MCHENRY COUNTY MHB ETHICS & COMPLIANCE

AGENDA ● APRIL 22, 2019

Public Meeting Mental Health Board - Main Floor Conference Room 5:00 PM 620 Dakota Street, Crystal Lake, IL 60012

McHenry County Page 1 Updated 4/17/2019 11:08 AM

I. CALL TO ORDER Roll Call

II. PUBLIC COMMENT III. APPROVAL OF MINUTES - FOR ACTION

Minutes of the September 19, 2018 Ethics and Compliance Committee Meeting

IV. AGENDA ITEMS FOR DISCUSSION / FOR RECOMMENDATION A. Review of 1st Quarter Provider Outcomes - FFS, Grant, POP

FY19 FFS-POP-Grant Outcomes Summary Report and Graphs Q1

B. Review of 1st Quarter Provider Outcomes - P4P P4P Outcomes Report Q1

C. Review of FY19 Compliance Audits to-date

V. OLD BUSINESS - FOR DISCUSSION / FOR RECOMMENDATION VI. NEW BUSINESS - FOR DISCUSSION / FOR RECOMMENDATION

A. Communication, Education & Training on Compliance Issues Communication, Education & Training on Compliance Issues

VII. PUBLIC COMMENT VIII. ADJOURN

McHenry County Mental Health Board

MHB Ethics and Compliance Committee

September 19, 2018 ● 4:00 p.m.

Held at: Mental Health Board, 620 Dakota Street, Crystal Lake, IL 60012

Minutes

Committee members present: Mike Baber, Cathy Ferguson, Sarah Wilson

Committee members absent: Dawn Pruchniak

Others Present: Scott Block, Terry Braune, Jane Wacker, Vickie Johansen, Pat Peterson

I. CALL TO ORDER – Cathy Ferguson called the meeting to order at 4:04 p.m. Roll Call was taken.

II. PUBLIC COMMENT – none.

III. APPROVAL OF MINUTES - FOR ACTION

Mike Baber motioned to approve the Minutes of the April 11, 2018 Ethics and Compliance Committee meeting.

Seconded by Sarah Wilson. A VOICE VOTE WAS TAKEN. All in favor. Motion carried.

IV. AGENDA ITEMS FOR DISCUSSION / FOR RECOMMENDATION

Scott asked for Committee permission to reorder the agenda, moving up items B, C then A and D. The Committee

agreed to the change in agenda items.

A. Compliance Audit Updates – moved down in agenda

B. Compliance Audit Process

1. MHB Compliance Audit Process Packet

Pp 5, 6, and 7 are reminder “cheat sheets” for providers.

Pp 7 is based on the types of funding as to how each agency is audited. There are 4 types of funding: FFS, POP, Grant,

and P4P. These drive type of funding, work plan, execution of audits, etc.

Pp 9 is the Records Auditing and monitoring policy spells out how records are pulled for audit and determines audit

period, usually 3-4 months.

Pp 10 is a checklist completed before hand prior to performing an audit and includes every document required by

agency at some point throughout the year. Highlighted items are new for FY18 as result of CARF process and are

covered in the discussion with providers. The checklist is reviewed at the entrance conference with expectation of that

all required items have been submitted to the MHB. An exit interview is to review any findings and wrap up issues

identified.

The CARF Standards manual is included with highlights of background checks, processes, safety, etc.

On pp 58 Required Written Documentation are all policies that all agencies should have in place. Providers are given

this list with the expectation that all are working toward getting these policies in place.

Pp 60 - 62 show the final audit report.

Pp 63 is the MHB Audit and Appeals Policy.

Terry reviews: Residency of individual, Coordination of Benefits, Assessment of the client, Current Plan in place,

Transaction support, No comment is made on clinical content, unless the documentation references non-billable

activities taking place.

Terry discuss service delivery consistency in alignment with State rules.

Providers receive a minimum of two weeks advance notice scheduled convenient to them and receive a listing of

client files 24 hours in advance.

Depending on funding type: payroll is verified, background checks of MHB funded individuals, and documentation

of any background check hits, which demonstrate that provider policies have been followed.

Every agency gets visited at least once a year, some agencies up to four times a year, if the agencies are newly

funded by the MHB or there have been compliance findings at previous audits.

Scott noted that he wanted Board members to be aware of MHB compliance standards.

All referenced contractual policies are included with the Contract each year.

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Scott noted that DASA is now known as Substance Use Prevention and Recovery (SUPR). The department’s

expectations are much more stringent including a new “stop payment,” if State contractual expectations are not met.

Expectations of the MHB are in alignment with industry standards.

C. Data Validation System Demo

Vickie Johansen, Contract and Grant Lifecycle Monitor attended the meeting to illustrate the system that inputs the

data. Terry explained the excel spreadsheet looks for billing overlap by client and by clinician. . The program also

identifies invalid codes, as well as valid modifier.

Client insurance benefits are documented in the audit process. There is a contractual expectation of coordination of

benefits.

Discussion of insurance, billing, Medicaid eligibility was held.

Scott has set up a follow up meeting with representatives of Illinois Association of Medicaid Health Plans (IAMHP) to

start a conversation between 708 Board and IAMHP. They were not aware that the State had 708 Boards.

A. Compliance Audit Updates

Terry reviewed audit reports completed with recommendations performed this quarter.

New Directions is still working on their financial policy and procedures; they did provide a plan of correction to the

MHB. The MHB will monitor the plan.

Rosecrance – releases with no recoupment attached. Only Grant and POP affected.

22nd Judicial – no findings.

NAMI – scope of work slightly above what they should be doing caused MHB to consider contractual partnerships for

licensed supervision. Other smaller agencies have the same issue.

Turning Point – PAIP documentation referenced non-billable services. A recommendation was provided to review

what the service was.

Thresholds – recoupment of one client’s services, due to a missing release.

Sheriff’s Dept. – no findings.

TLS – lengthy group time, peer support program without evidence of clinical supervision, signature of client to allow

review of files during audit. The New Horizons program records were pristine.

The need for additional training was discussed for Peer Specialists. Certified Recovery Support Specialist training is

more comprehensive than the VA training for Support Specialists.

D. Review and Recommendations for Provider Plan of Correction - FOR ACTION

Scott reviewed Pioneer Center (PC) issues. In December, with development of new contracts, special conditions were

developed for the FFS programs.

Section 7 of MHB Funding Agreement states that services are to be delivered in alignment with Administrative rules.

According to these rules, all clients must have an assessment and an individual service plan in their files. This

requirement was identified in December. In March it was again identified in PC’s first Compliance Audit of FY18–

multiple files were missing WON, assessments, and plans. Scott and Terry met with PC Staff who assured this would

not be a problem and the WONs would be in file by July 1 Audit.

Compliance Audit was again conducted in August, still PC had missing WONs, assessments and plans. The appropriate

leadership were included in the audit entrance and exit conferences.

Caitlin, Compliance Manager provided an August email with plan of correction admitting PC’s deficiencies and

outlining corrective steps to be put in place.

According to MHB this was receipt of plan. There is 45 days to reply.

Sam Tenuto has since asked to revise the plan and have a hearing before the Board to contest this issue.

Scott has contacted legal counsel who they have responded within 45 days. Dave said we should allow them the 45

days, Oct. 8 to revise response or request a hearing. This hearing would be a public meeting of the Board including legal

counsel from both sides. Sam’s defense is that MHB staff is stretched thin. At the end MHB must decide whether or not

to uphold its Policy.

Cathy noted that ignorance is not an excuse and she is tired of PC turning issues around to be someone else’s fault. She

does have think the MHB should wait until October 8 and should request the recoupment.

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MHB Policy stated the audit appeal process clearly. PC states that services were provided but not documented. Other

agencies doing the same work have complied with Administrative Rules and MHB contractual requirements for

documentation. Legal counsel suggests MHB let calendar run out by October 8.

Additionally during this issue, Pioneer Center asked that $30,000 be reallocated from unutilized contracts to another

program. Scott did not wish to consider this. The Committee concurred and felt that the Pioneer Center Board members

need to be approached and told of the situation.

Cathy noted concern that Pioneer Center has new programming that is making money in behavioral health

programming. They have a new program called TAMI and are also providing services to Garden Quarter. These

services are not funded by the MHB.

Discussion followed that MHB needs to uphold audit findings and recoup the dollars. If the MHB does not enforce this

it is not fair to other agencies. Sarah reminded the members of the recoupment from New Directions last year that was a

difficult decision on behalf of the Board but upheld the contractual requirements.

Per MHB policy, Pioneer Center needs to respond by Oct. 8. If they do not respond then recoupment is due.

V. OLD BUSINESS - FOR DISCUSSION / FOR RECOMMENDATION - None.

VI. NEW BUSINESS - FOR DISCUSSION / FOR RECOMMENDATION - None.

VII. PUBLIC COMMENT - none.

VIII. ADJOURN – Sarah Wilson motioned to adjourn. Seconded by Mike Baber. A VOICE VOTE WAS

TAKEN. All in favor. Motion passed. The meeting adjourned at 5:44 p.m.

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McHenry County Mental Health Board Network Fee for Service, Grant and Purchase of Position Outcomes Report

2019 Q1

Domain 1 - Increased Knowledge/Resiliency Q1

Total # of Active Participants receiving a service to increase knowledge/resiliency 8,162

Average % of Active Participants reporting increased knowledge/resiliency 86%

Domain 2 - Abstinence/Reduction in Use Q1

Total # of Active Participants receiving a service to refrain from or reduce alcohol/drug use 435

Average % of Active Participants refraining from alcohol/drug use 69%

Domain 3 - Increased Level of Functioning Q1

Total # of Active Participants receiving a service to increase level of functioning 4,326

Average % of Active Participants reporting an increased level of functioning 69%

Domain 4 - Employment & Education Q1

Total # of Active Participants receiving a service to increase employment or education 585

Average % of Active Participants engaged in employment employment services or education program 98%

Domain 5 - Housing Stability Q1

Total # of Active Participants receiving a service to increase housing stability 310

Average % of Active Participants reporting an increase in housing stability 80%

Comparison Data: Bureau of Labor definition of "Labor Force" includes employed/unemployed but seeking. National Outcome Measures (2017) SAMHSA Uniform Reporting (Employment Status) 44% in labor force

Measurement Tools**: Document Verification, Occupancy rates, lease agreements Evidence-based Practices**: Housing First, Permanent Supportive Housing, Supported Living Services include use of CBT and Motivational Interviewing

Comparison Data: National Outcome Measures (2017) SAMHSA Uniform Reporting (Living Situation) 82.7% Private Residence

Comparison Data: Relapse is common in addiction treatment, with relapse rates being between 40 and 60 percent (National Institute on Drug Abuse) This rate is very similar to rates of relapse with other chronic diseases like hypertension, asthma, or type I diabetes.

Measurement Tools**: C-GAS, Functional Assessment of Mental Health and Addiction (FAMHA), GADS-7, Ohio Scale, PHQ-9, DLA-20

Evidence-based Practices**: Assertive Community Treatment, Cognitive Behavior Therapy, Dialectical Behavioral Therapy, Expressive Therapy, Integrated Dual Diagnosis Treatment, Motivational Interviewing, SBIRT, Solution Focused Therapy, TREM, WRAP

Comparison Data: National Outcome Measures (2017) SAMHSA Uniform Reporting (Improved Functioning) Children Avg 74.9% Adult Avg 78.5%

Measurement Tools**: Self-Report, Document Verification

Evidence-based Practices**: CBT, Individual Placement & Support, Supported Employment, Health Matters Curriculum

Network Averages/Totals*

Measurement Tools**: Brief Resilience Scale (BRS), OPQOL-brief, CGAS, provider surveys

Evidence-based Practices**: Family to Family, Illness Management & Recovery, Incredible Years, Mental Health First Aid, Psych-Education Wellness Recovery Action Planning, Seeking Safety, TREM

Comparison Data: Seeking National data.

Measurement Tools**: Drug Screens, Breathalyzers, Lab TestsEvidence-based Practices**: Cognitive Behavior Therapy, Motivational Interviewing, 12 Step Facilitation, Matrix Model, SMART Recovery

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McHenry County Mental Health Board Network Fee for Service, Grant and Purchase of Position Outcomes Report

2019 Q1

Domain 6 - Criminal Justice Involvement Q1

Total # of Active Participants receiving a service to decrease criminal justice involvement 41

Average % of Active Participants reporting decreased criminal justice involvement 96%

Domain 7 - Social Connectedness Q1

Total # of Active Participants receiving a service to increase social connectedness 4,921

Average % of Active Participants reporting an increase in social connectedness 71%

Domain 9 - Consumer Satisfaction Survey (response required) Q1

Total # of Unduplicated Satisfaction Survey Responses during this reporting period 1,995

Average % of Satisfaction Rate 96%

Wait Lists Q1

Total # of Programs reporting a wait list 15

Total # of Individuals on wait lists 389

Average length of time (in days) from first contact to initial assessment/intake 23

** A representation of Provider reported Measurement Tools and Evidence-based Practices in use.

December 1, 2018 - February 28, 2019 = 8

A Way Out Program

December 1, 2018 - February 28, 2019 = 24 participants

First Responder Naloxone Program

December 1, 2018 - February 27, 2019 = 10 administrations / 8 survivals

McHenry County Overdose Deaths

January 1, 2019 - February 28, 2019 = 4

Comparison Data: NADCP Adult drug courts reduce recidivism by as much as 45%. 75% of drug court graduates remain arrest free. National Outcome Measures (2017) SAMHSA Uniform Reporting (Adult Criminal Justice Contacts (3.9%)

Measurement Tools**: Social Connectedness Scale, OPQOL-brief, Social Isolation Scale, Individual Plan Update

Evidence-based Practices**: ACT, CBT, Family to Family, Incredible Years, Motivational Interviewing, PEARLS, TREM Comparison Data: National Outcome Measures (2017) SAMHSA Uniform Reporting (Improved Social Conectedness) Children Avg 87.2% Adult Avg 78.8%

Comparison Data: National Outcome Measures (2017) SAMHSA Uniform Reporting (General Satisfaction of Care) 90%

McHenry County Suicide Deaths

25 Agencies receive FY19 Fee for Service, Purchase of Position and Grant funding 62 Programs receive FY19 Fee for Service, Purchase of Positions and Grant funding

* May include duplication of persons served.

Measurement Tools**: Clerk of the Circuit Court - Public Case Access, McHenry County Specialty Courts Information System

Evidence-based Practices**: Moral Reconation Therapy, Trauma Focused Moral Reconation Therapy,

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McHenry County Mental Health BoardNetwork Outcomes

2019 Q1

8,162

435

4,326

585

310

41

4,921

1,995

7,042  (86%)

300  (69%)

2,971  (69%)

574  (98%)

247  (80%)

39  (96%)

3,506  (71%)

96% Satisfaction Rate

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000

Domain 1: Increased Knowledge/Resiliency

Domain 2: Abstinence/Reduction in Use

Domain 3: Increased Level of Functioning

Domain 4: Employment & Education

Domain 5: Housing Stability

Domain 6: Criminal Justice Involvement

Domain 7: Social Connectedness

Domain 9: Consumer Satisfaction Survey

Active Participants Receiving Services & Percentage Reporting Improvement

Total Receiving Services Percentage Reporting Improvement

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McHenry County Mental Health Board FY 2019 Network Outcomes Report

Quarter 1

1,442 

1,167 

4,234 

6,843 

5,450 

5,057 

3,283 

800 

1,420 

5,503 

2,698 

2,519 

 ‐  2,000  4,000  6,000  8,000  10,000  12,000  14,000

Age 0 ‐ 16

Age 17‐24

Age 25+

YEAR TO DATE TOTAL

Females

Males

Domain 8 ‐ Access/Capacity*

12/1/2018 1st Quarter*May include duplication of persons served

= 5,654

= 1,967

= 12,346

= 8,148

= 7,576

= 4,725

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McHenry County Mental Health BoardNetwork Pay-for-Performance Outcomes

2019 Q1

Q1 Q2 Q3 Q4 To Date

Network Capacity

Average prescriber capacity (hours) 196 0 0 0 196

Total prescriber capacity (hours) 1960 0 0 0 1960

Network Utilization

Average prescriber utilization (hours) 150 0 0 0 150

Total prescriber utilization (hours) 1503 0 0 0 1503

Network No Show Rate

Average no show rate 15% 0% 0% 0% 15%

Network Productivity Rate

Average productivity 77% 0% 0% 0% 77%

Network Wait Time

Average wait time (days) 19 0 0 0 19

Clients Served

Total active clients on Dec. 1, 2018 2392 2392

Total new clients served 389 0 0 0 389

Total clients served 2781 0 0 0 2781

Total discharges (293) 0 0 0 (293)

Cost Per Client

Average cost per client $169.61 $0.00 $0.00 $0.00 $169.61

Cost Per Hour of Service

Average cost per hour of service $433.79 $0.00 $0.00 $0.00 $433.79

Level of Functioning

Average level of functioning improvement 58% 0% 0% 0% 58%

Client Reported Hospitalization

Average client reported hospitalization 4% 0% 0% 0% 4%

Client Reported Crisis

Average client reported crisis 1% 0% 0% 0% 1%

Client Satisfaction

Average client satisfaction 94% 0% 0% 0% 94%

Total client satisfaction surveys received 1195 0 0 0 1195

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Quality Management Team

Communication, Education, and Training on Compliance Issues

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The Framework of Effective Compliance Programs

1. Standards, Policies, and Procedures

2. Compliance Program Administration

3. Screening and Evaluation of Employees, Physicians, Vendors, and other Agents

4. Communication, Education, and Training on Compliance Issues

5. Monitoring, Auditing, and Internal Reporting Systems

6. Discipline for Non‐Compliance

7. Investigations and Remedial Measures

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Initiating Compliance Training Plans

• Define and prioritize high risk areas and the audience(s) needing training

• Process for communicating and training for new laws, regulations, policies and procedures

• Create compliance training around “job families” – group together to address similar risk

• Evaluate occurrences, critical and sentinel events for compliance and policy failures

• Track disclosures through hotline calls, complaints and direct contact

• New employee, board and vendor onboarding processes and training

• Require individuals to keep up with CEUs (licenses and certifications) as a condition of employment

• Maintain documentation of all education provided

• Review and update the compliance training plan at least annually

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• Cost effective

• Methodology – online, written, in-person, small or large group

• Record keeping – training handouts, presentations, pre- and post tests, certificates, personnel records

• Accessibility – physical location, Internet connection, language, vision, hearing, reading level, and other disabilities that may affect training

• Employee perception of compliance training usefulness, sufficiency, and pertinence to job duties

• Ongoing feedback of training needs from staff, board, volunteers, and vendors – surveys, suggestion boxes

• Policies regarding frequency

Logistics of Training

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Accountability

• Review job descriptions for compliance metrics

• Compliance tied to performance evaluations, merits and incentives

• Standards of conduct

• Sanctions for employees not completing required compliance training according to established guidelines

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Board Concerns – Compliance Training Recommendations

• Established, specific compliance competencies for Board members and governing committees

• Formal orientation for board members – obligations and responsibilities, core competencies

• Receive regular compliance program updates

• Organization requires compliance representatives to be present at every senior management and governance-level meeting

• Provide HR, management, and board with training to recognize compliance risk associated with employee misconduct

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Competencies of Compliance Staff

• Defined criteria, certifications, specific skills and expertise

• Continuing education to maintain/increase professional competence

• Specific training in evaluating and investigating issues

• Ability to distill complex laws and regulations into a format that employees can understand

• Communicate compliance information throughout the organization –legitimacy, credibility, and confidence in compliance staff

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