Quality Administrator (730)
CSFA Number: 444-22-0640
Agency Name
Department Of Human Services (444)
Agency Identification
DMH
Agency Contact
Barb Roberson
217-557-5876
Barb.roberson@illinois.gov
Short Description
Exhibit A – Scope of Services
The Grantee will provide the services of a Quality Administrator (QA) staff position(s). The QA(s) will function as part of the community agency's quality improvement or quality assurance department with strong oversight for community service delivery to Williams and Colbert Class Members. The Quality Administrator serves as the conduit for information and reporting between the Department of Human Services and the contracted agency for the Williams and Colbert Consent Decrees. DHS funds these position(s) to be independent of direct care service delivery to Class Members, yet responsible for conveying all information on the interface of services and coordination of care outcomes to the Department. The services provided by this position are not Medicaid billable. The Grantee will ensure that the QA(s):
1. Participates in DHS’ hosted and/or sponsored trainings related to the Consent Decrees (including training on the duties and responsibilities of the QA staff position(s)), quality initiatives, Quality Improvement Committee meetings, and any other related DHS quality initiatives deemed necessary by Department.
2. Serves as the single point of contact with DHS regarding assigned Class Members and transition related issues.
3. Receives referrals on Class Member case assignments from DHS or the designated agent. CMHCs will provide reports weekly to DHS on CMs not seen within time frames allotted in the Consent Decrees.
4. Assures assignment of Class Members’ case records to the agency’s respective direct care team services or appropriate staff. CMHC will provide DHS with the date and name of intake assignment within 7 days from receipt of the referral.
5. Provides oversight and agency’s performance accountability for all Williams and Colbert related processes and policies.
6. Provides direction to clinical staff serving Class Members with significant oversight into job performance and productivity.
7. Is responsible for the provision of reports and data to DHS in prescribed formats to facilitate review, tracking and monitoring of data.
a. Reportable Incident forms to be completed and submitted to DMH within 7 days after the actual incident (Williams)
b. Reportable Incident tracking reports and supporting documents to be submitted to the University of Illinois College of Nursing (UIC CON) and Colbert program within 7 business days after the actual incident (Colbert).
c. 30-day summaries for each reportable incident are to be submitted to DMH 30 days after the reported incident (Williams)
d. Active Participation in scheduled Reportable Incident Calls with UIC CON and Colbert program (Colbert)
e. Mandatory Summaries for each reportable incident are to be submitted to UIC CON and Colbert program within 30 days following the Reportable Incident Call. (Colbert)

8. Monitors multiple aspects of the transition and services being received by Class Members, such as completion of the Comprehensive Service Plans, development of the Treatment Plans and the actual services provided, post transition, as well as the consumers stability, wellness in the community (housing management, medication management, eating, socialization, etc.) and ongoing mental health services provided. Documentation is via review of the actual Treatment Plan and ongoing progress notes, as well as participation in daily team meetings. Quality Administrators will be responsible for submitting agency attendance for each pre-discharge meetings and final discharge meetings within 48 hours of occurrence.
9. Is responsible for monitoring the Comprehensive Service Plan and documenting Service Plan quality indicators.
I. Ensure that Comprehensive Service Plans are completed and submitted to the respective Consent Decree designee within the time frame indicated on the CSP for the identified Consent Decree.
II. Ensure that the CSPs are written in detailed, logical and individualized language and that plans are based on the Class Members’ respective transition needs, services, ancillary supports and/or risk factors.
III. Ensure that the CSP returned to an agency for correction is adequately reviewed to address the deficit or provide requested detail(s) and is returned to the designee within five (5) business days from receipt.
IV. Ensure that Plans, where risk factors are indicated, have a defendable mitigation strategy attached.
10. Is responsible for monitoring the Risk Assessment and Mitigation Strategies for individuals who have transitioned to the community.
11. Quality Administrators will conduct quality care visits to Class Members for the first twelve months, post transition. Q Quality Administrators will prepare monthly reports of CMs seen and assessed for 12 months post transition.

Exhibit B – Deliverables
The QA(s) is/are responsible for services and the provision of reports and data to DHS. Reports and data shall be separated by consent decree and/or program. Services and reporting to DHS will include (but not be limited to):
1. Ensuring that Comprehensive Service Plans are thoroughly completed, reviewed by the respective supervisors, based on the individualized needs of the respective Class Member, and include appropriate signatures of participation.
2. Routine quality reports, including a completed Transition Checklist for each client placed in the community, documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community, completed prior to transition.
3. Sentinel indicators completed upon notification of a Reportable Incident, within 24 hours.
4. Notification to DHS when barriers or other problems or issues arise in assuring that Class Members can access and continue to receive needed services and supports.
5. Monitoring the multiple aspects of the transition, services and supports as detailed and planned in the individual’s Comprehensive Service Plan (inclusive of services and supports beyond just mental health services) for assigned Class Members, with a minimum monitoring schedule for both Consent Decrees, as follows:
a. at least weekly from initial transition through the first four weeks following the Class Member’s move to the community.
b. at least every other week for the second and third month following the Class Member’s transition to the community.
c. at least monthly for the remaining nine months following the Class Member’s transition to the community.
6. Documentation of the QA’s monitoring of the transition, services and supports received by Class Members, as well as the quality of the services. Monitoring is to be conducted by:
a. Attendance at service planning meetings, including service team meetings;
b. Review of clinical record documentation;
c. Through direct interview and observation of the Class Members in their living environment or other chosen location.

Reporting Requirements:
1. Financial Report in accordance with Exhibit C.
2. Performance Report in accordance with Exhibit E.

Exhibit C – Payment
Reference the Uniform Grant Agreement, Article IV Payment, Section 4.2 Return of Grant Funds and 4.3 Cash Management Improvement Act of 1990. Payment will be issued monthly and reconciled with reported allowable expenses. Grantee shall submit a quarterly Periodic Financial Report (GOMBGATU-4002 (N-08-17)) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reported expenses should be consistent with the approved annual grant budget. Any expenditure variances require prior Grantor approval in accordance with Article VI of the Uniform Grant Agreement to be reimbursable.

PFR Email Address for General Grants:
DHS.DMHQuarterlyReports@illinois.gov

PFR Email Address for Williams Consent Decree: DHS.DMHWilliamsInvoices@Illinois.gov

PFR Email Address for Colbert Consent Decree:
DHS.DMHColbertInvoices@illinois.gov


DMH reporting templates and detailed instructions for submitting reports can be found in the Provider section of the DHS website.

Exhibit E – Performance Measures
The Grantee shall submit quarterly Periodic Performance Report (GOMBGATU-4001 (N-08-17)) and the Periodic Performance Report Template by Program (PRTP) to the appropriate email address below no later than November 1, February 1, May 1, and August 1. Reporting templates and instructions for submitting reports can be found in the Provider section of the DHS website.

PPR and PPRT Email Address for All Grants:
DHS.DMHQuarterlyReports@illinois.gov


The following are included in the reporting template:
1. Number of Class Members assigned to the agency.
2. Number of Class Members for whom Quality Administrators completed routine quality reports, including a completed Transition Checklist for each client placed in the community, documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Class Members transitioning to the Community, completed prior to that actual transition, was submitted.
3. Number of case assignment from DHS are referred to a program or clinical team within five business days.
4. Number of sentinel indicators completed upon notification of a Reportable Incident within 24 hours.
5. Number of Class Members who received a weekly visit from the Quality Administrator for the first four weeks post transition to the community.
6. Number of Class Members who received a bi-weekly visit from the Quality Administrator during the second and third months, post transition.
7. Number of Class Members who received a monthly Quality Administrator’s visit during the fourth through twelfth month, post transition
8. Number of Class Members whose Comprehensive Service Plans were monitored in accordance to DHS policies and expectations.

Exhibit F – Performance Standards
1. 100% of Class Members referred to the agency will be assigned.

2. 100% of required quality reports and supporting documentation is submitted to DHS within the designated time frames.
3. 100% of cases assigned by the Consent Decrees to the agency was processed to appropriate clinical team or program within 5 business days.
4. 100% of sentinel events reported, including Reportable Incidents and Root Cause Analyses were submitted to DHS (Williams) and UIC College of Nursing (Colbert) within 24 hours and 72 hours, respective, of the incident.
5. 100% of Class Members transitioned receives a weekly monitoring visit from the Quality Administrator during the first month, post transition.
6. 100% of Class Members assigned and moved to the community had a bi-weekly monitoring visit during the second and third month, post transition.
7. 100% of Class Members had a monthly visit from the Quality Administrator from the fourth month through the twelfth months, post transition.
8. 100% of the Class Members Comprehensive Service Plans were monitored in accordance to policies and expectations of the respective Consent Decrees.
Subject Area
Human Services
Program Function
Health
Enabling Legislation
Mental Health Community Services Act (405 ILCS 30/)

20 ILCS 1705 Sect. 73(a)

Consent Decree
Objectives and Goals
The QA(s) is/are responsible for services and the provision of reports and data to DHS/DMH. Reports and data shall be separated by consent decree and/or program. Services and reporting to DHS/DMH will include (but not be limited to):
1. Routine quality reports, including a completed Transition Checklist for each client placed in the community, documentation of completed Comprehensive Service Plans and Risk Assessment and Mitigation Strategies for Individuals Transitioning into the Community, completed prior to transition.
2. Sentinel indicator completed upon notification of a Critical Incident, within 24 hours, resulting in a Root Cause Analysis to be completed within 72 hours.
3. Notification to DHS/DMH when barriers or other problems or issues arise in assuring that clients can access and continue to receive needed services and supports
4. Monitoring the multiple aspects of the transition, services and supports as detailed and planned in the individual’s Comprehensive Service Plan (inclusive of services and supports beyond just mental health services) for assigned clients, with a minimum monitoring schedule of:
a. at least weekly from initial assignment to the provider through the first four weeks following the client’s move into their community placement
b. at least every other week for the second four weeks following the client’s move into their community placement
c. at least monthly for the remaining twelve months following the client’s move into their community placement
5. Documentation of the QA’s monitoring of the transition, services and supports received by clients, as well as the quality of the services. Monitoring is to be conducted by:
a. Attendance at service planning meetings, including service team meetings
b. Review of clinical record documentation
c. Through direct interview and observation of the client in their current living situation or other location

Reporting Requirements:
1. Financial Report in accordance with Exhibit C.
2. Performance Report in accordance with Exhibit E.
Types of Assistance
Direct Payments for Specific Use
Uses and Restrictions
Funding for this award will come from the State's General Revenue Fund and does NOT have a match or cost sharing requirement.

Funding Restrictions
DHS/DMH is not obligated to reimburse applicants for expenses or services incurred prior to the complete and final execution of the grant agreement and filing with the Illinois Office of the Comptroller.

Allowable Costs
Allowable costs are those that are necessary, and reasonable and permissible under the law and can be found in 2 CFR 200 - Subpart E - Cost Principles.

Unallowable Costs
Please refer to 2 CFR 200 - Subpart E - Cost Principles to see a collection of unallowable costs.

Indirect Cost Rate Requirements
Please refer to 2 CFR 200.414 regarding Indirect (F&A) Costs.

In order to charge indirect costs to a grant, agencies must have an annually negotiated indirect cost rate agreement (NICRA). There are three types of NICRAs: a. Federally Negotiated Rate; b. State Negotiated Rate and c. De Minimis Rate

5. Renewals
This program is a 12 month contract with 2, one-year renewal options. Renewals are at the discretion of the DHS/DMH and are contingent on the meeting the following criteria:
a. Applicant has performed satisfactorily during the past six months; b. All required reports have been submitted on time, unless a written exception has been provided by the Division; and c. No outstanding issues are present (i.e. in good standing with all pre-qualification requirements and no outstanding corrective action, etc.)

This program was competitively bid through the Notice of Funding Opportunity (NOFO) process in FY 2019 with 2 one-year extensions. FY 2022 will be considered competitive opportunity.
Eligibility Requirements
1. Be certified by IDHS as a Community Mental Health Provider or a Community Mental Health Center;
2. Be in good-standing with the Illinois Secretary of State (not applicable to governmental entities)
3. Not be on the Federal Excluded Parties List;
4. Not be on the Illinois Stop Payment list;
5. Not be on the Department of Healthcare and Family Services Provider Sanctions List;
6. Complete one Fiscal and Administrative Risk Assessment (ICQ);
7. Complete a Programmatic Risk Assessment for each competitive program;
8. Register and access both the Illinois Department of Human Services Community Service Agreement (CSA) tracking system and the Centralized Repository Vault (CRV);
9. Obtain a Dun and Bradstreet University Numbering System (DUNS) number. The DUNS number does not replace an Employer Identification Number. DUNS numbers may be obtained at no cost by calling the DUNS number request line at (866) 705-5711 or by applying online: DUNS Request Service. It is recommended that service providers register at least 30 days before the application due date.
10. Register with the System for Award Management (SAM) and maintain an active SAM registration until the application process is complete, and if a grant is awarded, throughout the life of the award. SAM registration must be renewed annually. It is recommended that service providers finalize a new registration or renew an existing one at least two weeks before the application deadline to allow time to resolve any issues that may arise. Applicants must use their SAM-registered legal name and address on all grant applications to DHS/DMH.
Eligible Applicants
Government Organizations; Nonprofit Organizations;
Application and Award Processing
1. 3 page Uniform Application for State Grant Assistance completed, signed and dated.
2. Uniform Grant Budget completed and submitted in the CSA tracking system
3. Notice of State Award to be accepted or declined. The NOSA shall include:
a. The terms and conditions of the award.
b. Specific conditions assigned to the grantee based on the fiscal and administrative, programmatic risk assessments and merit-based review conditions.
c. The NOSA is not an authorization to begin performance or incur costs.
d. Upon acceptance of the NOSA, announcement of the grant award shall be published by the awarding agency to www.Grants.Illinois.gov
4. Grant Agreement prepared in CSA Tracking system
5. Grant Agreement signed by Grantee and returned to DHS
6. Grant Agreement signed by DHS
7. Grant Agreement obligated at Comptroller Office
Assistance Consideration
Serves as Maintenance of Effort to the Federal Substance Abuse and Mental Health Services Administration Community Mental Health Block Grant
Post Assistance Requirements
a) Reporting
The Grantee shall report quarterly allowable grant expenses on the appropriate DMH reporting template to the DMH program contact no later than November 1, February 1, May 1, and August 1, and reported expenses should be consistent with the submitted annual grant budget. If any budget variances are noted, the DMH program contact may request that the provider submit a revised grant budget before subsequent monthly payments will be made. DMH program contacts and reporting templates can be found in the Provider section of the DHS website.

The Grantee shall report quarterly performance on the appropriate DMH reporting template to the DMH program contact no later than November 1, February 1, May 1, and August 1. DMH program contacts and reporting templates can be found in the Provider section of the DHS website.

b) Audits
Grantee shall be subject to the audit requirements contained in the Single Audit Act Amendments of 1996 (31 USC 7501-7507) and subpart F of 2 CFR Part 200, and the audit rules set forth by the Governor’s Office of Management and Budget. See 30 ILCS 708/65(c).

c) Records
Grantee shall maintain for three (3) years from the date of submission of the final expenditure report, adequate books, all financial records and, supporting documents, statistical records, and all other records pertinent to this Award, adequate to comply with 2 CFR 200.333, unless a different retention period is specified in 2 CFR 200.333. If any litigation, claim or audit is started before the expiration of the retention period, the records must be retained until all litigation, claims or audit exceptions involving the records have been resolved and final action taken.
Regulations, Guidelines, Literature
Title 59: Mental Health of the Administrative Code

2 CFR 200/45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements

DHS/DMH Attachment B
DHS/DMH Program Manual
Federal Funding
None
Notice of Funding Opportunities
Agency IDAward RangeApplication Range
Details19-444-22-0640-01$74004 - $71970602/02/2018 - 03/19/2018 : 5:00 pm
Details19-444-22-0640-02$74004 - $71970604/30/2018 - 05/04/2018 : 5:00 pm
Agency IDGrantee NameStart DateEnd DateAmount
45CYB00328-45CYB00328THE THRESHOLDS07/01/201906/30/2020737,699
45CYB04002-45CYB04002THE THRESHOLDS07/01/201906/30/2020411,089
45CYB00329-45CYB00329TRILOGY, INC.07/01/201906/30/2020377,854
45CYB04003-45CYB04003TRILOGY, INC.07/01/201906/30/2020293,724
45CYB03320-45CYB03320LUTHERAN SOCIAL SERVICES OF ILLINOIS07/01/201906/30/2020178,557