Accountability budgets Youth Peel region

With the advent of the Wmo 2015 and Youth Act, municipalities are responsible not only for implementing care tasks, but also for monitoring and enforcing the quality and legality of care. A lot of money is involved within the social domain. It is social money that is used to pay for the care of vulnerable residents. In order to keep care affordable and accessible, it is essential that the Peel municipalities purchase good quality and efficient care and check whether care is claimed correctly. This monitoring plan informs care providers and residents about:

1. The framework within which the Peel Municipalities conducts the legality audit of declared care;
2. The various audit processes that can be undertaken and the exchange of personal data in the process;
3. Measures that can be used.

Appendices include:

• The table General risk analysis;
• Support plan requirements;
• Control principles;
• Sources used.

Questions about this accountability can be directed to the email address wmopeel@bizob.nl.

The GR Peelgemeenten (partnership of Asten, Deurne, Gemert-Bakel, Laarbeek and Someren for the social domain) is responsible for the lawful and efficient implementation Care In Natura (ZIN) of the Wmo 2015 c.a. and the Youth Act c.a.. One of the statutory tasks concerns (material) control. The Peel municipalities adhere to the laws & regulations when carrying out checks. The principles of proportionality and subsidiarity are taken as a starting point when carrying out checks. No more personal data are processed than necessary for the purpose of the audit. For the controls described in this plan, only those provisions that relate to control and/or data exchange are relevant.
The following laws and regulations are relevant to the performance of checks and audits in the Social Domain:

• Youth Act (Jw)
• Youth Act Regulation (Rjw).
• Social Support Act 2015 (Wmo2015) ; As far as the implementation of monitoring is concerned, since the Wmo has no provisions of its own for this purpose, the implementation rules included in the Regulation Jw for the Jw are followed; General Data Protection Regulation (AVG);
• General Data Protection Regulation (UAVG) Implementation Act.
• Wmo regulation of the 5 Peel municipalities.
• Further rules Wmo of the 5 Peel municipalities
• Youth aid regulation of the 5 Peel municipalities.
• Protocol Youth aid after referral by family doctor, medical specialist and youth doctor
• Agreements between the 5 Peel municipalities and care providers
• See appendix 4, sources

The college has the following control processes:

1. Formal audit
2. Material control
3. Detail check
4. Contract compliance monitoring

Checks are made in advance and during the claims process whenever possible. In addition, controls are performed based on risk analysis. The various control processes are explained below. During the year, new risks may emerge that can lead to an audit at any time. In the design and execution of an audit, the college can make a reasoned choice not to use lighter means of control if, in the college's estimation, they will not contribute to obtaining more assurance about the actual and justified delivery. More on the principles taken into account during the audit are described in Appendix 3 Principles of Audit.

3.1 Formal control

The Youth Act Regulations stipulate that personal data may be processed for the purpose of funding (§6a.), describing specific personal data to be mentioned when charging (Articles 6a.1 - 6a.3), and also processed when performing a formal audit (Article 6a.7).
The Youth Act Regulations (Article 1) define formal audit as follows: An examination in which the college or a person designated by the college verifies that the amount declared:

1. Concerns a performance provided for the benefit of a youth who is domiciled within the municipality of the college;
2. A performance concerns for a service referred to in the law;
3. Concerns a performance to the delivery of which the person submitting the claim is authorized vis-à-vis the municipality, and
4. Corresponds to agreements or subsidy conditions made for that purpose by or on behalf of the College, or corresponds in height to what can reasonably be considered appropriate in Dutch market conditions;

The above includes whether the submitted claim falls within the decision issued on behalf of the college (in terms of scope, duration, intensity, product).
Formal checks involve checking part of the legitimacy of the submitted claims and are performed during the regular processing of invoices. Formal checks do not include verification of actual delivery, which is an important part of legality.

The procedure for formal control under the Youth Act, is applied analogously to the Wmo 2015.

3.2 Material control

The Youth Act Regulations (Article 1) define material verification as follows: An examination in which the college or a person designated by the college verifies that the declared performance;

1. Has been delivered (actual delivery) and,
2. or that performance (in accordance with legally required use of appropriate care and professional standards):
   1. Is consistent with a decision issued by or on behalf of the college, stating an entitlement to prevention or youth assistance;
   2. If the college has mandated a provider to provide prevention or youth care on its behalf, falls within that mandate;
   3. Fits within a referral by a general practitioner, medical specialist or youth doctor,
   4. Connects with a decision taken by the certified institution as referred to in article 3.5 of the law, stating that youth care is appropriate, or
   5. Connects to a court decision, in which the youth is designated for a child protection measure or youth probation.

Re 1. Actual delivery may be investigated in various forms of examination, including in a material audit and/or in an examination as (if any) stipulated in the Agreement.

Re 2. The legally required use of appropriate care and professional standards in youth care includes:

• Appropriate care in the sense of realistically foreseeable outcomes in the individual youth assistance provided and declared (Youth Act, Art. 4.1.1., para. 1):
  • Necessity
  • Effectiveness, efficiency, safety, client-centeredness;
  • Relevant contribution to healthy and safe growing up and development, the higher goals when using youth aid;
  • For Wmo 2015, the same requirements for appropriate care apply, albeit that contributions to self-reliance or participation apply as higher goals.
• Professional action includes at least working in accordance with professional quality frameworks (content and reference; Youth Act, art. 4.1.1., paragraphs 2 and 3), such as, for example:
  • Ensuring appropriate care in scope and content, both at the start of and during individual youth care;
  • Working with an up-to-date, concrete support plan agreed upon with the client (see Appendix 2);
  • Evaluations;
  • Acting in accordance with state of science and practice;
  • The procedure for material control under the Youth Act, is applied analogously to the Wmo 2015.

3.3 Detailed control

The Youth Act Regulations define detailed monitoring (1) as follows:
Examination by the college or by a person designated by the college of personal data held by a provider relating to juveniles who are domiciled in the municipality for which the college in question operates, for the purpose of material control or fraud investigation.
Detailed monitoring serves to deepen a substantive monitoring or fraud investigation. As an extension of a substantive audit, a detailed audit (the heaviest control instrument) will only be used if, after the implementation of the general control plan, there is insufficient certainty with regard to one of the control objectives from the general control plan or if it is estimated in advance that the control objective cannot be achieved with the use of a general control instrument (2). Thereby, the detailed control will be carried out after the following conditions are met (3):

• GR Peelgemeenten (4) conducted a specific risk analysis on the findings from the implemented general control plan referred to in Article 6b.3, second paragraph;
• Following the specific risk analysis, GR Peelgemeenten has prepared a specific control plan and specific control objective, which includes the objects of material control and the methods of detailed control;
• The specific purpose of material control established in accordance with subsection b cannot be achieved without detailed control;
• The specific control plan shows that in the context of detailed control, no more personal data shall be processed than is necessary in view of the purpose of the investigation and the circumstances of the case under investigation;
• The GR Peelgemeenten has provided the provider with adequate and - at the provider's request - written information prior to the implementation of the detailed audit justifying how the conditions mentioned in this paragraph have been met.

The procedure for detailed monitoring under the Youth Act, is applied analogously to the Wmo 2015.

(1) Regulation Youth Act, article 1
(2) Youth Act Regulation, article 6b.3, paragraphs 3 and 4 and article 6b.5, paragraph 1c
(3) Regulation Youth Act, article 6b.5
(4) Or the party to which the GR has mandated the power

3.4 Monitoring compliance with contract terms

This involves investigation by the college into compliance with conditions as agreed upon with care providers who have entered into the agreement with the municipality. It concerns requirements that are additional to current laws and regulations (which must be met in full). The peel municipalities have included conditions in the agreement such as:

• Requirements for the support plan (see also Appendix 2);
• Quality of care requirements;
• Proficiency requirements of personnel;
• Disclosure;
• Financial, administrative and related arrangements.

The control of compliance with the contract terms is carried out, among other things, by means of risk, data analysis, data retrieval and examination, by officials or external employees (5) entrusted with this. Here, for personal data, the principles as stated under formal control apply. The control ends if the control objective has been achieved and there are no other signals showing that there is insufficient assurance. If there is insufficient or no such assurance, the audit continues. However, the audit can also end if both parties reach an agreement, as a result of which, in the opinion of the municipality, the uncertainties and risks appear to be sufficiently compensated and covered.

(5) To which the duty of confidentiality applies

The general risk analysis precedes material control and is aimed at determining what data the control or investigation will focus on. The general risk analysis is the basis for this general control plan. The purpose of the risk analysis is to identify all relevant risks that are not already controlled by measures such as formal control. The result is a list of risks that the municipality sees within the Youth Act and/or Wmo 2015, which serves as a guide when performing material controls. See "table of general risk analysis" (Appendix 1) for the currently applicable general risk analysis based on youth aid in the form of Child & Youth (K&J) Mental Health Care and Wmo 2015. In this table the risks that are already tested in a formal audit are not named again, but they are applicable.

The preparation, establishment and, if necessary, adjustment of the general risk analysis is an ongoing process. A general risk analysis and a general control plan are hard, minimum requirements for starting a material control. A general risk analysis and a general control plan also provide relevant frameworks for all (regular or signal-initiated) analyses, controls or (preliminary) investigations that may take place before the decision is made to initiate a material control. In addition, the municipality reserves the right to pick up new signals and/or risks during the implementation of this general control plan if they arise and it is suspected that they may lead to potential financial damage and/or poor client value.

The overall risk analysis currently adopted was created based on:

• Inventory of signals and risks.
  The following sources were used for the inventory of signals and risks:
  • (formal) inspections already carried out;
  • Laws and regulations/Regulations Youth Aid and Wmo of the 5 Peel municipalities;
  • Professional standards/guidelines;
  • Known risks from the adult mental health care, as far as applicable for the K&J mental health care ( 6)
  • Known risks from the Wmo 2015;
  • Contract agreements;
  • Signs from contract management interviews;
  • Signals from conversations with clients in access;
  • External signals from e.g. VNG, media (Follow the Money), residents, etc.
• Impact analysis
  To arrive at a list of the most important risk topics, consideration was given to whether:
  • A management measure is already in place that sufficiently mitigates the risk;
  • A risk, if it occurs, can lead to financial damage (excessive expenditure);
  • A risk, if it occurs, can lead to poor client value.

Risk objects and risks

The general risk analysis and impact analysis in relation to K&J GGZ and Wmo 2015 resulted in three main risk objects. In each of these topics, risks are recognized that, if they lead to actual illegality, have substantial impact in terms of overspending and/or insufficient positive outcomes for clients (see Appendix 1 'table of general risk analysis').

The three risk objects are:

1. Financial legality;
2. Legitimacy in terms of appropriate youth and Wmo measure provision;
3. Legality in the sense of professional responsibility.

(5) To which the duty of confidentiality applies.
(6) a.o. 'EX-19-2358 Risk list and explanation cGGZ 2020' published on the site of Zorgverzekeraars Nederland

Physical control can be terminated after the deployment of general control tools or after the deployment of detailed control tools. The consequences depend on the findings in relation to the control objective. The substantive audit can be terminated without consequences for the provider if the audit objective has been achieved and there is sufficient certainty about the lawfulness and/or effectiveness of the audited claims.

The physical audit may be terminated with consequences for the provider if:

• The audit objective has not been achieved, but the parties do agree on acceptable compensation and/or other measures, as a result of which the risk of financial loss for the municipality has been sufficiently reduced. And the risk of damage for clients in the present and in the future is sufficiently reduced and it is sufficiently established that there have been irregularities. The municipality unilaterally imposes one or more repressive and/or preventive measures, as described below;
• The audit objective was not achieved because there was sufficient evidence of illegality, with the municipality unilaterally deciding to recover claims and, if relevant, other punitive measures.

measures

The municipality may proceed with:

• Written warning;
• Modified and/or additional agreements between a healthcare provider and municipality;
• Set-off or recovery of payments based on improper claims;
• Suspension of fees or payment of claims;
• Agreement is terminated;
• Report to IGZ, IJZ, disciplinary court, FIOD or Wmo supervisor and/or report to police.

Prevention

Measures can also be preventive:

• Tightening policies;
• Provider improvement plan in coordination with the municipality;
• Expand or tighten contract agreements;
• Termination or dissolution of the agreement.

This is an investigation in which the board examines whether the care provider intentionally and deliberately acts in violation of laws and regulations, for its own or others' financial gain (7). This investigation may take place as a result of signals received by the board or as a result of findings in a formal, material audit and/or compliance with contract terms. Fraud signals and suspicions of fraud are subsequently investigated by the designated officials responsible for monitoring compliance. officials of the municipal enforcement department in a professional manner specific to them.

(7) commits forgery, deceit, prejudice to beneficiaries or embezzlement to the detriment of the municipality, for the purpose of obtaining a payment or other benefit to which there is or may be no entitlement (not exhaustive)

(8) Youth Act, article 4.1.1, paragraph 2
(9) Jeugdwet, article 1.1
(10) Jeugdwet, article 4.1.1, paragraph 1
(11) Jeugdwet, article 2.3, paragraph 1.
(12) Jeugdwet, article 4.1.4, paragraph 1 and paragraph 2
(13) Jeugdwet, article 4.1.1, paragraph 3, article 7.3.8, paragraph 1, and WGBO
(14) Youth Act, Article 4.1.3(2) and Article 7.3.2
(15) Youth Act, Article 4.1.4(1) and (2)
(16) Jeugdwet, article 4.1.1, paragraph 2, Besluit Jeugdwet, artikel 5.1.1, and SKJ Kwaliteitskader Jeugd, Toepassen van de norm van de verantwoorde werktoedeling in de praktijk, version 2.1 September 2016

The Wmo 2015 stipulates that a facility must in any case be provided in a safe, effective, efficient and client-oriented manner, tailored to the real need of the client and to other forms of care or assistance received by the client. And that the provision is provided in accordance with the responsibility resting on the professional, arising from the professional standard (17). Including the "model basic set of quality requirements Wmo support for very vulnerable citizens" (18) The Youth Act stipulates that the care provider provides responsible assistance, which is understood to mean assistance of a good level, which is in any case safe, effective, efficient and client-oriented and which is tailored to the real needs of the youth or parent (19). The care provider shall exercise the care of a good care provider in his activities, acting in accordance with the responsibility incumbent upon him, arising from the professional standard applicable to that care provider (20).

Support plan Wmo guidance

The Agreement Wmo Begeleiding stipulates (21) that within the framework of result, result areas and activities as mentioned by the Municipality (22) in the support plan the objectives and activities are named. The support plan meets the following requirements/characteristics:

• The support plan is form-free;
• There is no Support Plan until it is signed by both Provider and Client;
• The support plan is up to date. Essential changes to goals and/or activities are incorporated each time into a new or updated plan that is re-signed each time by Provider and Client;
• The support plan shall be prepared by the Provider in compliance with privacy laws. Information that prevents the support plan, without prior consent of the client, from being handed over to the Municipality shall not be included by the Provider in the plan.

Also, with the decision for a customized Wmo counseling service, a guideline that can be used for preparing the support plan is sent along:

• Context: brief description of current situation, making clear what the request for help and main problems are;
• Goals: concrete and SMART goals in which it is clear what the main goals are. It is clear whether the goals are aimed at improving, stabilizing or compensating for self-reliance and/or participation. Goals are related to what makes client currently dependent on care, linked to the client's request for help. Goals include (if possible) a goal in terms of decreasing dependence on professional care and support.
• Approach: what activity needed to achieve goal, who does what and with what scope/time investment?
• Term: start time of the plan, duration of the plan and to what extent can the goals be fully achieved within plan period?
• Evaluation: at what times, how and by whom will formal evaluation take place?

Youth Support Plan

The Agreement on Individual Provision of Youth stipulates with regard to the support plan (23) that the support plan used by the Youth Care Provider is drawn up on a legal basis or in accordance with a quality standard explicitly applicable or supported in the industry. Also in other cases, the Support Plan meets the following requirements / characteristics:

• A support plan describes the activities, quality, intensity, duration, goals and intended outcomes of the use of assistance;
• The Support Plan is form-free;
• There is only a support plan when the Youth Care Provider can prove that the Youth and/or parent(s) have been informed about the plan and agree to it. The burden of proof for agreement Youth Care Provider always lies with the Youth Care Provider;
• The support plan is up to date. Essential changes are always incorporated into a new or updated plan for which the Youth Care Provider can demonstrate that the Youth Worker has been informed of and agrees to the changes. The burden of proof for agreement Youthee always lies with the Youth Care Provider;
• The Support Plan shall be prepared by the Youth Care Provider in compliance with privacy laws. Information that prevents the support plan from being handed over to the Municipality, without the prior consent of the Youth, the Youth Care Provider shall not include in the plan.

Youth support plan evaluation

• Youth Care Provider prepares an evaluation report for each agreed upon evaluation moment and at least 4 weeks before the end of the indication. The evaluation report meets the following requirements / characteristics:
  • The evaluation report describes in any case:
    • The development that the Youth has gone through
    • For each SMART goal whether the result has or has not been partially achieved and an explanation of this
    • What activities the Youth Care Provider has undertaken to achieve the results
    • Description of what is still needed (if applicable);
  • The evaluation report is free of form.

(17) Wmo, article 3.1 paragraph 2
(18) Agreement Wmo 2015 guidance, article 2.2 paragraph 3
(19) Youth Act, article 4.1.1 paragraph 1
(20) Youth Act, article 4.1.1 paragraph 3
(21) Agreement Wmo 2015 guidance, article 2.5
(22) Agreement Wmo 2015 accompaniment, article 2.3 and appendix 7
(23) Agreement Individual Provision Youth, article 2.4 paragraph 7

• Proportionality; the least intrusive means of control, which can achieve the goal, is used;
  • Request for information, relating to organization, care delivery, form, conversation, among other things;
  • Process control, relating to care process, among other things;
  • Relationship check (24);
  • Resident survey of clients of care providers involved in the study;
• In determining adequate assurance of legality and effectiveness, consideration is given to, among other things:
  • The extent of the error or discrepancy;
  • Normative familiarity with health care and claims regulations;
  • Any prior errors or warnings;
  • Care provider's attitude (including willingness to cooperate with investigation);
  • Careful consideration of legitimate interests;
  • Careful procedure (including timely communication and adequate justification by the college);
  • Client interests;
  • The consequence is proportionate to the deficiency found;
  • Reasonableness and fairness.
• Right to be informed; the college discloses information about the general risk analysis and the general control plan in a manner that is readily available to residents, youth and their legal representatives, and care providers. Prior to an audit (general or detailed), the health care provider is informed - in writing upon request of the health care provider - about the audit step, reason, purpose and form of audit;
• Transparency; the findings of each audit step are discussed, in an adversarial manner with the healthcare provider;
• Hearing & rehearing; during hearing & rehearing, the healthcare provider receives feedback on the results for each control (step). If there is sufficient certainty about the legitimacy and effectiveness of the care provided, the physical inspection is concluded. If there is uncertainty about the legitimacy, the care provider must remove the doubt by providing substantiation in the adversarial process, for example by submitting additional evidence. If this cannot be met, additional control steps are taken.

(24) Control approach based on testing the interrelationship between two quantities

• Youth Act, Article 4.1.1(2);
• Youth Act, Article 4.1.1(3), Article 7.3.8(1);
• Youth Act, Articles 4.1.3(2) and 7.3.2;
• Youth Act, Article 4.1.4(1) and (2);
• Youth Act Decree, Article 5.1.1;
• Youth Act Regulations, Article 6a.7, paragraph 2;
• Youth Act regulation, article 6b;
• Youth Act regulation, Article 6b.1(3);
• Youth Act regulation, article 6b.3;
• Youth Act regulation, article 6b.5;
• Regulation Wmo 5 Peel Municipalities;
• Youth aid regulation Peelgemeenten
• Wmo 2015 guidance agreement
• Agreement on Individual Provision of Youth
• Wmo 2015, Article 6.1;
• SKJ Quality Framework for Youth, Applying the standard of responsible action in practice, version 2.1 September 2016;
• Medical Treatment Agreement Act (WGBO) - EX-19-2358 Risk list and explanation GGZ 2020 published on the website of Zorgverzekeraars .