Coordination Between the LME-MCOs and DHSR in the Monitoring of Licensed Facilities

1. Coordination Between the LME-MCOs and DHSR in the Monitoringof Licensed Facilities Presented by: Stephanie Gilliam Section Chief, Mental Health Licensure & Certification DHHS/Division of Health Service Regulation Eugene Naughton Acting Network Operations Manager CenterPoint Human Services Representing the NC Council of Community Programs 3-15-14 Developed by the NC DHHS-LME/MCO-Provider Collaboration Workgroup February 2014

2. 2 DHSR Role, Process and Authority • Role is to determine provider compliance with rules and statutes in licensed facilities. • Process is to conduct the following types of surveys: • Initial • Annual • Complaint • Follow-up

3. Initial Survey The Initial Survey is a review of the policies, procedures and staffing to determine if the provider can demonstrate compliance with rules and statutes. These rules include: • Core Rules • Program specific rules • Client Rights • Confidentiality

4. Annual Surveys Annual Surveys are conducted in all residential facilities and outpatient opioid facilities. • These surveys occur every 12-15 months and focus on whether or not the treatment needs are being met in a safe and healthy environment.

5. Complaint Surveys Complaint Surveys: are based on an allegation related to a rule area. • Anyone can call in a complaint to the DHSR Compliant Intake Unit: 800-624-3004

6. Frequency Grid The frequency grid can be found on the fourth tab in the Provider Monitoring workbook on the DMH/DD/SAS website: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/index.htm#tools

7. Follow-Up Surveys Follow-Up Surveys are conducted within specific time frames to determine if deficiencies have been corrected.

8. DHSR Authority DHSR has the Regulatory authority to levy penalties and sanctions for non-compliance. This includes: Type A1, Type A2, & Type B Violations Fines associated with these violations Suspension of admissions Revocation.

9. DHSR Authority: Type As and Bs • Type A1 is violation of a rule or regulation that results in serious physical harm, abuse, neglect, or exploitation. • Type A2 is a violation of a rule or regulation that results in substantial risk that serious physical harm, abuse neglect or exploitation will occur. • Type B is a violation of a rule or regulation that is detrimental to the health, safety, or welfare of the individual but does not rise to the level of a Type A1 or A2 See NCGS 122C-24.1: http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_122C/GS_122C-24.1.html

10. DHSR Authority: Type As and Bs (cont) • Plan of Protection: If a Type A or Type B is identified on survey, the provider must give our surveyor a “plan of protection” before we exit the survey—to protect individuals from further harm. • Plan of Correction: A more thorough Plan of Correction must be developed and submitted by the provider after they have received our statement of deficiencies.

11. DHSR Authority: Other Sanctions • Fines: are assessed for Type As and Type Bs based on NCGS 122C-24.1 • Suspension of Admissions • Revocation

12. DHSR Authority: Appeals We are required by NCGS 150-B to resolve disputes informally if possible. This includes: • Informal Appeals-meeting with the Chief of the Mental Health Licensure & Certification Section, Branch Manager and Team Leader • Formal Appeals through the Office of Administrative Hearings • Settlement Discussions • Mediation • Hearings

13. LME-MCO Role, Process, Authority • 13 The Role of the LME-MCO is to: • Ensure consumers receive treatment appropriate to their needs. • Manage their provider network

14. LME-MCO Role, Process, Authority • Process includes: • Monitor contracts with providers • Authorize services • Monitor programs (licensed and unlicensed) for fidelity to service definition • Monitor licensed services that don’t receive annual surveys from DHSR for health and safety • Conduct Post payment reviews

15. LME-MCO Role, Process, Authority, cont. Authority to suspend referrals, cancel contracts. May also conduct limited monitoring of non-contracted facilities, provide technical assistance to providers, and provide care coordination to consumers. No monitoring of ICF-IID

16. Collaboration Steps • 16 • DHSR sends copies of all surveys, including any administrative actions, to the LME-MCO catchment area in which the facility resides, and to any LME-MCOs that contract with the facility or have an enrollee in that provider’s care. • The LME-MCO tracks DHSR surveys in a provider profile and uses this information to help make placement and/or contractual decisions.

17. Collaboration Steps (cont) • The LME-MCO conducts Routine Monitoring Reviews plus post-payment reviews at a minimum ofevery two years for licensed day services, (excluding outpatient opioid and residential programs). • The LME-MCO copies DHSR when taking the following actions: • Termination of contract • Suspension of referrals • The LME-MCO conducts complaint investigations to determine compliance with service definitions.

18. DHSR-Mental Health Licensure and Certification Section Web Site: http://www.ncdhhs.gov/dhsr/mhlcs/mhpage.html

19. Questions Please send your questions to the Provider Monitoring mailbox: provider.monitoring@dhhs.nc.gov To expedite a response, please include the nature of your question in the Subject line.