Behavioral Health Quality Review Final Assessment Report

Behavioral Health Quality Review

Final Assessment Report

Provider Name:

Turning Point Behavioral Health & Wellness

PVGA #277

Location of Review:

4292 Memorial Drive Suite C, Decatur, GA 30032

Regions of Operation:

3

Date Range of Review:

November 23-24, 2015

Quality Assessors: Amanda L Hawes, LCSW and Brianne Slover, LCSW

Records Reviewed: 6 Provider Tier Level: 2

The ASO Collaborative in partnership with the Department of Behavioral Health and Developmental
Disabilities (DBHDD) believes in easy access to high-quality care that leads to a life of recovery and
independence for the people we serve. The Quality Division is dedicated to ensuring services
provided are person-centered and include a commitment to wellness and recovery.

Individual’s Staff’s
Perception of Care Perception of Care
Number Interviewed: 3 Number Interviewed: 5

Rights Whole Safety Rights Whole Safety
100% Health 93% 100% Health 100%
65% 98%
Choice Person Choice Person
93% Focused Centered 100% Focused Centered
Outcome Practices Outcome Practices

Areas 100% Areas 100%
89% 100%

Community Community
93% 100%

The Individual Interview is not calculated into the overall score. The Staff Interview is not calculated into the overall score.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 1 of 10 Rev. 9-21-15

Individual Interview Observations:
• One guardian expressed how responsive staff were when she needed additional resources for
her child who receives services. Shares that they adjust the frequency of their visits based on
how the individual is doing. “I love the services. I don’t have any complaints. They’re always
available if I call. They will come out that day if I need something.”
• Another guardian shared that the staff are helping her child become more independent and
honor their preferences by having male staff working with him.
• A guardian shared that staff were helping her child gain access to extracurricular activities
and sports by addressing the family’s need for transportation.
• Some concerns shared by individuals include not knowing what a safety or crisis plan is and
not being aware that the agency provides psychiatric services.

Staff Interview Observations:
• Staff repeatedly stated how supported they feel by administration and shared that leadership
is always available for consultation and supervision as needed. “The company is great! I can
call them anytime.”
• Staff shared the helpfulness of staff meetings and agency trainings.
• Staff shared their passion for providing services in the community by stating how much more
effective they feel they are able to be when able to meet the individual and family where
they live. “Going into the home is very important and gives you the opportunity to get close
to those we serve.”
• All staff were aware of mandated reporting and safety planning.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 2 of 10 Rev. 9-21-15

Billing
Validation

84%

Compliance Overall Focused
w/ Service Score Outcome
Guidelines 82%
Areas
90%
77%

Assessment
&

Tx Planning
78%

The overall score is calculated by averaging the four areas:
• Billing Validation
• Focused Outcome Areas
• Assessment and Treatment Planning
• Compliance with Service Guidelines

Each area accounts for twenty-five percent (25%) of the Overall Score.
Review questions are based on DBHDD and Medicaid requirements.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 3 of 10 Rev. 9-21-15

54% Billing Validation Total $ Unjustified
Total $ Justified
$6,000.00 $901.22
$5,000.00
$4,000.00 $4,645.96
$3,000.00
$2,000.00 Total Amount Reviewed: $5,547.18
$1,000.00

$0.00

Billing Validation*

Strengths:

84% • The majority of notes contained documentation that reflected
interventions that supported the units billed and addressed the
assessed needs of the individual served. For example, paraprofessional
staff documented identifying triggers for disruptive behaviors and

strategies to address identified triggers to assure the individual would

be more likely to stay in class and avoid physical altercations in school.

Opportunities for Growth:
• Six progress notes were not filed in the record.
• Three progress notes lacked the staff member’s signature and date of
entry.
• Three progress notes did not contain documentation to support the
units billed. The narrative of the note stated “fix note.”
• One progress note for Community Supports documented interventions
that were insight oriented in nature and lacked skills-building
interventions.

*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; Fee for
Service (FFS) is the sum of paid encounters; State Contracted Services (SCS) is the estimated sum of the
value of accepted encounters.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 4 of 10 Rev. 9-21-15

Assessment & Treatment Planning

Core Customer Criteria 33% 100%
Medical Screening 33% 100%
83%
Individualized Language 100%
Goals honor achievement of the individual and/or family 100%

Interventions/objectives are related to goals 100%
Needs assessed are addressed

Whole-health wellness goals and interventions

Co-occurring health conditions included 0%

Discharge plan has step-down service

Assessment & Treatment Planning

Strengths:

78% • Behavioral Health Assessments contained prompts for most recent
dental and physical exam and prompts to list current and previous
prescribed medications.

Opportunities for Growth:
• Four treatment plans did not address all the individual’s assessed
needs. For example, an individual’s history of suicide attempts and
alcohol use was not included on the treatment plan.
• Four treatment plans lacked goals, objectives, or interventions that
addressed the individual’s wellness.
• Neither of the treatment plans for individuals with co-occurring
disorders had those disorders addressed on the treatment plan. For
example, one individual had a rare blood disorder that affected his
access to traditional treatment, but this was not addressed on the
treatment plan. The other example was an individual who failed a drug
test, but substance abuse was not included on the IRP.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 5 of 10 Rev. 9-21-15

Rights Whole Safety
83% Health 13% 86%

Choice Focused Person
86% Outcome Centered
Practices
Areas
96%
77%

Community
81%

Focused Outcome Areas

Strengths:

77% • Records contained a “Freedom of Choice” document that
acknowledged that individuals were informed they had the right to
choose from which provider they received services.

• A “Patient Confidential Communication Preference” survey
identified in what manner the individual and legal guardian prefer to

be contacted and whether or not messages can be left.

Opportunities for Growth:
• Whole health
o Records lacked documentation which reflected that ongoing
assessments to determine needs for external health referrals
was occurring and that subsequently staff were
communicating with these external referrals. Several
individuals were receiving medication from primary care
physicians or other doctors, but there was no documentation
supporting that staff were attempting to communicate with
these other providers or that documentation was kept up-to-
date with what treatment the individual was receiving from
these external sources.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 6 of 10 Rev. 9-21-15

o Three individuals lacked evidence that conditions were
assessed, monitored and recorded. For example, an
individual prescribed Adderall had no documentation
pertaining to the monitoring of this medication and its
potential side effects.

• Safety
o The two individuals who were prescribed medication by the
agency’s psychiatrist did not have an informed consent
signed by both the individual or legal guardian and the
prescribing physician.
o While all records documented a safety plan, the majority of
plans did not identify emergency numbers to call or that the
agency was primarily responsible.

• Rights
o While rights and responsibilities were clearly reviewed at the
onset of services, documentation did not reflect that the
individual’s rights and responsibilities were reviewed
annually with the individual.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 7 of 10 Rev. 9-21-15

Compliance With Service Guidelines

PSYCHIATRIC TREATMENT 100%
INDIVIDUAL OUTPATIENT SERVICES 90%

FAMILY OUTPATIENT SERVICES 100%
COMMUNITY SUPPORT - INDIVIDUAL 81%

Compliance with Service Guidelines

Strengths:

90% • Records contained a “Monthly Progress Report” completed by the
individual’s therapist that summarizes interventions provided that
month, the individual’s response to interventions, an overall
assessment of progress, and planned future interventions.

Opportunities for Growth:
• Community Supports lacked documentation of resource and service
coordination in four records. One individual was failing classes and
wanted to obtain employment, but documentation lacked evidence
that community support staff were providing resources to address
these needs.
• Community Supports and Individual Outpatient Services lacked
documentation of the individual’s progress (or lack of progress)
toward goals specified on the treatment plan. Typically,
documentation would reflect the same vague statement from note
to note. Progress statements on the “Monthly Progress Report” also
failed to document information supporting an assessment of
progress.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 8 of 10 Rev. 9-21-15

Additional Comments on Practices/Concerns beyond the general scope of the
Practices review were discovered by the Quality Assessors that
may have the potential to impact service delivery,
quality of care, or may represent a risk for the provider.
The following practices or concerns were noted during
the review:

Strengths:
• The agency’s psychiatrist and nurse are available for appointments during the weekend to
work with individual’s school schedules.

Opportunities for Growth:
• Records contained releases of information that were signed by the individual’s guardian but
did not indicate to what agency or individual the protected information was to be released or
received.
• Records did not document allergy alerts. An assessment for one individual reflected that the
individual was allergic to bananas and penicillin, but the front of the record lacked an alert to
notify staff of these allergies.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 9 of 10 Rev. 9-21-15

Technical Assistance Providers are reminded of the responsibility to maintain
Recommendations 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.

The following are recommendations given as a result of the review:
Billing Validation

Ensure documentation supports what is billed (see comments in Billing Validation section).
Ensure codes/services billed are consistent with documentation.
Ensure time/units billed is supported by documentation.

Assessment & Treatment Planning

Ensure treatment/recovery/service plans address all areas of assessed need.
Ensure treatment/recovery/service plans contain goals, objectives, and interventions that
promote whole health and wellness.
Ensure treatment/recovery/service plans address co-occurring issues and/ conditions.

Focused Outcome Areas

Ensure there is documented communication with external referrals and resources to
determine the results of testing, treatment, and referral.
Ensure individuals’ current medical conditions are assessed, monitored, and recorded.
Ensure there are documented safeguards utilized for medications known to have substantial
risk or undesirable effects.
Ensure documentation supports that individuals (or parent/guardian) have been educated on
the risks and benefits of all prescribed medications.
Ensure documentation supports that individuals have been informed of their rights and
responsibilities at the beginning of services and then at least annually thereafter.

The Georgia Collaborative ASO / Beacon Health Options

For information on appeals and post-review surveys, please visit www.georgiacollaborative.com

Page 10 of 10 Rev. 9-21-15