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ALLIANCE RECOVERY CENTER INC

GAC000675

Behavioral Health Quality Review Final Assessment

Address: Remote Quality Review 3430 Highway 20, Conyers, Georgia, 30013

Assessors: Dorian Milam, RN; John Dury, LPC, LMFT, MAC; Natalee Fritsch, LPC

Records Reviewed: 20

Date Range of Review: 6/28/2021 - 7/1/2021

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.

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Summary of Significant Review Findings

Strengths and Improvements:

• Due to COVID-19, the Behavioral Health Quality Review (BHQR) was conducted remotely versus on-site.

• Individualized Recovery Plans (IRPs) were individualized, addressed co-occurring issues, and a variety of whole health and wellness needs.

◦ Examples of objectives were the following: "Patient will follow-up with their liver specialist to discuss any abnormal lab results as evidence by verification of appointment and self-report."

◦ "Patient will improve his eating habits by decreasing the amount of processed, high sugar, high sodium, high fat foods that are eaten and include more fresh fruit and vegetables, lean proteins, and water in his diet."

◦ "Patient will schedule an appointment with their primary care physician as needed for annual preventative care as evidenced through self-report."

◦ "Patient will maintain a physical fitness routine as evidence by self-report and physical appearance."

• The provider utilized a separate lab notification consent form where the individual acknowledged that the provider had reviewed bloodwork/urine results, acknowledged the provider does not provide follow-up care for abnormal labs, and that it was the individual's responsibility to follow-up with a primary care physician (PCP).

• In addition, the provider utilized a "Physician Lab Review" document indicating normal or abnormal blood results, urine results, and lab comments. This served as a means for the prescriber to review lab results and share the results with the individual.

Opportunities for Improvement:

• Please see the Billing Validation section for more information on the following:

◦ Two progress notes did not include responses to interventions provided. One note did not support units billed as the note was blank.

• Please see the Assessment and Planning section for more information on the following:

◦ In one record, suicidality was not addressed on the IR/RP, as applicable.

• Please see the Focused Outcome Area section for more information on the following:

◦ In one record, when an individual had been assessed to be at risk for suicide, there was no documented evidence of ongoing assessment; documentation also did not support that clinically appropriate actions or steps were taken and linkages or referrals were made based upon the findings/outcome of suicide risk assessment.

◦ In 12 records, the individual/guardian had not signed formal acknowledgement of rights and responsibilities at least annually.

◦ Records did not include a psychiatric or other advanced directive or evidence the individual denied the existence of a directive or declined to have it in their record.

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Billing Validation: 96%

Strengths and Improvements:

• All individuals served met admission criteria. This is continued strength for the provider.

• All reviewed claims were supported by an order for service from a qualified practitioner, as required. This is continued strength for the provider.

Opportunities for Improvement:

• Two progress notes for Individual Counseling did not include a response to the interventions provided.

• Two progress notes for nursing services (T1001U4U6) were unrelated to Individual Recovery Plans (IRPs) due to the treatment plans only listing "Opioid Use-Disorder-Maintenance Therapy" as the service to be provided. Neither of the IRPs in these two records listed Nursing Assessment and Health Services nor Medication Assisted Treatment. 

• One note was blank; therefore, the units billed were not supported.

Standard

Reason

# of Discrepancies

Performance Standards

Intervention unrelated to IRP w/o clinical justification

2

Note does not include response to intervention

2

Content does not support units billed

1

Medicaid

Total

Justified

$3,943.42

$3,943.42

Unjustified

$143.42

$143.42

Total

$4,086.84

$4,086.84

Billing Validation

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 

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Assessment & Planning: 99%

Strengths and Improvements:

• All records contained the following:

◦ A current medical screening

◦ Documentation that the individual had been screened for suicide risk

◦ A personalized IRP

◦ Whole Health and wellness goals

◦ A complete transition/discharge plan that included step-down services, criteria for discharge, and an anticipated discharge date

Opportunities for Improvement:

• One IRP was missing goals, objectives, and/or interventions to address suicide when the individual was assessed to be at risk due to the individual having suicidal ideation.

• Although it did not impact scoring in this area, it is noted that IRPs stated "Opioid Use Disorder-Maintenance Therapy" and/or "Medication Assisted Treatment" in the "Problem List" at the top of the document as the service(s)to be provided for all goals, objectives, interventions listed in the document versus listing specific services with specific interventions.

◦ Each service to be provided must be listed or planned on IRPs with corresponding interventions  (i.e. Individual Counseling, Opioid Maintenance, Psychiatric Treatment, Nursing Assessment and Health Services, Behavioral Health Assessment/Service Plan Development, etc.).

◦ Medication Assisted Treatment (MAT) is a milieu that encompasses multiple and distinct services.

◦ It is noted that Group Counseling and Individual Counseling were documented within the narrative of objectives or interventions within IRPs.

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Focused Outcome Areas: 91%

Strengths and Improvements

:

• All records contained evidence that the individual had been provided education regarding the risks and benefits of all medications prescribed, an improvement since the last BHQR (8/2019).

• In all records, there were documented safeguards utilized for medications known to have substantial risk or undesirable effects (lab work, assessments, AIMS, etc.).

• In all records, releases of information contain all required components.

• When telemedicine or telehealth was utilized, there was evidence in all records that the individual had given consent for this modality.

Opportunities for Improvement

:

Safety

• In the one applicable record, documentation did not support that clinically-appropriate actions or steps were taken and linkages or referrals were made based upon the findings/outcome of suicide risk assessment.

Additionally, documentation did not include evidence of ongoing assessment for this individual who had reported a prior attempt at self harm.

Rights

• In 12 applicable records, the individual/guardian has not signed formal acknowledgement of rights and

responsibilities at least annually. In all examples, the notifications of rights were signed by only the staff, not the individual being served. This is a re-occurring issue from the previous BHQR (8/2019).

• None of the records reviewed contained documentation of a psychiatric or other advanced directive or that the

Focused Outcome Areas

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Service Guidelines: 98%

Strengths and Improvements

:

• Documentation in all records supported that personal health education was provided which included, but was not limited to, HIV, TB, and STD's, an improvement over the last BHQR (8-2019).

• Documentation in all records supported that the individual was being trained in self-administration of medication or that the individual was unable to self-administer, an improvement over the last BHQR (8-2019).

• In all records, documentation included goals and objectives that were individualized and specific to the individual who needed treatment for opiate addiction.

• In all records, random drug screens were conducted and results were present in records and utilized to mark progress toward meeting goals and for service planning.

• All records contained a signed Informed Consent for Treatment that ensures the individual has voluntarily chosen MAT.

Opportunities for Improvement

:

Group Counseling/Training

• None of the reviewed progress notes contained documentation of the individual's progress (or lack of) toward specific goals/objectives on the treatment plan or specific responses from the individuals in the two records reviewed. 

Nursing Assessment & Health Services

• Both records reviewed for Nursing Assessment & Health Services were scored "no" for the following items due to the service not being documented on the IRP:

◦ Progress notes had documentation of the individual's progress (or lack of) toward specific goals/objectives on the treatment plan.

◦ Staff interventions reflected in the progress notes are related to the staff interventions listed on the treatment plan.

◦ Progress notes had individual responses to the staff interventions provided. Service was provided as planned.

Although it did not impact scoring in this area, it is noted IRPs stated "Opioid Use Disorder-Maintenance Therapy" and/or "Medication Assisted Treatment" in the Problem list at the top of the document instead of listing specific services to be provided to coincide with each staff intervention.

• Each service to be provided must be listed or planned on IRPs with corresponding interventions  (i.e. Individual  Counseling, Opioid Maintenance, Psychiatric Treatment, Nursing Assessment and Health Services, Behavioral Health Assessment/Service Plan Development, etc.).

• Medication Assisted Treatment (MAT) is a milieu that encompasses multiple and distinct services. It was noted that Group Counseling and Individual Counseling were documented within the narrative of objectives or interventions within IRPs.

 

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

Yes

5 The provider employs an ASL-fluent practitioner. N/A

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

Yes

# Yes # No # N/A

SCORE*

4 0 2

100%

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

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

• Documentation related to dosing did not contain signatures or credentials of staff.  Assessors utilized other reports generated from the electronic medical record (EMR) to cross-reference these required billing characteristics.

• As noted in prior review, IRPs continue to not list the frequency of services to be provided.

• During the tour of the clinic, the following was noted:

◦ In the lobby where individuals check-in, a sanitizer station is located, and an informational board is posted.

◦ Individuals are offered vitamins to address side effects from methadone.

◦ Socially-distanced seating is offered in the lobby area.

◦ A grievance box, information regarding health referrals, dentistry, mental health as well as housing information is located in the common area.

◦ A pharmacist is on site.

◦ The nursing station has a double-locked safe to ensure safe storage of medications.

◦ Individuals are called into the private dosing areas by number.

◦ One dosing window is reserved for individuals who may be experiencing health issues in order to decrease the possibility of transmission of illnesses.

◦ The cashier's area is equipped with a panic button.

◦ Restrooms are monitored via a camera and individuals are made aware of this fact by a posted notice.

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Individual Interviews

Individual Interviews Conducted: 2

• Both individuals interviewed were satisfied with supports and services. One individual commented, "They have been inspirational to me and helped me recover from my stroke and my addiction. I've been able to stop going back and forth in my addiction. I'm 62 years old and I have to take care of myself now."

• The individuals interviewed stated they felt supported in moving toward their desired goals and dreams. Comments included:

"I always try to take control of things myself. My counselor helped me look at my

associations. She was instrumental in me getting away from that old crowd."

"I love to write and target shoot and play music and all of these goals have helped me to stay sober and stay out of jail."

• Both of the individuals also felt treated with respect and dignity by the staff (including physicians). Comments included:

"The doctor realized I needed to come down on my doses and I have the ultimate respect for him. I have been in other programs and all they care about is you coming in for the dose. There is real recovery here for me."

"The doctor talked and talked with me about my stroke, I didn't expect it. I couldn't believe how supportive he has been after my stroke."

"The doctor is funny and once I had carried my firearm into the clinic. During my physical, I kind of slipped and he saw the gun. I thought he was afraid of me, but we laughed and he said I promise you no one is going to hurt you here. He and I always get along. He is very knowledgeable."

• When the individuals were asked, "What about this agency makes you keep coming back?" the responses were the following:

"My counselor has been so considerate, she's been an inspiration to me."

"I keep coming back there because of my family; my mom and my lady. I am not doing this just for me. Alliance has helped me see what is really important, it's more about family."

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Recommendations: Current and Prior Review

Focused Outcome Areas - Rights

• Ensure individuals are informed of their rights and responsibilities at the onset of services and at least annually thereafter.

Recommendations: Current Review

Billing Validation - Performance Standards

• Ensure all Performance Standards are met in documentation.

Assessment and Planning

• Ensure suicidality is addressed on the IR/RP when the individual is assessed as having any suicide risk.

Focused Outcome Areas - Safety

• Ensure documentation supports that clinically-appropriate actions or steps were taken and linkages or referrals were made based upon the findings/outcome of suicide risk assessment.

Focused Outcome Areas - Rights

• Ensure the individual's record includes a psychiatric or other advanced directive; or, documentation indicates the individual has either denied the existence of a directive or declined to have it in their record.

Compliance With Service Guidelines - All

• Ensure documentation addresses individuals’ progress toward specific goals and objectives.

• Ensure documentation reflects individuals’ response to interventions.

Quality Improvement

Recommendations

References

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