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FAIRFAX-FALLS CHURCH COMMUNITY SERVICES BOARDCOMPLIANCE COMMITTEE MEETINGGarrett McGuire, ChairWednesday, October 20, 2021, 4:00 p.m.Will be held electronically due to the COVID-19 pandemicDial by your location to access live audio of the meeting: 1 301 715 8592 US (Washington DC) 1 669 900 9128 US (San Jose) 1 646 558 8656 US (New York) 1 253 215 8782 US (Tacoma) 1 312 626 6799 US (Chicago) 1 346 248 7799 US (Houston)Meeting ID: 821 3919 9339 Passcode: 054872MEETING AGENDA1. Meeting Called to OrderGarrett McGuire2. Roll Call, Audibility and Preliminary MotionsGarrett McGuire3. Matters of the PublicGarrett McGuire4. Amendments to the Meeting AgendaGarrett McGuire5. Approval of the September 15, 2021, Meeting MinutesGarrett McGuire6. Follow up items from the September meetingDaniel Herr7. UpdatesA. ComplyTrack ReportsB. Electronic Health Record UpdateC. CSB Serious Incident (Level III) ReportDaniel Herr8. Open DiscussionClosed Session: Discussion of a personnel matter as permitted by Virginia Code Section 2.2-3711(A)(1) andconsultation with legal counsel employed by a public body regarding specific legal matters requiring the provisionof legal advice by such counsel, as permitted by Virginia Code Section 2.2-3711(A)(8).9.AdjournmentMeeting materials are posted online at rchives or may be requested bycontacting Joseline Cadima at 703-324-7827 or at fax County is committed to a policy of nondiscrimination in all county programs, services and activities and will provide reasonable accommodations uponrequest. To request special accommodations, call 703-324-7000 or TTY 711. Please allow seven working days in advance of the event to make the necessaryarrangements. These services are available at no charge to the individual.
FAIRFAX FALLS-CHURCH COMMUNITY SERVICES BOARDCOMPLIANCE COMMITTEE VIRTUAL MEETING MINUTESSEPTEMBER 15, 2021The Compliance Committee of the Fairfax-Falls Church Community Services Board met electronically dueto the COVID-19 pandemic that has made it unsafe to physically assemble a quorum in one location or tohave the public present. Access was made available via video and web conferencing platform to CSB Boardmembers, CSB staff, and members of the public. The meeting notice, including participation instructions,was posted electronically and on the building in which the meeting is typically held. Additionally,attendees were offered an opportunity to register for public comment during the 30 minutes prior to themeeting being called to order.1. Meeting Called to OrderBoard Chair Garrett McGuire called the meeting to order at 4:01 p.m.2. Roll Call, Audibility, and Preliminary MotionsPRESENT:ABSENT:BOARD MEMBERS: GARRETT MCGUIRE (ALEXANDRIA, VA), BOARD CHAIR;BETTINA LAWTON (VIENNA, VA); DAN SHERRANGE (CHANTILLY, VA); ANNEWHIPPLE (GREAT FALLS, VA)BOARD MEMBERS: JENNIFER ADELI; CAPTAIN DEREK DEGEAREAlso present: Deputy Director of Clinical Operations Lyn Tomlinson, Deputy Director ofAdministrative Operations Daniel Herr, and Board Clerk Joseline Cadima.Board Chair Garrett McGuire conducted roll call, as identified above, to confirm that a quorum ofBoard members was present and audible. Board Chair McGuire passed the virtual gavel to BoardVice Chair Dan Sherrange to make several motions required to begin the meeting. A motion wasoffered confirming that each member’s voice was audible to each other member of the CSB Boardpresent; this motion was seconded by Board Member Anne Whipple and passed unanimously.Preliminary MotionsBoard Chair McGuire made a motion that the State of Emergency caused by the COVID-19pandemic makes it unsafe for the CSB Board to physically assemble and unsafe for the public tophysically attend any such meeting, and that as such, FOIA’s usual procedures, which require thephysical assembly of this CSB Board and the physical presence of the public, cannot beimplemented safely or practically. A further motion was made that this Board may conduct thismeeting electronically through a video and web conferencing platform, that may be accessed viaMeeting ID: 870 4735 3445 and Passcode: 923207. Motions were seconded by Board Member DanSherrange and unanimously approved. Board Chair McGuire made a final motion that all thematters addressed on today’s agenda are statutorily required or necessary to continue operationsand the discharge of the CSB Board’s lawful purposes, duties, and responsibilities. The motion wasseconded by Board Member Dan Sherrange and unanimously passed.AGENDA ITEM#5.1
Compliance Committee Meeting MinutesSeptember 15, 2021Page 2 of 33. Matters of the Public.None were presented.4. Amendments to the Meeting AgendaThe meeting agenda was provided for review, no amendments were made.CONSENSUS TO ADOPT AGENDA ITEM NO. 4AYES: BOARD MEMBERS: GARRETT MCGUIRE (ALEXANDRIA, VA), BOARD CHAIR; BETTINALAWTON (VIENNA, VA); DAN SHERRANGE (CHANTILLY, VA); ANNE WHIPPLE (GREATFALLS, VA)NOES: BOARD MEMBERS: NONEABSTAIN: BOARD MEMBERS: NONEABSENT: BOARD MEMBERS: JENNIFER ADELI, CAPTAIN DEREK DEGEARE5. Approval of MinutesMeeting minutes of the August 18, 2021, Compliance Committee were provided for review.MOVED BY BOARD MEMBER BETTINA LAWTON, SECONDED BY VICE CHAIR DAN SHERRANGE TOAPPROVE AGENDA ITEM NO. 5AYES: BOARD MEMBERS: GARRETT MCGUIRE (ALEXANDRIA, VA), BOARD CHAIR; BETTINALAWTON (VIENNA, VA); DAN SHERRANGE (CHANTILLY, VA)NOES: BOARD MEMBERS: NONEABSTAIN: BOARD MEMBERS: ANNE WHIPPLE (GREAT FALLS, VA)*ABSENT: BOARD MEMBERS: JENNIFER ADELI; CAPTAIN DEREK DEGEARE*Board Member Anne Whipple abstained from the approval of Minutes, she noted she was absentfor the August 18, 2021, meeting.6. Follow up itemsDeputy Director of Administrative Operations Daniel Herr reported on the progress of therecruitment for the Quality Improvement Director position and noted that five candidates will beinterviewed in the next week and half, and mentioned that the second round of interviews, assuggested by the chair, should include two Compliance Committee members.7. UpdatesA. ComplyTrack ReportsAGENDA ITEM#5.2
Compliance Committee Meeting MinutesSeptember 15, 2021Page 3 of 3 Deputy Director of Administrative Operations Daniel Herr provided the Audit ActionPlan Report, Corrective Action Plan Report, and the Education Report. Stated that thenext Compliance Committee meeting will receive detailed information in regard to thetri-annual review of licenses completed by the Department of Behavioral Health andDevelopment Services in which ten programs were reviewed and three general areasof focus that were noted for improvement were the annual training requirements,individualized service plans, and supported living programs.B. Electronic Health Record Update Deputy Director of Administrative Operations Daniel Herr reported a continued and ontime implementation process with Welligent.C. CSB Serious Incident (Level III) Report Deputy Director of Administrative Operations Daniel Herr provided the Serious IncidentReport (SIR) Report for August 2021.8. Open DiscussionExecutive Director Daryl Washington noted that the Fairfax County Board of Supervisors has theirindependent auditors who conducted an audit of the CSB billing services, which will be presentedto the Board of Supervisors next week at their monthly meeting, this report will be released to thepublic on Monday, September 20, 2021, and will be forwarded to the Board.Board Chair McGuire inquired whether there any matters that required discussion in closedsession, none were raised.9. AdjournmentBoard Member Bettina Lawton made the motion to adjourn the meeting at 4:44 p.m.AYES: BOARD MEMBERS: GARRETT MCGUIRE (ALEXANDRIA, VA), BOARD CHAIR; BETTINALAWTON (VIENNA, VA); DAN SHERRANGE (CHANTILLY, VA); ANNE WHIPPLE (GREATFALLS, VA)NOES: BOARD MEMBERS: NONEABSENT: BOARD MEMBERS: JENNIFER ADELI, CAPTAIN DEREK DEGEAREDate ApprovedClerk to the BoardAGENDA ITEM#5.3
Audit Report CSB Board For September 2021ItemAudit StartCustomDateId000784Dec 1, 2020002186EntityAudit ScopeAuditTypeMerrifieldTargeted ReviewRecordJun 15, 2021MerrifieldDBHDS TriennialReview002187Jun 15, 2021Merrifield002188Jun 15, 2021002189SampleSizeCSB BoardReportingAudit ActionPlan87Standardbusiness riskMonitoring - 12monthsRecord2Potential riskDBHDS TriennialReviewRecord2Standardbusiness riskMerrifieldDBHDS TriennialReviewRecord2Standardbusiness riskJun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness risk002191Jun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness risk002192Jun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness risk002194Jun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness risk002196Jun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness riskAdditional InformationThe Turning Point Program movedfrom a grant funded status toMedicaid billable and is underreview to ensure regulatorycomplianceCorrective Action Please see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective Action Please see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective ActionPlease see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective ActionPlease see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective Action Please see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective ActionPlease see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective Action Please see attached summary oflicensing citations for additionalPlan ReceivedinformationCorrective ActionPlease see attached summary ofPlan Receivedlicensing citations for additionalinformationAGENDA ITEM#7.1
002198Jun 15, 2021GartlanDBHDS TriennialReviewRecord2Standardbusiness risk002199Jun 15, 2021MerrifieldDBHDS TriennialReviewRecord2Standardbusiness risk002242Jul 1, 2021MerrifieldTargeted ReviewRecord6Standardbusiness risk002255Jul 1, 2021MerrifieldTargeted ReviewRecordStandardbusiness riskCorrective Action Please see attached summary ofPlan Receivedlicensing citations for additionalinformationCorrective Action Please see attached summary ofPlan Receivedlicensing citations for additionalinformationMonitoring - 12The OBOT Program is beingmonthsreviewed to ensure that it meetsbillable standards according toregulatory requirementsMonitoring - 12The Turning Point Program is beingmonthsreviewed to ensure they meet002256Jul 1, 2021ChantillyNew ProgramRecordStandardbusiness riskMonitoring - 12months002257Jul 1, 2021ChantillyNew ProgramRecordStandardbusiness riskMonitoring - 12months002258Jul 1, 2021PenninoTargeted ReviewRecordStandardbusiness riskMonitoring - 12monthsContinued reviews of the ACRSSupervised Living Program for FY2022002259Jul 1, 2021ChantillyNew ProgramRecordStandardbusiness riskMonitoring - 12months002260Jul 1, 2021ChantillyNew ProgramRecordStandardbusiness riskMonitoring - 12monthsThe New Generations Programconverted to a new license byDBHDS and is reviewed as a newprogram due to changes in as partof the ASAM criteria being instatedThe A New Beginning Programconverted to a new license and isbeing reviewed as a new programdue to changes in as part of theASAM criteria being instatedregulatory requirementsThe Crossraods Program convertedto a new license and is beingreviewed as a new program due tochanges in as part of the ASAMcriteria being instatedThe Detox Program converted to anew license and is being reviewedas a new program due to changesin as part of the ASAM criteriabeing instatedAGENDA ITEM#7.2
Monitoring - 12monthsThe Intensive Outpatient Programconverted to a new license and isbeing reviewed as a new programdue to changes in as part of theASAM criteria being instatedMonitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.1Monitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.Record1Monitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.MonitoringRecord2Monitoring - 3monthsMonitoringRecord1Standardbusiness riskMonitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.Sep 20, 2021South County MonitoringCenterRecord1Standardbusiness riskMonitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.Sep 20, 2021ChantillyRecord1Standardbusiness riskMonitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.002261Jul 1, 2021ChantillyNew Program002376Jul 1, 2021South County MonitoringCenterRecord002378Jul 1, 2021NorthwestCenterRestonMonitoringRecord002381Jul 1, 2021ChantillyMonitoring002384Jul 1, 2021Merrifield002379Sep 20, ordStandardbusiness riskQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.AGENDA ITEM#7.3
002386Sep 20, 2021MerrifieldMonitoringRecord2002392Sep 20, 2021ChantillyMonitoringRecord3002394Sep 20, 2021ChantillyMonitoringRecord3Standardbusiness riskMonitoring - 3monthsMonitoring - 3monthsStandardbusiness riskMonitoring - 3monthsQuality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.Quality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.Quality Improvement Teamconducted this audit to obtainbaseline for this program as part ofan agency wide initiative.AUDIT LEGENDItemCustomID Identification number automatically assigned by ComplyTrackerAudit StartDateDate the audit was initiatedEntityLocation where the audited service was providedAuditScopeThe agency conducting the audit and the scope of the auditAudit Type Description of audit, e.g., record review only, onsite auditSampleSizeNumber of charts reviewedCSB BoardReportingLevel of business risk associated with audit findingsAuditActionPlanDescription of actions taken in response to the auditAGENDA ITEM#7.4
CAP Report for CSB Board For September 2021ItemCustom IdStart DateEntityReviewingAgencyCorrective Action (Narrative)Date CAPClosedAdditional Information0019925/26/21PenninoDBHDSThe Corrective Action Plan was submitted to DBHDS forreview and approval. This was a direct result of a review fromthe Incident Management Unit (IMU).7/14/21Late submission of aSerious IncidentReport0021016/21/21PenninoDBHDSThe Corrective Action Plan has been submitted to DBHDS forreview and approval. This was a direct result of a review fromthe Office of Licensing (OL).8/10/21The ISP did not includechange in medical andmental healthtreatment needs0021207/14/21PenninoDBHDSA Corrective Action Plan was submitted for review andapproval. This was a direct result of a Quality Service Reviewby the Office of Licensing (OL). Please reference Audit ID#001850.9/15/210021587/23/21PenninoDBHDSThe Corrective Action Plan has been submitted to DBHDS forreview and approval. The CAP was due to ACRS' late entry ofa Serious Incident Report.9/15/210022008/4/21Merrifield DBHDS0022018/10/21Merrifield DBHDS0022028/10/21Merrifield DBHDSThe Corrective Action Plan was submitted to DBHDS and was Resubmittedpartially approved. The CAP was re-submitted to the ProgramCAP andDirector for review and completion. This was a direct result awaiting reviewof the 2021 Triennial Review by the Office of Licensing ctionwas approved by DBHDS on9/15/219/7/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #002187Please see attachedsummary of licensingcitations for additionalinformationThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #002188Please see attachedsummary of licensingcitations for additionalinformation9/7/21Please see attachedsummary of licensingcitations for additionalinformationAGENDA ITEM#7.5
0022038/10/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/10/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #0021899/10/210022048/12/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #0021919/7/210022078/12/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 Triennial Reviewby the Office of Licensing (OL). Please reference Audit#0021929/7/210022088/10/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 Triennial Reviewby the Office of Licensing (OL). Please reference Audit#0021949/7/21Please see attachedsummary of licensingcitations for additionalinformation0022098/12/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #0021969/15/21Please see attachedsummary of licensingcitations for additionalinformation0022108/12/21GartlanThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 Triennial Reviewby the Office of Licensing (OL). Please reference Audit#0021989/14/21Please see attachedsummary of licensingcitations for additionalinformation0022118/10/21Merrifield DBHDSThe Corrective Action Plan was approved by DBHDS on9/7/2021. This was a direct result of the 2021 TriennialReview by the Office of Licensing (OL). Please referenceAudit #0021999/7/21Please see attachedsummary of licensingcitations for additionalinformation0022978/24/21PenninoDBHDSThe Corrective Action Plan was submitted to DBHDS forreview and approval. This was a direct result of aninvestigation by the Office of Licensing (OL) and Office ofHuman Rights (OHR).9/15/21Services did not reflectcurrent needs andrisks0023099/8/21PenninoDBHDSThe Corrective Action Plan was approved by DBHDS. Thiswas a direct result of a review by the Office of Licensing (OL).9/15/21DBHDSPlease see attachedsummary of licensingcitations for additionalinformationPlease see attachedsummary of licensingcitations for additionalinformationPlease see attachedsummary of licensingcitations for additionalinformationServices did not reflectcurrent needs andrisksAGENDA ITEM#7.6
0023288/9/21PenninoDBHDSThe Corrective Action Plan was submitted to DBHDS forreview and approval. This was a direct result of a review fromthe Office of Licensing (OL).0023299/21/21PenninoDBHDSThe Corrective Action Plan was submitted to DBHDS forreview and approval. This was a direct result of a review fromthe Office of Human Rights (OHR).Care coordination wasnot provided for allservicesStaff supervision notmatched to risk levelCAP LEGENDItemCustomId Identification number automatically assigned by Comply TrackerAudit No. References the audit number in the Audit ReportStart Date Date the CSB was notified of the need for a CAPEntityLocation where the audited service was providedReviewingAgencyAgency requesting and reviewing the CAPCAPNarrative Description of the reason for the CAPDate CAPClosedDate the reviewing agency approved the CAPAGENDA ITEM#7.7
Summary Of Triennial Licensing Review1. Ten Licensed Services audited by DBHDSa. Mental Health Supported Livingb. Crisis Carec. Emergency Servicesd. Mental Health Support Servicese. Youth Mental Health Case Managementf. Adult Mental Health Case Managementg. Outpatient Servicesh. Substance Abuse Case Managementi. Partial Hospitalizationj. Outpatient Crisis Stabilization2. Summary Of Findingsa. New employee training completed within 15 daysi. Serious incident and Confidentialityb. Annual employee retraining completed within one yeari. Serious Incident training, Behavioral management training, Emergencypreparedness, Human rights, and Infection controlc. Physical Plant & Emergency Preparedness (one location)i. Emergency water supplies, Water temperatures, and Smoke detectorsd. Quality of Documentationi. Individual service plans were not updated within required time periodsii. Individual was not cooperative with the service planiii. Discharge summary did not include all required informationAGENDA ITEM#7.8
Education Report CSB Board For September 2021ItemCustomIdStart DateTraining NameDurationEntityNumber ofAttendeesMethod ofDeliveryTraining 96000597000667000668000736000737001696001699Jul 16, 2020Jul 16, 2020Aug 20, 2020Aug 20, 2020Sep 24, 2020Sep 24, 2020Sep 11, 2020Oct 22, 2020Oct 22, 2020Nov 19, 2020Nov 19, 2020Dec 10, 2020Dec 10, 2020Jan 14, 2021Jan 27, 2021DMAS TrainingDMAS Update and Refresher TrainingDMAS TrainingDMAS Update and Refresher TrainingDMAS TrainingDMAS Update and Refresher TrainingQA Tool EducationDMAS TrainingDMAS Update and Refresher TrainingDMAS TrainingDMAS Update and Refresher TrainingDMAS TrainingDMAS Update and Refresher TrainingSIR TrainingQA Tool west Center PenninoMerrifieldNorthwest Center RestonChantillyMerrifieldGartlanNorthwest Center 01918002028002029002167002374Jan 28, 2021Mar 8, 2021Apr 7, 2021May 5, 2021Jun 9, 2021Jun 9, 2021Aug 5, 2021Oct 6, 2021DBHDS Licensure EducationDBHDS Licensure EducationSIR TrainingSIR EducationHuman Rights Training RefresherHuman Rights Training RefresherRoot Cause AnalysisSIR Training1.50.521220.51.5PenninoPenninoNorthwest Center 18381552220327WebinarWebinarWebinarWebinarLive On-siteLive tionalItem Custom IDStart DateTraining NameDurationEntityNumber of AttendeesMethod of DeliveryTraining TypeEDUCATION REPORT LEGENDNumber automatically assigned by ComplyTrackerDate the education was providedType of Training ProvidedLength of time for the educational activitySite receiving the educationNumber of staff who participated in the educational activityHow the training was providedWhether the training was to address a regulatory matter or for professional developmentAGENDA ITEM#7.9
Oct 20, 2021 · Follow up items from the September meeting Daniel Herr 7. Updates Daniel Herr A. ComplyTrack Reports . Deputy Director of Administrative Operations Daniel Herr provided the Audit Action Plan Report, Corrective Action Plan Report, and the Education Report. Stated that the . The Detox
