Crisis Stabilization Unit Behavioral Health Quality Review Final Assessment Report

Crisis Stabilization Unit Behavioral Health Quality Review Final Assessment Report Provider Name: Pineland Community Service Board GAC000535 Location of Review: 5 West Altman Street Statesboro, GA 30458 Regions of Operation: Region 5 Date Range of Review: June 27-29, 2016 Quality Assessors: Katie Durden, RN; Helen Rohrich, RN; Michelle McIntosh, LPC, NCC Records Reviewed: 15 Provider Tier Level: 1 CSU Beds: 10 Temporary Observation Beds: 0 Transitional Beds: 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 Perception of Care Number Interviewed: 5 Staff s Perception of Care Number Interviewed: 5 Rights Choice 88% Whole Health 88% Focused Outcome Areas 92% Community 95% Safety 90% Person Centered Practices 91% Rights Choice Whole Health 95% Focused Outcome Areas 99% Community Safety Person Centered Practices The Individual Interview is not calculated into the overall score. The Staff Interview is not calculated into the overall score. Page 1 of 13 Rev. 12-31-15

Individual Interviews Staff Interviews Focused Outcome Area Yes No NA Yes No NA Choice 21 3 1 25 0 0 Person-Centered Practices 30 3 2 27 0 13 Whole Health 35 5 35 53 3 9 Safety 27 3 0 88 0 2 Rights 48 0 2 34 0 1 Community Life 18 1 1 15 0 10 Individual Interview Observations: All five individuals reported that they feel safe on the Crisis Stabilization Unit (CSU). All five individuals reported that they were satisfied with supports and services provided. All five individuals felt they are treated with dignity and respect. The following were comments made by individuals on the CSU: o I think this is a great program. o They are working on getting me into transitional housing and hopefully my discharge is tomorrow. o This is a helpful place to help you get back into the community, help find you a job and a place to live. o Everybody has been very nice to me. Staff Interview Observations: All five staff members report that they promote dignity for the individuals served. All five staff members understand how to report instances of abuse, neglect and exploitation. All five staff members feel adequately trained in techniques to promote de-escalation in a crisis. The following were comments made by staff on the CSU: o We correspond with providers at short and long term facilities about the individual's medical and behavioral health status and what issues need to be followed up. o Pineland is a good place. It is huge to have a place for individuals with addiction to go to and having a 28 day short term program is so important. Without the short term program I would have to discharge them to outpatient services. o If an individual is diagnosed with Human Immunodeficiency Virus (HIV) we have the HIV staff person talk with them before discharge and have a follow up appointment with the Health Department to make sure they can continue their medications and follow up care. Page 2 of 13 Rev. 12-31-15

Individual Record Review 75% CSU Service Guidelines 80% Overall Score 80% Focused Outcome Areas 83% The overall score is calculated by averaging the three areas: Individual Record Review Focused Outcome Areas CSU Compliance with Service Guidelines Each area accounts for one-third (33.33%) of the Overall Score. Review questions are based on DBHDD and Medicaid requirements. Page 3 of 13 Rev. 12-31-15

Individual Record Review Assessment/Treatment Planning 79% Admission/Initial Evaluation/Screening for Risk 92% Crisis Stabilization Specific Treatment Planning Crisis Stabilization Course of Stay 50% 50% Documentation 99% Transition/Discharge Planning 75% *The individual category scores are an average of questions within the category and are for the agency s reference only. Individual Record Review Strengths: All individuals receive a physical assessment by a physician at the time of admission. Documentation reflected this practice. 75% Fall risk assessments were completed by nursing staff and evident in multiple records. Running nursing note documentation was thorough, included vital signs and reflected relevant information to justify individual s continuation of stay. Opportunities for Growth: Assessment/Treatment Planning/Billing Individual Record Six of seven applicable records reviewed did not show evidence that cooccurring health conditions, in addition to the primary presenting condition, were addressed and documented in the Individual Recovery Plan (IRP) or Nursing Care Plan (NCP). For example, an individual admitted for detox and for Suicidal Ideation (SI) with a plan also had multiple medical diagnoses including chronic gout, diverticulosis, Degenerative Joint Disease (DJD), history of Gastrointestinal (GI) bleed, hypertension, high cholesterol, obesity and a history of a Coronary Artery Bypass Grafting (CABG); however the medical issues and SI were Page 4 of 13 Rev. 12-31-15

not addressed on his IRP. He was also homeless which was also not addressed on the IRP. Thirteen of 14 applicable records documented anticipated discharge plan/step-down service was not specific to the individual served. Many step-down services stated, MHOP (Mental Health Outpatient) or SAOP (Substance Abuse Outpatient). These are not specific services. Admission/Initial Evaluation/Screening for Risk Three of 14 applicable records documentation did not reflect that a biopsychosocial assessment was included in the individual s record. Additionally, many of the biopsychosocial assessments present in the records did not reflect a comprehensive assessment. Crisis Stabilization Specific Treatment Planning One of 11 applicable records did not reflect all verbal or telephone orders taken by the nurse were co-signed by the ordering prescriber within 24 hours. Seven of 15 records documentation did not support that the IRP s goals/objectives were written using the person s own language, was individualized or specific to the individual receiving services. Multiple IRP s included the same goals, objectives and interventions across records such as, Detox and Get stable. Eight of 13 applicable records documentation did not reflect that specific safety issues were incorporated into the IRP when safety issues were identified. For example, an individual with epilepsy was not placed on seizure precautions nor was this diagnosis addressed on the IRP. Another individual admitted with SI did not have suicide addressed on the IRP. Two applicable records documentation did not reflect that the IRP incorporated medical updates as needed. For example, an individual who was sent to the Emergency Department for evaluation after complaining of chest pain was discharged back to the CSU. The IRP was not updated after their return to the CSU. Eleven of 13 individual s documentation did not reflect that their plan of care was discussed every 72 hours with treatment team. The agency reported and documentation reflected that treatment team meetings occurred weekly. One of 13 applicable individuals participated in a treatment team meeting. The agency reported that they have recently incorporated inviting the individual into treatment team meetings which has not been a past practice. Crisis Stabilization Course of Stay Seven of 14 applicable records documentation did not reflect that the individual participated in one or more therapy/training services such as Individual Counseling, Family or Group Outpatient Services. Page 5 of 13 Rev. 12-31-15

Six of 14 applicable records documentation did not reflect that groups were offered to individuals while they were on the CSU. Four of six applicable records documentation did not reflect that cooccurring disorders were addressed simultaneously on the CSU. For example, an individual admitted for SI with a history of alcohol and opiate abuse did not have Substance Use (SU) addressed on the IRP nor was there any documentation of groups offered during the course of stay. Transition/Discharge Planning Four of 14 applicable records did not contain all documentation for discharge/after-care plans. For example, the physician wrote an order for the individual with epilepsy to follow-up with his neurologist after discharge; however, this was not addressed on the discharge plan. Another individual was referred outside of the agency; however, there was not a Release of Information (ROI) which is needed for discharge planning, coordination of care, discussion with the agency and to schedule an aftercare appointment. Three of 14 applicable record s discharge/after-care notes did not include all information needed. For example, one discharge note did not include a Strengths, Needs, Abilities, Preferences (SNAP). Another note included a SNAP; however, it was unorganized and did not include all four areas of SNAP documentation. Non-scored Six of 12 applicable records documentation did not include follow-up with the receiving referral source after discharge. The agency reported that individuals referred to Pineland CSB are followed-up by outpatient services. All individuals received a medication reconciliation list at the time of discharge. Two individuals had been readmitted within 30 days. One individual had been receiving Community Support Team services. All 15 records documentation reflected that the individual did receive vital signs every 8 hours. Three of the 15 individuals were receiving Non-Intensive Outpatient Services prior to admission which included Nursing Services, Psychiatrist Services, Community Transition Planning, Group Outpatient Services, and Psychosocial Rehabilitation-Individual. Page 6 of 13 Rev. 12-31-15

Rights Choice 97% Whole Health 94% Focused Outcome Areas 83% Community 98% Safety 71% Person Centered Practices 35% Focused Outcome Areas Strengths: Screenings for Ebola Virus were present in the records reviewed. Baseline Abnormal Involuntary Movement Scale (AIMS) assessments 83% are completed on all individuals who receive psychotropic medications and documentation reflected this best practice. The agency reported and documentation reflected that Line of Sight observations are completed every 15 minutes on all individuals during the entire length of stay. The agency reported that Human Immunodeficiency Virus (HIV) testing, education and post-testing counseling is provided upon request on the CSU. Documentation reflected that all individuals reviewed were informed of their rights, responsibilities and HIPAA practices at the time of admission. Non-billable notes by the therapist and communication logs between nurses contained important information to determine progress and transition planning including plan for discharge, issues on the CSU and communication with supports such as family members. Page 7 of 13 Rev. 12-31-15

Opportunities for Growth: Person Centered Practices Four of the 15 records reviewed did not reflect that the individual was receiving individualized services. For example, IRP goals/objectives were identical across multiple records and many did not include all presenting symptoms and issues. Twelve of 15 records documentation did not reflect that the individuals were an active participant in planning and receiving services provided. For example, many treatment plans were not signed by the individual or indicated if the individual refused to sign making it difficult for assessors to determine if individuals were offered to participate in the treatment planning process. Eight of nine applicable individual s documentation did not reflect that the individual was an active participant in modifying the treatment plan or services. Treatment team meetings take place weekly on each individual; however, documentation did not reflect that all individuals were offered to participate in treatment team meetings to discuss their plan of care. Four applicable individual s IRPs were not reassessed based on changing needs. For example, an individual admitted for SI experienced a psychotic episode where he was paranoid and hallucinating; however, his plan was not reassessed or modified. Safety Nine of the 15 individuals documentation did not receive a safety/crisis plan while on the CSU. Many individuals admitted had serious safety issues such as SI, suicide attempt, drug and alcohol abuse and at risk for relapse and readmission after discharge. Best practice for an individual who has had a CSU admission is to participate in safety/crisis planning. The agency reported that only individuals with SI receive a safety plan; however, this was not always reflected in the documentation. Four of 15 records did not contain documentation that the individual was educated on the risk/benefits of all medications prescribed with a signed consent form. Page 8 of 13 Rev. 12-31-15

1 Yes 2 charge nurse at all times. (If the charge nurse is an APRN, then he/she may not simultaneously serve as NA 3 NA 4 basis of the clinical care needs of the individual, including required levels of observation for high risk NA individuals. Provider adheres to their policy which define requirements and procedures for timely notification to 5 prescribing professional regarding drug reactions, medication problems, medication errors and refusal Yes of medications. There are protocols for handling of licit and illicit drugs brought into the service setting. This includes 6 confiscating, reporting, documenting, educating, and appropriate discarding of the substances. The Yes provider adheres to said protocols. 7 Provider is adhering to their current policy and procedure for safe storage of medications. No 8 Provider adheres to their Infection Control Plan. No 9 Provider adheres to their Seclusion and Restraint procedures. Yes Provider adheres to their procedures for monitoring of therapeutic blood levels, if required by the 10 medication, such as Blood Glucose testing, Dilantin blood levels and Depakote blood levels; kidney or Yes liver function tests. Individuals who are Deaf, Deaf-Blind, and Hard of Hearing Policies and procedures are present for 11 adherence to Required Components of Crisis Service Plans for Provision of Crisis Services to Individuals Yes who are Deaf, Deaf-Blind, and Hard of Hearing. 12 NON-SCORED: The agency has an identified Model or Curriculum for SU treatment on the CSU. Yes Staff Training The agency has a physician who is either on site or available twenty-four (24) hours a day by telephone with 3.7-WM. 13 Yes If the agency Physician(s) are not a Psychiatrist or Addictionologist do they have access to physician(s) 14 with Psychiatric or Addiction expertise for consultation for Individuals admitted to the Crisis Yes Stabilization Unit (CSU)? CSU Compliance with Service Guidelines Program Offerings The Crisis Stabilization Unit (CSU) meets all staffing requirements: a. Physician or staff member under Physician b. Full time Nursing Administrator is an RN c. RN present in facility at all times d. Staff to Individual ratio is based on acuity level e. Licensed or credentialed staff present to provide Individual, Group and Family Therapy Child and Adolescent: There is at a minimum of (3) staff present within the C&A CSU including the the accessible physician during the same shift.) Child and Adolescent: Staff to Individual ratio is no more than (4) Individuals to every (1) staff (including the charge nurse.) Child and Adolescent: Staffing demonstrates the ratio of nursing staff to individual s increases on the NON-SCORED: Child and Adolescent: Does the C&A CSU provide services under the direction of a psychiatrist with training or experience in working with children and youth? 15 NA # Yes # No # NA SCORE 8 2 3 80% Page 9 of 13 Rev. 12-31-15

CSU Compliance with Service Guidelines Strengths: The agency provided policies and procedures relevant to this review process in a well-organized manner. 80% The agency s identified model for Substance Use treatment is Living in Balance which is an evidence-based practice. The agency reported that the Director of Addictive Diseases is a Certified Addiction Counselor II with many years of experience and training under an Addictionologist provides oversight for the CSU. Opportunities for Growth: Program Offerings The agency s policy, Medication Storage, Handling and Control, states Medications must be stored under conditions which protect their integrity. Proper sanitation, refrigeration and temperature logs, lighting, humidity control and ventilation are to be maintained. Disinfectants and drugs for external use are to be stored separately from internal and injectable drugs. During the tour of the facility, bottled water was noted to be in the medication refrigerator. The agency s Infection Control Policy stated that the Health and Safety Sub-committee will, make recommendations on Infection Control policies, practices and functions to the Safety Committee and the Executive Director. The Health and Safety Committee meeting minutes provided from August 4, 2015 did not include infection control information or recommendations for the CSU. Page 10 of 13 Rev. 12-31-15

Additional Comments on Practices Practices/Concerns beyond the general scope of the 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: Documentation reflected that the CSU HIPAA code, H0018, was documented every 24 hours for all individuals reviewed. Opportunities for Growth: Although a claims review of billed units was not part of this review, the following items may pose a risk to the provider: Ensure all verbal/telephone orders taken by the nurse are cosigned by the ordering prescriber within 24 hours. There was only one order noted that was not co-signed within 24 hours. During the tour of the facility, the milieu appeared dated and in disrepair. A few safety issues were noted such as nails protruding from a piece of wood in a patient room, a bathtub in the women s restroom, and a hole in a wall; all of which increases risk for potential harm to self or others. The CSU would benefit from structural enhancements. Staff reported that the wood with nails had received a corrective action plan and had been removed before the end of the review. Although documentation stated that individuals met ASAM Level III.7 criteria to initiate a withdrawal protocol, there was only one corresponding assessment present in the documentation. The CSU s daily schedule included individual counseling sessions; however, documentation did not reflect this practice. An individual s treatment team note dated 4/26/2016 was signed Sunday, 6/26/2016. Multiple documents included different hand-writing and colored ink within the same document. The CSU does not employ either a Certified Peer Specialist (CPS) or Certified Psychiatric Rehabilitation Practitioner (CPRP) which is a best practice. The CSU does not employ a psychiatrist or Addictionologist to provide services on the CSU; however, the agency does have access to both for consultation as needed. The CSU does not employ security guards; however, there were security cameras throughout the CSU with monitoring at the nurse s station. Page 11 of 13 Rev. 12-31-15

Technical Assistance Recommendations Providers are reminded of the responsibility to maintain 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. Individual Record Review Assessment/Treatment Planning/Billing Individual Record Review Ensure co-occurring health conditions, to include MH/IDD/SA/Medical/Physical, in addition to the primary presenting condition, have been assessed, addressed, coordinated, and documented if applicable in the Individual Recovery Plan (IRP) or Nursing Care Plan (NCP). Ensure the discharge plan includes specific step-down service/activity/supports to meet individualized needs. Admission/Initial Evaluation Ensure a bio-psychosocial assessment is present with all required components. Crisis Stabilization Specific Treatment Planning Ensure all verbal orders received by the nurse are signed by the physician or physician extender within 24 hours.. Ensure the documentation supports the IRP or NCP s goals/objectives are written using the person s own language, individualized and specific to the individual who needs psychiatric stabilization or SU withdrawal treatment. Ensure the NCP or IRP addresses the following safety issue(s), SI, seizure precautions. Ensure the NCP or IRP incorporates medical updates as indicated. Ensure the individual s plan of care is discussed a minimum of once every 72 hours with the treatment team. Ensure the individual was present or offered to participate in his/her plan of care discussion during treatment team. Crisis Stabilization Course of Stay Ensure the Individual participated in one or more therapy/training services such as Individual Counseling, Family and Group Outpatient Services. Ensure documentation supports the Individual is offered groups on the CSU. Ensure documentation reflects co-occurring disorders are addressed and treated simultaneously. Transition/Discharge Planning Ensure Discharge/Transition plans include required documentation specifically ROI for receiving agency, discussion of course of stay. Ensure discharge notes and aftercare plans, includes the Individual s status at discharge, ongoing needs, aftercare plan, and the date, time and method of discharge. Page 12 of 13 Rev. 12-31-15

Non-Scored Ensure there is evidence in the medical record of follow-up and connection to continuing care. Compliance with Service Guidelines Program Offerings Ensure the Crisis Stabilization Program adheres to the policy and procedure for safe storage of medications. Ensure the Crisis Stabilization Program adheres to the Infection Control policy. Focused Outcome Areas Person Centered Ensure documentation demonstrates the Individual is receiving individualized services. Ensure documentation demonstrates the Individual is an active participant (has a voice) in the planning and receiving of services. Ensure documentation demonstrates the individual is an active participant n modifying the plan and/or services. Ensure documentation demonstrates the plan is reassessed based upon any changing needs, circumstances and/or response by the Individual. Safety Ensure documentation shows how providers work with each Individual to develop, document, and implement a safety/crisis plan as needed. Ensure there is documentation the Individual (or legal representative, guardian/parent of a minor) has been educated on the risk/benefits of all medications prescribed and there is a signed consent form that correlates to each medication. Page 13 of 13 Rev. 12-31-15