Crossroads Treatment Center of NW GA, PC

[Pages:10]GAC000788

Crossroads Treatment Center of NW GA, PC

Behavioral Health Quality Review Final Assessment

Address: Remote Quality Review - 4083 Cloud Springs Road, Ringgold, GA 30736

Assessors: Faith M Simpson, LPC, CADCII, MATS; Jennifer Byrd, LPC, CPCS; Jerald Carter, MPA

Records Reviewed: 10

Date Range of Review: 6/14/2021 - 6/17/2021

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

40%

Service Guidelines

95%

Overall Score 83%

Focused Outcome

Areas 99%

Assessment &

Planning 97%

Review Date: 07/23/2019 Review Date: 01/09/2018 FY20 Statewide Average

Overall Score

87% 89% 84%*

Billing Validation

73% 100% 76%

Focused Outcome

Areas 99%

93%

93%

Assessment Service & Planning Guidelines

91% 68% 88%

86% 95% 90%

*For reviews conducted July 1, 2019 through June 30, 2020, Quality Risk Items (where identified) were deducted from the Overall Score. Additionally, in response to the COVID-19 pandemic, Quality Reviews were postponed between March 16 through June 30, 2020. Therefore, caution should be made when comparing scores to this time period.

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 1 of 10

Summary of Significant Review Findings

Strengths and Improvements:

Due to COVID-19, this Behavioral Health Quality Review (BHQR) was conducted virtually versus on-site.

? The provider has implemented policies and procedures to ensure the safety of the staff and individuals during the global pandemic.

? The provider continues to provide a detailed handbook, "Path to Recovery," which clearly explains MedicationAssisted Treatment (MAT).

? Records contain a "Social Media Policy Acknowledgement" that outlines the use of social media platforms such as Facebook, Twitter, and Instagram. The policy details guidelines staff will follow to ensure privacy and confidentially of individuals served in relation to how conversation and communication is open to others on the public forums.

? "Consent for Verification of Non-Multiple Enrollment" forms were filed in the records. This form is reviewed and signed with individuals to help prevent individuals from being enrolled in more than one opioid treatment program at a time.

? Documentation within records includes, "Exception Request and Record of Justification Under 42 CFR" and "Phase Up Request Form"; these forms support the need for a change in phase or dosage and protocol for take-home doses related to change in attendance status.

? A staff credentialing review was conducted of two staff members, and all staff possessed a current certification and/or licensure.

? The provider's scored 90% or above in the area of Assessment & Planning and Focused Outcome Areas (FOAs). This is continued strength of the provider from the previous review, 7/2019.

? The provider's score in the area of Service Guidelines improved from 86% from the previous review, 7/2019 to 95% this review.

Opportunities for Improvement: ? Documentation did not list billing codes; Assessors utilized "Billing Claims Reports" generated from the Electronic Medical Record (EMR) to cross reference billing codes.

Please refer to Billing Validation for specific details regarding the following:

? Forty-eight (48) nursing progress notes were missing. ? Nine (9) nursing progress notes did not match service definition and did not include time in and out.

Please refer to Assessment & Planning for specific details regarding the following:

? Two applicable Individual Recovery Plans (IRPs) did not address suicidality.

Please refer to Focused Outcome Areas (FOAs) for specific details regarding the following:

? In the area of Safety, two of the applicable records did not contain evidence of a safety/crisis plan when the individual was identified at risk for suicide. In addition, there was no evidence of ongoing assessment in one applicable record.

Please refer to Service Guidelines for specific details regarding the following:

Medication Assisted Treatment:

? Nursing assessments in eight records lacked detailed documentation that included providing education to the individual and the family/ significant other(s) regarding nutritional, medical and other health issues, and side effects of medications; majority of nursing interventions were dosing only.

Nursing and Health Assessment Services:

? Nursing assessments in seven records lacked detailed documentation that supported education related to identified health issues including (but not limited to) medication, nutrition, and infectious disease assessment, testing, and referral. Generally, nursing notes primarily documented dosing information only.

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 2 of 10

Billing Validation

Justified Unjustified Total

Medicaid $1,053.48 $1,562.25 $2,615.73

Total $1,053.48 $1,562.25 $2,615.73

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 Performance Standards

Quantitative Standards

Reason Content of note does not match service definition Multiple services billed at same time Progress note is missing Time in/Time out missing Progress note not filed within seven calendar days Staff credential missing

# of Discrepancies 9 1 48 9 2 2

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 3 of 10

Billing Validation: 40%

Strengths and Improvements:

? All of the individuals met admission criteria for the service provided. This is a continued strength of the provider from the previous reviews (01/2018 and 07/2019).

? Services were included on IRPs; therefore, there was clinical justification for the interventions documented on the IRPs. This is an improvement for the previous review, 7-2019.

Opportunities for Improvement:

Performance Standards:

? Nine (9) Nursing Assessment and Health Services progress notes did not meet the service definition. In all cases, the content of these "weekly nursing notes" did not contain vital signs or indicate education was provided, as required for this service; additionally each note stated "documentation of dosing to cover dates from xxx through xxx." Staff report this is a weekly note that is intended to cover multiple dates of service. Progress notes for each contact must be an independent note. Additionally, these nine nursing notes lacked time in and out as required.

? One claim was unjustified due to multiple services being billed at the same time. Psychiatric Treatment was billed on 04/20/2021 from 9:22 am to 9:38 am; however, Nursing Assessment and Health Services was billed on the same day from 9:20 am to 9:36 am.

Quantitative Standards:

? Forty-eight (48) Nursing Assessment and Health Services progress notes were missing. In these instances, a weekly nursing progress note was present in the records; however, there was no separate nursing progress note on the date service was billed.

? Two claims were unjustified due to the progress note not being filed within seven calendar days. A Psychiatric Treatment progress note's date of service was documented as 04/20/2021; however, the progress note was not signed until 06/07/2021. Another Psychiatric Treatment progress note date of service was documented as 04/27/2021; however, the progress note was also not signed until 06/07/2021.

? The staff credential was missing on two dosing progress notes.

Review ID: 10921

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

The Georgia Collaborative ASO / Beacon Health Options Page 4 of 10

Assessment & Planning: 97%

Strengths and Improvements:

? The provider continues to score 90% or above in this area. ? One hundred percent (100%) of the individuals were assessed for suicide risk. ? Services ("Medication Assisted Treatment'') were included on IRPs. This is an improvement from the previous

review, 7-2019 ? The following are continued strengths of the provider from the previous review, 7-2019:

All assessed needs and whole health and wellness goals were included on the IRPs to be addressed. Co-occurring health conditions were also included on the IRP to be addressed, deferred, or referred. Transition/discharge plans in all of the records reviewed met the discharge criteria (e.g. a specific step-

down service, an anticipated step-down date, and measurable clinical benchmarks.

Opportunities for Improvement:

? Two applicable IRPs did not address suicidality. In these instances, both individuals reported having a history of suicide attempts; however, the IRP did not include any goals, objectives, and/or interventions to address the individuals' risk for suicide.

Focused Outcome Areas

Rights 100%

Choice 100%

Whole Health 100%

Safety 86%

Focused Outcome

Areas 99%

Community 100%

Person Centered Practices

100%

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 5 of 10

Focused Outcome Areas: 99%

Strengths and Improvements:

? The provider continues to score 90% or above in this area. ? All records contained a signed formal acknowledgement of rights and responsibilities at the onset of treatment

and at least annually, when applicable. ? Records contained a consent for telehealth or telemedicine, when applicable. ? There was evidence of resource coordination to assist individuals in gaining access to necessary services to

promote recovery/resiliency. For example, one individual was referred to a behavioral health provider to address their depression.

Opportunities for Improvement:

Safety:

? Two records contained safety/crisis plans that lacked details in the event of a crisis. Although the records contained safety/crisis plans, there were no numbers listed for the agency and/or external supports. Also, one of the records did not contain evidence of ongoing assessment for risk of suicide for the individual. This was also an issue in the previous review, 7/2019.

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 6 of 10

Service Guidelines: 95%

Strengths and Improvements:

? The provider's score improved from 86% from the previous review to 95% this review. ? Individual Counseling was provided by appropriately licensed or credentialed clinicians. In addition, progress

notes documented the individual's progress or lack thereof toward specific goals/objectives on when this service was included on the IRP. This is a continued strength of the provider from the previous review. ? Documentation supported that psychosocial services (i.e. Individual Counseling) was being offered and/or provided in conjunction with medication dosing. This is also a continued strength of the provider from the previous review.

Opportunities for Improvement:

Medication-Assisted Treatment:

? Eight records lacked detailed documentation of education to the individual and/or the family/significant other(s) regarding nutritional, medical and other health issues, and side effects of medications. In these instances, nursing progress notes primarily documented dosing information and lacked education related to medical issues such as high blood pressure as well as educating the individual the risk and benefits of medication.

Nursing Assessment & Health Services:

? Seven records lacked detailed documentation that supported evidence of education related to identified health issues including (but not limited to) medication, nutrition, and infectious disease assessment, testing, and referral. As previously mentioned, nursing progress notes primarily documented dosing information.

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: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 7 of 10

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.

? Assessors were not given access to the Electronic Medical Record (EMR), Methasoft; instead the provider opted

to scan and email/fax records to Assessors for review. The following was noted regarding submission of records: The provider reported technical difficulties regarding submission of records related to emailing and faxing

the large files. The provider is reminded of standards related to submission of records and credentialing documents as

outlined in the GA Collaborative ASO Handbook. "Any record (paper or electronic) not supplied within the allotted timeframe will be considered to have not been delivered and these records will be scored as "No" on all areas. ? IRPs listed MAT instead of each specific service to be provided (i.e. Individual Counseling, Opioid Maintenance,

Psychiatric Treatment, Nursing Assessment and Health, Behavioral Health Assessment/Service Plan

Development). MAT is a milieu that encompasses multiple and distinct services. IRPS must specifically list each

service versus MAT. ? A consent for medication that explains the risks and benefits of Methadone is embedded within the "Consent to

Treat" form; however, as best practice, a stand-alone medication consent form that includes the medications prescribed and documents the risks/benefits of the medication should be separate from a consent to treatment. ? Some physician progress notes did not include billing codes, a mental status or a summarization of the

contact. The notes often alerted to withdrawal or not and medications. In addition, the physician's assessments were handwritten and at times illegible. ? The "Opiate Withdrawal Scale" assessment, if billed by the nurse, needs to include all required elements for

Nursing Assessment and Health Services to include vital signs, billing code, time in and out, a summary of

findings, and educational information. ? A virtual tour was conducted of the clinic, and following was noted:

Convex mirrors were placed throughout the building.

Medication is stored in safes which are located in a locked room. Cameras were present throughout the building to include in the dosing area.

Fire Exit Plan Routes, Exit signs, and fire extinguishers were visible. The dosing lobby had eight windows separated by curtains for privacy.

There were two lobby areas called the "Cash lobby" and the "dosing lobby." Positive quotes related to recovery were posted throughout the building. A "Storyboard Wall" was present in the lobby where individuals can post anonymous stories or poems

regarding the loss of a loved one due to drugs or alcohol. There was an area posted on the wall called the "Forest of Hope" where individuals can post anonymous

success stories. Multiple boards were placed throughout the facility with resources and job opportunities. A children's play area was present in the dosing lobby. Areas of improvement:

Walls and door frames were in need of painting throughout the building.

The toilet in the drug screening bathroom was in need of cleaning.

Review ID: 10921

The Georgia Collaborative ASO / Beacon Health Options

Page 8 of 10

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