First Step Community Services, LLC

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First Step Community Services, LLC

GAC003169

Behavioral Health Quality Review Final Assessment Address: Remote Quality Review-901 C Washington Avenue, Macon, Georgia 31201 Assessors: Dorian Milam, RN; Alisa Monfalcone, LCSW

Records Reviewed: 5 Date Range of Review: 11/29/2021 - 12/1/2021

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.

Assessment

&

Planning 65%

Focused Outcome Areas

95%

Overall Score

61%

Service Guidelines

83%

Billing Validation

0%

Overall Score

Billing Validation

Focused Outcome Areas

Assessment

& Planning

Service Guidelines

FY21 Statewide Average 85% 70% 92% 88% 91%

This is the provider's first Behavioral Health Quality Review.

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.

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Summary of Significant Review Findings

Strengths and Improvements:

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

• This was the first Behavioral Health Quality Review (BHQR) for First Step Community Services. The provider began providing Medicaid services in Georgia in December 2020 and they are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).

• The agency is contracted as a DBHDD provider in Regions 2 and 6. They provide adult outpatient services in Bibb, Jones, Monroe, Houston, Peach, and several other counties. Administrative offices are located in Macon, Georgia.

• The provider utilizes Share Note, an electronic medical record (EMR), with some paper records that are uploaded into the EMR.

• Protocols for addressing emergency and crisis situations were documented.

• The provider's program plan/description for Mental Health Peer Support-Individual was lacking many of the components required by the Department of Behavioral Health and Developmental Disabilities' (DBHDD) Provider Manual.

• A Quality Improvement and Risk Management policy was present. There was a separate policy for addressing suicide risk in individuals served.

• All required staff were present and listed within the provider's organizational chart.

• The clinical director is a full time employee and has been licensed in Georgia since October 2017.

• The personnel files of two staff members were reviewed and both contained the necessary documentation to support the credentials utilized.

• Crisis plans were detailed and listed appropriate telephone contacts as well as preferences and situations to avoid. In addition, crisis plans listed information about the individual's living situation (including any children and their ages), pets, and transportation needs.

• Whole health and wellness was discussed in notes.

• The provider's "Services Agreement" contained detailed expectations held for the provider and individual served in order to maximize the benefit of services provided. The document contained seven agreements by the individual (i.e., "Have any potentially dangerous animals physically separated from the provider"; "attend all sessions substance free from the influence or drugs or alcohol") and eight guidelines they agree to follow (i.e., "to contact my provider should there be a change in my phone number or my address," and "I will make an effort to prevent distractions during the session (i.e., TVs, phone calls, visitors) to make the best use of my time during sessions."

• Some records contained a Home Safety Inspection Checklist, described as "an annual home and safety checklist to be completed with the consumer after they have been provided with the home safety training," with sections addressing stairs, halls/entrances, living room, kitchen, bedrooms, and other. This is important both as an assessment of resources and needs, as well as helpful information for staff providing community-based services.

The Georgia Collaborative ASO / Beacon Health Options www.georgiacollaborative.com

Review ID: 11428 Page 2 of 10

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Opportunities for Improvement:

Overall areas of concern:

• A staff member lacked a DBHDD-required criminal records background check prior to contact with individuals served.

Billing Validation:

• All notes were unjustified due to not having a valid, verified diagnosis on the date the service was provided; the individual receiving services did not meet admission criteria for service billed; and the intervention was unrelated to the Individual Recovery Plan (IRP) without clinical justification.

• A verified diagnosis was not provided by an appropriately-credentialed practitioner.

• Some notes were missing the time in/out, and other notes were signed prior to the end of the session.

Assessment and Planning:

• None of the records addressed the whole health and wellness needs of the individual on the IRP.

• Transition/discharge plans lacked one or more of the three required components.

Focused Outcome Areas:

• All applicable records lacked documentation of communication with external referral sources and providers to obtain results of testing, treatment, and follow up.

Compliance with Service Guidelines:

• The service was not provided as planned within the IRP in all records reviewed.

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Billing Validation: 0%

Opportunities for Improvement:

Eligibility Standards

• None of the reviewed individuals had been assessed and diagnosed by an appropriately-credentialed professional per the DBHDD Provider Manual; therefore, all reviewed claims were unjustified for:

◦ No valid, verified diagnosis on date service provided.

◦ Individual receiving services does not meet admission criteria for service billed.

Performance Standards

• Documented interventions were unrelated to the IRP without clinical justification in all notes reviewed. In each record, the IRP referenced "Peer Support Services" (a category of service that would include several possible service definitions) without specifying "Mental Health Peer Support Services-Individual."

Quantitative Standards

• There were seven progress notes that were signed prior to end of session. For example, the time in/out for a note dated 9/1/21 was 10:15am-1:15pm but the time stamp on the signature was 8:58am on the same date.

• Time in/Time out was missing on 28 progress notes. The notes included the duration of the session (i.e., "two hours" or "three hours") but did not include the time in or out.

Standard Reason # of Discrepancies

Eligibility Standards

Individual receiving services does not meet admission criteria for service billed

50 No valid, verified diagnosis on date service provided 50 Performance Standards Intervention unrelated to IRP w/o clinical justification 50 Documentation/note signed prior to end of session. 7

Quantitative Standards Time in/Time out missing 28

Medicaid Total

Justified $0.00 $0.00

Unjustified $10,254.00 $10,254.00 Total $10,254.00 $10,254.00

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 Encounters is the estimated sum of the value of accepted encounters).

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

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Assessment & Planning: 65%

Strengths and Improvements:

• Behavioral health assessments of needs were present in all records; this included and assessment of housing, financial, and family issues.

• A current medical screening was present in all records which noted physical issues of concern to the individual being served.

• In all records, the IRP was individualized and in the personalized language of the individual being served.

Examples included financial issues as well as issues with loneliness. Examples included "I want to learn better ways to manage my money" and "I want to save my money so I can move to a safer community within the next 12 months."

Opportunities for Improvement:

• None of the five records reviewed contained a behavioral health or addictive disease diagnosis verified by an appropriately-credentialed practitioner. Assessments (which included a diagnosis) were completed by a certified peer specialist (CPS) with a Master's degree. These were later signed by a licensed professional counselor (LPC) who never saw nor interviewed the individuals. From the Georgia DBHDD Provider Manual, pages 372- 373 of 593:

◦ "A. A verified diagnosis is defined as a behavioral health diagnosis that has been provided following a face-to-face (to include telemedicine) evaluation by a professional identified in O.C.G.A Practice Acts as qualified to provide a diagnosis. These include a licensed psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed physician, or a physician assistant or APRN (NP and CNS-PMH) working in conjunction with a physician with an approved job description or protocol."

◦ "C. The diagnosing professional may rely on assessment information provided by other professionals and collateral informants (as permitted by the individual), but a face-to-face interaction between the

diagnosing professional and the individual must also occur (to include telemedicine). A signature by such a person on documentation leading to or supporting a diagnostic impression does not meet this

requirement for performing an assessment adequate to support assigning a behavioral health diagnosis." http://dbhdd.org/files/Provider-Manual-BH.pdf."

• None of the five IRPs reviewed addressed whole health and wellness. Examples of appropriate whole health and wellness goals could include appropriate nutrition, exercise, sleep hygiene, and safety measures that can contribute to overall wellness.

• Three of the four applicable records did not address co-occurring conditions on the IRP. For example, one individual's medical conditions of high blood pressure, lupus, glaucoma and a liver transplant were not

referenced or deferred on the IRP. The IRPs did not reflect whether the provider was coordinating care with other providers or discussing the co-occurring conditions with the individuals.

• Transition/discharge plans lacked one or more of the three required components in all records reviewed to include an anticipated step-down date, anticipated step-down service(s), and clear clinical benchmarks/criteria.

For example, step-down services were listed as "Outpatient Therapy" without indicating specifically if intended services were for individual, family, and/or group counseling. In addition, plans lacked clear clinical

benchmarks. Instead, terms like "when needed" were indicated for individuals.

• In the one record reviewed of an individual who had been discharged, the Discharge Summary lacked the following required components: strengths, needs, preferences, and abilities of the individual; services, supports, and treatment provided; and necessary plans for referral.

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Focused Outcome Areas: 95%

Strengths and Improvements

:

• Documentation of ongoing assessment to determine external referrals for health services, supports, and

treatment when not available within organization was present in all records. In all applicable records, a release of information for the individual's primary care physician was noted.

• In all records, a Safety/Crisis was developed, as needed, which directed, in advance, the individual's desires/wishes/plans/objectives in the event of a crisis.

• All records contained documentation that HIPAA Privacy and Security Rules (as outlined in 45 CFR Parts 160 and 164) were reviewed with the individual being served.

Opportunities for Improvement

:

Whole Health

• Four of five applicable records lacked documentation of communication with external referral sources and providers to obtain results of testing, treatment, and follow up. For example, while records contained an appropriate release of information (ROI) for the primary healthcare provider, there was no indication that efforts were made to obtain documentation from this provider treating individual's high blood pressure, lupus, glaucoma and history of a liver transplant. Also, assessment indicated individual reported that she needs to schedule her routine checkup and there was no documentation to indicate staff assisted with this.

Focused Outcome Areas

Choice 100%

Rights 100%

Whole Health 50%

Safety 100%

Focused Outcome Areas

95% Person

Centered Practices

100%

Community 100%

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Service Guidelines: 83%

Strengths and Improvements

:

• Documentation included interventions that promote socialization, recovery, wellness, self advocacy,

development of natural supports, and maintenance of community living skills. Examples included discussion of family dynamics and assistance with housing.

• The providing practitioner is a Georgia-certified peer specialist. (CPS.)

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

Opportunities for Improvement

:

Mental Health Peer Support Services-Individual

• The service was not provided as planned within the IRPs in all records reviewed. The IRPs stated, "Peer Support Services" without specifying "Mental Health Peer Support Services-Individual."

Overall Programmatic

Provider-Level Indicators

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

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

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

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

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.

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

No

# Yes # No # N/A

SCORE*

3 1 2

75%

* 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

• Several notes in one record referred to a female individual as "he" and "him," indicating a lack of individualization in the documentation.

• A policy and procedure should be developed (in compliance with DBHDD policy) for providing reasonable accommodations to individuals who are deaf/hard of hearing. The current policy and procedure appears to relate only to staff members, not individuals being served.

• Although Quality Risk Items (QRI) no longer represent a point deduction from the Overall Score, the following QRI was noted during this review:

◦ The provider lacked proof of criminal records check on an employee, staff, or contractor prior to contact with individuals. One employee began contact with clients on 1/13/21 but did not have a letter from DBHDD indicating a satisfactory Criminal Records Check until 2/17/21. The provider stated the employee had worked with the provider in North Carolina and they did not realize they needed a new Criminal Records Check in order to work in Georgia.

Individual Interviews

Individual Interviews Conducted: 2

• Both individuals interviewed reported that options for supports and services were offered, that they could access appointments, provider staff, and other agency supports in timely manner when requested, and that they felt supported to achieve their desired level of involvement in the community.

• The following are quotes by individuals interviewed:

◦ "Their willingness to go out of their way is just unbelievable."

◦ "They are really great people there. Everyone I have met there is really nice."

◦ "My case manager is an angel and they helped me get into housing."

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Recommendations: Current Review Provider Level

• Ensure an appropriate criminal records check has been obtained on all employees, staffs, and/or contractors.

Billing Validation - Eligibility

• Ensure documentation supports that all Eligibility Standards are met.

Billing Validation - Quantitative

• Ensure all Quantitative Standards are met in documentation.

Billing Validation - Performance Standards

• Ensure all Performance Standards are met in documentation.

Assessment and Planning

• Ensure services are provided only to individuals who meet admission or continuing stay criteria.

• Ensure all individuals have a current comprehensive assessment of their behavioral health and support needs.

• Ensure treatment/recovery/service plans contain goals, objectives, and interventions that promote whole health and wellness.

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

• Ensure transition/discharge plans define criteria for discharge, planned discharge date, and specific services.

Focused Outcome Areas - Whole Health

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

Compliance With Service Guidelines - All

• Ensure documentation is related to goals and objectives on the plan.

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.