Sandhills Center
LME-MCO
Quality Management
Committee
Executive Summary
January-March 2016
Quality Management Committee
Executive Summary
Time Period Covered January-March 2016
· The Quality Management Committee (QMC) met face-to-face three times for regular meetings during the 3rd quarter of this fiscal year, and had 63 reviews for approval of policies, procedures and other documents. There were five additional documents reviewed though the expedited process, making the total 68 for the quarter. The Executive Summary includes Quality Management Program activities that systematically monitor the quality and effectiveness of Sandhills Center's internal systems, as well as ensuring the provision of high quality services delivered by the Provider Network to Members. The Quality Management Program's design helps ensure adherence to the Sandhills Center mission to develop, manage and assure that persons in need have access to quality mental health, intellectual/developmental disabilities and substance abuse services.
Complaints, Incident Reporting and Quality of Care Concerns
Quarterly Level II/III Report
3rd Quarter FY 15-16 Jan—Mar
Brief Description of the Report:
The report shows the Level II and III Incident results for the third quarter of fiscal year 2015-2016.
There were 395 incident reports received this quarter. Out of the total incidents, the highest number of reports for a single consumer was 7.
For Q3 FY 15/16 Guilford continues to have the highest number of incidents reported.
The highest type of incident reports received continues to be consumer behavior. This amount has slightly increased since the previous quarter. ***There were 3 suicides, one individual had reports from two providers.
Other is the largest factor for consumer behavior incident reports.
Females are reported as making suicide attempts more than males. The majority of suicide attempts overall were from Guilford County.
Consumers enrolled in OPT services had the most incident reports for suicide attempts by service.
The main methods of suicide attempts reported were by overdose and cutting.
The location of most suicide attempts was in the home environment.
The most frequent intervention was a safety plan. Please note some consumers had more than one intervention implemented to ensure another suicide attempt does not occur.
The most frequent diagnosis reported for a consumer making a suicide attempt was Attention Deficit Hyperactivity Disorder. Please note these consumers may have more than one diagnosis.
Increase in physical abuse incident reports when comparing Q3 FY 15/16 to last quarter.
Allegations of Abuse/Neglect show 30 allegations against non-staff and 40 allegations against staff.
Standing Restraint continues have the leading cause of restrictive intervention incidents. There were not any Level III incidents for this category for Q3 FY15/16.
Falls were the leading causes of Consumer Injury Incident Reports.
There were six deaths reported due to unknown cause.
The highest frequency for this category was for Suspension. There were not any Level III incidents reported for Q3 FY 15/16.
The most frequent medication error incident was related to refusal of the medication. There were not any Level III incidents reported for this category in Q3 FY 15/16.
Quarterly Complaints Report
3rd Quarter FY 15-16 Jan—Mar
Brief Description of the Report: This report reflects the number and type of Complaints received during the third quarter of Fiscal Year 2015-2016.
Analysis and Trends Identified:
Complaints against Providers are the leading cause of complaints.
Quality of service continues to have the highest number of complaints.
For Third Quarter FY 15/16 the majority of complaints came from members with a Mental Health Disability.
LME-MCO continues to refer the most complaints to DHSR as these complaints are from licensed facilities.
Continue to resolve majority of complaints within 30 days of receipt of complaint.
Majority of complaints found to not be substantiated.
Leading cause of complaints is Quality of Services.
Majority of complaints come from Guilford County.
Most providers with complaints only had a single consumer complaint.
Quality of Care Concerns Report
3rd Quarter FY 15-16 Jan—Mar
Brief Description of the Report:
The report shows the Quality of Care (QOC) referrals received including referral source and type of QOC concerns for Third Quarter FY 2015-16.
Analysis and Trends:
Approximately 44% of QOCs were issues with documentation, which include not only notes but assessments, diagnoses and polypharmacy. Twenty-one percent (21%) were referred for services not provided true to the model. Provider training has been held both for documentation and services definitions and will continue to be ongoing on the Training Plan. Both the Global Continuous Quality Improvement Committee and the Network Leadership Council are aware of these concerns and are discussing ways to resolve.
Providers with multiple QOCs in consecutive quarters will be tracked moving forward to see if additional training or technical assistance is needed.
The # of Quality of Care concerns has increased to 66 for Third Quarter FY 15/16 when compared to 43 for Second Quarter FY 15/16.
CM/UM continues to be the largest referral source for Quality of Care concerns.
There has been steady improvement over the past year in QOC referrals from documentation issues.
· Appeals: During the 3rd quarter, no appeals related to complaint resolution, provider disputes or utilization management were brought to the QMC for review.
· Executive Summaries (beginning on page 26) were reviewed from the following programs:
§ Care Management/Utilization Management
§ Health Network and Network Leadership Council
§ Customer Services
· Reports: The following reports were reviewed by the QM Committee and QM Program Committees, as well as stakeholders, Consumer and Family Advisory Committee (CFAC), Client Rights Committee (CLT), Network Leadership Council (NLC), LME-MCO Executive Management Team, and the Board of Directors:
§ Quarterly Level II and III Incident Reports
§ Quarterly Complaint Reports
§ Quarterly Quality of Care Concerns
§ Quarterly Evidence-based Practices Reports
· Critical Incident Reports (CIR) Quarterly Report : The Committee met monthly and reviewed a total of 66 incidents (These are also included in the larger Level II-III report.). This is a decrease from the previous quarter. The CIR Committee reviewed 18 suicide attempts during the 3rd quarter. There were three suicides this quarter.
· Access to and Monitoring of Services: The Program QM Committees reviewed the identified
performance indicators during the quarter. The lack of availability of ACTT services in all 9 counties continues to be discussed at CFRM, Network and QMC.
· Policies, procedures, correspondence and other materials presented for QOC approval
Expedited January 2016 / Reason/TypeConsumer & Family Service Needs Survey / Consumer/family
Stakeholders/Provider Service Needs Survey / Community
Annual Network Development Plan
Expedited March 2016
Generic Integrated Care Scripts / For staff use
Approved at Regular QMC meeting – January 2016
Internal Claims Audit Medicaid/State / Procedure / Revisions based on Mercer & DMA recommendations
Cash Receipts Control / Procedure / Minor language changes
Travel / Procedure / Changes in reimbursement rates
To Ensure TCLI Eligibles are Offered Alternative Housing Subsidies / Policy & Procedure / New policy and procedure related to Housing Plan required by State include options and subsidies for consumers.
To ensure the Emergency and Alternative Housing is Included in the Service/Crisis Plan of Every TCLI Member / Policy & Procedure / See above.
MH/SA Care Coordination/TCLI Plan to Expand, Maintain, and Monitor Housing Options / Policy & Procedure / See above.
January Help Desk Questions and Answers / For providers
Credentialing process flow sheet / Internal use
QM Waiver for one agency / Internal use
Program Integrity Orientation / Community
Approved at Regular QMC meeting – February 2016
Bad Debt request from Collection Agency Regarding Medicaid Claims / Procedure / Developed to outline process for responding to collection agencies that Sandhills Center is not responsible for.
AP 835 Source File General Ledger / Procedure / Deleted; no longer valid due to changes in the software systems.
Positive Pay / Procedure / Added Medcost would upload positive pay files to BB&T Cash Manager; Sandhills staff will work exceptions re to the files uploaded by MedCost.
Payback / Procedure / Added payment plans will be in writing with a contract approved by General Counsel and added mailing to be via certified mail as well as regular mail.
Workplace Safety / Procedure / Updated to address workplace violence.
Review, Approval and Follow up of Plans of Correction / Procedure / Removed from Quality Management; Due to reorganization, will go to Network.
Provider Performance Profile Review / Procedure / Removed from Quality Management; Due to reorganization; will go to Network.
Sandhills Center QIP Process / Add QIP flow chart to QM 32a
Onsite Review of Providers and Facilities / Procedure / Removed from Quality Management; Due to reorganization, will go to Network.
Practitioners Office Site Quality Review / Procedure / Delete: No longer performing office site quality reviews.
Provider Sanctions / Procedure / Removed from Quality Management; Due to reorganization, will go to Network.
External Assessments Sanctions Grid & Provider Sanctions Grid – final / Removed from Quality Management; Due to reorganization, will go to Network.
Consumer Complaint Process – Medicaid, IPRS / Procedure / Revised to include Network Monitoring staff and Complaints and Incidents Reports Specialist.
Staff Operational Tools and Support / Procedure / Minor language changes include “but are not limited to”; deleted reference to IPRS script; changes made to Clinical Triage script.
Access to Services / Procedure / Changes to performance standard; added “of the decision” in reference to application within 10 calendar days; changed language from 48 hours to two days
Consumer Safety Mechanism / Procedure / Inserted “improvement” in section referencing monitoring.
Client Rights Committee / Procedure / Changes made referencing compliance and addition of sentence which reads “every effort will be made to ensure each county in SHC area has representation on the committee.”
Protection from Harm, Abuse, Neglect or Exploitation / Procedure / Deleted NC G.S. 7A 543 from documents; inserted additional General Statutes and made grammatical corrections.
Reporting of Abuse, Neglect or Exploitation of Members / Procedure / Several changes made to General Statutes and processes referenced in policy and procedure.
Service Non-Discrimination / Procedure / Policy and Procedure rewritten by General Counsel
Customer Service Program Inter-rater Reliability / Policy / Corrected punctuation
Transfer of Medical/Clinical Emergency Calls to Clinical Triage and Referral / Procedure / Corrected grammar in first sentence
Clinical Director Consultation / Procedure / Corrections in grammar
Limitations in Use of Non Clinical Staff Training and Policies / Procedure / Corrections in grammar
Clinical Decision Support Tool Requirements / Procedure / Corrections in grammar; Clinical Triage Script/Medicaid deleted; Clinical Triage Script/IRPS was changed to Clinical Triage Script.
Clinical Decision Support Tool Documentation / Procedure / Corrections in grammar.
Clinical Triage Dispostions / Procedure / Corrections in grammar; changed DHSS to DHHS
Information Collection Limitations / Procedure / Corrections in grammar; expanded list of demographical information collected and changes in language
Follow-up Communication Documentation / Procedure / Corrections in grammar; major changes in processes.
Feedback to Provider / Corrections in grammar; changes in processes.
Written Notice of Non-Certification Decisions and Rationale / Procedure / Changed principle to principal.
Clinical Rationale for Non-Certification Requirements / Procedure / Changed “principle” to principal.
Non-Certification Appeals Process – IPRS & Medicaid / Procedure / Changed principle to principal; removed “legal” when referencing representative.
Appeals Process IPRS & Medicaid / Procedure / Changed principle to principal; removed “legal” when referencing representative.
Expedited Appeals Process Timeframe- IPRS & Medicaid / Procedure / Changed principle to principal.
Standard Appeals Process Timeframe – IPRS & Medicaid / Procedure / Changed principle to principal.
Lack of Information / Procedure / Changed the number of contacts made to providers by staff for missing information from three times to two times.
Written Notice of Upheld Non-Certifications / Procedure / Added North Carolina Office of Administrative Hearings.
Written Notice of Upheld Non-Certifications – IPRS / Procedure / Changed principle to principal; Changed UM Manager to UM Appeals Coordinator
Written Notice of Upheld Non-Certifications – Medicaid / Procedure / Changed principle to principal and added Appeals.
Appeal Record Documentation – IPRS / Procedure / Changed principle to principal and added Appeals.
Appeal Record Documentation - Medicaid / Procedure / Changed principle to principal and changed UM Manager to UM Appeals Coordinator.
Credentialing Plan – State & Medicaid / Procedure / N-CR 15 & 16 revised per URAC recommendations; affects N-CR 15a.
Access & Availability – State & Medicaid / Procedure / Revised for clarification.
Help Desk Q&A / For providers
Care Coordination / Brochures / Transition to Community Living Initiative, Supportive Housing Opportunities, Supported Employment
Community Relations / Brochures / Complaints, Crisis Intervention Team, Consumer & Family Advisory Committee
Approved at Regular QMC meeting – March 2016
Network final Re-credentialing letters / Providers
Evidence-based Practice worksheets / Monitoring staff
Network Quality Improvement Project – revision / QIP / Network program
QM Internal Monitoring Workplan / Internal
Care Coordination Referral form / Care Coordinators
Finance Department ACH Direct Deposit of Accounts Payable Authorization agreement form / For providers
The QMC recommended approval of the above policies, procedures, and other documents, following approval by the respective Program Committees and departments.
· Delegation Contracts: The QMC received Delegation of Function Reports for PREST and determined PREST is meeting contract expectations.
· CM/UM Appeals: During the 3rd quarter, there were 45 Medicaid appeals (an increase of four) and four State dollar appeals (a decrease of two). Most appeals continue to be with PSR and Intensive In-home services.
· Community Care of North Carolina:
The Sandhills Center area SBIRT Grant Initiative was expanded to include a Robeson Health Care Center clinic in Lumberton N.C.
This expansion along with an expanded and experienced workforce has resulted in improved numbers for the area’s SBIRT operations.
Given the positive outcomes that have been identified with the use of SBIRT interventions, the SBIRT Policy Steering Committee continues to consider sustainability options for the program.
Otherwise, Sandhills Center maintains ongoing interactions with three networks of the CCNC as indicated in previous publications.