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DM & ADR, Inc.

Behavioral Health Quality Review Final Assessment

Address: Remote Quality Review - 1710 Commerce Road, Athens, Georgia, 30607

Assessors: Faith M Simpson, LPC, CADCII, MATS; Jerald Carter, MPA; John Dury, LPC, LMFT, MAC; Mary Malaguti, RN

Records Reviewed: 10

Date Range of Review: 4/18/2022 - 4/20/2022

The Georgia Collaborative ASO, in partnership with the Department of Behavioral Health and Developmental Disabilities (DBHDD), believes in accessible, high-quality care that leads to a life of recovery and independence. The provider should note any recommendations as an opportunity for quality improvement activities. The review is intended to measure the quality of your organization's systems and practices in adherence to DBHDD policies and standards. The Overall Score is calculated by averaging the categories below.

Billing Validation

91%

Service Guidelines

100%

Overall Score 96%

Focused Outcome

Areas 95%

Assessment &

Planning 97%

Review Date: 05/17/2021 Review Date: 08/06/2019 FY21 Statewide Average

Overall Score

93% 58% 85%

Billing Validation

85% 8% 70%

Focused Outcome

Areas 95%

86%

92%

Assessment Service & Planning Guidelines

91% 74% 88%

100% 65% 91%

Note: The FY21 Statewide Averages represent the mean of scores of all reviewed providers. Due to the COVID-19 pandemic, several reviews were postponed or conducted remotely (rather than on site). Additionally, reviews conducted in FY20 (July 1, 2019 to June 30, 2020), may have had points removed from the Overall Score due to identified Quality Risk Items; therefore, caution should be taken when comparing scores across fiscal years.

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 1 of 8

Summary of Significant Review Findings

Strengths and Improvements:

Due to the COVID-19 pandemic, this review was conducted remotely instead of on-site.

? The following is a continued strength of the provider from the previous Behavioral Health Quality Review (BHQR) in May 2021: The provider continued to score 90% or higher in the areas of Assessment and Planning, Focused Outcome Areas, and Service Guidelines.

? Documentation supported that individuals were given overdose kits at intake. ? All of the individuals were assessed for risk of suicide utilizing the Tool for Assessing Suicide Risk (TASR).

Furthermore, suicidality was included on the IRP to be addressed, when applicable. ? All of the records included documentation that the individual denied the existence of an advanced directive or

declined to have one included in their medical record. This is an improvement from the previous review, 5-2021 in which none of the ten records contained such documentation. ? The two personnel records reviewed for staff credentialing met all requirements.

Opportunities for Improvement: ? The following were cited in Billing Validation: There was a gap in which there was no order for services (OFS) in one record. Five claims were unjustified. Two progress notes were missing. Two progress notes were not filed within seven calendar days. ? Consent for medication was imbedded within a consent to treat form instead of being it's own distinct form of consent; this resulted in nine records being scored "No" for this requirement. Please refer to FOAs for details. Please refer to FOAs for details.

Billing Validation

Justified Unjustified Total

Medicaid $1,732.43 $173.03 $1,905.46

Total $1,732.43

$173.03 $1,905.46

The Billing Validation Score is the percentage of justified billed units vs. paid/billed units for the reviewed claims. Paid dollars are calculated based on payer: 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 Eligibility Standards

Quantitative Standards

Reason Missing/incomplete service order Progress note is missing Progress note not filed within seven calendar days

# of Discrepancies 5 2 2

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 2 of 8

Billing Validation: 91%

Strengths and Improvements:

? All of the individuals had a current, verified diagnosis by an appropriately credentialed practitioner. This is an improvement from the previous review.

? The billing code billed was the billing code documented on the progress notes reviewed. This is also an improvement from the previous review,

? The following are continued strengths of the provider from the previous review, 5-2021: Documented interventions were related to the IRP. Examples included services such as Opioid Maintenance and Individual Counseling being documented on the IRP.

Opportunities for Improvement:

Eligibility Standards:

? The physician signed an OFS for Opioid Maintenance (H0020) on 02/15/2022; however, services were billed on the following dates prior to the order being signed in one record (01/28/2022, 02/02/2022, 02/04/2022, 02/05/2022, and 02/11/2022).

Quantitative Standards:

? There was no documentation to support two billed claims for dosing (H0020). ? Two progress notes were not signed/filed within seven calendar days. Examples included,

The date of service documented on an individual counseling progress note was 02/08/2022; however, the note was signed/filed on 02/17/2022.

A dosing (H0020) note was signed over 30-days after the date of service. The date of service was documented on 01/06/2022; however, the progress note was signed on 02/14/2022.

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

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 3 of 8

Assessment & Planning: 97%

Strengths and Improvements:

? All of the individuals were assessed for risk of suicide utilizing the Tool for Assessing Suicide Risk (TASR). Furthermore, suicidality was included on the IRP to be addressed, when applicable.

? The provider completed a separate strengths, needs, abilities, and preferences (SNAPs) assessment with the individual.

? All assessed needs were included on IPRs to be addressed or deferred, if applicable. ? Individualized Recovery Plans (IRPs) documented whole health and wellness goals, objectives, and

interventions. For example, "Pt. will eat a balanced diet." "[Patient] will exercise 3-4 times per week for approximately 30 minutes."

Opportunities for Improvement:

? Two transition/discharge plans did not list all required content. One transition/discharge plan contained an expired discharge date and the other plan did not have a discharge date documented; this is a recurring issue identified during the prior review.

Focused Outcome Areas

Rights 100%

Choice 100%

Whole Health

96%

Safety 59%

Focused Outcome

Areas 95%

Community 100%

Person Centered Practices

97%

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 4 of 8

Focused Outcome Areas: 95%

Strengths and Improvements:

? All of the records included documentation that the individual denied the existence of an advanced directive or declined to have one included in their medical record. This is an improvement from the previous review, 5-2021 in which none of the ten records contained such documentation.

? There was evidence of ongoing assessment to determine external referrals for health services, supports, and treatment when not available within the organization. For example, staff documented referring an individual to their primary care physician (PCP) to address their chronic back pain and fibromyalgia.

? All of the records contained a safety/crisis plan. This is a continued strength of the provider from the previous review, 5-2021.

? All of the records contained a consent for telehealth.

Opportunities for Improvement:

Safety:

? Nine of ten records contained a packet in which consent for medication was imbedded along with consent for treatment. The provider is required to have a stand-alone medication consent form that includes the specific medication prescribed to the individual and documents the risks and benefits of the medication and that education was provided. This is a separate document from consent to treatment. This is a recurring issue identified in the prior review. One record did contain a medication consent form that documented all required content and reflected medication was the only item that was explained and consented to; this was scored "yes."

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 5 of 8

Service Guidelines: 100%

Strengths and Improvements:

? The provider scored 100% in this area during this review. This is a continued strength of the provider from the previous review, 5-2021.

? Nursing Assessments in all records included assessing and monitoring individuals' responses to medication(s), determining the need for a medication review, and the individual's medical and health issues. This is also a continued strength of the provider.

? For Medication Assisted Treatment (MAT), there was documentation of individuals participating in one or more services such as Individual and Family Counseling.

? Services were provided by appropriately credentialed practitioners. ? There was evidence of random urine drug screens (UDS) conducted by staff. Furthermore, staff discussed the

results and the individual's progress during sessions.

Overall Programmatic

The Programmatic standards below, relevant to services reviewed during this BHQR, are not currently calculated into any scored area of the review; however, Quality Improvement Recommendations are made based on findings.

Provider-Level Indicators

1

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

2

On-site nurse is present 10 hours/week.

3

Staff safety and protection policies/procedures are present.

4

Quality Assurance Plan includes assuring/monitoring quality of services for individuals at risk for suicide.

5

The provider employs an ASL-fluent practitioner.

6

The provider has policies and procedures for providing reasonable accommodations to individuals who are deaf/hard of hearing.

# Yes

# No

# N/A

4

0

2

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

Yes N/A Yes Yes

N/A Yes

SCORE* 100%

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 6 of 8

Additional Comments on Practices

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.

? All documentation must be submitted within timeframes outlined in the Georgia Collaborative ASO Provider Handbook; an order for services was submitted on day three of the review, therefore not reviewed.

? Order for services must list "Medication Assisted Treatment" in addition to each service i.e., individual counseling, opioid maintenance, and behavioral health assessment, etc.

? "Annual Examination Forms" were signed more than seven days from services rendered; these were outside of the billing sample. For example, one note reflected a date of service of 1/24/22 but was not signed by the nurse practitioner until 2/25/22.

? Some documentation contained the signature of both the nurse practitioner and physician on one signature line and the printed name of only one of the practitioners.

? Some hand-written annual examinations and physician progress notes were illegible. ? A virtual tour of the clinic was conducted, and the following was noted:

the lobby was clean and organized. the clinic has three dosing windows (currently utilizing two dosing windows). the dosing procedures ensured privacy and confidentiality of individuals. security cameras were located in the pharmacy and nursing station. medications were stored in three safes behind locked doors. group offerings were listed on a board in the lobby that covered topics such as Human Immunodeficiency

Virus (HIV) education, Coping with Pain, and Detox Aftercare.

Individual Interviews

Individual Interviews Conducted: 2

? Two individuals were interviewed during this review and the following comments were made: "(My counselor) is easy to talk to and she gives me resources when I need them. She has helped me a lot." Yes, I am very satisfied, with the services. My counselor has been helping me with grief after I lost my husband." "The doctor listens to me."

? When asked "What about this agency make you keep coming?" Interviewees shared, "They have great personalities, they make you feel welcome, they never treat you like a number and they are very helpful." "The way they treat you. They don't treat you like a number, they treat you like you are somebody. They are excellent people. I love them."

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

Page 7 of 8

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.

Recommendations: Current and Prior Review Billing Validation - Eligibility

? Ensure documentation supports that all Eligibility Standards are met. Billing Validation - Quantitative

? Ensure all Quantitative Standards are met in documentation. Assessment and Planning

? Ensure transition/discharge plans define criteria for discharge, planned discharge date, and specific services. Focused Outcome Areas - Safety

? Ensure that individuals (or parent/guardian) have been educated on the risks and benefits of all prescribed medications.

Review ID: 12103

The Georgia Collaborative ASO / Beacon Health Options

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