Behavioral Health Compliance and Quality: Opportunities ... · 3/26/2013 1 Behavioral Health Compliance and Quality: Opportunities and Challenges for Integration and Implementation

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BehavioralHealthComplianceandQuality:OpportunitiesandChallengesforIntegration

andImplementation

(sessionP14)

17th Annual InstituteHealth Care Compliance Association

National Harbor, MD

April 21 – April 24, 2013

PanelMembers

• Marcella Henry, Compliance Officer,

Sunrise Community Inc.

• Lori McLaughlin, Sr. V.P., General Counsel & Secretary, Devereux Foundation

• Robyn Joppy, V.P. Corporate Compliance,

Keystone Human Services

• Cheryl Wagonhurst, Attorney at Law,

Law Offices of Cheryl Wagonhurst

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PollingQuestion

What is your industry?

A. BEHAVIORAL HEALTH

B. MENTAL HEALTH

C. SUBSTANCE ABUSE

D. HOME HEALTH

E. OTHER

PollingQuestionHow long has your company had a compliance program?

A. One year or less

B. One – Five years

C. Five – ten years

D. More than ten years

E. Company does not have a compliance program!

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PollingQuestion

How would you rate the degree of compliance challenges that your organization is facing today?

A. More than prior years

B. Less than prior years

C. About the same

D. I have no clue what kind of impact the Affordable Care Act will have on my organization’s compliance challenges

PollingQuestion

Why did you come to this session?

A. Learn about the compliance challenges faced by my peers and ways to deal with challenges

B. CEU credits

C. Opportunity to share my ideas and dialogue with my peers and develop solutions to benefit everyone!

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Introduction

• Session Goals

•Audience Participation

•Use of Polling Software

• Toolkit

• Take‐away Points

PanelMemberPerspectiveson“ChangingEnvironment”forBehavioralHealthProviders

• Marcella Henry – Compliance Officer (Florida and southern states)

• Lori McLaughlin – General Counsel (National Presence)

• Robyn Joppy – Compliance Officer (National and International Presence)

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OVERSEEINGQUALITYOFCAREFROMACOMPLIANCEOFFICER’SPERSPECTIVE

• SUNRISE COMMUNITY INC, HEADQUARTERED IN MIAMI, FLORIDA.

• A PRIVATE NOT FOR PROFIT ORGANIZATION ASSISTING OVER 2157 PEOPLE WITH INTELLECTUAL AND PHYSICAL DISABILITIES THROUGHOUT 7 STATES IN A VARIETY OF SETTINGS INCLUDING RESIDENTIAL, ADULT DAY CENTERS, ELDER CARE, SUPPORTED LIVING, SUPPORTED EMPLOYMENT.

LOCATIONS: FLORIDA; GEORGIA; ALABAMA; TENNESSEE;

MARYLAND; VIRGINIA AND CONNECTICUT.

• STAFF = 3399

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THE ORGANIZATION’S MISSION

“To provide people with disabilities the assistance and supports necessary to enable them to live valued lives in the community”

PollingQuestion

IS QUALITY A MAJOR FOCUS FOR YOUR ORGANIZATION?

A. YES

B. NO

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PollingQuestion

Do you monitor quality in your organization?

A. Yes

B. No

PollingQuestion

How does your organization monitor quality?

A. External

B. Internal

C. Observations

D. All of the above

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• WHAT DOES QUALITY OF CARE MEAN IN OUR INDUSTRY

• WHY IS IT SO IMPORTANT?

• THE MOST IMPORTANT CHALLENGE OF OUR MISSION IS TO ENSURE THE HEALTH & SAFETY OF EVERY INDIVIDUAL OFFERED SERVICES BY SUNRISE!

• WE MUST VALIDATE THAT QUALITY SERVICES ARE BEING PROVIDED!


• IT IS ALSO THE TOP PRIORITY OF THE HEALTH & HUMAN SERVICES OFFICE OF THE INSPECTOR GENERAL AND IT IS WRITTEN IN THEIR WORK PLAN TO ENSURE THAT ORGANIZATIONS THAT RECEIVE MEDICAID FUNDS ARE ENSURING THAT THE QUALITY OF CARE FOR ALL, IS BEING PROVIDED & PRACTICED.

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HOW DO WE GO ABOUT ENSURING THAT THIS IS ACCOMPLISHED?

THERE ARE FEDERAL AND STATE REGULATIONS THAT WE MUST ENSURE ARE MET IN ORDER TO BE FUNDED.

THERE ARE INTERNAL POLICIES & PROCEDURES TO GUIDE US.

• THERE ARE ESTABLISHED INTERNAL SYSTEMS AND PROTOCOLS.

• THERE ARE MANAGEMENT STRUCTURES THAT HAVE BEEN DESIGNED TO ENSURE COMPLIANCE OCCURS.


• WHAT DO WE NEED TO OVERSEE?

• ALL ASPECTS OF THE SERVICES PROVIDED!!

• STAFF TRAINING IS ESSENTIAL!!!WHAT TYPES OF TRAINING DO YOU PROVIDE?

• MAIN FOCUS IS THROUGH AUDITS, MONITORING & SITE REVIEWS.

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PollingQuestion

Do you feel that you have all the supports you need to perform your job as a Compliance Officer?

A. Yes

B. No

PollingQuestion

Are you kept informed on important issues that affect your job in the company?

A. Yes

B. No

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• WHAT ARE THE IDENTIFIED RISKS FOR THE ORGANIZATION?

• HOW DO YOU GO ABOUT MONITORING THOSE RISKS & TIE THEM TO QUALITY??

• HOW DO YOU GO ABOUT GETTING SUPPORT AS COMPLIANCE OFFICERS IN OVERSEEING QUALITY??


• ACCOUNTABILITY AT ALL TIMES

FUNDED SERVICES PROVIDED?? PROOF!!!.

• HEALTH SERVICES & MEDICATION PROTOCOL

• INTERNAL CONTROLS FOR OPERATIONAL EXPENDITURES

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MANAGING CLIENT TRUST FUNDS, AND ALL

FEDERAL/ MEDICAID FUNDS THAT FLOW THROUGH THE

ORGANIZATION!

WHAT ARE THE COMPANY’S CHECKS AND

BALANCES???


DOCUMENTATION INCLUDES…CASE NOTES, SERVICE LOGS, MARS, HOME/COMMUNICATION

LOGS,INCIDENT REPORTS, AS EXAMPLES!

BILLING FOR SERVICES

TRANSPORTATION SERVICES

ON SITE REVIEWS ON VARIED SHIFTS.

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• SO…OVERSEEING QUALITY OF CARE INVOLVES US AS COMPLIANCE OFFICERS.

• WE MUST EMPOWER EVERY EMPLOYEE TO DO THINGS CONSISTENTLY RIGHT, ALL THE TIMES!

• ANY DEPARTURE FROM EXISTING POLICIES AND PROCEDURES; AND TRIED AND TRUE PROTOCOLS, WILL INEVITABLY LEAD TO MISTAKES!

DEVELOPING A CULTURE THAT WORKS TOWARDS

BEING TRANSPARENT WITH SUPPORTS, WILL BE A

WIN WIN SITUATION!

PollingQuestion

Are the results of your Quality reviews received well by management?

A. Yes

B. No

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• HERE IS AN EXAMPLE OF AN PROGRAM THAT WAS IMPLELEMENTED OVER A YEAR AGO EMPOWERING ALL EMPLOYEES TO BE INVOLVED IN ESURING QUALITY SERVICES IS BEING PROVIDED AND IF NOT, WHAT TO DO!

STOPSTOP

Conversations

ThinkTalkAct

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Stop . . Wait a minute . . . We need to talk.

When . . .

• Individual or group of individuals is at risk

• Employee is at risk

• Violation of Sunrise Policy or Procedure

Staff will be. . .• Empowered!

• Expected to speak

• Risk for individual(s)

• Risk for self

• Risk for Sunrise Policy or Procedure

A Sunrise employee must say “YES” to a STOP Conversation request!

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What do you do when you receive a “STOP Conversation” request?

• Say “YES”

• Listen Respectfully

• Talk (Discuss)

• Think

• Act or Consult (boss or NHQ)

• Provide Closure

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What is your role as Supervisor/Manager/Leader?

• Encourage

• Reinforce

• Facilitate a Learning Circle

• Insist on STOP Conversations

• Probe why a STOP conversation did not take place (when it should have)

TheResults• MORE STAFF ARE SPEAKING UP.

• INTERVENTIONS ARE HAPPENING

QUICKER.

STAFF ARE MORE EMPOWERED.

STAFF HAVE ACCESS TO MANAGEMENT AT ALL LEVELS IN THE ORGANIZATION.

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QUESTIONS/COMMENTS??

DEVEREUX

• 501(C)(3)non‐profit organization

• Largest national provider of behavioral health services

• Revenues of $400m

• Over 6000 employees

• Serves over 20,000 individuals in 12 states

• Infants in foster care to senior citizens

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DEVEREUX’SMISSION

DEVEREUX CHANGES LIVES AND NURTURES HUMAN POTENTIAL. WE INSPIRE HOPE, ENSURE WELL‐BEING, AND PROMOTE MEANINGFUL LIFE CHOICES. OUR MISSION IS ACHIEVED THROUGH A WIDE RANGE OF SERVICES AND SUPPORTS FOR INDIVIDUALS AND THEIR FAMILIES.

MakingComplianceaFriendofQuality

“When you find it, fix it!”Of course, according to your policies for updating Plans of Care!

Also:Ensure full compliance with the Conditions of Participation for all services provided (credentials of staff, background checks, maintenance of attendance records, etc.)Focus on the basics – timeliness of all documentation legibility, listing of credentials, appropriate signatures

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MakingComplianceaFriendofQuality

Focus on improving therapeutic service delivery and ensure compliant documentation at the practitioner levelEmphasize an active concurrent review process for each service line and use supervision to assess improvement

MakingComplianceaFriendofQuality‐PROCESS

• Internal Audit & Clinical Operations staff partner to perform audits

• Include Center Clinical, Quality and Finance staff

• Audit staff performs quantitative billing review –presence/absence of documentation

• Clinical & QI staff perform qualitative review – quality & appropriateness of documentation

• Opening and Closing Conferences

• Audit Reports to each Center

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MakingComplianceaFriendofQuality‐OUTCOMES

• Comprehensive risk assessment of compliance with Medicaid billing requirements

• Determination of risk of give backs

• Training of center Clinical, QI and Finance staff

• Sense of historical non‐compliance and revenues that may need to be disclosed

• Avoidance of future non‐compliance and give backs

MakingComplianceaFriendofQuality‐Methodology

• Center staff identify high volume / high dollar programs

• Targeting high volume / high dollar programs & clients

Programs: e.g. outpatient, case management, foster care, group homes residential (biggest financial risk)

(Note: residential is high dollar, low volume but due to

bundled rate, risk of pay back is higher)

Clients: e.g. out of state Medicaid clients, adult autistic clients,

young adult high functioning IDD clients, Asperger’s &

foster care clients

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MakingComplianceaFriendofQuality‐ Methodology

• Audit staff pull random sample of clients from program

• Record review on site

• Based on billable events

• Focal point: Must meet conditions of participation; medical necessity

• Require Corrective Action Plans (CAP) after each review

• Conduct further audits based on CAPs

MakingComplianceaFriendofQuality‐ TOOLKIT• Medicaid Quick Tips

• Action Verbs for Documenting “Active Treatment”

• What is active treatment?

• What is required for

• Assessments?

• Treatment plans?

• Clinician progress notes?

• Physician progress notes?

• Case Management and Targeted Case Management?

• Community Based Waiver Programs?

• Outpatient and Clinic Based Services?

• Psychiatric Residential Treatment Facilities (PRTF)?

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POLLINGQUESTIONWhat do the Conditions of Participation require when staff conduct a debriefing after a restraint or seclusion?

A. Face to Face discussion within 12 hours with staff and client

B. Parent/Guardian must be present

C. Discussion/documentation must include:

‐ The emergency safety intervention that was required

‐ Alternative techniques that may have prevented the restraint‐ Procedures to be used to prevent any recurrence

‐ Outcome of the intervention, including any injuries

‐ Staff who were present

‐ Staff who were excused

D. All of the above

E. C only

POLLINGQUESTIONWhat must an Assessment contain in order to meet Medicaid billing requirements?

A. Consumer Strengths

B. Prioritization of the problems presented

C. Evidence of re‐assessment on an on‐going and as‐needed basis

D. Identification of clear criteria for the use and discontinuation of benefits

E. All of the above

F. A, B,C only

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MakingComplianceaFriendofQuality– AUDITTOOLS

• Financial Audit Tool

• Self Assessment for Medicaid Challenges – I/DD Programs

• Self Assessment for Medicaid Challenges – Mental (Behavioral) Health Programs

• Residential Treatment Log – used for collecting Active Treatment Hours in PRTFs

MedicaidPrioritiesinPhaseIII

• More targeted – weighted measures (e.g. analyze Direct care compliance vs. physician compliance)

• Physician progress notes

• Treatment Planning documentation

• Support Planning documentation

• Non‐clinical progress notes

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PollingQuestion

What is necessary in order to address the Medicaid Priorities?

A. Better and more robust training

B. Better internal enforcement and consequences when documentation is poor or lacking

C. More policies and procedures

D. iPads for providers

PollingQuestionWhat must employees do when a government investigator shows up without a subpoena?

A. Meet secretly if the investigator requests it and not tell employer

B. Agree to meet at home

C. Speak the truth

D. All of the above

E. C only

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GreaterEnforcement

• Are you ready?

• Do you have a plan?

HowToActWhentheGovernmentComesKnocking?

• Must speak the truth;

• Employees are not required to talk to investigator and can exercise right to decide unless there is a subpoena;

• May call at home address (request to another location and time;

• Follow your organization’s policy on notifying supervisor;

• Right to counsel (not organization’s counsel);

• May stop interview at any time;

• Agents have no right to request you meet secretly and not tell employer;

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HowToActWhentheGovernmentComesKnocking?

• Do ask questions;

• Do cooperate; but…

• Don’t volunteer information;

• Don’t discuss merits of investigation;

• Don’t compare your organization with others;

• Subpoenas and Search Warrants

PollingQuestion

What should you do when you receive a document subpoena?

A. Answer the person’s questions at once

B. Make a list of requested documents and copy sending the copies in response to the subpoena

C. Have counsel review the subpoena

D. All of the above

E. B and C only

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Subpoenas• “Document subpoenas” usually directed to custodian of records

• Can’t use this type of subpoena to force employee to talk to them

• Make list of requested documents and copy – keep originals

• If in‐person subpoena, take business card and subpoena and tell them you will get back to them

• Have counsel review subpoena

PollingQuestionWhat would you consider advisable when you receive a search warrant?

A. Request a copy of the Warrant and Affidavit

B. Contact your supervisor and legal counsel

C. Allow investigator presenting warrant to seize documents even though they are not specifically on warrant

D. All of the Above

E. A and B only

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SearchWarrants• Authorizes investigator to:

‐ Enter private property‐ Search for evidence of criminal activity‐ Seize documents listed on warrant

• Does not require employees to speak with investigators; only to provide documents etc. requested on the warrant

• Request a copy of warrant

• Request a copy of affidavit (lists reasons why search warrant was issued)

• Employees must instruct investigator to wait for designated Administrator

• Contact legal who will speak to investigator and review warrant

SearchWarrants

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• With counsel and compliance develop “search and production procedure”

‐ Sequence of search‐ Copies of originals‐ Who will make copies‐ Clarify how to access seized records and computers

SearchWarrants

• Do NOT prevent agents from conducting search

• How to handle “Privileged Documents.”

• “Plain View” Rule – investigators have the right to seize evidence in plain view, even if it is not identified on the warrant

SearchWarrants

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• Remove non‐essential employees from the area being searched

• Monitor the search (two employees)

• Don’t leave investigators alone

• Privileged documents (counsel)

• Computer hard drives and diskettes

SearchWarrants

• Agents must give a detailed list of all things taken

• Document where agents searched’ what files were examined; for how long and with whom?

• Create inventory list of documents and any other items seized

SearchWarrants

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IFYouWantCompliance,DoYouTreatYourEmployeesWithQuality?

• Shaky economy can mean lay offs, Reduction in Force (RIF), salary freezes – how do you handle?

• Be forthcoming with staff about changes in the organization;

• Develop communication best practices;

• Establish and document methods to determine who will be laid off;

• Train managers on proper methodology for structuring and implementing a RIF;

• Document everything;

• Do not make false promises or be dishonest to employees;

• Extend goodwill to the employees by offering severance packages with health care for a period of time if possible;

IFYouWantCompliance,DoYouTreatYourEmployeesWithQuality?

• As a measure of concern for employee’s well‐being, offer EAP;

• Communicate to employees other steps the company is taking to control costs (expense controls; not granting increases to executives);

• Share good agency news with employees to increase morale;

• Express overall reasons to staff about reasons for layoffs;

• Have statistics available to justify why certain employees were let go;

• Have 2 managers meet with employee to be laid off;

• Analyze suspicious Workers’ Compensation claims.

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StaffInjuriesandQualityEmployees

• Are you looking at trends for staff injuries by clients (assaults/bite by clients)?

• Best Practices

• Training regularly to avoid injury

• Don’t assume employee is a slacker because they filed a claim for WC

• Are you assuring your injured employees are getting good medical care?

POLLINGQUESTIONIf an employee refuses to get a flu vaccine when your organization mandates it in policy what should you do?

A. Terminate employee

B. Reassign employee

C. Require employee to wear a mask

D. A only

E. B and C only

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EmployeesandtheFluVaccine

• What does the court say about employers who mandate that all employees have a flu vaccine?

• Best Practices

• Sample Policy

RiskandLiabilityExistsbeyondMC/MAComplianceandResidentialCare• Top risks/liability as a Provider of Foster Care

• Increase in severity of behavior in less restrictive level of care (anger management, sex offending & victimization issues, educational deficits, mental health/behavioral health issues, lack of independent living skills)

• Insufficient client information at time of admission (hostile behavior, fire setter, health issues)

• Decreased capacity to supervise care provider (risk of abuse allegations)

• Decreased capacity to manage the Environment of Care (physical plant issues)

• Decreased capacity to supervise the client (AWOL, risks to community, sexually inappropriate behavior)

How do you transfer some of this risk?

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RiskandQualityIssuesinDealingwithSexuallyReactiveChildren

• Family/House rules

• Bathroom etiquette;

• Privacy;

• Affection;

• Sleeping arrangements;

• Age appropriate entertainment;

• Anticipated consequences for breaking or failing to comply with Family Rules.

• Guidelines for staff

• Have a working knowledge of normative development;

• Don’t be easily embarrassed;

• Consider the age of the child;

• Have details on the nature, frequency and intensity of the specific behaviors.

How the Relationship Between Employees and Ethical Culture

Affects Quality

Robyn S. JoppyVice President, Corporate Compliance & Integrity

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Polling Question

Does your company struggle with recruiting direct care professionals, case managers, etc.?

A. Yes

B. No

Polling Question

How do you maintain quality services when you are short-staffed?

A. Incentives

B. Education

C. Increased internal audits

D. All of the above

E. None of the above

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3,075 Employees

Four Service Areas (5,000+ individuals served yearly):• Intellectual Disabilities Services

• Adult Mental Health Services

• Children and Family Services

• Autism Spectrum Disorders

Keystone at a GlanceGeographic LocationsGeographic Locations

United States: PA (29 counties), MD, DE, and CT

Internationally: Russia, Moldova, and Azerbaijan

Keystone’s Mission

Create opportunities for growth and meaningful life

choices so that all people can be valued, contributing

members of their community.

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Good governance

Being seen to do the right and lawful thing

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Quality

,

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Look at quality from various perspectives:

Quality of internal systems and processes

Quality of service

Quality of employees

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• Not only quality of service, but also quality of employees performing the service

• Environment and ethical culture of the organization vital to employee morale

Polling Question

Do you conduct employee satisfaction surveys to assess your ethical culture?

A. Yes

B. No

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“To find out how to improve productivity, quality and

performance—ask the people who do the work.”

Harvard Business Review

Background

• Keystone was one of three companies in the U.S. selected by the Ethics Resource Center (ERC) to participate in a pilot research program, which was funded by the Society for Corporate Compliance and Ethics (SCCE) and the Health Care Compliance Association (HCCA)

• The ERC conducted the online survey of Keystone employees

• August 12 - September 9, 2009

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About the Ethics Resource Center (ERC)

O Founded in 1922

O Devoted to independent research and the advancement of high ethical standards and practices in public and private companies

O A resource for public and private organizations committed to cultivating strong ethical cultures.

Survey objectives

O Measure employee perceptions of Keystone’s compliance and integrity program and ethical culture

O Benchmark against U.S. Business Average Data collected in ERC’s 2009 National Business Ethics Survey

O Identify strengths and areas of opportunity

O Recommend next steps to help Keystone continue its commitment to enhancing the professional standards throughout the organization

O Assess the impact of the compliance and integrity (ethical) culture and program on cost reductions and the investment of human capital

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Benefits of participation

O Establishment of baseline data for use in future assessments

O Findings on the effectiveness of the organization’s compliance and integrity program and ethical culture

O The ROI associated with the organization’s ethical culture

How was the Survey conducted?

• Survey Instrument– Online questionnaire

– Approximately 160 questions

plus 1 demographic

• Census Survey of All

U.S.-Based Employees

• Distribution Method

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Polling Question

What are your top three concerns with having unhappy employees?

A. Increased absence

B. Increased overtime

C. Fraudulent activity

D. Decreased employee morale

E. Other

Ways to Measure Return on Investment

• Number of employee sick days used

• Number of employee vacation days used

• Worker’s compensation pay-outs

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• Staff burnout

• Errors/mistakes (medication, documentation)

• Forgetfulness

• Potential for increased allegations of abuse and neglect– Require investigations – and there are costs involved

with that!

• Potential for increased fraudulent activity

There are costs when employees are absent from work:

Happy Employees Mean . . .

• They will stay with the company– Don’t need to conduct job searches and interviews

– Don’t need to train new employees

– Staff becomes more familiar with the person we support

– Staff builds relationships with that person

• More likely to participate in educational opportunities and have greater comprehension of information

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Conclusions and Next Steps

• Results of research was positive/hopeful. Demonstrates that those who perceive the organization as having a strong ethical culture use less vacation and sick time.

• A lot more work to do – benchmarking

• More comparisons with weak vs. strong ethical cultures

“Compliance is a goal – a journey – a process – a culture.”

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Questions and Discussion