This letter notifies an agency that the Office of Quality Management, Metrics and Analytics will be conducting an on-site monitoring of the agency's OLTL Waiver and ACT 150 operations over a specified period. The monitoring is to ensure compliance with regulations and program standards. Key agency staff should be available for an entrance and exit conference. Various documents and files must be made available for review, including participant files, employee files, and claims documentation.

1. (Template) Initial Waiver Notification Letter
Insert date
Agency
Insert Prefix First Name Last Name, Insert Title [Director/Administrator]
Insert Street Address
Insert City, State Zip
MPI #
Dear Prefix Last Name:
This is to inform you that on (date) at (time), staff from the Office of Quality Management, Metrics and Analytics (QMMA), of the Office of Long Term Living (OLTL), will be on-site at your agency to conduct a monitoring of your OLTL Waiver and ACT 150 operations for the period from ________to _______ (enter dates starting 7-1-12 to last day of the month prior to the review)
Providers are monitored by the Quality Management Efficiency Teams (QMETs), the regional provider monitoring agents of OLTL, to ensure provider compliance with regulations as per 55 PA Code §52 in addition to Home and Community Based Services (HCBS) Waivers and ACT 150 program standards. Additional staff members from OLTL may accompany QMET members during the on-site monitoring. We estimate the on-site monitoring will take approximately _ days; however, this could vary depending upon the findings and availability of information during the monitoring.
Please be advised when an OLTL provider has offices in two or more regions, the location of the corporate headquarters of the OLTL provider is where the Waiver monitoring will take place. In cases where the provider has satellite offices performing Waiver functions, all information will need to be present at the corporate headquarters.
The Monitoring Materials List contains information that will need to be available for the on-site monitoring. Please ensure that this information is available on the first day of your monitoring.
QMET will be reviewing participant and employee files and claim documentation during their visit.
An Employee Information Request Template is being emailed for you to complete and submit to QMET. In completing this template, only include the names of those employees who have provided services to Waiver and ACT 150 participants during the period specified above. Only direct employees of the agency are to be included for purpose of creating this list. Once the template is completed, return it via email to the

2. QMET Program Specialist (insert name & email). Your employee sample will be determined from this list.
Once QMET determines your employee sample, you will receive an email which includes the Participant Sample List, the Employee Sample List and the Type, Scope, Amount, Duration and Frequency (TSADF) Claims for Review List. Please be sure to have all of these files and other documentation specified on the enclosure with this letter available to QMET on the first day of the monitoring.
A Voluntary Disenrollment Letter from the Bureau of Provider Supports is also enclosed. This letter provides appropriate instructions for providers who wish to disenroll from participation as a Home and Community Based Services provider. Please follow the instructions contained in the letter should you wish to disenroll from participation in any Waiver.
Please ensure that key Waiver staff at your agency is available to participate in an entrance conference on the morning of the first day of your on-site monitoring to discuss the purpose and scope of the visit. Key staff is also asked to participate in an exit conference at end of the monitoring to discuss preliminary findings, recommendations, and next steps.
Should you have any questions or comments regarding the monitoring of your Waiver operations please feel free to contact (Program Specialist) at (phone # and email address).
Sincerely,
Insert QMET Program Specialist Name, Title
Office of Quality, Management, Metrics and Analytics
Enclosures
cc: QMEU Statewide Coordinator

3. Monitoring Materials List
The following are some of the items that will need to be available for on-site review the first day of the monitoring :
•
Agency Policy and Procedure Manual
•
Executed sub-contract agreements (if applicable)
.
•
Copy of signed Medical Assistance Agreement
•
Files of participants included on the Participant Sample List that will be emailed to you.
•
Files of employees included on the Employee Sample List that will be emailed to you.
•
All supporting documentation for the Claims Review Sample that will be emailed to you, including but not limited to timesheets (or other method used to capture time), contact logs, invoices and/or service notes.
•
Participant incident/complaint file (if applicable).
•
Department of Health License (if applicable)
•
Commercial General Liability Insurance Policy
•
Professional Liability Errors & Omissions Insurance Policy
•
Workers Compensation Insurance Policy
Voluntary Disenrollment Letter

4. COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
DEPARTMENT OF AGING
OFFICE OF LONG TERM LIVING
PROVIDER SERVICES P.O. BOX 8025 TELEPHONE (717) 772-2570
DIVISION HARRISBURG, PENNSYLVANIA 17105-8025 FAX (717) 772-0965
Dear Provider,
The purpose of this letter is to provide your agency with instructions on how to accomplish disenrollment from participation as a Home and Community Based Waiver (HCBS) Provider. In order to complete your request, please include the following information in writing on your company letterhead:
1.
State your request for disenrollment
2.
Include your nine digit provider number and appropriate service location(s)
3.
Name of waiver(s) you are enrolled in
4.
Effective date of disenrollment
5.
Your plan for transfer of your participants
Return the letter to the Office of Long Term Living (OLTL) to the above address or fax to (717) 772-0965, Attention: Certification & Enrollment Unit.
As a reminder, it is the responsibility of the waiver provider to plan and provide for the safe and orderly transfer of Medical Assistance waiver participants to other OLTL-HCBS Waiver Providers in order to maintain the appropriate level of care. Please contact your service coordinator or local Area Agency on Aging for assistance.
Should you have any questions contact the OLTL Call Center at 1-800-932-0939.
Bureau of Provider Supports
Certification and Enrollment Section