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GAC002227Ariel Community Care, LLCBehavioral Health Quality Review Final AssessmentAddress: Remote Quality Review - 8316 Office Park Drive, Douglasville, GA 30134Assessors: Jerald Carter, MPA; Faith M Simpson, LPC, CADCII, MATSRecords Reviewed: 5Date Range of Review: 2/7/2022 - 2/9/2022The Georgia Collaborative ASO, in partnership with the Department of Behavioral Health and Developmental Disabilities(DBHDD), believes in accessible, high-quality care that leads to a life of recovery and independence. The provider shouldnote any recommendations as an opportunity for quality improvement activities. The review is intended to measure thequality of your organization’s systems and practices in adherence to DBHDD policies and standards. The Overall Scoreis calculated by averaging the categories easAssessment& PlanningServiceGuidelinesReview Date: 04/05/202191%90%98%80%94%Review Date: 09/03/201983%77%81%86%89%FY21 Statewide Average85%70%92%88%91%Note: The FY21 Statewide Averages represent the mean of scores of all reviewed providers. Due to the COVID-19 pandemic, several reviews werepostponed or conducted remotely (rather than on site). Additionally, reviews conducted in FY20 (July 1, 2019 to June 30, 2020), may have had pointsremoved from the Overall Score due to identified Quality Risk Items; therefore, caution should be taken when comparing scores across fiscal years.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 1 of 8
Summary of Significant Review FindingsStrengths and Improvements: Due to the COVID-19 pandemic, this review was conducted remotely instead of on site.All staff providing services are certified peer specialist (CPS) credentialed. Additionally, several employees arealso licensed clinicians (independent or associate-level). This is a continued strength from the previous tworeviews.The provider utilizes a current problem list to help formulate goals and objectives with individuals.The provider has detailed documentation about each individual's co-occurring health conditions from health careagencies.Opportunities for Improvement:Billing Validation Twenty-two progress notes were missing.Six progress notes were missing the staff signature.Five progress notes were missing the specific out-of-clinic location.Assessment and Planning Transition/discharge plans did not contain all the required criteria in all five records reviewed.Focused Outcome Areas (FOAs) One of two applicable records did not did not contain evidence that the individual/guardian had signed formalacknowledgement of rights and responsibilities at least annually.Compliance with Service Guidelines Peer Support Whole Health & Wellness Staff members did not meet the minimum one weekly contact in two of three applicable records reviewed. Collaboration with other healthcare providers to assure the individuals have access to needed services wasnot documented in two of three applicable records. There was not evidence in the documentation that an annual physical or at a minimum a discussion andencouragement to have an annual physical exam in two of three applicable records.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 2 of 8
Billing ValidationMedicaidTotalJustified 1,510.58 1,510.58Unjustified 3,603.10 3,603.10Total 5,113.68 5,113.68The Billing Validation Score is the percentage of justified billed units vs. paid/billed units for the reviewed claims. Paid dollars are calculated based onpayer: Medicaid is the sum of paid claims; State Funded Services are Fee for Service and State Funded Encounters combined (State FundedEncounters is the estimated sum of the value of accepted encounters).StandardPerformance StandardsQuantitative StandardsReason# of DiscrepanciesContent of documentation is not unique1Progress note is missing22Signature missing6Location missing5Billing code is missing or different from code billed1Billing Validation: 30%Strengths and Improvements:The following are improvements since the last Behavioral Health Quality Review (BHQR) in April 2021: All billing claims reviewed contained a valid and current order for service (OFS).All billing claims supported the units billed.Opportunities for Improvement:Performance Standards The content of one note, H0038HFU5U7 on 11/4/2021 was nearly identical to a note on 10/28/2021 documentedby the same staff. The note did not contain unique documentation.Quantitative Standards Twenty-two progress notes were missing.Six progress notes were missing the staff signature.Five progress notes were missing the specific out-of-clinic location when the U7 (out-of-clinic) modifier wasbilled.One progress documented the incorrect billing code. H0038HFU5U7 was billed; however, H0038HFU5U6 wasdocumented on the progress note.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 3 of 8
When all responses to a question are “Not Applicable”, no percentage is displayed.Assessment & Planning: 91%Strengths and Improvements:Improvements from the previous BHQR in April 2021 included: All individual recovery plans (IRPs) reviewed addressed all assessed needs.All IRPs documented goals and objectives that honored the individuals' hopes, choice, preferences, andoutcomes for treatment.All IRPs documented whole health and wellness goals, objectives, and interventions.All IRPs documented co-occurring health conditions.Opportunities for Improvement: Transition/discharge plans did not contain all the required criteria in all five records reviewed. The clinicalbenchmarks were not indicated or documented. This is a recurring issue from the previous BHQR in April 2021.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 4 of 8
Focused Outcome mmunity100%Focused Outcome Areas: 99%Strengths and Improvements: Five of six Focused Outcome Areas (FOA's) scored 100% in all indicators with a total FOA score of 99%; this isup one point from the provider's previous score of 98%.The provider has detailed external communication documentation with other providers and health care agencies.All of the records contained documentation of tuberculosis screenings and test results.All release of information (ROI) forms contained all required components.Opportunities for Improvement:Rights One of two applicable records did not contain evidence that the individual/guardian had signed formalacknowledgement of rights and responsibilities at least annually. The record was missing the 2021 rights.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 5 of 8
Service Guidelines: 95%Strengths and Improvements: All staff providing services are certified peer specialist (CPS) credentialed. Additionally, several employees arealso licensed clinicians (independent or associate-level). This is a continued strength from the previous tworeviews.Documentation supported that interventions promoted socialization, recovery, wellness, self-advocacy,development of natural supports and maintenance of community living skills. For example, there was evidenceof staff working with individuals regarding their weight-loss and fitness goals, as well as goals related tobudgeting and medication compliance.MH Peer Support Program staff discussed environmental wellness, personal values, how to be a good listener,and conflict resolution, among other topics, in one record.Opportunities for Improvement:Peer Support Whole Health & Wellness Staff did not meet the minimum one weekly contact in two of three applicable records reviewed. In one record, there were no contacts documented in the record for the months of October, November,and December 2021. In another record, there were no contacts for the months of September, October, and November 2021.Collaboration with other healthcare providers to assure the individuals have access to needed services was notdocumented in two of three applicable records.There was not evidence in the documentation that an annual physical or at a minimum a discussion andencouragement to have an annual physical exam in two of three applicable records.Overall ProgrammaticThe Programmatic standards below, relevant to services reviewed during this BHQR, are not currently calculated into anyscored area of the review; however, Quality Improvement Recommendations are made based on findings.Provider-Level Indicators1Where applicable, all services are provided at approved Medicaid sites.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 6 of 8Yes
2On-site nurse is present 10 hours/week.Yes3Staff safety and protection policies/procedures are present.Yes4Quality Assurance Plan includes assuring/monitoring quality of services for individualsat risk for suicide.Yes5The provider employs an ASL-fluent practitioner.N/A6The provider has policies and procedures for providing reasonable accommodations toindividuals who are deaf/hard of hearing.Yes# Yes# No# N/ASCORE*501100%* Overall Programmatic Score is not calculated into the Overall score at this time.Additional Comments onPractices Additional strengths and concerns beyond the general scope of the reviewwere discovered by reviewers. Additional issues/practice concerns mayhave the potential to impact service delivery, quality of care, or mayrepresent a risk to the provider.While the agency does have a suicide risk assessment built into the behavioral health assessment, this riskassessment is cursory and only asks if suicidal thoughts are present, if the individual has a plan and access forself-harm, and if there is a safety plan in place. None of the five records contained a Columbia Suicide SeverityRating Scale (C-SSRS). While this is not currently a requirement for Tier 3 providers, the agency is encouragedto use a more thorough suicide risk assessment as a best practice.Safety/crisis plans reviewed during this BHQR were unsigned. They either documented that verbal consent wasprovided or a corresponding progress note documented that the individual participated in the development of thesafety plan and consented within the session.Individual InterviewsIndividual Interviews Conducted: 2When asked if the individual was satisfied with supports andservices, interviewees shared: "I like that they care about me and know how to helpyou.""I am accomplishing some goals and working onothers that I want to accomplish."When asked, "What about this agency makes you keepcoming back?," interviewees shared: "I feel that I am more than a number to my counselor.They make me feel a part of them and more likefamily.""They genuinely care about me and my recovery."The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 7 of 8
Quality ImprovementRecommendationsProviders are reminded of the responsibility to maintain internal processeswhich ensure immediate and permanent corrective actions on issues identifiedduring the quality review process. DBHDD may request corrective action plans(CAPs) as quality review findings warrant as well as review agencies’ internaldocumentation regarding corrective actions and ongoing quality assurance andquality improvement. Please refer to the comments documented in each sectionabove for specific information pertaining to the recommendations below.Recommendations: Current and Prior ReviewBilling Validation - Quantitative Ensure all Quantitative Standards are met in documentation.Billing Validation - Performance Standards Ensure all Performance Standards are met in documentation.Focused Outcome Areas - Rights Ensure individuals are informed of their rights and responsibilities at the onset of services and at least annuallythereafter.The Georgia Collaborative ASO / Beacon Health Optionswww.georgiacollaborative.comReview ID: 11740Page 8 of 8
Ariel Community Care, LLC GAC002227 Behavioral Health Quality Review Final Assessment Address: Remote Quality Review - 8316 Office Park Drive, Douglasville, GA 30134 Assessors: Jerald Carter, MPA; Faith M Simpson, LPC, CADCII, MATS Records Reviewed: 5 Date Range of Review: 2/7/2022 - 2/9/2022
