: Number and percent of prior-authorization requests
processed timely by the PAC Waiver Disease Management provider. Performance measure description
Expand All Button to expand or collapse all of the content boxes on the page
V
Arrow to expand or collapse related content box
PM: LEVEL OF CARE Evaluation: Number and percent of participants' Level of Care determinations processed by
the Department of Elder Affairs (DOEA), CARES Unit within the required timeframes.
For a performance measure to be considered complete, you must fill in every field. If you are
reporting partial data or if you are not reporting on this specific performance measure, please
indicate this using one of the check boxes below.
Details on what makes a performance measure "complete", which is shown after saving an incomplete performance measure
Report Year:
2019
Report year drop down input field
Performance measure
• Numerator: Number of PAC participants' level of care determinations processed within the required numerator and
timeframes.
denominator
• Denominator: Number of PAC participants' level of care determinations processed.
descriptions
Sample size
The number of items selected to determine compliance (e.g., total number of records selected for review)
Sample size field to input the total number of records selected for review
Sample universe
Total number of items available for selection (e.g., total number of records available for review)
Sample Universe field to input the total number of records available for review
Numerator
Number of items reviewed in compliance
Numerator field to input the number of items reviewed in compliance
Denominator
Total number of items reviewed
Denominator field to input the total number of items reviewed
Threshold
I would like to provide a custom threshold
□
Threshold Percentage
186
The percent compliance based on the given numerator and denominator Percent Compliance:
Custom Threshold checkbox to indicate that you would like to use a custom threshold
value when considering this performance measure deficient
Custom threshold percentage input field to enter what value should be used to
determine deficiency
Deficiency:
Invalid Data
0
0
0
I will be reporting partial data for this performance measure.
I will not be reporting on this performance measure.
Whether or not a deficiency is detected with the given
values
Checkbox to indicate partial data is being reported
Checkbox to indicate that this performance measure is not being reported on
The Sample Universe for this performance measure is O. [Enter O for all fields]
Provide details about why the Sample Universe is O, you are not reporting on the performance
measure, or partial data was reported on this performance measure.
Checkbox to indicate that this performance measure
has no sample universe
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special cases indicated by the previous checkboxes
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1915(c).
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372 Report Maintenance - Assurance A
Report State
State
B.a
B.b
Related Waiver's Renewal Number
Renewa l Number
zz
B.c
ZZ.12345.R02
Quality Waiver Year Begin and End Dates
Quality Waiver Year Begi n and End Dates
Quality Report Status
Quality Report Status O
Completed
Apr 11, 2018 - Apr 11, 2019
C.a
C.b
Assurance 1 of 18
C.c
D.a
Currently on the detail page for the first of eighteen assurances present in the current 372 report
As surance - A
D.b
D.c
The Medica id Agency retains ultimate administrative authority and r esponsibility for the operation of the waiver program by exercising oversight of the
performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and co ntracted en tities.
D.d
D.e
Performance Measures Reporting On:
G.a
V
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G.b
Performance
measure "complete"
indicator
G.c
G.d
I.a
I.b
Deficiencies
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0
A 1:
0
0
PM: PRIOR AUTHORIAZATI ON OF WAIVER SERVI CES: Number and percent of prior-authorization requests
processed timely by the PAC Waiver Disease Management provider. Performance measure description
V
A 2:
PM: LEVEL OF CARE Evaluation : Number and percent of part icipants' Level of Care determinations processed by
t he Department of Elder Affairs ( DOEA), CARES Unit w ithin the req uired t imeframes.
V
A 3:
PM: PARTICIPANT WAIVER ENROLLMENT: #a nd% of participants who were enrolled by case managemen t agency
(CMA} following a completed, sign ed, and dated wa iver applicat ion in accordan ce with t he Medicaid Agency
agreement.
V
A Files:
Arrow to expand or collapse related content box
V
Were individual inst ances of subst antiated abuse, neglect, or explotiation identified?
Measurements Reference
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Continue to B.a
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PRA Disclosure St atement
All State Medicaid agencies administering or supervising the administration of 1915(c) home and commu nity-based services {HCBS) waivers are required to submit an annual Form CMS-372(S) Report for each approved waive r. Section 1915{c){2)(E) of the Social Security Act requires states to annuall y
provide CMS with information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Pri vacy Act of 1974 any personally identifying information obtained will be kept private to the ext ent of the law.
According to the Paperwork Red uction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The va lid 0MB control number for this information co llection is 0938-0272. The time required to complete this information collection is
estimat ed to average 44 hours per response, including the time to review instructions, search existing dat a resources, gather the data needed, and co mplete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report s Clearance Offi cer, Mail Stop C4- 26-05, Baltimore, Maryland 21244-1850.
FA~
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A list of all the validation errors present on the
page when an attempt to submit invalid data is
made.
Summary
Data
Quality
...
Overview
Assurances
...
•
I
Performance
• Performance
Measure 1 - input must be a number
Measure 2 - input must be greater than zero
372 Report Maintenance - Assurance A
Report State
Related Waiver's Renewal Number
B.a
State
Renewal Number
Quality Report Status
Quality Report Status O
B.b
zz
ZZ.12345.R02
Completed
Quality Waiver Year Begin and End Dates
Quality Waiver Year Begin and End Dates
Apr 11, 2018 - Apr 11, 2019
B.c
C.a
Assurance 1 of 18
C.b
Currently on the detail page for the first of eighteen assurances present in the current 372 report
C.c
Assurance - A
D.a
D.b
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the
performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
D.c
D.d
D.e
Performance Measures Reporting On:
V
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G.a
G.b
Performance
measure "complete"
indicator
G.c
G.d
0
Al:
I.a
I.b
Deficiencies
PM: PRIOR AUTHORIAZATION OF WAIVER SERVICES: Number and percent of prior-authorization requests
processed timely by the PAC Waiver Disease Management provider.
Performance measure description
Report Year:
,..
2019
Arrow to expand or collapse related content box
Report year drop down input field
• Numerator: Number of prior-authorization
Expanding
navigation menu
requests processed timely by the PAC Waiver Disease
Management provider.
• Denominator: Number of prior-authorizations requested processed.
Sample size
The number of items selected to determine compliance (e.g., total number of records selected for review)
I
text
Sample size field to input the total number of records selected for review
Sample universe
Total number of items available for selection ( e.g., total number of records available for review)
Sample Universe field to input the total number of records available for review
Numerator
Number of items reviewed in compliance
Numerator field to input the number of items reviewed in compliance
Denominator
Total number of items reviewed
Denominator field to input the total number of items reviewed
Threshold
I would like to provide a custom threshold
□
Custom Threshold checkbox to indicate that you would like to use a custom threshold
value when considering this performance measure deficient
Threshold Percentage
186
The percent compliance based on the given numerator and denominator
Percent Compliance:
Invalid Data
Custom threshold percentage input field to enter what value should be used to
determine deficiency
Deficiency: Whether or not a deficiency is detected with the given values
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372 Report Maintenance - Sub-assurance B.a
Summary
Data
Quality
.....
Overview
Assurances
...
State
Renewal Number
Quality Report Sta tus O
Qual ity Waiv er Year Beg in an d End Dates
zz
ZZ.12345.R02
I n Progress
Apr 11, 2018 - Apr 11, 20 19
A
Sub- assurance 2 of 18
B.b
B.c
Sub-assurance - B.a
C.a
C.b
The Medicaid Agency retains ult imate administ rative authority and responsibility for the operat ion of the waiver program by exercising oversight of the
performance of waiver fu nctions by other st ate and local/regional non-st at e agencies (if appropriate) and contracted entities.
C.c
D.a
D.b
Performance Measures Reporting On:
V
D.c
D.d
D.e
G.a
0
B.a 1:
0
B.a 2:
PM : Number and percent of participants' who have a curr ent level of ca re based on the 701B Departmen t of Elder
V
Affa irs assessment fo rm .
G.b
G.c
G.d
V
PM : Number and percent of applicants receiving ...
I.a
I.b
Deficiencies
,..
B.a Files:
w ere individual instances of subst antiated abuse, neglect, or explotiation identified?
0
Yes
Attachments
Attach supporting document (s) for sub-assurance B.a
Subassurance B.a Attachment.pdf
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B_a Report-1.pdf
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Remediation
Description of the State's actions to remediate t hese instances
0 / 1000
Measurements Reference
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372 Report Maintenance - Deficiencies
Summary
Data
Quality ._
State
zz
Overview
Assurances ,..
Renewal Number
Quality Report Status O
ZZ.12345.R02
Completed
Quality Waiver Year Begin and End Dates
Apr 11, 2018 - Apr 11, 2019
Deficiencies A.
Sub-assurance B.b 1
Sub-assurance C.a 2
Deficiencies
Complete Report
Deficiency ll
Sub-assurance B.b 1
Statusn
Deficiency Label
Completed
Sub-assurance c.a 2
Items per page: 10
Completed
Type!!
Deficiency Status
Individual
Compliance Percentage!!
Deficiency Type
Systemic
75%
Deficiency Compliance
100%
1 - 2 of 2 items
1 .., of 1 pages
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PRA Disclosure Statement
All State Medicaid agencies administering or supervising the administration of 1915(c) home and community-based services (HCBS) w aivers are required to submit an annual Form CMS-372(S) Report for each approved waiver. Section 1915(c)(2)(E) of the Social Security Act requires states to annually
provide CMS w ith information on the waiver's impact on the type, amount and cost of services provided under the state plan in addition to the health and welfare of recipients. Under the Privacy Act of 1974 any personally identifying information obtained w ill be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0272. The time required to complete this information collection is estimated
to average 44 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 2 1244-1850.
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372 Report Maintenance - Deficiency
Summary
Data
Quality
Report State
._
Overview
Assurances
Deficiencies
in as QI_TEST_STATE_MEO_OIR(State
Related Waiver's Renewal Number
Renewal Number
ZZ.12345.R02
State
zz
-y
Quality Waiver Year Begin and End Dates
Quality Report Status
Quality Report Status O
Quality Waiver Year Begin and End Dates
Completed
Apr 11, 2018 - Apr 11, 2019
,._
Sub-assurance B.b 1
Sub-assurance C.a 2
Deficiencv.: 1 of 2
Deficiency
Expanding
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- Performance
Currently on the detail page for the first of two deficiencies present in the current 372 report
measure
- Sub-assurance
B.b 1
Label indicating the current page contains deficiency details for the first performance measure within sub-assurance B.b
PM: Number and percent of waiver recipients ...
• Numerator: # of waiver recipients ...
• Denominator: # of waiver recipients receiving annual redeterminations.
The description of the performance measure, and the descriptions for both
the numerator and denominator for what's being considered in this
performance measurement
Numerator /Denominator
Percent compliance
3/4
75%
Individual
The numerator and denominator values pulled from the related performance
measure, and the percentage calculation given those values.
or Systemic deficiency
Individual: Issues are limited to a select group of individuals.
Systemic: Issues have the potential to impact the entire waiver population.
Deficiency Type:
The description of each available deficiency type, and the
expanded dropdown selector to indicate which type of
deficiency this is.
Testing Remediation
19 / 4000
Text field for the Remediation/QIP field, the
description of the state's actions to resolve the
deficiency
Entity Responsible for remediation/QIP
Entity responsible for overseeing implementation of the remediation/QIP.,..
Testing Entity Responsible
26 / 1000
Text field for the Responsible Entity field, the
entity responsible for overseeing the
implementation of the remediation
Timeline
Entity's timeline for completing the remediation/QIP actions.*
Testing Timeline
16 / 1000
Text field for the Timeline field, the
entity's timeline for completing the
remediation actions
Comment
Additional comments related to the performance measure, deficiency, or remediation/QIP.
0 / 4000
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Text field for the Comment field, for
additional comments related to the
performance measure, deficiency, or
remediation
Medic.aid Dir)
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Date:
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logged in as QI_TEST_STATE_MEO_OIR(State
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Summary
Data
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._
Overview
Assurances
Deficiencies
372 Report Maintenance - Deficiency
-y
,._
Sub-assurance B.b 1
Sub-assurance C.a 2
State
Renewal Number
Quality Report Status O
Quality Waiver Year Begin and End Dates
zz
ZZ.12345.R02
Completed
Apr 11, 2018 - Apr 11, 2019
Deficiencv. 1 of 2
Deficiency - Performance
measure - Sub-assurance
B.b 1
PM: Number and percent of waiver recipients ...
• Numerator: # of waiver recipients ...
• Denominator: # of waiver recipients receiving annual redeterminations.
Numerator /Denominator
Percent compliance
3/4
75%
Individual
or Systemic deficiency
Individual: Issues are limited to a select group of individuals.
Systemic: Issues have the potential to impact the entire waiver population.
Deficiency Type:
I
Individual
"..,
Remediation/QIP
Description of the state's actions to resolve the deficiency.*
Testing Remediation
19 / 4000
Entity Responsible for remediation/QIP
Entity responsible for overseeing implementation of the remediation/QIP."'
Testing Entity Responsible
26 / 1000
Timeline
Entity's timeline for completing the remediation/QIP actions.*
Testing Timeline
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A list of all the validation errors present on the
page when an attempt to submit invalid data is
made.
Data
._
•
•
•
•
Validation
Validation
Validation
Validation
error
error
error
error
on
on
on
on
Remediation/QIP
input - must be fewer than 4000 characters
Entity Responsible input - must be fewer than 1000 characters
Timeline input - must be fewer than 1000 characters
Comment input - must be fewer than 4000 characters
Overview
Assurances
Deficiencies
-y
,._
372 Report Maintenance
- Deficiency
Sub-assurance B.b 1
Sub-assurance C.a 2
State
Renewal Number
Quality Report Status O
Quality Waiver Year Begin and End Dates
zz
ZZ.12345.R02
Completed
Apr 11, 2018 - Apr 11, 2019
Deficiency: 1 of 2
Deficiency - Performance
measure - Sub-assurance
B.b 1
PM: Number and percent of waiver recipients ...
• Numerator: # of waiver recipients ...
• Denominator: # of waiver recipients receiving annual redeterminations.
Numerator /Denominator
Percent compliance
3/4
75%
Individual
or Systemic deficiency
Individual: Issues are limited to a select group of individuals.
systemic: Issues have the potential to impact the entire waiver population.
Deficiency Type:
I
,..
Individual
V
Remediation/QIP
Description of the state's actions to resolve the deficiency."'
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Text field for the Remediation/QIP field, the
description of the state's actions to resolve the
deficiency
Validation error box that appears if invalid data is entered in the above Remediation/QIP field
input - must be fewer than 4000 characters
Entity Responsible for remediation/QIP
Entity responsible for overseeing implementation of the remediation/QIP."'
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Text field for the Responsible Entity field, the
entity responsible for overseeing the
implementation of the remediation
Validation error on Entity Responsible input - must be fewer than 1000 characters
Validation error box that appears if invalid data is entered in the above Responsible Entity field
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Entity's timeline for completing the remediation/QIP actions.*
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Medic.aid Dir)
update mode
0MB Control Number, 0938--0272
Expiration
Date: 11/30/2024
Print
Summary
Quality
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Text field for the Timeline field, the
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Validation error box that appears if invalid data is entered in the above Timeline field
| File Type | application/pdf |
| File Title | 372 Report Layout Update |
| File Modified | 2024-05-10 |
| File Created | 2024-04-23 |