bh final report - beacon health options

Behavioral Health Quality Review

Final Assessment Report

The Potter's House Family & Children Treatment Center, LLC

GAC000586

The ASO Collaborative in partnership with the Department of Behavioral Health and Developmental Disabilities

(DBHDD) believes in easy access to high-quality care that leads to a life of recovery and independence for the people

e se e. The Qualit Di isio is dedi ated to e su i g se i es p o ided a e pe so - e te ed a d i lude a commitment to wellness and recovery.

Location of Review: 2300 W. Park Place Blvd, Stone Mountain, GA 30087

Names of Quality Assessors: Kelly Brown, LCSW; Michelle McIntosh, LPC, NCC; Natalee Fritsch, LPC; Amanda Hawes,

LCSW; Dorian Milam, RN; Helen Rohrich, RN

Individuals Interviewed: 4 Staff Interviewed: 5

Records Reviewed: 30 Date Range of Review: 1/30/2019 - 2/1/2019

Individual Interviews Conducted: 4

The Individual Interview is not calculated into the overall score.

Whole

Health

100%

Safety

100%

Rights

100%

Focused

Outcome

Areas

100% Person

Centered

Practices

100%

Choice

100%

Community

100%

Staff Interviews Conducted: 5

The Staff Interview is not calculated into the overall score.

Whole

Health

100%

Safety

100%

Rights

100%

Focused

Outcome

Areas

100% Person

Centered

Practices

100%

Choice

100%

Community

100%

The Georgia Collaborative ASO / Beacon Health OptionsFor information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Review ID: 8522 of 12

http://www.georgiacollaborative.com/

Individual Interview:

• All four individuals/guardians reported they were aware of his or her diagnosis, felt safe when receiving services

at The Potter's House, knew who to contact with safety concerns, and felt that they were treated with respect

by all staff members.

• The following were comments made by individuals/guardians:

◦ "My granddaughter set her own goals with the assistance of staff members."

◦ "The after-school program has been a big help to us, my grandkids love it."

◦ "Staff have been great, they really have helped me out a lot here. I don’t know what I would do without

them."

◦ "Staff are very responsive and accessible, I really recommend The Potter's House."

◦ "My son loves The Potter's House, especially the after-school activities."

Staff Interview:

• All five staff members reported they were aware of what each individual needed to feel safe, were aware of the

individual's right to refuse treatment, services or supports without retaliation, were knowledgeable of The

Potter's House's complaint and grievance policy, were able to describe each individual's strengths, and had been

educated on how to assist individuals in accessing community resources.

• The following were comments made by staff members:

◦ "I enjoy interacting with the individuals as well as families; they really seem to appreciate our work."

◦ "We have an after-school program that individuals can attend. We pick them up from school and it gives

us extra time to meet with individuals."

◦ "I love seeing the progress that my individuals make in treatment."

◦ "I helped schedule a ride-along for one of my individuals who is interested in becoming a police officer."

◦ "I lo e the fa il at osphe e e ha e he e a d I thi k the i di iduals e jo it also." ◦ "I like that we can provide many resources in one location, it makes it easy for the individuals to access

care."




Billing

Validation

99%

Focused

Outcome Areas

91%

Overall

Score 92%

Compliance w/

Service

Guidelines

94%

Assessment

&

Planning

82%

The overall score is calculated by averaging the four areas: Billing Validation, Focused Outcome Areas, Assessment and

Pla i g, Co plia e ith Se i e Guideli es. Ea h a ea a ou ts fo t e t -fi e pe e t % of the o e all s o e. Re ie questions are based on DBHDD Provider Manual and Medicaid Requirements.

The Potter's House Family & Children Treatment Center, LLC

Overall

Score

Billing

Validation

Focused

Outcome Areas

Assessment

& Planning

Service

Guidelines

Review Date: 02/26/2018 95% 96% 99% 91% 95%

Review Date: 03/30/2017 92% 86% 97% 97% 96%

FY18 Statewide Average 88% 85% 92% 84% 90%




The Billi g Validatio S o e is the pe e tage of justified illed u its s. paid/ illed u its fo the e ie ed lai s. Paid dolla s a e al ulated ased o pa e : Medicaid is the sum of paid claims; State Funded Services are Fee for Service and State Funded Encounters combined (State Funded Encounters is the estimated

sum of the value of accepted encounters).

Standard Reason # of Discrepancies

Performance StandardsContent does not support code billed 1

Content of documentation is not unique 1

Quantitative Standards Progress note is missing 2

Billing Validation: 99%

Strengths and Improvements:

The following are improvements since the previous Behavioral Health Quality Review (BHQR) 2-2018:

• All progress notes matched the service definition for the services billed.

• The date of entry was present on all progress notes.

• Signatures of staff members providing services were documented on all progress notes reviewed.

Medicaid Total

Justified $28,213.76 $28,213.76

Unjustified $198.77 $198.77

Total $28,412.53 $28,412.53

Billing Validation




Opportunities for Improvement:

Performance Standards

• The content did not support the code billed for one progress note. The progress note documented that the individual was

not present in session, but the billing code used was H0004HRU4U7. The "HS" modifier should have been used instead. This

was an issue identified during the last two BHQRs 2-2018 and 3-2017.

• The content of one Diagnostic Assessment was not unique to the individual. The Diagnostic Assessment was a duplicate to

the Behavioral Health Assessment (BHA) completed one day prior by the same staff. This is an issue that was also identified

during the last BHQR 3-2017.

Quantitative Standards

• Two progress notes were missing. The progress notes for Nursing Assessment and Health Services dated 11/5/18 and

11/10/18 referenced "see assessment" as the intervention but there was no supporting documentation filed in either

record to indicate the assessments had been completed. The provider stated these had not yet been filed in the records

and presented them to Assessors outside of the required time-frame (on day 2), therefore they were not accepted.




Assessment & Planning: 82%


• All individuals had a verified diagnosis that was updated annually, when applicable. This is an improvement since the last

BHQR 2-2018.

• Whole health and wellness goals, objectives, and/or interventions were present in 90% of Individual Resiliency Plans

IRPs . This is a i p o e e t si e the last BHQR - i hi h o l % of e o ds et this e ui e e t.


• Needs that were assessed, such as trauma, family relationship issues, educational issues, independent living skills, spiritual

needs, stealing, aggression, nightmares, and substance abuse were not addressed in 16 of 30 IRPs.

• Co-occurring health conditions such as Reactive Attachment Disorder (RAD), eczema, asthma, sleep apnea, autism and

other Intellectual Developmental Disabilities (IDD) were not addressed in nine of 17 applicable IRPs.

• Nineteen of the 30 IRPs did not include the required discharge criteria. None of these plans had a specific step-down

service. This was an issue that was also identified during the last BHQR 2-2018. For example:

◦ "Extracurricular activities" and "community-based program that will foster social skills" were listed but are non-

spe ifi . ◦ Other anticipated step-down services listed services that the individual was already receiving without any change

in frequency (e.g. Family Counseling, Medication Management, Community Support, and Individual Counseling).

When all responses to a question are Not Applicable , no percentage is displayed.




Whole

Health

83%

Safety

83%

Person

Centered

Practices

92%

Community

96%

Choice

96%

Rights

91%

Focused

Outcome

Areas

91%

Focused Outcome Areas

Focused Outcome Areas: 91%


Safety

• All Individuals/guardians and prescriber had signed consent as having been educated on the risks and benefits of all

medications prescribed.

Person-Centered

• Documentation indicated that all individuals received individualized services and that they were active participants (had a

voice) in the planning, receiving, and when applicable, the modification of services.

Community Life

• Documentation supported all individuals were assessed for any need to make a "stay or go" decision in their living,

learning, working, and/or social environments.





Whole Health

• Eight of 25 applicable records did not contain documentation of communication with external referral sources and

providers to obtain results of testing, treatment, and follow-up. Fo e a ple, a e o ds la ked eleases of i fo atio (ROIs) for primary care physicians and schools, even though youth were often seen by staff in the school setting. One

individual was recommended for a sleep study but documentation did not evidence a referral had been made.

Safety

Nine of 28 applicable records did not evidence that a Safety/Crisis plan was developed, as needed, that directs, in advance, the

individual's desires/wishes/plans/objectives in the event of a crisis.

• Although safety plan templates were present and signed, the content of the document resembled an IRP. For example, for

an individual with depression the following was listed:

◦ "Coping Skills: [Ind] will learn to verbalize his feelings/thoughts. Engage in positive self-talk. Focus on the good

memories of the deceased relative.

◦ "Action Plan: [Ind] will implement coping skills."

◦ One individual's safety plan only acknowledged one symptom and stated the following:

▪ "Dep essio : Histo : He othe e do ses the s/ s of dep essio aloof , a ge , i ita ilit , f ust atio , poor concentration etc.)

T igge s: the atu e of the d a d she feels a he i al i ala eCopi g Skills: ot u e tl o edi atio ut eed to eesta lish he edi atio egi e A tio Pla : eesta lish he edi atio egi e a d to to tea h opi g skills to a age life's isis."

◦ Additionally safety plans did not incorporate additional community resources in addition to the provider's after-

hours contact information.

Rights

• Four records lacked evidence that the individual/guardian has signed formal acknowledgement of rights and

responsibilities at the onset of services, supports, and treatment.

Person-Centered

• Eight of 12 applicable records lacked evidence that the IRP was reassessed based upon any changing needs, circumstances

and/or response by the individual. Some individuals presented with new symptoms such as suicidal ideation, stealing,

trauma, and substance abuse that were not updated on the IRP. Another individual lost a family member, but grief was not

added to the IRP.

Community Life

• One of two applicable records did not contain evidence that informed choice drove the selection of housing options. One

i di idual had a desi e to li e i depe de tl , ut the e as o e ide e that this desi e as add essed o the IRP.




Compliance With Service Guidelines: 94%


• Psychiatric Treatment scored 100% in Compliance with Service Guidelines. This is an ongoing strength for the provider.

• All Ps hoso ial Reha ilitatio -I di idual PSR-I p og ess otes do u e ted staff i te e tio s that suppo ted the individual was trained in specific skills in the areas of self-management and crisis prevention; interpersonal, community

coping, and functional skills relevant to living, education, working, or socializing; minimizing the effects and impact of

symptoms of illness; reducing life stresses, and; gaining access to needed community supports and services


Case Management

• One of three records did not contain documentation that reflected referral and linkage to services and resources

identified on the IRP including housing, social supports, family/natural supports, and entitlements. (1 x authorization). In

this e o d, staff e ou aged the i di idual to esea h p og a s ut did ot p o ide a efe als to the i di idual. • One of three records did not contain evidence of joint development of a crisis plan to include both the provider and

individual with the provider listed as primarily responsible. There were no individualized triggers or plans on the safety

plan template. This was an issue identified during the last BHQR, 2-2018.

• One of three records lacked the required twice a month contacts. The individual had only one Case Management contact

i O to e ith o do u e tatio to e plai the issi g o ta t. This as also a issue ide tified du i g the last BHQR, 2-2018.

Community Support

The following issues were also identified during the last BHQR, 2-2018:

• Seven of 20 records lacked the required twice a month contacts. For example, one individual's services stopped on

11/29/2018 with no further explanation. Another individual had no contacts in August 2018, one in September 2018, and

o e i O to e . • Ten of 18 applicable records lacked evidence of service and resource coordination. Many of the individuals were seen in

the school setting and had educational issues, but there was no documentation that staff coordinated services with the

s hool o p o ided additio al esou es.




Additional strengths and concerns beyond the general scope of the review

were discovered by reviewers. Additional issues/practice concerns may have

the potential to impact service delivery, quality of care, or may represent a

risk to the provider. Additional Comments on

Practices


• Interviews with individuals being served indicated satisfaction with supports and services as well as after-school activities

that are provided by the agency.

• Some records indicated that staff provided teacher's with the Vanderbilt Attention Deficit Hyperactivity Disorder (ADHD)

s ale to help ide tif ho the diag osis a ifests i the lass oo setti g.


• As stated in the Billing Section, the content of Diagnostic Assessments was often not unique to the individual. The

Diagnostic Assessment was a duplicate to the Behavioral Health Assessment (BHA) completed one day prior by the same

staff in multiple records. These were outside of the billing sample, therefore they did not result in billing discrepancies.

• High utilization of services without clinical rationale is a recurring issue for this provider among multiple reviews as records

continue to evidence high frequency of sessions and/or sessions back-to-back of each other, without clear clinical

justification. Examples include:

◦ Family Counseling and Family Training routinely billed for one hour each and sessions occur consecutively with no

breaks.

◦ BHAs and IRPs were routinely billed for two hours each regardless of age, behaviors or symptoms.

◦ Progress notes documented Individual Counseling and Community Support being provided back to back within the

school setting with limited information surrounding behaviors and symptoms to warrant the lengthy sessions within

the academic setting.

◦ A sibling set received a Behavioral Health Assessment, Service Plan Development, and Nursing Assessment each on

11/23/18. The family was at the agency from 8:00 am until 4:30 pm with three minutes in between each service

p o ided. ◦ Several children's records with an ADHD diagnosis routinely documented Individual Counseling sessions for one hour

in addition to providing a Community Support session for another 45-minutes directly after the Individual

Cou seli g sessio o the sa e date of se i e. • Documentation routinely referred to individual's by the incorrect name and/or pronoun.

• In one record, the date of signature of the legal documents was noted with white-out for the day and year (6/6/18) and did

not contain the guardian's original signature. According to the DBHDD Provider Manual, "Any corrections or alterations

made to existing documentation must be clearly visible. No white-out or unreadable cross-outs are allowed. A single line is

used to strike an entry and that strike must be labeled with error , initialed, and dated."

• The organizational chart indicated the clinical team is comprised of up to 22 Supervisee Trainee's and two licensed clinicians

(LPC, APC).

• Order/recommendations for services must list the name of the service as listed in the DBHDD Provider Manual. Specifically,

"Nursing Assessment and Health Services."

• Ensure paper records and the Electronic Medical Record (EMR) system contain identified individual's documentation only.

Examples included:

◦ One individual's medication consent form was located in another individual's paper chart.

◦ In the EMR, Document Management tab, another individual's medication consent form was uploaded into the

incorrect individual's electronic chart.




Quality Improvement

Recommendations

Providers are reminded of the responsibility to maintain internal processes which

ensure immediate and permanent corrective actions on issues identified during the

quality review process. DBHDD may request corrective action plans (CAPs) as

quality review findings warrant as well as review agencies’ internal documentation

regarding corrective actions and ongoing quality assurance and quality

improvement. Please refer to the comments documented in each section above for

specific information pertaining to the recommendations below.

The following are recommendations given as a result of the review:

Billing Validation - Quantitative

• Ensure documentation supports what is billed (see comments in Billing Validation section).

Billing Validation - Performance Standards

• Ensure codes billed are consistent with the type of contact and content of the documentation.

• Ensure content of documentation is unique to the individual and/or session.

Assessment and Planning

• Ensure treatment/recovery/service plans address all areas of assessed need.

• Ensure treatment/recovery/service plans address co-occurring issues and/conditions.

• Ensure transition/discharge plans include clear, relevant, achievable, and individualized clinical benchmarks.

Focused Outcome Areas - Whole Health

• Ensure there is documented communication with external referrals and resources to determine the results of testing,

treatment, and referral.

Focused Outcome Areas - Safety

• Ensure that individuals have individualized safety/crisis plans (as needed).

Focused Outcome Areas - Person Centered

• Ensure individuals served are assessed and re-assessed for changing needs and circumstances and updated plans are

reflective of current assessments.

Compliance With Service Guidelines - All

• Ensure individuals are referred/linked to community resources that meet their unique needs.

• Ensure the minimum face-to-face contacts are made as required for each service.

Compliance With Service Guidelines - Case Management

• Ensure the minimum monthly contacts are made with individuals served.

• Ensure the minimum face-to-face contacts are made as required for each service.

• Ensure Case Management services include referral and linkage to services identified in the individual

treatment/recovery/service plan.




Overall Programmatic (Non-Scored)Provider-Level Indicators

1 Where applicable, all services are provided at approved Medicaid sites. Yes

2 On-site nurse is present 10 hours/week. Yes

3 Staff safety and protection policies/procedures are present. Yes

The Programmatic standards below, relevant to services reviewed during this BHQR, are not calculated into any scored area of

this review at this time; however, they are assessed, reported, and may become scored items in the future. The provider should

note any negatively-scored item or area as an opportunity for quality improvement activities and take steps to ensure adherence

to the Service Definitions in the DBHDD Provider Manual.

# Yes # No # N/A SCORE*

3 0 0 100%

* Overall Programmatic Score is not calculated into the Overall Score at this time




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