RFP# 202605096

Quality Improvement Organization (QIO) Quality Management and Support for Aging and Disability Services

PROPOSED SERVICES RESPONSE FORM

Bidder Name:

INTRUCTIONS: Bidder must complete this form to discuss the Services to be Provided referenced in Part II of the RFP and what the Bidder will offer, including:

· A description of the methods and resources the Bidder will use and how each task involved will be accomplished.

· A description of how the expectations and/or desired outcomes as a result of these services will be achieved.

· If subcontractors are involved, Bidders must clearly identify the work each will perform.

Bidders may expand each of the response (white) spaces within this document in order to provide a full response to each requirement.

A. Start-Up Capabilities (First six (6) months)

1. Develop and provide a project plan to the Department within thirty (30) calendar days of the start of the initial period of performance.

2. Reportable Event Categories: Work with the Department to integrate the Office of Aging and Disability Services (OADS) reportable event categories, refer to Appendix I (Reportable Events Review Form Examples), into the Bidder’s proposed workflow.

a. Evaluate existing categories and identify strategies to use categories and related information for reporting.

i. Make recommendations to the Department, as appropriate, about changes to how reportable event information is collected from Reporters due to overlap between existing categories.

b. Update workflows and reports when reporting categories change or when information collection fields change.

Bidders must describe and identify all expected impacts of category changes.

3. Reportable Event Review Form: Redesign the Reportable Event Review Form, a form directly built in Evergreen where documentation of triage scores occur, (not the Reportable Events Form referenced in Appendix I) in collaboration with OADS, ensuring the necessary fields are included for Event Triage.

a. Ensure the newly designed form is inclusive of reportable events under 10-144 CMR Chapter 101 Ch. II Sections 18, 19, 20, 21, and 29, with an ability to be hosted in Evergreen and the Long-Term Services and Supports (LTSS) Data System (i.e., SharePoint).

i. Event Triage for Sections 18, 20, 21, and 29 must be documented in the Evergreen system. Work with the Department to finalize processes for event intake, triage, review, and investigation, including the design of necessary Evergreen system components for triage.

ii. Event Triage for Section 19 must be documented in the LTSS Reportable Event System, including SharePoint. Work with OADS to finalize processes for event intake, triage, review, and investigation, including the design of necessary Reportable Event System components for triage.

Describe the Bidder’s approach to using existing reporting fields to complete triage in the event the form is not redesigned within the first six (6) months of the initial period of performance.

4. Consumer Concern Management, Including Grievances: Work with the Department to integrate the management of consumer concerns at OADS, including Grievances, into the awarded Bidder’s workflow.

a. Update workflows and reports when changes to processes are made, such as updates to the State’s Grievance Rule outlined in 14-197 CMR Ch. 8.

b. Work with the Department to finalize processes for intake, investigation, resolution or escalation, and tracking consumer concerns, including Grievances, within the first six (6) months of the start of the initial period of performance.

i. Develop standardized resolution activities for Grievances and escalation criteria to be used to determine which Grievances will escalate to the Department for resolution.

c. Implement customer-service functionalities, including a hotline during business hours, to make information submission as accessible to the public as possible.

5. Routing Business Rules: Facilitate decision-making and provide subject-matter expertise to ensure business rules are developed and documented to guide the routing / resolution process for reportable events and Grievances / Consumer Complaints.

a. For reportable events, make recommendations about what thresholds must be in place before an event and/or a cluster of events is escalated to the Department for further review during a Desk-level Review.

b. For Grievances and Consumer Complaint management, identifying relevant sources of intake for each distinct type of complaint and associated resolution pathway.

6. On-Site Presence: Establish a presence in Maine, which includes, at minimum, part-time on-site presence for the project manager in order to meet with Department staff, providers, or other interest holders at a meeting space provided by OADS.

7. Establish Adequate Staffing: Provide sufficient staff to perform the services outlined in this RFP.

a. Ensure staff have adequate home and community-based service expertise, including knowledge of federal requirements such as 1915(c) Waiver requirements, Access Rule requirements (CMS-2442-F), and Settings Rule requirements (CMS-2499-F/CMS-2296-F).

8. Enhanced Federal Financial Participation: Maintain the designation of a Quality Improvement Organization (QIO) or QIO-Like entity, which qualifies the Department to receive Medicaid enhanced Federal Fund Participation match from CMS.

a. Work with the Department and its Medicaid partners to develop the application to CMS for activities within the scope of work that is eligible for the seventy-five (75%) enhanced match.

9. Scalability of Work: Provide rapid scaling up or down of services as the Department moves towards aligning reportable events and Grievance practices across LTSS and Developmental Disability (DD) services.

Describe the Bidder’s approach to adding in new programs to the contract resulting from this RFP (e.g. new waiver or new operational area).

10. Provider Technical Assistance (TA) and Communications Planning: Educate the OADS provider community about newly developed processes during the Start-up Period and the awarded Bidder’s role.

Bidders must demonstrate the ability to address start-up issues that arise during the early implementation phase of the contract.

11. Adapting to Changes: Work with the Department to update the project plan, workflows, and reporting requirements impacted by future federal and/state rule changes (e.g., federal Access Rule (CMS-2442-F), Grievance Rule (14-197 CMR Ch. 8), (34-B M.R.S.A. § 3803), Reportable Events Rule (14-197 CMR Ch. 12,), provider licensing requirements (10-144 CMR Ch. 108) and the addition of new programs, such as Lifespan Waiver).

Describe the Bidder’s capacity to adapt to such changes over the term of the contract.

B. Reportable Event Management (aka Critical Incident Management)

1. Event Triage: Complete Event Triage and tracking of approximately thirty thousand (30,000) reportable events submitted annually for OADS (10-144 CMR Chapter 101 Ch. II Sections 18, 19, 20, 21, 29, and the anticipated Lifespan Waiver).

a. View submitted events and run reports through the Department’s Evergreen system and SharePoint.

i. Ensure Event Triage identifies clusters of related events, so that situational risk is identified even when individual triaged events may not identify the risk.

b. Establish contingency plans which address triage and track operations in the event submitted information is routinely not sufficient to complete valid triaging for OADS.

c. Promote inter-rater reliability of all triaging and tracking decisions for OADS.

d. Complete triage and tracking activities for OADS within one (1) business day from the date of reportable event submission in Evergreen.

2. Event Desk-Level Reviews: Complete and track Desk-Level Reviews of all Reportable Events

a. During the Start-Up Period, make recommendations about what thresholds must be in place before an event and/or a cluster of events is escalated to the Department for further review/action (i.e., events identified as “high risk”).

b. Complete expedited Desk-Level Reviews for events identified as high risk during the triage process.

c. Develop and document a recommended process for event intake, triaging, and review, including expedited review of high-risk events, for review and approval by OADS, including but not limited to:

i. Determining what, if any, Desk-Level Review and tracking requirements are to be included in the triaging process.

ii. Completing and tracking a Desk-Level Review, including what activities are a part of this type of review.

iii. A standard approach and/or tool to guide completion and tracking of Desk-Level Reviews.

iv. Leveraging clinical expertise in review, tracking, and triage activities.

Explain the Bidder’s approach to completing expedited reviews.

If the Bidder anticipates that some events may not require desk-level review, the Bidder must describe this rationale and the proposed approach for review and tracking as part of the incident report triage process.

3. Event Routing: Route, prioritize, and track events that require review from Department teams.

Routing teams may include but are not limited to the Division of Licensing and Certification (DLC), Adult Protective Services (APS), Crisis Management Services, Child Protective Services, Quality Assurance teams (ID or DD, Brain Injury (BI), and LTSS), and/or other appropriate parties/partners.

a. Determine the final list of teams, circumstances, and timing for routing during the Start-Up Period.

b. Determine which teams, offices, and/or groups need to receive routing of each event type.

c. Develop a process to identify redundancy in reporting and tracking (times in which a single event may have been Reported multiple times, or in which a single quality concern led to the reporting of multiple, related events) that protects against duplicate referrals to Department teams for review and approval by OADS.

d. Ensure events are routed and tracked within no more than three (3) business days, with high-risk events being routed within one (1) business day.

e. The awarded Bidder must have processes in place to ensure systematic routing of events.

Explain the Bidder’s approach to completing reporting activities if, while completing their review activity, they identify unreported reportable events.

4. Trend Analysis: Identify and track trends in reportable events, including the identification of clusters of related events.

a. Analyze and report to OADS, at least monthly, any notable trends in event reporting or underreporting, including the timeliness of provider reporting.

i. To support analysis on underreporting, OADS will provide access to a dashboard that includes a cross comparison of Medicaid claims data and reportable event data.

b. Analyze and report to OADS, at least monthly, descriptive statistics regarding the number of events Reported, triaged, and reviewed, which must include:

i. Subcategory reporting that identifies the type of review for an event received and any routing that occurred.

ii. Analysis of whether the events occurred during service provision or due to the failure to deliver services.

c. Analyze and report to OADS, at last quarterly, any notable trends in event remediation and follow up.

i. Ensure trends are actionable and able to lead to Department decision making regarding system-level interventions such as issuing new training.

d. Provide trending by program, population group, or other meaningful breakdowns, across all reports, where there are identified trends.

e. Provide ad hoc reporting, as needed and as requested by the Department.

f. Manage duplicate report submissions or event clusters.

5. Tracking: Follow up with OADS regarding the final outcome of items escalated to the Department (or other designated entities) for actions to document final outcomes and mitigate unresolved activity.

C. Consumer Concern Management, including Grievances

1. Complete intake, resolution, and tracking of Consumer Complaints and concerns, including Grievances from recipients of services of MaineCare Home and Community Based Services (HCBS) Waiver programs and services for persons with an Intellectual Disability (ID), Autism Spectrum Disorder (ASD), or an acquired BI consistent with 34-B M.R.S. § 5604, which must include but is not limited to

0. Consumer Complaints regarding noncompliance of licensed providers;

0. Consumer Grievances; or

0. Concerns from public community members about the safety and welfare of Waiver members or impacted parties.

1. Grievance Intake: Complete intake and tracking of Grievances from individuals receiving services in alignment with, or in pursuit of alignment with, standards defined in the federal Ensuring Access to Medicaid Services Final Rule (CMS-2442-F), 14-197 CMR Chapter 8 Grievance Process for Persons with an Intellectual Disability, ASD or acquired BI, and 14-197 CMR Chapter 12: Reportable Events System.

a. Receive Grievances from consumers using the method of their choice, which must include written or oral communication.

i. Provide reasonable assistance to Grievances with the completion of forms and other administrative steps related to the Grievances.

ii. Ensure the Grievance system provides accessibility to people with disabilities and/or limited English proficiency, including assistance such as written translation and/or auxiliary aids, and translators or interpreters.

iii. Ensure the Grievances system includes a toll-free number with adequate teletypewriter capabilities.

iv. Upon receipt, acknowledge receipt of a Grievance in writing regardless of how the grievance was received and request information necessary to investigate (this does not apply to any other types of Consumer Complaints and concerns received.)

1. Grievance Resolution and Routing: Initiate resolution activities for all Grievances received.

a. Ensure consumer Grievances are reviewed, and resolution is pursued by an individual who has the appropriate expertise needed to attempt to resolve the Grievances.

b. Escalate Grievances that require Department action for resolution to OADS in alignment with the workflows and escalation criteria established during the Start-Up Period.

c. Provide assistance and tracking to the Department to ensure that essential components of the Grievance process are met, such as sending written documentation of final outcomes.

d. Participate in administrative hearings related to Grievances as a subject matter expert.

e. Issue a written notice of decision or track OADS’ issuance of a notice of decision within ninety (90) calendar days of the receipt of a Grievance.

f. In the event a notice of decision cannot be issued within ninety (90) days due to external factors or parallel administrative or legal processes, receive written approval from OADS to extend the timeline and notify grievant of decision status.

4. Consumer Complaint and Concern Intake: In coordination with implementing intake of Grievances, complete intake and tabulation of other Consumer Complaints and concerns.

a. Provide a public facing intake form that can receive Consumer Complaints.

b. Provide a mechanism for submission of Consumer Complaints via oral communication, such as a hotline.

c. Operate intake in alignment with industry best practice for accessibility and ease of documentation.

d. Offer customer service support to people who are having trouble completing concern / complaint submission without assistance.

5. Consumer Complaint and Concern Routing: In coordination with implementing intake of Grievances, route other Consumer Complaints and concerns appropriately.

a. Have processes in place such that intakes are sorted into appropriate classifications and routed to the appropriate entity, as designated by the Department during the Start-Up Period.

6. Reporting: Design and deliver monthly, quarterly, and annual reports related to Grievances and Consumer Complaint management that provide meaningful insights.

a. Ensure reporting includes a detailed excerpt that includes a data set of all Grievances with key information fields, including but not limited to beneficiary name, description of Grievance reason, date received, date of each review or review meeting, date of resolution, and resolution summary narrative (if applicable).

b. Provide, as needed, an analysis of the number of reports and Consumer Complaints aggregated by agencies across complaints, Grievances, incident management.

c. Provide ad hoc:

i. Reporting to support urgent or emerging OADS quality priorities.

ii. Analysis for Evergreen and SharePoint.

5. Tracking: Follow up with OADS regarding the final outcome of items escalated to OADS (or other designated entities) for follow-up actions to:

a. Document final outcomes; and

b. Mitigate unresolved activity.

D. State Systems and Confidentiality

1. Evergreen: Leverage Evergreen to view information needed to manage reportable events and Grievances.

2. LTSS Data Systems: Leverage the LTSS Reportable Event Management and Grievance Systems, inclusive of SharePoint, Microsoft Forms, and Excel, to view, triage, and route reportable events.

3. State Licensing Data System (ALMS): Work within or receiving regular extracts from the State’s licensing data system (ALMS).

4. Process Information: Process all information exchanges and feeds, including potentially retrieving/sending daily incoming/outgoing file feeds, with secure mechanisms (FTPS or HTTPS, encrypted to at least TLS 1.0).

5. Ensure all access to the State systems are performed using devices, accounts, authentication methods, and virtual private network, provisioned by the Department.

a. Ensure all staff/personnel comply with current MaineIT Policies & Standards related to its:

i. Access Control Policy;

ii. Access Control Procedure for Users;

iii. Security Awareness Training;

iv. Rules of Behavior Policy; and

v. User Device and Commodity Application Policy.

6. Comply with all applicable State and Federal confidentiality regulations when providing quality management services including, but not limited to: the Health Insurance Portability and Accountability Act Privacy, 45 C.F.R. Part 160, and 45 C.F.R. Part 164.

7. Comply with all applicable Department Privacy and Security of Health Information policies.

8. Comply with all current State and Federal laws regarding the protection of confidential and/or sensitive information that is collected or maintained by the awarded Bidder, including, as applicable, notification to individuals in the event of unauthorized access or disclosure

9. Obtain and maintain insurance as outlined in the current State of Maine IT-Service Contract (IT-SC), Rider B-IT, Section 19. Insurance Requirements. The current IT-SC may be obtained on the Office of State Procurement Services Forms & Templates webpage.

10. Implement risk assessment and vulnerability scanning policies and procedures for collecting sensitive information electronically (PII, PHI, and/or other confidential data) as part of the services provided as a result of the contract awarded under this RFP, at minimum to be equivalent to current MaineIT Policies & Standards for:

a. Risk Assessment Policy & Procedures;

b. Rules of Behavior; and

c. Vulnerability Scanning Procedure.

11. The State will not consume (use) any awarded Bidder application, but the awarded Bidder will consume (use) one/more State application(s).

E. Compliance with Applicable Laws and Regulations

1. Develop processes that promotes an understanding and align with governing laws and regulations; specifically:

a. Relevant Federal Law and Rule

i. Social Security Act Section 1915(c)

ii. 42 CFR Section 441.301(c)(4)

iii. 42 CFR Section 441.302(a): State Assurances

iv. 45 CFR Part 1324

v. CMS-2442-F

vi. CMS-2449-F/CMS-2296-F

b. Relevant State Rule Related to HCBS

i. 10-149 Chapter 5: Home Based Supports and Services for Older and Disabled Adults and Disability Services Policy Manual

c. State Law and Rule Related to Reportable Events

i. 14-197 Chapter 12: Reportable Events System

ii. 34-B M.R.S. § 5604-A: Duty to Report Incidents; Adult Protective Services Act and Rights Violations

d. State Rule Related to Grievances

i. 14-197 Chapter 8: Grievance Process for Persons with an Intellectual Disability, Autism Spectrum Disorder or Acquired Brain Injury

e. State Law and Rule Related to Provider Licensing

i. 10-144 CMR Chapter 108: Home and Community Support Services Agencies Licensing Rule

ii. 34-B M.R.S §1203-B: Licenses for Agencies that Provide Services to Adults with Certain Conditions

iii. 10-144 CMR Chapter 129: Personal Care Agency Licensing Rule

f. State Law and Rule Related to Adult Protective Services

i. 10-149 Chapter 2: Adult Protective Services System

ii. 22 M.R.S. Chapter 958-A: Adult Protective Services Act

F. Performance Measures

1. Perform all services proposed in response to this RFP by achieving all Performance Measures listed in Table 1.

0. Submit data to support the performance measures utilizing the Department’s Deliverables Performance Tracking Template (to be provided upon contract execution) or via a third-party data source, as indicated within the performance measure data source column of Table 1.

Table 1 Mandatory Performance Measures

G. Reports

1. Ensure Reportable Event, Grievance and/or Consumer Complaint Reporting complies with Social Security Act Section 1915(c) reporting requirements described in the federal Access rule 42 CFR 431, 438, 441, and 447 (CMS-2442-F). Reports developed to meet requirements in subsections (3) – (10) must include program-level reporting.

2. Track and record all data/information necessary to complete the required reports listed in Table 2:

Table 2 – Required Reports

1. Reportable Events Reporting

2. Grievance/ Consumer Complaint Reporting

3. General Reporting

Summarizes activities for the previous 12-month period as determined by the Department, including breakdowns of data to provide insights into underlying trends, and recommendations about how to improve service quality. Explain the Bidder’s approach to incorporating staff insights into the Annual Report.

2. Submit all the required reports to the Department in accordance with the timelines established in Table 3:

Table 3 – Required Reports Timelines

a. Reportable Events Reporting

b. Grievance/ Consumer Complaint Reporting

c. General Reporting

H. Optional Future Requirements Based on the awarded Bidder’s demonstrated capabilities, the Department may consider expanding the scope of work under the contract resulting from this RFP.

1. Technical Assistance (TA) and Training

a. Provide TA, and potentially training, to providers.

i. TA requests must be at the discretion of the Department or in response to quality trends identified by the awarded Bidder through reportable event reviews and consumer quality Consumer Complaint reviews.

2. Provider Data Management

a. Combine existing data about providers into a single meaningful view of provider compliance and quality.

i. Data elements to consider include reportable events, Consumer Complaints, APS data, and licensing reviews; as well as alternative or additional data elements identified by the awarded Bidder.

ii. Manage imperfect data by developing at minimum strategies to address:

1) Data sets with missing provider information; and

2) Discrepancies in provider settings across data sets.

iii. Outline the frequency of updates, key elements that will be presented, and anticipated limitations.

3. Surge Review Capacity

a. Provide urgent support to the Department to complete on-site reviews of providers.

i. Reviews will be completed using a standardized tool developed by the Department.

ii. Reviews will assess the likelihood that a provider compliance issue would contribute harm to a person receiving services from the same provider.

4. Special Projects Capacity

a. Provide special project support on an ad hoc basis (e.g., reviewing behavior support plans).

5. Data Entry Capacity

a. Provide time-limited support to the Department to complete data entry activities, for example, within the Evergreen system.

6. Client Prior Authorization Review

a. Provide service authorization requests in accordance with medical necessity criteria defined in 10-144 CMR Chapter 101 Ch. I Section 1.

i. Ensure reviews are timely and consistent with the quality review policy of provider prior authorization submissions and associated person-centered planning documentation defined in 10-144 CMR Chapter 101 Ch. I Section 6.

ii. Use the Department’s Evergreen database to receive and review requests associated with service planning for prior authorization of services, level of support needed and determination of services by type, amount and frequency.

Identify and describe what reports would be used to monitor and report progress on activities included in the Optional Future Requirements.

DHHS RFP Proposed Services Response Form (Rev. 10/2025)