Colonial Intermediate Unit #20 RESOLVE Program Provider 50 Services

1. Colonial Intermediate Unit #20RESOLVE ProgramProvider 50 Services Administrative Field Staff Meeting 5/18/09 4:00 pm to 6:00 pm

2. Agenda • Billing for Services • What is Fraud and Possible Consequences • Administrative Review of Paperwork • Timesheets, Data collection, Progress Notes and On Site Supervision • Clinical Concerns • Case Assignments and Commitment • Percentage Reports • Program Goals, Review Process and Consequences • Supervision and Training • Requirements and Opportunities • Question and Answers

3. Billing for ServicesTrust and Understanding • Provider 50 is a very independent program and the vast majority of staff consistently provide services appropriately and ethically Thank you!!!! • It only takes one “bad apple” to bring down a program!!! • The P50 Program has recently experienced a fraudulent billing situation that is being addressed through the legal system. • The program has also encountered some concerning practices that necessitated need for the present training.

4. What is Medicare Fraud • Completing and billing for treatment documentation that is inaccurate and/or completely false. This includes: • Incorrect start/end times and service dates • Listing interventions/behavioral responses that were not provided and/or observed • Listing inaccurate service locations or individuals present during sessions • Forging signatures

5. Encounter Forms • Encounter Forms are the only way a provider can verify that a service was provided given a specific date, and timeframe. • The signature by the parent/guardian or teacher is that verification. Signatures must be obtained at the end of each session and not done at the end of the week, all at once or ahead of time. • Any errors or omissions on this form will indicate to us that further investigation is needed. Only have parents, Guardians, or other’s sign fully completed Encounter Forms. • Remember, if services are provided in a setting other than the home, a representative from that setting must sign off on all encounter form sessions. A parent cannot sign for a session provided in the school setting. • Remember face to face sessions are required to appropriately bill for a session. The BSC has some additional flexibility in providing non direct services related to phone contacts, treatment plan development and revisions.

6. This is an example of how to make an appropriate correction on an Encounter Form Encounter Form Examples

7. Staff name is entered in the client section No signatures were included to verify dates and times Client name was included in the staff signature section Encounter Form Samples (Cont)

8. 5/1/09 ending time was corrected inappropriately 5/2/09 service date was corrected inappropriately 5/4/09 ending time was incomplete Parent/Guardian signature was incorrectly bracketed for all services dates Further questions would exist as to why a parent/guardian would sign for service dates that were incomplete Staff did not sign the Encounter Form Encounter Form Samples (cont)

9. 5/1/09 is missing start/stop times 5/3/09 is missing a start time 5/6/09 is missing a stop time 5/8/09 has inappropriate correction procedures to the date and ending times Last parent/guardian signature is on a blank line which bring s into questions how the staff person is getting verification signatures As with the previous example, further questions would exist as to why a parent/guardian would sign for service dates that were incomplete Encounter Form Samples (cont)

10. Client name is omitted 5/3/09 ending time is inappropriately corrected Last parent/guardian signature is on a blank line which bring s into questions how the staff person is getting verification signatures As with the previous examples, further questions would exist as to why a parent/guardian would sign for service dates that were incomplete Encounter Form Samples (cont)

11. Parent/Guardian inappropriately signed for all service dates by signing diagonally across the date lines Encounter Form Samples (cont)

12. Parent/Guardian signed every line even though staff person entered session information on every other line Because the parent/guardian signed blank lines, further investigation will take place to make sure session data was recorded correctly. 5/3/09 services date took place in the school setting and was signed off by the parent/guardian. This is the incorrect signature to obtain for this session which should have been a school representative (i.e. teacher, principal, secretary, associate, etc.) This last example is particularly important because this is the exact scenario that CIU20 encountered with led to the staff person mention earlier to be investigated and removed from the Board Approved List. Encounter Form Samples (cont)

13. Consequence for Fraud CIU20 Investigation Process will include: • Internal review of concern which includes a call to the client, family, community and school settings. • In office meeting to discuss the concern. • If fraud is strongly indicated, staff person will be immediately removed from the Board Approved List. • Staff information will be submitted to DPW and local MCO’s in order for them to conduct their own investigation. • Dependent upon the above investigation, staff information could be forwarded to the Attorney General’s Office for further investigation and possible prosecution.

14. Consequence for Fraud (cont.) • Staff may be fined or imprisoned • Staff may lose their professional certificates (i.e. teaching certificates) and licenses • For full time IU employees, fraudulent billing may lead to removal from salaried or other contractual positions. • CIU20 may then be audited which could lead to an agency fine, licensing infraction, or termination • License termination means that there would no longer be a P50, PHP, or Day Treatment Program at the CIU20 • Fraudulent billing affects all of us!!!!

15. Consequence for Fraud (cont.) • Locally, there was a Northampton County Based provider that closed it’s doors as a result of a fraudulent billing situation initiated by a single individual. • Currently, CIU20 has removed one staff person for engaging in alleged fraudulent billing practices. That person is being investigated with the potential of facing significant fines and restitution. • That person will not longer be allowed to provide BHRS in the Northampton, Monroe, Pike and Lehigh County’s.

16. Administrative Review of Paperwork • In general, the Facilitators have begun to see increasing amounts of paperwork issues. • These issues cause delays in billing, staff payment and other internal mechanisms that assist in monitoring the program. • As a result of these ongoing and increasing issues, strict administrative procedures are now in place to address and correct the problem.

17. Administrative Review of Paperwork (cont) • The Progressive Discipline Procedure will be followed for chronic incomplete, inaccurate or tardy paperwork. This procedure is as follows: • Step #1: Phone contact to staff person notifying them of the issue and the need to correct the error. A summary of the phone call will be placed in your program file. • Step #2; If continued, the staff person will be required to attend a face to face office meeting to further discuss the matter along with necessary corrective plan of action. A summary of this meeting will be placed in the staff’s program file. • Step #3: Continued violations will lead to removal form the Board Approved List

18. Common Errors and OmissionsNoted on Paperwork • Timesheets • Not handed in on time, staff save several pay periods and submit all the paperwork at once. Time sheets, related Encounter Forms, Progress Notes, and Data Collection Sheets (for TSS only) are due the Tuesday 8 am following a payday. • Completed in pencil, pen color other than black, sloppy, incomplete, use of whiteout and dates/times that do not match the Encounter Form and Progress Note • Completed timesheet (i.e. Report of Work) is one sided and does not include reason codes on the reverse side. • Reason codes on the reverse side of the timesheet are incomplete or completed incorrectly (i.e. overuse or incorrect use of code #14, etc.).

19. Common Errors and OmissionsNoted on Paperwork (cont) • Timesheets (cont) • Use of only one reason code when there were multiple reasons services were not fully provided in a given week. • Form lacking the necessary signatures to process or required sections left blank (i.e. procedure code, address, and pay period sections left blank. • Timesheets need to be submitted for all assigned clients for every pay period regardless of whether or not services were rendered. In this situation, the timesheets would reflects zero service hours provided with an accurate reason code. • Procedure codes for the individual BHRS are as follows: • BSC (PhD Level) Y9608 -TSS (A and B) Y9607 • BSC (Master’s Level) Y9609 -MT Y9610 • TSS Aide and Respite Worker does not have a code, just indicate your position in the procedure code box • Improper correction procedure utilized. Any corrections should be made with a single line through the error with the term “error” and the staff initials next to the error circled. Scribbling out, erasing, writing over and other methods of correction are not allowed. No White Out!!!! • When in doubt, please call a Facilitator and ask the question instead of submitting incorrectly!!!!

20. Time Sheet Sample • When documenting multiple session on a given day, please enter the two sets of start and ending times but only provide the overall total duration for that the day. See example:

21. Data Collection Forms • Please note, data collection is required for all P50 cases. The TSS Data Collection Form is required for all non-Autistic clients receiving TSS services. For client’s on the spectrum you may use the TSS Data Collection Form or other collection forms that relate specifically to Verbal Behavior Concepts (i.e. Mand/Tacting Data Form, etc) • BSC are allowed to utilize their own data collection form if it better suits their client’s programming needs • The TSS Data Collection Form should be viewed as a minimum standard of data collection and not the only way data could be collected for the clients.

22. Data Collection Forms (cont.) • Data is only valuable if it is analyzed on a regular basis and the results applied to the client’s programming. • Currently, some TSS are not completing the TSS Data Form and some BSC’s are not providing the office with any documentation related to the data analysis. • With this in mind, the Provider 50 program is now requiring all BSC’s to submit monthly documentation that their client’s data is being analyzed. The most common form of this analysis is to graph the data. This can be done on either the computer (i.e. excel) or hand scored on graph paper. • Facilitators will now give TSS notes and data forms directly to the assigned BSC, before their administrative review, in order to allow BSC’s the maximum time to gather analyze and graph their client’s data. • All graphs will be due with the regularly scheduled paperwork submission closest to the 5th of the month. For example, paperwork for the 4/18-5/1/09 pay period was due on 5/5/09. All monthly graphs would have been submitted with that paperwork submission by 5/5/09. • This first graph submissions will be required in July 2009 (for data collected during the month of June 2009). • BSC’s should remember that the graphing and analysis of data are billable services and should be reflected on the Encounter Form as TP or TR service type.

23. Progress Notes • Make sure all progress notes are clearly written, measurable, provide enough detail and justify the length of the session. • Notes should follow the appropriate correction procedures. All content should be related to the client’s Goal treatment Plan • Make sure all your dates and time match on your timesheets, progress notes and encounter forms. • Make sure you only use black ink, no white out, and do not make copies of hand written notes. Staff may type their progress notes. • For TSS, make sure the data you collect for each session “makes sense” with the content of your session note (i.e. if your data indicated high frequency of targeted behaviors then the content of your note should not reflect a “great day” and “no issues observed”). Parents need to also sign data collection forms.

24. Progress Notes (cont.) • No section of the progress note should be left blank. This includes the signature, DOB, EVS Check, Parent/guardian Involvement and Authorization Time Period sections. The Authorization Time Period section is located at the bottom of your progress note. • If a specific section is not applicable to that session (i.e. the service overlap section if no overlap occurred) then write “NA” or “None” in that section.

25. On Site Supervision Form • New TSS are required to receive either 3 or 6 hours of on site supervision before they can work in the field alone. This supervision must be done by a master’s level clinician. • Master’s Level Clinician's are assigned on site supervision time separate from regular BSC or MT time. As a result, on site supervision time must be documented separately form regular on going BSC or MT time. Do not include on site supervision sessions on the same time sheet and encounter form as regular BSC and MT sessions. • If you have questions regarding on site supervision time, please contact a Facilitator to clarify before submitting treatment documentation.

26. Clinical Concerns Ethics and Commitment to a Case • When a staff person accepts a case, it is CIU20’s expectation that you will be able to meet the client’s needs for at least a 4 month period!!! • Recently, we have experienced staff who have verbally accepted cases and signed assignment sheets and then removed themselves from case within a few days or weeks. • In some cases, we only became aware of this after the family had made a call to the office questioning the status of their son or daughter’s services. • Also, it is the expectation of the IU that once you sign an assignment sheet you are officially assigned to a client. Contact to the family should be made within 48 hours of signing the assignment sheet. If you are experiencing difficulty in initiating services with a family, contact the assigned Facilitator for assistance. • If staff “back out” of cases or delay the start of cases without sufficient reason, the progressive discipline procedure mentioned earlier in this presentation will be implemented.

27. Clinical Concerns (cont.) • Staff should remember that they should never be left alone with a client. This does not mean that the parent/guardian has to be over your shoulder for every session, however, a parent/guardian has to be in the immediate vicinity and available in case a crisis were to occur. • A parent/guardian needs to be available and involved in treatment in order to transition effective skills which is a discharge criteria for every P50 case. • Staff should never transport a client in their own car Transportation is not a billable services and should not be included in any billing submissions. If a community session is scheduled, a location within walking distance should be selected or arrangements should be made to meet the client and his/her family within a community setting. • The Provider 50 program at CIU20 is a “hands off” program and staff should not engage in any type of restraint procedure. This remains the case even if staff have specialized crisis/restraint training through their salaried position. • All active staff should maintain weekly contact (i.e. phone, email, face to face) with their assigned Facilitator.

28. Clinical Concerns (cont.) • Although restraints are not permissible within the P50 program, staff are expected to provide any crisis de-escalation techniques appropriate for the circumstance of the session. Staff and families should follow the crisis plan during any crisis episodes. • Completed crisis plans are required for every P50 client. It is the responsibility of the lead clinician to complete and update this form on a regular basis. It is the responsibility of the lead clinician to also forward a copy of the crisis form to team members ( i.e. TSS, MT, client/family) and the IU office. • TSS should still be completing regular on going TSS Supervision Notes anytime they discuss their case with either the assigned MT, BSC, or Clinical Supervisor. The information reflected on the TSS Supervision Note should match the Progress Note content if the communication was a service overlap situation. • The TSS Supervision Note should be submitted with regular treatment documentation (i.e. Encounter Form, Time Sheet, Data Collection Form, and Progress Note), every two weeks following the established pay period calendar. • TSS working 19 hours or less per week should have a total of 30 minutes of supervision time across their entire caseload while TSS providing 20 hours or more of services per week should have at least 60 minutes of supervision time across their entire caseload. • TSS staff having difficulty meeting this weekly supervision requirement should contact Ken Smith (Treatment Coordinator) to discuss options to rectify this problem.

29. Percentages Report • We have noticed a trend in our program related to the amount of services we are providing for each of our clients. Specifically, on average the P50 program is only providing about half of the authorized services across the entire caseload. • Local MCO’s have also begun to look at this information and have issued reports to all local providers related to their service percentages. • Because of this, CIU20 has developed a Percentages Report that will be monitored each pay period. • The report will list each client and their corresponding authorized services along with the authorized amount and rendered amount of services. The report will indicate service percentages for each service (i.e. TSS, BSC, MT), along with an overall percentage for each client. • Our goal is to have all clients maintain a 70% or better service percentage. Clients that have percentages consistently below this percentage will be reviewed with a plan developed to increase the amount of services rendered.

30. Percentage Report (cont.) • We acknowledge there are some situations that exist which are out of your control when it comes to providing services. Client’s cancel, do not show up for a session, and get hospitalized to name a few. • Our focus on service percentages is to first improve on those areas we have control of, then focus on the other obstacles we encounter when providing services. • If you experience a case that has frequent cancelations or “no shows” please let your assigned facilitator know and we will address the situation administratively. • If the percentages are low due to staff reasons, then the progressive discipline procedure will be initiated to improve the situation.

31. Supervision and Training Requirements Training • Staff should be aware that the yearly training requirement for all Provider 50 staff is 20 hours. • This requirement is monitored by Chad Henritzy and begins in September and ends in August. • New TSS have additional training requirements that can be discussed individually with Chad at a later time. • Staff that are hired during the year have a prorated amount of training hours required the first year. The specific amount is roughly calculated at 2 hours for each month remaining in the year. Chad can discuss specific situations at a later time. • The training requirement of 20 hours per school calendar is required for both active and inactive staff

32. Supervision and Training Requirements (cont) Supervision • All active staff must attend one of three scheduled group supervision sessions each month. • The schedule for these sessions are coordinated one year in advance and they are held from 3:00pm to 5:00 pm at the CIU20 Main Office, Colonial Academy, and Monroe Public Library. See previously sent memo for specific dates. • Chronic absences from these supervision sessions will initiate the progressive discipline procedures reviewed earlier in this training. • Unfortunately, those staff who are unable to meet this requirement, under all circumstances and scenarios, will need to be transitioned off their caseload. • Web based sessions are available for staff who have pre-arranged these sessions with Ken Smith

33. Training Opportunities • Youth and Family Institute Web Cast and Video Conferences Series • Magellan Behavioral Health website • Community Care Behavioral Health website • Bureau of Autism Services Website • CIU20 and PaTTAN Sponsored Trainings • Training Packets

34. Questions and Answers • Functional Behavioral Assessments • Open Discussion