Download DeKalb Community Service Board CSU Final Assessment BHQR 1

Crisis Stabilization Unit
Behavioral Health Quality Review
Final Assessment Report
Provider Name:
DeKalb CSB PVGA#7
Location of Review:
450 Winn Way, Decatur, GA 30030
Regions of Operation:
Region 3
Date Range of Review:
January 11-15, 2016
Quality Assessors: Brownie Childs MSN, RN & Katie Durden RN
Records Reviewed: 15
Provider Tier Level: 1
CSU Beds: 36
Temporary Observation Beds: 6
Transitional Beds: 0
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
Whole
Health
79%
Whole
Health
83%
Rights
100%
Choice
96%
Safety
90%
Focused
Outcome
Areas
93%
Person
Centered
Practices
93%
Rights
100%
Choice
96%
Safety
94%
Focused
Outcome
Areas
88%
Person
Centered
Practices
75%
Community
100%
Community
80%
The Individual Interview is not calculated into the overall score.
The Staff Interview is not calculated into the overall score.
The Georgia Collaborative ASO / Beacon Health Options
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Page 1 of 11
Rev. 12-31-15
Individual Interviews
Staff Interviews
Focused Outcome Area
Yes
No
NA
Yes
No
NA
Choice
22
1
2
23
1
1
Person-Centered Practices
25
2
1
27
9
4
Whole Health
48
13
14
48
10
7
Safety
27
3
0
80
5
5
Rights
50
0
0
35
0
0
Community Life
18
0
2
8
2
15
Individual Interview Observations:

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All five individuals interviewed felt they were given options for services.
All five individuals interviewed reported they were given choices of short and long term treatment
upon discharge.
The following were statements made by individuals interviewed during this review.
o “Dr. Galloway discussed all his medication side effects with him at length today."
o “Staff helped me develop a safety/crisis plan when I came in."
o “One of the nurses has gone out of her way to discuss my low blood sugar and how to manage it.”
o “Dr. Galloway is very easy to talk to."
o "Staff worked to get me home to Tifton."
Staff Interview Observations:
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All staff interviewed reported they understand how and when to report instances of abuse, neglect,
and exploitation.
All staff received training and feel proficient in techniques to promote de-escalation during crisis.
All staff interviewed were aware of suicide risk assessments and knows the protocol to follow if
warning signs are identified.
All staff interviewed were aware of any cultural practices and beliefs related to rights and exercising
those rights.
The following were statements made by staff that were interviewed during this review.
o “We really try to accommodate different cultural needs.”
o "I've been with this agency for 24 years, and I really like the work and the services they provide to
the community. I love to see people get well."
o “I've been working here since April and the supervisors work just like me, roll their sleeves up and
do whatever needs to be done.”
o “The length of the stay is too short for the consumer's acuity sometimes. Some could benefit
from a longer stay to avoid relapse.”
o “Outside groups come in and provide AA, NA, and spiritual group.”
o “I enjoy working here!”
The Georgia Collaborative ASO / Beacon Health Options
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Page 2 of 11
Rev. 12-31-15
Individual
Record
Review
91%
CSU
Service
Guidelines
100%
Overall
Score
91%
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.
The Georgia Collaborative ASO / Beacon Health Options
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Rev. 12-31-15
Individual Record Review
Assessment/Treatment Planning
90%
Admission/Initial Evaluation/Screening for Risk
Crisis Stabilization Specific Treatment Planning
Crisis Stabilization Course of Stay
Documentation
Transition/Discharge Planning
100%
77%
100%
97%
100%
*The individual category scores are an average of questions within the category. The overall
score is calculated by taking the total Yes answers vs. total No answers (NA excluded).
Individual Record Review
91%
Strengths:
 The agency’s Crisis Stabilization Unit (CSU) physical assessments were
comprehensive with a complete review of systems.
 The CSU conducts the following routine assessments at the time of
admission:
o Falls Risk Assessments that included sitting and standing blood
pressure
o Risk Assessment for Suicidality and Threats of Violence
o Screening for Tuberculosis (TB) testing and Human
Immunodeficiency Virus (HIV)
o Clinical Institute Withdrawal Assessment (CIWA) Scale
Opportunities for Growth:
Assessment/Tx Planning/Billing/Individual Record
 In nine out of 15 records reviewed, the Individual Recovery Plan (IRP)
goals were not written using the person’s own language. Examples
include: “Assess need for hospitalization”, “Client will report/exhibit
reduction of psychotic symptoms (AH, aggressive, insomnia, irritable,
racing thoughts and paranoia) from daily to zero and demonstrate they
are oriented x 4 prior to D/C”, and “Client will adhere to protocol for
cocaine, THC and alcohol detoxification if needed and not exhibit any
signs or symptoms of cravings for any drugs.” These goals were used
routinely and seen in many of the records reviewed.
The Georgia Collaborative ASO / Beacon Health Options
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Page 4 of 11
Rev. 12-31-15
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Two out of the 15 records reviewed did not reflect an order for
admission to the CSU. In one case there was a verbal order received by
a nurse for the Clinical Nurse Specialist (CNS), but the order was not cosigned by the CNS. In the second record, there was a verbal order by
the Registered Nurse (RN) for Physician/CNS that did not reflect a cosignature.
In one record, there was not an order to initiate a withdrawal
management regimen. In this case the nurse received a telephone
order, but the order was not co-signed by the ordering practitioner.
Crisis Stabilization Specific Treatment Planning
 There were three orders for services that were not endorsed or cosigned within 24 hours. These included two orders for admission to the
CSU and one for initiation of a withdrawal management regimen.
 None of the records reviewed reflected documentation that the
individual was present or offered to participate in his/her plan of care
discussion during treatment team. Formal Treatment Team Meetings
do not occur, but the individual is staffed with the physician extenders
(APRN/CNS), nurse, and counselor every morning prior to the
APRN/CNS making rounds. There is a clinical rounds sign-in roster
where staff document that they were present and this document is
attached to the roster of individuals currently on the unit for that day.
Staff reports, discussion of treatment with the individual occurs when
the Advanced Practice Registered Nurse (APRN)/CNS makes rounds and
the counselor is then responsible for documenting any changes to the
plan of care. This documentation was not reflected in the individual
records reviewed.
Non-Scored Items:
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Ten out of 15 records reviewed did not reflect vital signs documented at
a minimum of every eight hours. The agency reported vital signs were
taken once a shift which are 12 hour shifts.
Eight out of eight records did not reflect documentation of follow-up
and connection to continuing care upon discharge. Seven individuals
left Against Medical Advice (AMA) and was scored Not Applicable (N/A).
All 15 records reflected the individual received a reconciled medication
list at the time of discharge.
Two of the 15 individuals reviewed were readmitted within 30 days.
None of the individuals reviewed were receiving Assertive Community
Treatment (ACT) or Community Support Team (CST) services prior to
admission.
The Georgia Collaborative ASO / Beacon Health Options
For information on appeals and post-review surveys, please visit www.georgiacollaborative.com
Page 5 of 11
Rev. 12-31-15
Whole
Health
70%
Rights
100%
Choice
100%
Safety
Focused
Outcome
Areas
83%
43%
Person
Centered
Practices
87%
Community
100%
Focused Outcome Areas
83%
Strengths:
 Release of Information (ROI) forms were present and signed in order
to share information with referral sources.
 There was a metal detector walk through at the entrance of the CSU
for detection of weapons and for safety.
 The DeKalb CSU employs full time security guards, female and male.
Opportunities for Growth:
Whole Health

Nine out of 13 records reviewed had the following issues relating to
Abnormal Involuntary Movement Scale (AIMS) assessment and Lab
Reports:
o Seven records reviewed lacked a baseline AIMS assessment
on individuals that were receiving psychotropic medications.
o Two records were missing ordered lab results.
Safety

None of the records reviewed reflected documentation that
demonstrates how providers work with the individual to develop,
document and implement a safety/crisis plan. The agency reported
they implemented developing safety/crisis plans with individuals the
beginning of October 2015.
The Georgia Collaborative ASO / Beacon Health Options
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Page 6 of 11
Rev. 12-31-15

Ten out of 14 records reviewed did not document a signed
medication risk/benefit consent form that correlated to
medication(s) the individual received.
CSU Compliance with Service Guidelines
Program Offerings
1
The Crisis Stabilization Unit (CSU) meets all staffing requirements.
Yes
2
Provider adheres to their policy which define requirements and
procedures for timely notification to prescribing professional regarding
drug reactions, medication problems, medication errors and refusal of
medications.
Yes
3
There are protocols for handling of licit and illicit drugs brought into the
service setting. This includes confiscating, reporting, documenting,
educating, and appropriate discarding of the substances. The provider
adheres to said protocols.
Yes
4
Provider is adhering to their current policy and procedure for safe storage
of medications.
Yes
5
Provider adheres to their Infection Control Plan.
6
Provider adheres to their Seclusion and Restraint procedures.
Yes
Yes
7
Provider adheres to their procedures for monitoring of therapeutic blood
levels, if required by the medication, such as Blood Glucose testing,
Dilantin blood levels and Depakote blood levels; kidney or liver function
tests.
Yes
8
Individuals who are Deaf, Deaf-Blind, and Hard of Hearing Policies and
procedures are present for adherence to Required Components of Crisis
Service Plans for Provision of Crisis Services to Individuals who are Deaf,
Deaf-Blind, and Hard of Hearing.
Yes
Staff Training
9
10
The agency has a physician who is either on site or available twenty-four
(24) hours a day by telephone with 3.7-WM.
Yes
If the agency Physician(s) are not a Psychiatrist or Addictionologist do they
have access to physician(s) with Psychiatric or Addiction expertise for
consultation for Individuals admitted to the Crisis Stabilization Unit (CSU)?
Yes
# Yes
# No
# NA
SCORE
10
0
0
100%
The Georgia Collaborative ASO / Beacon Health Options
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Page 7 of 11
Rev. 12-31-15
CSU Compliance with Service Guidelines
100%
Strengths:
 The agency scored 100% on all questions within the Compliance
with Service Guidelines section.
 DeKalb CSB’s CSU adheres to all the policies and procedures
reviewed.
 The daily CSU unit schedule consist of mental health and substance
abuse groups as well as co-occurring groups.
 Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) groups
are held daily.
 The agency utilizes the 12 step curriculum as their model for
treatment for substance abuse.
 The agency contracts with a food service for meals. The contractor
has a nutritionist that is accessible for special diet needs of
individuals on the unit. For example, an individual who came in
dehydrate, had not eaten in five days, and with a low pulse rate was
ordered health shakes twice a day.
 The agency has three full time physicians, two psychiatrists and one
family practitioner. These physicians are full time and dedicated to
the CSU. The agency has access to an Addictionologist if needed for
a consult.
 The agency employs two advance practice nurses, an APRN and
CNS, who are utilized as physician extenders.
 The CSU has adopted the procedures for the Deaf, Deaf-Blind, and
Hard of Hearing individuals set forth by DBHDD beginning 10-1-15.
Opportunities for Growth:
 No issues were identified during this review.
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Page 8 of 11
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:
 The agency provides a seven day supply of medications and a refill prescription for 30 days of
medications upon discharge.
 The agency has their own pharmacy and is able to utilize “sample medications” received from
pharmaceutical companies as part of their stock. Pharmaceutical company’s patient
assistance programs are utilized to help individual’s access medications that normally would
not be affordable.
 Documentation reflected that the Pharmacist provides groups on medications.
 The agency uses a code for incidents on the Crisis Stabilization Unit called “Dr. Strong”. This
code is announced when there is a need for crisis intervention on the unit. There is a daily
team designated to respond if “Dr. Strong” is announced. The team consist of two security
guards, two RN’s, and two paraprofessionals.
Opportunities for Growth:
 Although a claims reviews of billed units was not part of this review, the following items may
pose a risk to the provider:
o The CSU reports they shred the paper record 90 days after discharge and after it is
scanned into their electronic medical record. Although this did not impact the overall
score for this review, this may pose a risk to the provider if the Assessors needed to
review the original signatures (not the scanned copies), as outlined in the DBHDD
Provider Manual (page 260, xiv. Signature, printed staff name, qualifications and/or title).
o Progress notes did not consistently contain both a printed and signed signature by the
RN, SST, and Counselor.
o Crisis Stabilization progress notes did not document the CSU code (H0018).
o The RN who is not an Advance Practice Nurse ordered services such as Behavioral Health
Assessment, Physician Diagnostic Assessment, Nursing Assessment and Care, and Crisis
Stabilization.
o Reviewers found identifying physician progress notes, orders, and signatures difficult to
read in all records reviewed.
 In one record reviewed there was no documentation by anyone for 24 hours.
 The agency reported if there was a medical or life threatening emergency they utilized the 911
call system. They also reported they don’t utilized a “crash cart” for emergency medications or
AED in case of cardiac arrest. Agency staff reported they do utilize the 911 system approximately
once a month for medical emergencies.
The Georgia Collaborative ASO / Beacon Health Options
For information on appeals and post-review surveys, please visit www.georgiacollaborative.com
Page 9 of 11
Rev. 12-31-15
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ASAM level is documented on the Psychiatric Evaluation Form as meets criteria for “Level III.7
(Inpatient Detox)”. However, documentation of the ASAM assessment is not present in the
record.
Running progress notes that include documentation by the nurse, social worker, and APRN/CNS
were not always succinct. For example: in one record reviewed the nurse documented a note on
9/21/15 at 2:30pm, then the CNS documented and dated 9/20/15 a 3:45pm to 4:45pm, next the
nurse documented 9/20/15 from 1:30pm to 2pm and 2pm to 3:45pm, again on 9/20/15 at 7pm,
then 9/21/15 at 2:15am by the Social Service Technician (SST). Proper documentation for late
entry notes was not reflective on the progress notes.
In one record reviewed documentation reflected a relapse plan for someone in the CSU for
Depressive Disorder and Post-Traumatic Stress Disorder (PTSD) with no Substance Abuse (SA)
diagnosis.
Group progress notes did not consistently reflect the staff signature and credentials of the
person providing the group. In most cases there were initials only of the person providing the
group.
Documentation reflected interchanging of pronouns and information regarding another
individual in a nursing progress note.
Medication Administration Record (MAR) signatures were unorganized and illegible with no
printed names and credentials.
During the tour of the facility several things were noted. There was an unpleasant urine odor
throughout the unit. The CSU’s furnishings were outdated and in disrepair. One of the
individual’s on the unit pointed to two different structural issues: movement of plexiglass that
was unsecured to a window pane and a hole in the wall, both could be potential safety risks.
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.
Assessment & Treatment Planning
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 there is an order by a Physician or Physician extender for admission to the Crisis
Stabilization Unit.
Ensure there is a Physician or Physician extender’s order present in the individual’s record to
initiate a withdrawal management regimen.
Crisis Stabilization Specific Treatment Planning
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Page 10 of 11
Rev. 12-31-15
Ensure all verbal orders received by the nurse are signed by the physician or physician
extender within 24 hours. .
Ensure the individual was present or offered to participate in his/her plan of care discussion
during treatment team.
Non-Scored
Ensure there is evidence in the medical record of follow-up and connection to continuing
care.
Ensure there is a minimum set of Vital Signs every 8 hours.
Ensure the Crisis Stabilization Program adheres to Deaf, Deaf-Blind, and Hard of Hearing
policies and procedures.
Ensure the agency has an identified Model or Curriculum for SU treatment on the CSU.
Focused Outcome Areas
Whole Health
Ensure there are documented safeguards utilized for medications which are known to have
substantial risk or undesirable effects that have been identified (e.g. lab testing, AIMS,
assessments, etc.)
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.
The Georgia Collaborative ASO / Beacon Health Options
For information on appeals and post-review surveys, please visit www.georgiacollaborative.com
Page 11 of 11
Rev. 12-31-15