Onslow Carteret Behavioral Healthcare Service
Local Management Entity (LME) Fourth Quarter Report: Fourth Quarter Report: April through June 2008
This document includes data and reporting for the fourth quarter of the fiscal year (April 1, 2008 through June 30, 2008) completed by the Local Management Entity to assure compliance with General Statutes, the Performance Contract and Local Business Plan.
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
TABLE OF CONTENTS
TABLE OF CONTENTS.................................................................................................................................................................................. 2 GOVERNANCE AND ADMINISTRATION: Daniel M. Jones, Area Director; Susan Taggart, Assistant Area Director ................... 2 BUSINESS MANAGEMENT AND INFORMATION MANAGEMENT: Carlos Mirodipini, Human Resources Director; Stewart Ervin, Information Systems Director; Vicky Ewing, Finance Officer .................................................................................................... 4 PROVIDER RELATIONS AND DEVELOPMENT: Don Hoover, Provider Relations Director .................................................... 8
CUSTOMER SERVICES/CONSUMER AFFAIRS: Pat Myers, Customer Services and Affairs Director ..................................... 14 SERVICE MANAGEMENT /SCREENING, TRIAGE AND REFERRAL: Kathy Parker, Service Management Director, Paivi Johnson, STR Director ........................................................................................................................................................................................... 31 QUALITY MANAGEMENT: Julie Kokocha, Quality Management Director ..................................................................................... 40
GOVERNANCE AND ADMINISTRATION: DANIEL M. JONES, AREA DIRECTOR; SUSAN TAGGART, ASSISTANT AREA DIRECTOR COMMUNICATION BULLETIN #35, POLICY GUIDANCE FOR CRISIS SERVICES Delivery of Crisis Services Service (List services) Allocated Funding Funding Expended To Date Number of Individuals Served to Date 61 Status of Service (Specify number of providers and area covered)
Respite for Crisis Services
$64,965
Quality Care (Onslow and Carteret), House of David (onslow and Carteret), Carolina Choice (Onslow and Carteret), LeChris (Carteret), IQuolics (Onslow), Claytor Home (Onslow and Carteret), Easter Seals (Onslow and Carteret)
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
24/7/365 Crisis Response (Phone or Faceto-Face) Non-Hospital Medical Detox
86,000
$113,194
SOS provides 24/7 crisis response in catchment area.
700,000
$894,404
656
Onslow and Carteret (CASP agency). CASP funds have been fully exhausted. Additional funds are needed to support outof –catchment services. Brynn Marr Hospital (Onslow and Carteret)
Community Inpatient (Psychiatric and SA) Transportation Mobile Crisis
50,000
$60,129.44
25
16,000
$124.00 $298,266.07 730
Crisis Intervention Team (CIT): The LME received an allocation from the Division to initiate CIT in the local community. The LME hosted two events for local law enforcement and community partners to begin initiating the CIT project. The events were successful supporting buy-in to the CIT philosophy. The plan is to begin training law enforcement in the first half of the FY 2009. The LME continues to meet monthly with Carteret General Hospital to assure clients receive appropriate services and are transitioned from the hospital expeditiously and effectively. The hospital has been very satisfied with the mobile crisis management provider responding to individuals at the hospital instead of 1st responders from several agencies. The LME is in the process of setting-up meetings with Onslow General Hospital. An extensive amount of technical assistance, monitoring and corrective action has been initiated with provider agencies to improve person-centered and crisis planning for person’s experiencing an emergency. Admissions to State Hospitals Month April May June Total for report quarter
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
SFY 06-07 admissions SFY 07-08 admissions Change in # of admissions
27 14 -13
17 14 -3
26 10 -16
70 38 -32
BUSINESS MANAGEMENT AND INFORMATION MANAGEMENT: CARLOS MIRODIPINI, HUMAN RESOURCES DIRECTOR; STEWART ERVIN, INFORMATION SYSTEMS DIRECTOR; VICKY EWING, FINANCE OFFICER
HUMAN RESOURCES Human Resources continues to provide and promote a safe and healthful working environment, encourage a high level of morale through recognition and positive employee relations, and inspire employees by offering opportunities for challenging work, personal development and growth. RECRUITMENT OCBHS continues to hire and/or promote only those with suitable qualifications to perform the job. We are committed to hiring, developing and retaining the most talented people. The following statistics for April through June show an improvement in vacancy/turnover rate. Vacancy Rate Averages – 12.94% Turnover Rate Averages – 1.35% Vacant positions are taking approximately 2 months to fill. STAFF DEVELOPMENT Human Resources provided adequate and specific help to aid employees to perform satisfactorily. This was done by providing proper direction, arranging for training, supplying the necessary resources, maintaining a safe working environment, and removing unnecessary barriers to employee performance. EMPLOYEE RELATIONS/MORALE During this quarter, OCBHS enhanced organizational effectiveness by promoting teamwork between groups and work units during a date dedicated to recognize employee contributions to the agency. The employee Relations Team continues to work as a team, striving for a quality work experience for OCBHS employees. POSITION MANAGEMENT/SALARY ADMINISTRATION Human Resources arranged for timely planning and definition of organizational structures and future staffing to ensure OCBHS’ strength and continuity for the new FY 2008-2009. Management also designed employee benefits and services which are competitive and which effectively meet employee needs within the limits of economic feasibility. Decisions were made with proper regard for the ever so delicate balance between individual needs on the one hand and OCBHS needs on the other.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
1.8.2.1. CLIENT DATA WAREHOUSE (CDW) - ADMISSIONS For the three month reporting period from March 16 to June 15, 2008, OCBHS submitted 551 admission records (record type 11) to the Client Data Warehouse (CDW). 1.8.2.3. Client Data Warehouse (CDW) CDW Overall Elements DATE: 7/20/2008
1.8.2.4. CONSUMER INFORMATION - CLIENT DATA WAREHOUSE (CDW) Identifying and Demographic Records Missing Identifying and Demographic Report 01/01/2008 to 03/31/2008 DATE: 07/20/2008 YTD Missing numbers YTD Valid numbers YTD Total numbers YTD Completed Percentage 2 1057 1059 100
1.8.2.5. CONSUMER INFORMATION - CLIENT DATA WAREHOUSE (CDW) Drug of Choice Data There were 438 drug of choice records (type 17) sent to Client Data Warehouse during the 4th Quarter cutoff of June 15.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Drug of Choice Data Compliance Report 01/01/2007-03/31/2008 Date: 07/20/2008 YTD Missing numbers YTD Valid numbers YTD Total numbers YTD Completed Percentage 4.0 CLAIMS PROCESSING 6 290 296 98
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Paid and Denied Claims by Target Population:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
PROVIDER RELATIONS AND DEVELOPMENT: DIRECTOR
DON HOOVER, PROVIDER RELATIONS
ASSESSMENT OF ADEQUACY OF THE PROVIDER COMMUNITY New Endorsements for the Quarter: Provider Access Behavioral Healthcare RHA Access Behavioral Healthcare Stevens Healthcare Date 4/2/08 4/9/09 4/25/08 5/27/08 Services Community Support Team Community Support Team CAP Services Community Support Team
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Service:
Number of Providers:
Location of Service Gap Onslow and Carteret Counties
Reason:
Substance Abuse Comprehensive Outpatient Treatment Assertive Community Treatment Team
No Provider
No referrals
No Provider
Onslow and Carteret Counties
One provider is in process of initiating the service.
Multi-Systemic Therapy
No Provider
Onslow and Carteret Counties
Service not cost effective for providers but one Provider seeking endorsement There are a number of providers on the QPC, most are out of catchment and all but 4 are for children
Community Respite
Carteret County
5.2 Choice of Providers The LME shall ensure that consumers eligible for Medicaid will have freedom of choice of providers. For State services, consumers will have a choice of at least two providers for every service, except for those services with very limited usage. Services Onslow County 2 0 4 Carteret County 1 0 2 Out of catchment 2 0 1
Community Support Team (CST) Consultation, Education, and Primary Prevention Day/Evening Activity
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Services
Onslow County 0
Carteret County 0
Out of catchment 0
Detox-Social Setting
Developmental Day Developmental Therapy Diagnostic Assessment Drop-In Center Evaluation (Bill as Outpatient Treatment)
0 24 11 0 2
1 12 9 0 1
0 6 9 0 1
Family Living Financial Supports Group Living Guardianship Independent Living Inpatient Hospital Intensive In Home Services Medically Supervised or ADACT Detoxification/ Crisis Stabilization
6 0 13 0 0 1 7 1
3 0 4 1 0 0 6 2
2 0 7 1 1 3 7 4
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Services
Onslow County 1 0 1 23 11 31 1 23 2 13 7 0 24 0
Carteret County 1 0 0 18 8 12 0 10 3 5 5 0 8 0
Out of catchment 0 1 0 19 13 11 0 8 5 13 20 1 8 1
Mobile Crisis Unit Multi- Systemic Therapy (MST) Non- Hospitalization Medical Detoxification Outpatient Treatment Personal Assistance Personal Care Services Psychiatric Residential Treatment Facility (PRTF) Residential Supports Residential Level 1 Residential Level 2 Residential Level 3 Residential Level 4 Respite (Community) Substance Abuse Comprehensive Outpatient Treatment Program Substance Abuse Comprehensive Intensive Outpatient
1
1
1
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Services
Onslow County
Carteret County
Out of catchment
Program Supervised Living Supported Employment Targeted Case Management TECHNICAL ASSISTANCE TO PROVIDERS Provider Relations staffs provided technical assistance to Providers either on request or as systemic issues are identified. Date: 04/02/08 04/07/08 04/08/08 Provider: Burklo Home SOS Vocational Rehabilitation Roundtable Discussion Claytor Home SOS RHA Topic: Renting trailers for Supervised Living & Respite Mobile Crisis Navigating the system Time: 1:00 PM 9:00 AM 2:00 PM 30 34 28 13 13 14 19 19 14
04/10/08
Educating the community on individuals we support
11:30 AM
04/11/08 04/11/08 04/21/08
Billing Mobile Crisis & Detox Monthly Meeting
1:00 PM 2:00 PM 1:00 PM
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date: 04/22/08 04/23/08
Provider: SOS Onslow Memorial Hospital Allied and RHA RHA Concordia RHA
Topic: Monitoring of SOS & Mobile Crisis Mobile Crisis
Time: 9:00 AM 1:00 PM
04/25/08 04/25/08 05/02/08
Billing Consumer Issues 1) Coordination with other Providers 2)Intensive in Home Services 3) Placement issues Monthly Meeting Summer Camps Work first requirements
9:00 AM 12:00 PM 08:30 AM
05/02/08 05/09/08 05/19/08
RHA/DSS Genesis Carteret Counseling & Discovery Disability RHA IQuOLIOC RHA Provider Workgroup Provider Workgroup Provider Workgroup
2:00 PM 2:00 PM 9:30 AM
05/19/08 05/22/08 05/22/08 06/02/08 06/09/08 06/10/08
Monthly Meeting Consumer Issues Consumer Issues Residential Level III Hospital Diversion Community Supports
1:00 PM 9:00 AM 10:00 AM 9:00 AM 1:00 PM 1:00 PM
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date: 06/11/08 06/16/08 06/25/08 06/25/08 06/25/08 06/27/08 06/27/08 06/27/08
Provider: SOS RHA SOS Work first Claytor Home Detox Discovery Disability Malachi
Topic: Detox Monthly Meeting Mobile Crisis Services Contract Requirements NPI#s Full Endorsement Review PCP Endorsement
Time: 1:00 PM 1:00 PM 12:30 PM 2:30 PM 1:00 PM 10:00 AM 2:00 PM 2:30 PM
CUSTOMER SERVICES/CONSUMER AFFAIRS: PAT MYERS, CUSTOMER SERVICES AND AFFAIRS DIRECTOR CONSUMER APPEALS/GRIEVANCES: The LME oversees all complaints and non-Medicaid appeals through a coordinated system that is timely, efficient and effective and values the consumer and their family. The LME engages in arbitration with consumers and completes rights investigations. Complaints are logged, tracked and a follow up is conducted through the customer service and consumer affairs department. Rights investigations are conducted through the customer service and consumer affairs department and are reported to the client rights committee.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
NON-MEDICAID APPEALS Non-Medicaid appeals are processed and tracked by the customer services department and reported to the client rights committee. Non-Medicaid appeals are processed in accordance with the state guidelines and graphs are included for the quarter in this report.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Consumers and Providers receive notification when a service is denied, reduced or terminated by the LME. The consumer may appeal the decision by contacting the customer services department to initiate an appeal. The following information details the appeal requests for the fourth quarter:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
CLIENT RIGHTS: The OCBHS Area Board identified two new Client Rights Committee members this quarter. A CFAC member was appointed to the committee along with an Area Board member.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Rights investigations were conducted through the Customer Service Department and reported to the Client Right’s Committee.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
CONSUMER AND FAMILY ADVISORY COMMITTEE (CFAC) OCBHS CFAC meets on a monthly basis. During this quarter, CFAC met on April 8, 2008, May 20, 2008 and June 16, 2008. Staff support is provided on an ongoing basis through the LME CFAC Liaison and other management staff as needed. Training, updates and review of the Area Board report is provided by LME staff at the monthly CFAC meetings and more frequently as needed and/or requested by CFAC. OCBHS WEBSITE The LME maintains a web site on the Internet that includes current and accurate information on how consumers and families may access services in the catchment area. The home page identifies a toll free access number and a toll free customer service number within the catchment area. CONSUMER EDUCATION AND OUTREACH A workgroup is being formed as part of a Customer Service QI project to develop the welcome packet for new consumers. Customer Service is also working with an alliance of five LME's on a joint QI project to standardize information that is included in the welcome packet. Information on access to services is distributed in a variety of ways, including but not limited to: brochures, fact sheets, website, community health fairs, business expos, CFAC meetings, provider meetings, meetings with local agencies, etc. APRIL-JUNE 2008 COMMUNITY EVENTS
Date
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Event
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date April 1, 2008 April 1, 2008 April 2, 2008 April 2, 2008 April 3, 2008 April 4, 2008 April 8, 2008 April 8, 2008 April 9, 2008 April 10, 2008 April 10, 2008 April 14, 2008 April 15, 2008 April 17, 2008 April 17, 2008 April 22, 2008 Monthly Systems of Care Collaborative SPF-SIG Planning Meeting Monthly Systems of Care Collaborative
Event
Mayors Committee Persons with Disabilities OCBHS Community Relations State of the Child Breakfast OCBHS Fire Side Chat SPF-SIG Strategic Planning Meeting Community Needs Assessment Onslow Co. Health Department NC Council Customer Service Forum OCBHS Provider Meeting Onslow CHIP monthly board meeting Local Interagency Coordinating Council State of the Child Conference OCBHS Client Rights Committee Meeting Human Services Clinical Counsel Meeting
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date April 23, 2008 April 27-30 April 28, 2008 April 29, 2008 April 30-May 4, 2008 May 1, 2008 May 1, 2008 May 1, 2008 May 4, 2008 May 4-10, 2008 May 5, 2008 May 6, 2008 May 6, 2008 May 6, 2008 May 7, 2008 May 7, 2008 SPF-SIG Cap Meeting Spring FARO Conference OCBHS Area Board Meeting
Event
Administrative Professionals Day Breakfast 38th National Council Conference-Boston Housing Support Committee Carteret County Senior Games LME Directors Meeting National Childhood Depression Awareness Day National MH Counseling Week, National Anxiety and Depression Awareness Week, Children’s MH Week Carteret County Commissioners Meeting-Proclamation May is Mental Health Month Onslow County System of Care Local Collaborative Meeting OCBHS Community Relations Meeting SPF-SIG Conference Call Onslow County Mayors Committee for Persons with Disabilities Meeting Local Coalition for Substance Abuse Prevention
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date May 7, 2008 May 8, 2008 May 8, 2008 May 8, 2008 May 12, 2008 May 12-16, 2008 May 13, 2008 May 14, 2008 May 15, 2008 May 15, 2008 May 19, 2008 May 19, 2008 May 19-23, 2008 May 20, 2008 May 20, 2008 May 20, 2008
Event Carteret County System of Care Local Collaborative Meeting Healthy Carolinas of Carteret County Board Meeting Friends of Atlantic House Board Meeting OCBHS Provider Meeting Alliance Meeting National Alcohol and Other Drug Related Birth Defects Week Customer Service Train the Trainer Workshop Care Coordinators Meeting Crisis Intervention Team (CIT) Planning Meeting OCBHS Client Rights Meeting OCBHS Area Board Meeting Onslow County Commissioners May is Mental Health Month Proclamation National Schizophrenia Awareness Week, Older Americans Mental Health Week Local Interagency Coordinating Council OCBHS Consumer and Family Advisory Committee Meeting Department of Social Services Meeting
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date May 20, 2008 May 20, 2008 May 22, 2008 May 22, 2008 May 27, 2008 May 27, 2008 May 28, 2008 May 29, 2008 May 30, 2008 June 2, 2008 June 3, 2008 June 3, 2008 June 3, 2008 June 3, 2008 June 4, 2008 June 4, 2008
Event Information Systems Technology Alliance Meeting Quality Improvement Forum Clinical Services Workgroup Provider Community Mystery Shopping-Participation Included CFAC and OCBHS staff Human Services Clinical Council Consumer and Family Advisory Committee Brochure Planning Committee National Local Government Information Systems ConferenceCustomer Services Alliance Meeting OCBHS Staff Development Day Leadership Series Leadership Series Provider Relations Leadership Forum Onslow County System of Care Local Collaborative Meeting Onslow Department of Social Services and Onslow Health Department Meeting Leadership Series CFAC Bylaws Sub-Committee
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date June 4, 2008 June 4, 2008 June 5, 2008 June 5, 2008 June 6, 2008 June 6, 2008 June 6, 2008 June 9, 2008 June 9, 2008 June 9, 2008 June 10, 2008 June 12, 2008 June 12, 2008 June 12, 2008 June 16, 2008 June 16, 2008
Event Mayors Committee for Persons with Disabilities Carteret County System of Care Local Collaborative Meeting Housing Support Committee Carteret General Hospital, SOS Inc., OCBHS Meeting NC Council Customer Service Forum Customer Service Alliance Meeting IT Alliance Meeting NC Council Spring Policy Forum SIG Community Advisory Panel Meeting Hospital Diversion Workgroup NC Council Spring Policy Forum Healthy Carolinians of Carteret County Board Meeting OCBHS Provider Meeting Atlantic House Board Meeting Consumer and Family Advisory Committee regular meeting FARO Conference Call
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date June 17, 2008 June 18, 2008 June 18, 2008 June 18, 2008 June 19, 2008 June 19, 2008 June 20, 2008 June 20, 2008 June 23, 2008 June 24, 2008 June 24, 2008 June 25, 2008 June 26, 2008 OCBHS Client Rights Meeting Civitan Club-Dan Jones guest Speaker
Event
Substance Abuse Initiative Training-Raleigh System of Care Youth Summit Microsoft Exchange Seminar OCBHS Client Rights Committee Meeting Endorsement Committee Meeting QI Forum Conference Call OCBHS Area Board Regular Meeting Human Services Clinical Council Crisis Intervention Team (CIT) Orientation Crisis Intervention Team (CIT) Orientation Quality Improvement Alliance Meeting-Duplin
SERVICE MANAGEMENT /SCREENING, TRIAGE AND REFERRAL: KATHY PARKER, SERVICE MANAGEMENT DIRECTOR, PAIVI JOHNSON, STR DIRECTOR ACCESS, TRIAGE AND REFERRAL 1.2.1. Access to Emergent Care (Current Quarter Detailed Report)
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
DOMAINS Onslow: # Determined To Need Emergent Care: Carteret: # Determined To Need Emergent Care: Out of County: # Determined To Need Emergent Care: Onslow: Care Was Provided Within 2 Hours Of Request: Carteret: Care Was Provided Within 2 Hours Of Request: Out of County: Care Was Provided Within 2 Hours Of Request:
Apr 29 23 11 29 23
May 55 19 13 55 19
Jun 48 19 12 48 19
TOTAL 132 61 36 132 61
%
100% 100%
11
13
12
36
100%
SUMMARY: OCBHS met the SFY 2008 performance standard: 100% of persons in crisis receive face to face emergency care within no more than two hours after the request for care is initiated. 1.2.2. Access to Urgent Care (Current Quarter Detailed Report) DOMAINS Apr May Jun TOTAL % of TOTAL
Onslow: # Determined To Need Urgent Care: Carteret: # Determined To Need Urgent Care: Out of County: # Determined to need Urgent Care Onslow: Care Was Provided Within 48 Hours Of Request: Carteret: Care Was Provided Within 48 Hours Of Request:
52 31 1 42 16
46 32 3 32 21
48 35 4 34 29
146 98 8 108 66 74% 67%
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
DOMAINS
Apr
May
Jun
TOTAL
% of TOTAL 75%
Out of County: Care Was Provided Within 48 Hours Of Request: Onslow: # Offered But Declined Appt Within 48 Hours Of Request: Carteret: # Offered But Declined Appt Within 48 Hours Of Request: Out of County: # Offered But Declined Appt Within 48 Hours Of Request: Onslow: # Scheduled Within 48 Hours Of Request But Did Not Show: Carteret: # Scheduled Within 48 Hours Of Request But Did Not Show:
1
1
4
6 3%
1
3
0
4 7%
6
0
1
7 0%
0
0
0
0 17%
5
8
12
25 15%
6
6
3
15
Out of County: # Scheduled Within 48 Hours Of Request But Did Not Show:
0
2
0
2
25%
SUMMARY: OCBHS did not meet the SFY 2008 Performance Standard in achieving and maintaining the annual average of 80%, the percent of persons in urgent need of mh/dd/sa services who receive their first face-to-face service within 48 hours. Our overall percentage was 72%. 1.2.3. Access to Routine Care (Current Quarter Detailed Report) DOMAINS Apr May Jun TOTAL % of TOTAL
Onslow: # Determined To Need Routine Care:
33
171
82
128
381
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
DOMAINS
Apr
May
Jun
TOTAL
% of TOTAL
Carteret: # Determined To Need Routine Care: Onslow: Care Was Provided Within 7/14 Days Of Request: Carteret: Care Was Provided Within 7/14 Days Of Request:
73 109 49
69 35 58
83 82 58
225 226 165 59% 73%
Onslow: # Offered But Declined Appt Within 7/14 Days Of Request:
9
4
4
17
4%
Carteret: # Offered But Declined Appt Within 7/14 Days Of Request:
4
0
7
11
5% 18%
Onslow: # Scheduled Within 14 Days Of Request But Did Not Show: Carteret: # Scheduled Within 7/14 Days Of Request But Did Not Show:
32
8
32
72 21%
20
11
18
49
SUMMARY: OCBHS met the SFY Performance Standard for achieving and maintaining the most current annual state average of 63%. Average percentage of 66.33% was achieved. SERVICE MANAGEMENT 1.3.5. Transition to Community Services (Psychiatric Hospital Bed-Day Allocations)
CHERRY ADMISSIONS Apr 08 10 4 2
Total 16
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
CHERRY ADMISSIONS May 08 Jun 08 Average Admissions April 08 through June 2008 7 8 8.3333 9 2 5 0 0 0.66667
Total 16 10
Bed Day Utilization July 1, 2007 through June 30, 2008 by Admission Type Adult Acute Bed Days Allocated: Bed Days Authorized Percentages Utilized 3285 2786 84.81% Adult Long Term 4964 2871 57.84% Child 5-12 0 248 N/A Child/ Adolescent 520 519 99.81% Geriatric
584 316 54.11%
SERVICE AUTHORIZATIONS PROCESSED IN QUARTER:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
SERVICE AUTHORIZATION BY SERVICE:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
SERVICE AUTHORIZATION BY PROVIDER:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
GUARDIANSHIP FUNCTION(S) OF LME:
Date 4/2/08 4/3/2008 4/3/2008 4/3/2008 4/3/2008 4/10/08 4/23/2008 4/23/2008 4/24/2008 4/29/2008 5/6/2008 5/13/2008 5/13/2008 5/15/08
Client
Location Raleigh
Who Attended Krista Pears Brenda, DSS, OCHD, Harold Brenda, Harold, DSS, OCHD Brenda, Harold, DSS, OCHD Brenda, Harold, DSS, OCHD Joyce Mozell Harold, Brenda, DSS, OCHD Harold, Brenda, DSS, OCHD
Outcome NC Council
Non Client OCHD Non Client OCHD Non Client OCHD 63795 6057 OCHD DSS
Guardianship family family
Non Client OCHD 15321 63795 OCHD Court
Harold, Brenda, Cl. Attorneys family & DSS Harold, Brenda, Cl. Attorneys family Substance abuse Telecon.
Non Client Court
165 Center Street Brenda McCumbee 25535 31350 OCHD OCHD Carolina Beach OCHD Brenda, DSS, OCHD Brenda, DSS, OCHD Joyce Mozell Brenda & Harold
Guardianship Guardianship
5/19/2008 31350
CONCURRENT UTILIZATION REVIEW:
Date 4/10/08 4/10/08
Client # 28289 28290
Location OCBHS OCBHS
Representative (s) Krista Pears Krista Pears
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Purpose State $ appeals State $ appeals
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date 4/16/08 4/28/08 4/29/08 4/29/08 4/29/08 4/30/08 5/1/2008 5/2/2008 5/5/08 5/6/2008 5/6/08 5/15/2008
Client #
Location Carteret OCBHS
Representative (s) Krista Pears Krista Pears Don, Susan, Kathy RHA & Krista Pears Harold Dunlop Krista Pears Krista/RHA Krista/Tara/RHA Joyce Mozell Krista Joyce Mozell Krista/Paivi
Purpose State $ appeals State $ appeals Client issues Client issues Discharge State $ appeals Ct meeting Ct meeting Community Collaborative Comm. Colloborat. Community Collaborative Continuity of care committee & Peer Bridger Program Difficult client discussion
20132 20132 17908
OCBHS OCBHS Phone with Cherry Carteret
20132 20132
OCBHS Carteret Carteret OCBHS Carteret Cherry Hospital
5/22/2008 5 clients
OCBHS
KRISTA, DON, RHA
COMMUNITY COLLABORATION:
Date 4/4/08 4/15/08 4/15/08 4/15/08
Client # 50265 17928 Cherry ACE Cherry Cherry
Location
Representative Krista Pears Joyce Mozell Krista Pears Krista Pears
Purpose Tx Team Mtg. Tx meeting Tx Team Mtg Tx Team Mtg
4/17/2008 30132 & 30127 4/21/2008 29570
Treatment Team Meeting Tammy Knight Utilization Review Tammy Knight
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date 4/25/08 4/25/08
Client # 17605 20132
Location OCBHS OCBHS Cherry Hospital
Representative
Purpose
Allied, RHA & Krista Pears Tx Team Mtg RHA & Krista Pears Krista Krista Krista Joyce Mozell Krista Pears Krista Pears Krista Pears Joyce Mozell Tx meeting Tx Team Mtg Tx team meeting Acute clients AO worker Tx meeting
5/14/2008 Robert w.
5/14/2008 Acute Supervisor Cherry Hospital 5/14/2008 AO worker Ellen 5/19/08 6/3/2008 6/4/2008 6/16/2008 6/16/08 6/16/2008 17605 6/24/2008 Team meeting Training Cherry Hospital Caswell Systems of care TQM training RHA meeting on clients
Krista Pears Krista Pears
POST PAYMENT CLINICAL AND ADMINISTRATIVE REVIEWS
Date 4/11/08 5/2/2008 5/7/2008 5/20/2008
Client #
Location
Representative Joyce Mozell
Purpose Appeals Appeals PPR for hearings worked on all month Appeal
OCBHS PPR— Genesis 29634 Working on written summaries OCBHS
Krista/Tara Krista Krista/Tara
QUALITY MANAGEMENT: JULIE KOKOCHA, QUALITY MANAGEMENT DIRECTOR 1.6.3. INCIDENT REPORTING
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
A total of 120 incident reports were received during the quarter. 107 of the incident reports submitted were ―Home‖ and 13 were ―Host‖. During the 2nd and 3rd quarters the LME focused on incident reports that documented a restraint or missed/refused medication. Quality Management had requested the providers who teach their staff about Medication Administration to submit the curricula for those classes. Only 3 were submitted. That will be presented to the Provider Relations Committee as a request so that we can all work to ensure that our providers have the best training possible. It will also be necessary to request that if one client experiences 3 medication errors during the month, even though it may technically be a Level I incident and therefore not required to be sent in to the LME that the providers agree to submit a report regarding the 3 errors. That should include the current policy and procedure related to medication administration and the action to be completed by the provider. Another area that will be addressed with the providers is to agree to have team meetings to determine if the problem is with the client or with the staff. Restraints have generally decreased as more providers participate in incident training and learn more about restraints and the requirements. A third area of concern is the number of providers who are not submitting the QM11 as required. Administration and Quality Management are developing a process to identify these providers and will be working with Provider Relations to increase the compliance.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
42
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
43
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
44
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
45
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
46
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
1.8.2.9. NC TREATMENT OUTCOMES AND PROGRAM PERFORMANCE SYSTEM (NC-TOPPS) Initial Assessments Performance Requirement: The LME, through providers, will collect outcomes information on its consumers following sampling methods and reporting schedules for the instrument being used. The instrument used will depend on the type of consumer. The NC-TOPPS is required for all MH/SA consumers ages six and older and shall be entered in the web-based system within 30 days of completion of the assessment as specified in the NC-TOPPS Implementation Guidelines. The expected number of initial assessments will be based on the number of consumers in the relevant target populations for whom services are reimbursed through the IPRS or MMIS reimbursement systems during the time period under review. To ensure accuracy and completeness, data reported below are for two quarters ago (time-lagged two quarters). Update Assessments Performance Requirement: The LME, through providers, will collect outcomes information on its consumers following sampling methods and reporting schedules for the instrument being used. The instrument used will depend on the type of consumer. The NC-TOPPS is required for all MH/SA consumers ages six and older and shall be entered in the web-based system within 30 days of completion of the assessment as specified in the NC-TOPPS Implementation Guidelines. An update assessment must be completed within two weeks before or after the required update month (e.g. 3-months, 6-months, 12-months, 18-months, etc). All update assessments shall be complete and accurate. The DMH/DD/SAS shall annually sample consumers with initial assessments to determine the timeliness and accuracy of 3-month update assessments. The 3-month update assessments shall be administered between 76 and 104 days after the initial assessment. To ensure accuracy and completeness, data reported below are for two quarters ago (time-lagged two quarters). PROVIDER RELATIONS AND SUPPORT 1.4.2. SB 163 Provider Monitoring The Quality Management Department conducted twenty (20) onsite reviews during the quarter. They are as follows:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date
Provider Agency
County
Basis for Monitoring
Service Monitored
Outcome
Status
04/07/08 Breakthrough Homes & Services 04/11/08 Preferred Alternatives, Inc.
Onslow
Service Record Review
Community Support
Quality Management completed follow-up review. Quality Management completed follow-up review.
Complete
Carteret Service Record Review
Community Support
Complete
04/21/08 ReNu Life Extended
Wayne
Service Record Review Complaints
Community Support
Quality Management completed follow-up review. Quality Management began review with assistance from Provider Relations Department staff.
Complete
04/22/08 SOS, Inc.
Onslow
Detox Services and Mobile Crisis Management
Complete
04/23/08 Alofa Behavioral Healthcare, Inc.
Onslow
Service Record Review Complaints
Community Support
Quality Management completed follow-up monitoring review. Quality Management continued review of services from April 22, 2008.
Complete
04/23/08 SOS, Inc.
Onslow
Detox Services
Complete
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date
Provider Agency
County
Basis for Monitoring
Service Monitored
Outcome
Status
04/25/08 A Beacon of Hope
Onslow
Service Record Review
Community Support
Quality Management completed follow-up monitoring review.
Complete
04/25/08 SOS, Inc.
Onslow
Complaints
Detox Services
Quality Management continued review of services from April 22, 2008 and April 23, 2008. Quality Management completed review.
Complete
04/28/08 SOS, Inc.
Onslow
Complaints
Detox Services
Complete
Plan of Correction issued for deficiencies 05/01/08 Stevens Healthcare Onslow Service Record Review Community Support Quality Management completed follow-up review. Complete
05/05/08 Spirit of Excellence/ Guardian Care 05/06/08 Genesis Therapeutic
Onslow
Service Record Review Service Record
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Community Support
Quality Management completed follow-up review. Quality Management completed follow-up
Complete
Onslow
Community
Complete
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date
Provider Agency
County
Basis for Monitoring
Service Monitored
Outcome
Status
Services 05/08/08 Martha’s Group Home Onslow
Review Service Record Review
Support Community Support
review. Quality Management conducted 1st followup review. Quality Management Director and Customer Services & Affairs conducted the monitoring review. Complete
05/27/08 Newport Developmental Center
Carteret Compliance with Rules
Day Supports
Complete
05/29/08 SOS, Inc.
Onslow
Service Record Reviews
Community Support
Quality Management completed follow-up review.
Complete
06/06/08 Martha’s Group Home
Onslow
Service Record Review
Community Support
Quality Management conducted 2nd followup review and approved the implementation of the action steps. Quality Management conducted follow-up review. An additional review is required.
Complete
06/11/08 Advocates for Consumer Empowerment (ACE)
Onslow
Service Record Review
Community Support
In Progress
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Date
Provider Agency
County
Basis for Monitoring
Service Monitored
Outcome
Status
06/16/08 IQuOLIOC
Onslow
Service Record Review
Community Support
Quality Management completed follow-up review and approved the implementation of the action steps. Quality Management Assisted Provider Relations in postendorsement followup review.
Complete
06/27/08 SOS, Inc.
Onslow
Complaints
Detox Services
Complete
06/30/08 Helping Hands Community Support Services, Inc.
Onslow
Post Payment Clinical Review
Community Support
Quality Management completed follow-up review and approved the implementation of action steps.
Complete
INCIDENT REPORTING AND MANAGEMENT: The Quality Management Department conducted one (1) incident report training during the quarter for provider agencies within the Onslow and Carteret communities. There were five (5) provider agencies represented at the training with a total of seven (7) attendees.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
INVOLVEMENT IN COMMUNITY COLLABORATIVE(S): During the 4th quarter, the System of Care Coordinator (SOC) facilitated the 3rd, 4th and 5th Onslow County System of Care Local Community Collaborative and Carteret County System of Care Local Community Collaborative. During the month May, all participants were given information and green ribbons to wear for Children’s Mental Health Awareness Week. Child and Family Teams for Person-Centered Planning: In the 4th quarter, the SOC Coordinator facilitated 3 child and family team meetings and provided 10 technical assistance sessions regarding Child and Family Teams. Youth and Family Involvement and Leadership: In the 4th quarter, the SOC Coordinator attended 2 of the Onslow Carteret Behavioral Healthcare Services (OCBHS) Consumer Family Advisory Committee (CFAC) monthly meeting and provided information regarding SOC and Breakfast Club Youth Summit. During the 4th quarter, the SOC Coordinator held a total of 13 family member discussions to encouraged family members to be involved local and at the state level. The SOC Coordinator attended the Carteret County State of the Child Conference and watched the voices of local youth demonstrated by a musical/dramatic presentation.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
In the 4th quarter, the SOC Coordinator co-facilitated 6 Breakfast Club Youth Summit Committee Planning Meetings. The 1st Annual Breakfast Club Youth Summit was held for Onslow and Carteret Counties at-risk youth ages 15-18 years old gathered together to build life skills, explore resources and gain knowledge about becoming responsible adults in our communities. Interagency Collaboration: In the 4th quarter, the SOC Coordinator participated in a total of 36 meetings: 6 North Carolina Collaborative for Children, Youth and Families meetings 4 North Carolina Collaborative for Children, Youth and Families Training and Technical Assistance Workgroup meetings 3 OCBHS Provider Meetings 3 Carteret County Juvenile Crime Prevention Council meetings (JCPC) 3 Onslow County Child Fatality Prevention Team (CFPT) and Onslow County Community Child Protection Team (CCPT) meeting 3 Carteret County joint meeting regarding how to use Carteret County Health Department General Aidto-County funds to address suicide prevention in Carteret County 2 joint meetings between OCBHS, Onslow County Department of Social Services (DSS) and the Onslow Health Department 2 joint meetings between OCBHS and Carteret County Department of Social Services (DSS) 2 Onslow County Juvenile Crime Prevention Council meetings (JCPC) 2 North Carolina Child Advocate Weekly Conference Calls 1 Carteret County Child Fatality Prevention Team (CFPT) and Carteret County Community Child Protection Team (CCPT) meeting 1 North Carolina Trauma Task Force Teleconference 1 Camp Eckerd Agency Day 1 Onslow County Health Department regarding Youth Summit 1 Carteret County Health Department regarding Youth Summit 1 Carteret County Health Department HIV testing Day System of Care Training and Technical Assistance: In the 4th quarter, the SOC Coordinator provided a total of 33 Technical Assistance regarding SOC in Onslow and Carteret Counties and attended a total of 9 trainings/conferences/meetings: SOC Regional Learning Communities Hospice Foundation of America’s 15th Annual Living with Grief Teleconference ―Children and Adolescents‖ Strengths Based Supervision: ―Families as Leaders‖ Carteret County State of the Child Conference SOC Breeze ―Family Partnership‖‖ Strengths Based Supervision: ―Cultural Awareness and Impact‖ SOC Breeze ―Care Review‖‖ 1st Annual Breakfast Club Youth Summit
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
SOC Breeze ―Partnering with Providers‖
Quality Management: In the 4th quarter, the SOC Coordinator participated in a total of 15 quality management events: 6 OCBHS ―Fireside Chat‖ 3 Carteret County Department of Social Services (DSS) Foster Care Review Team 3 Onslow County Child Fatality Prevention Team (CFPT) and Onslow County Community Child Protection Team (CCPT) case reviews 1 Total Quality Management Training 1 Staff Development Day 1 OCBHS Quality Improvement Committee QUALITY MANAGEMENT: IDENTIFICATION AND REMEDIATION OF PROBLEMS The LME shall have a process for timely identification and response to consumer incidents and stakeholder complaints about service access or quality. Plans of Correction Issued: Date Provider Agency County Basis for Monitoring Service Monitored Outcome Status
05/12/08 SOS, Inc.
Onslow
Detox and Mobile Crisis complaints
Detox; Mobile Crisis
Quality Management and Provider Relations conducted a review of complaints during the month of April. Quality Management issued a Plan of Correction for Detox services.
In Progress
Plans of Correction Follow-up:
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency A Beacon of Hope
Source
Identified Issues
Outcome
Service Record Review
Ensure that service notes reflect treatment for the duration of the service that was billed.
Plan of Correction and follow-up monitoring review was approved and closed. Plan of Correction action steps were approved.
Advocates for Consumer Empowerment (ACE)
Service Record Review
Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed.
Initial and secondary follow-up monitoring reflected actions steps had not been implemented. Plan of Correction and follow-up monitoring review was approved and closed.
Allied Healthcare
Service Record Review
Alofa
Service Record Review
Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to
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Plan of Correction and follow-up monitoring review was approved and
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Alternative Care Treatment Systems (out of catchment provider) Service Record Review Ensure that the Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed.
closed.
Plan of Correction approved and closed.
Monitoring to be conducted by local LME.
Breakthrough Homes & Services
Service Record Review
Ensure that all service notes relate to goals listed in the service plan Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service
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Plan of Correction and follow-up monitoring review was approved and closed.
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
that was billed. Carolina Choice Service Record Review Ensure that there is a service note entry for every service event billed. Ensure that the Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. CNC/Access, Inc. Service Record Review Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that all service notes/service plans are individualized per person. Ensure that service notes reflect treatment for the duration of the service that was billed. Plan of Correction and follow-up monitoring review was approved and closed. Plan of Correction and follow-up monitoring review was approved and closed.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
Ensure that authorizations are in place to cover the date of service. Coordinated Healthcare Service Record Review Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Plan of Correction was Pended.
Plan of Correction could not be approved due to provider agency site closed in Onslow County. Plan of Correction was Pended.
Easter Seals
Service Record Review
Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed.
Plan of Correction could not be approved due to service no longer being provided in catchment area. Plan of Correction was Pended.
Family Perspectives
Service Record Review
Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments.
Plan of Correction
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
Ensure that all service notes/service plans are individualized per person. Ensure that service notes reflect treatment for the duration of the service that was billed. Ford Home Service Record Review Ensure there is a valid service order for the service billed. Ensure the service plan is current with the date of service. Ensure the service plan identifies the type of service billed. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. Genesis Therapeutic Service Services Record Review Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. Health Care Connections Service Record Ensure that service notes reflect treatment for the duration of the service
could not be approved due to service no longer being provided in catchment area.
Plan of Correction and follow-up monitoring review was approved and closed.
Plan of Correction and follow-up monitoring review was approved and closed.
Plan of Correction approved and closed.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
Review
that was billed. Ensure that authorizations are in place to cover the date of service.
Monitoring to be conducted by local LME. Plan of Correction and follow-up monitoring review was approved and closed.
IQuOLIOC
Service Record Review
Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed.
Martha’s Group Home
Service Record Review
Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed.
Plan of Correction and follow-up monitoring review was approved and closed.
May Francis Partnership (out of catchment provider)
Service Record Review
Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community
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Plan of Correction approved and closed.
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Parakletos (out of catchment provider) Service Record Review Ensure there is a valid service order for the service billed. Ensure the service plan is current with the date of service. Ensure the service plan identifies the type of service billed. Ensure that all service notes/service plans are individualized per person. Ensure that service notes reflect treatment for the duration of the service that was billed. People of Potential Service Record Review Ensure that all service notes relate to goals listed in the service plan. Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Plan of Correction was Pended. Monitoring to be conducted by local LME. Monitoring to be conducted by local LME.
Plan of Correction approved and closed.
Plan of Correction could not be approved due to service no longer being provided in
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. Preferred Alternatives Inc. (PAI) Service Record Review Ensure that there is a service note entry for every service event billed. Ensure that service notes indicate the duration of the service and that it matches the units billed. Pride of NC Service Record Review Ensure that service notes reflect treatment for the duration of the service that was billed.
catchment area.
Plan of Correction and follow-up monitoring review was approved and closed.
Plan of Correction and follow-up monitoring review was approved and closed. Plan of Correction approved and closed.
RASS LLC (out of catchment provider)
Service Record Review
Ensure that all service notes/service plans are individualized per person. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service.
Monitoring to be conducted by local LME.
ReNu Life Extended
Service Record Review
Ensure that the Community Support Adult service notes reflect one to one interventions with the community to
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Plan of Correction approved and closed.
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes indicate the duration of the service and that it matches the units billed. Ensure that service notes reflect treatment for the duration of the service that was billed. SOS, Inc. Service Record Review Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. Spirit of Excellence Service Record Review Ensure that all service notes relate to goals listed in the service plan. Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to
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Monitoring to be conducted by local LME.
Plan of Correction and follow-up monitoring review was approved and closed.
Plan of Correction and follow-up monitoring review was approved and closed.
LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
Responsible Agency
Source
Identified Issues
Outcome
develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Ensure that authorizations are in place to cover the date of service. Stevens Healthcare Service Record Review Ensure that the Community Support Adult and Community Support Child service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Vrooman Home Service Record Review Ensure that the Community Support Adult service notes reflect one to one interventions with the community to develop interpersonal and community coping skills including adaptation to home, school and work environments. Ensure that service notes reflect treatment for the duration of the service that was billed. Plan of Correction was Pended. Plan of Correction and follow-up monitoring review was approved and closed.
Plan of Correction could not be approved due to endorsement of service withdrawn by provider.
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LME Fourth Quarter Report: April through June 2008
Onslow Carteret Behavioral Healthcare Service
QUALITY MANAGEMENT SYSTEM The Quality Improvement Committee conducted three meetings during the quarter. Members reviewed monthly meeting minutes and reports, and discussed community events. The members were provided updates on the Frequency Extent of Monitoring (FEM) Tool, the Provider Monitoring Tool, Service Record Reviews, and issues reviewed at Quality Improvement Forums held in Raleigh, NC. The Quality Management Director attended the North Carolina FARO Conference in Wilmington, NC. Sessions attended included NC-TOPPS Update, QM102 – Internal Monitoring, QM103 – Systems Data, and QM104 – Impacting Performance. The Quality Management Department had two staff members attend the Adolescent Community Reinforcement Approach (ACRA) - an Evidence Based Treatment Program presentation in Raleigh, NC. The Quality Management Department attended three (3) North Carolina Quality Improvement Forums in Raleigh, NC during the quarter. Items discussed included the Frequency Extent Monitoring (FEM) Tool, the Provider Monitoring Tool, Person Centered Planning Review Tool, CMS Provider Reviews, and updates on Rules, the 25% Qualified Professional Requirements, the NC-TOPP system, and staff qualification. The Quality Management Director attended four (4) Alliance meetings during the quarter. The Quality Management Director attended the Local Management Entity’s Director’s meeting in Raleigh, an Alliance meeting held at the Caswell Center in Morehead City, an Information Technology Alliance conference call, and a Quality Alliance meeting in Wallace, NC. The Quality Management Department had two (2) staff members participate in the United Way 5th Annual Day of Caring event that was held in May 2008. The staff dedicated their time and efforts with assisting the local United Service Organization (USO) in moving items to their warehouse and sorting/organizing products being offered to the military service men and women. The Quality Management Director conducted a review of the Newport Developmental Center with the Customer Service & Affairs Director on May 27, 2008. SERVICE RECORD REVIEW The Quality Management Department is in the process of completing the follow-up monitoring reviews for the Plans of Corrections issued to twenty-seven (27) provider agencies as a result of the Service Record Reviews conducted in December 2007. Out of the twenty-seven (27) providers, five (5) agencies were outside of the Onslow Carteret catchment area and Home Local Management Entities were notified to conduct follow-up reviews. The remaining twenty-two (22) agencies within the catchment area are in the final stages of review. Sixteen (16) Plans of Corrections have been approved and closed, one (1) is still in progress, and five (5) are in a pending status due to services or sites no longer operating in the area.
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