Bureau of Drug and Alcohol Programs Provider Monitoring Summary Sheet SCA

Transcription

1 Provider: Bureau of Drug and Alcohol Programs Provider Monitoring Summary Sheet SCA Date: October 2002 Contracted Services: Administrative Care Management Intensive Case Management Outpatient Intensive Outpatient Partial Halfway House Residential Detoxification Prevention Intervention Identified areas not in compliance with Contract- Requiring corrective action: Recommendations for improvement: Follow-up Review: Implementation of Corrective Action status: Date:

2 Single County Authority - Provider Monitoring Tool October 2002 Facility Name: Facility Number: Facility Director s Name: Date of Visit: Services Provided: Prevention Intervention Assessment Treatment SCA Monitoring Staff: FY - ADMINISTRATIVE Submission of Timely Reports Boilerplate, VIII. D (page 5) 1. The provider submitted complete, timely, and accurate reporting to the SCA: PBPS CIS CM RMR Provider Invoices or Fee for Service Invoice Employee Deductions Boilerplate, VIII. F (page 6) 2. The Provider has met its obligation to pay (the employer s) share of and to withhold and remit from employees salaries, the correct amount of: Income taxes Workman s Comp FICA Other federal/state/local taxes Unemployment NOTE: Could be verified through provider audit. Provider Sub-Contracting (Information Only) 3. Does the provider sub-contract any of the SCA contracted services? a.) If so, what services are sub-contracted? (If yes, review at least one sample of each type of sub-contract) b.) How does provider monitor service delivery? 4. The provider has insurance coverage relating to: Provider Insurance Coverage Boilerplate, XII. (page 12)

3 Unemployment Comp Workman s Comp Public Liability Fidelity Bond Property Damage Professional Liability (Not contractually required by BDAP) October 2002 Human Experimentation Boilerplate, XVI. (page 15) 5. Is the provider engaging in human experimentation? If yes, has this activity been approved the Secretary of Health? If approved, how do you ensure that clients who have refused participation will not have their treatment adversely affected by their refusal? Lobbying Form Boilerplate, XXI. C (page 18) 6. Verification exists regarding an executed Certificate of Lobbying Form. (This form is attached to the contract so can be verified in-house) Suspended or Debarred Sub-Contractors Boilerplate, XXII. A (page 19) 7. Is the provider suspended or debarred by the Commonwealth or any other governmental authority? 8. The provider has a policy/procedure in place to assure that they do not subcontract or refer to entities under suspension or debarment by the Commonwealth, or any governmental authority? (Verification through the Dept. of General Services, Office of the Chief Counsel; in addition, verification of disbarred/suspended physicians: Valid Treatment License Work Statement, Appendix A, H (8) (page 11) 9. Does the provider have a valid treatment license from the Bureau of Community Program Licensure and Certification, Division of Drug and Alcohol Program Licensure? Drug Free Workplace Policies Boilerplate, XXIII. (page 20) 10. The provider has policies in place where staff has access to them related to the following: Establishing a drug-free awareness program to educate employees about the dangers of drug abuse in the work place, the provider s policy maintaining a drug-free workplace, available counseling/ rehabilitation/eap s, and penalties imposed on employees for drug abuse violations occurring in the workplace. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, or use of a controlled substance is prohibited.

4 A requirement that each employee shall abide by the statement related to the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the provider s workplace. Specifying actions that shall be taken against employees for violation of such provision. Including the statement published pursuant to the above, a requirement that each employee, as a condition of employment, shall: (1) Abide by the terms of the statement; and, (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction. Notifying the SCA within ten (10) days after receiving notice under subparagraph (2), above, from an employee or otherwise receiving actual notice of such conviction. Taking one of the following actions, within thirty (30) days of receiving notice under subparagraph (2), above, with respect to any employee who is so convicted: (1) Taking appropriate personnel action against such an employee, up to and including termination; or, (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state or local health, law enforcement, or other appropriate agency. Pro-Children Act Appendix H 11. Provider is in compliance with the Pro-Children s Act of 1994: (1) Does a non-smoking policy exist? (2) Are there no smoking signs posted?? (Smoking is not allowed in indoor areas of the facility that are used for the provision of services to children. Verification can be made through posted no smoking signs and/or other policies/procedures)

5 FEDERAL BLOCK GRANT Provider Capacity Work Statement, Appendix A, H (2) (page 10) Work Statement, Appendix A, R (7) (page 23) 12. The provider notifies the SCA when they have reached capacity*? (Verify through waiting lists, daily census, provider policies /procedures, etc.) (*Capacity is defined as either the provider has reached 90% capacity in terms of admissions to their program or they no longer have the ability to treat a federal block grant population. Ability to treat means that the provider has the means and staff to address the special needs of a pregnant woman.) If the provider receives FBG dollars: Referrals for Pregnant Woman & Interim Services Work Statement, Appendix A, H (3) (a-b) (page 10) 13. Is the provider a sub-contractor for assessment services? If yes, Do you identify and refer clients for interim services within 48 hours after you have established the need for these services? How do you document the need for and the referral to interim services? 14. Is the provider responsible for providing Interim Services? If yes, how are the following interim services provided: Counseling and education about HIV and Tuberculosis Risks of needle sharing Risks of transmission to sexual partners and infants Steps that can be taken to ensure that HIV and TB transmission does not occur Referral for HIV and TB treatment services Counseling on the effects of alcohol and drug use on the fetus (pregnant women only) Referral for prenatal care (pregnant women only) (The provider should have been informed by the SCA who they should refer to as a provider of interim services for IVDU and pregnant women, when needed.) If provider receives FBG dollars: Pregnant Women and Ancillary Services Work Statement, Appendix A, H (7) (page 11) 14. Is the provider a sub-contractor for treatment services receiving FBG funds?

6 If yes, Do you identify and refer pregnant women and women with dependent children for ancillary services after you have established the need for these services? How do you document the need for and the referral to ancillary services? TB Services Work Statement, Appendix A, Q (1) (a-e), (page 21); Q (2) (b), (page 22) If receiving FBG funds: 16. How does the provider document that TB services are available for all clients? 17. Does the provider make available, directly or through a sub-contractor, TB services to each individual receiving D&A treatment? 18. The provider documents TB reporting on CIS. (In the provider level of CIS - - in the one page for entering Utilization of services: Choice C Service Provided Under Intensive Treatment If the TB section is not showing, one needs to scroll down to see the 3 TB service choices to be selected Tested, Diagnosed, Refused.) NOTE: This section speaks to generic notification to clients that TB services are available, if needed. The provider should be able to administratively track through MOU or actually sub-contract for those services. Policies/procedures should exist related to TB process. Provision of Hypodermic Needles Work Statement, Appendix A, R (1) (page 22) 19. Do you provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs? If yes, what was the source of funds? If yes, did you obtain permission from appropriate authorities? (federal: U.S. Surgeon General PA: Secretary of Health) Treatment Preference to Pregnant Women Work Statement, Appendix A, R (3) (page 22) 20. What are the provider s identified priority populations? (Confirm through policies (priority populations) / chart reviews) 21. Do you publicize the availability of services and preference to treatment for pregnant women? (brochures, etc.)

7 Employee Continuing Education Work Statement, Appendix A, R (6) (page23) 22. How do you make continuing education credits available to employees related to FBG type services? (review employee training records, policies / procedures) Referrals for IVDU & Interim Services Work Statement, Appendix A, R (8) (page 23) 23. Is the provider a sub-contractor for assessment services? If yes, Do you identify and refer IVDU clients for interim services within 48 hours after you have established the need for interim services if the client cannot be placed into treatment within 14 days of determining the need for treatment? How do you document the need for and the referral to interim services? 24. Is the provider responsible for providing Interim Services? If yes, how are the following interim services provided: Counseling and education about HIV and Tuberculosis Risks of needle sharing Risks of transmission to sexual partners and infants Steps that can be taken to ensure that HIV and TB transmission does not occur Referral for HIV and TB treatment services (The provider should have been informed by the SCA who they should refer clients to as a provider of interim services when needed.) Outreach Services Work Statement, Appendix A., R (10) (page 24) 25. Is the provider a sub-contractor for outreach services? If yes, does the Provider s outreach model for IVDU s meet all of the following criteria? A. Selecting, training and supervising outreach workers; B. Contacting, communicating and following-up with high risk substance abusers, their associates and neighborhood residents, with the constraints of federal and state confidentiality requirements, including 42 C.F.R. Part 2; C. Promoting awareness among injection drug abusers about the relationship between injecting drug abuse and communicable diseases such as HIV; D. Recommending steps that can be taken to ensure that HIV transmission does not occur; and, E. Encouraging entry into treatment. 26. Does the provider have its outreach model written into policy? 27. What other agency does the provider coordinate with in meeting the above criteria?

8 CLIENT SERVICES (Treatment, Care Management, & Case Management) Confidentiality Boilerplate, XVII. A and B (pgs.15-16) In regards to Confidentiality, to include all client service providers under contract, respond to the following: 28. Is there adequate computer security? 29. Did all staff receive the 6-hour confidentiality training by a BDAP-approved trainer? (Need to verify training certificates) Screening Staff Assessment Staff ICM Staff Treatment Staff 30. Did all new staff receive confidentiality training within 180 days of hire? (Need to verify training certificate dates for new hires) If ICM services are sub-contracted by the SCA: Case Management Services Work Statement, Appendix A, K (4, 7, 9, 11), (pages 14-15); Case & Care Management Guidelines; ISS Training Handbook 31. ICM case managers meet applicable minimum experience and training requirements contained in State Civil Service Commission class specifications: D&A Case Management Specialist Trainee (L0685), D&A Case Management Specialist (L0686), D&A Case Management Supervisor (L0687) or any subsequent revisions, as approved by the Department. 32. Did all individuals providing ICM services receive ICM Core Training by a BDAP-approved trainer? Intro to Intensive Case Management Service Planning and Record Keeping Confidentiality and Ethics Utilization of the Inventory of Support Services (Check for Training certificates for all ICM staff and supervisors) 33. Does ICM staff perform ICM duties solely? 34. Does the provider have an Admission Policy? 35. Does the provider have a Referral Policy? 36. Does the provider have a policy of time frames for initial contact of client? 37. What is the provider s caseload requirement?

9 38. Does the provider have a Supervision policy? 39. Does the provider document the occurrence of supervision? 40. Does the provider s policies and procedures manual contain the following policies? a. BDAP Care and Case Management Services Description b. Client Orientation Procedures c. Structure of Client Files d. Client Grievance and Appeal Process e. Structure of the Case Management Unit f. Policy/Guidelines for Readmission to ICM g. Supervision Plan h. Special Needs Population Service Provision (HIV/AIDS) i. Admission/Discharge Criteria j. Updated Resource List k. Staff Orientation Procedures l. Referral Procedures m. Client File Access Procedure 41. Does the discharge criteria established by the provider meet the criteria outlined in the ISS Training Handbook? 42. Does the provider obtain a list of individuals to contact for the sole purpose of locating a client to conduct follow-up services? 43. If yes, does the provider obtain a signed consent for each of the individuals identified? 44. Are follow-up contacts occurring at the required time intervals? 45. Are client satisfaction surveys distributed to clients at the required time intervals? 46. ICM Client Record Review: Refer to attached client record review form 47. Are the following standardized forms being used? Inventory of Support Services (ISS) Client Satisfaction Survey Service Plan and Service Plan Update Discharge Form Support Services Follow-up Checklist (Review sample client ICM records, policies and procedures, training certificates, use of client satisfaction surveys to improve services, etc.) Care Management Services Work Statement, Appendix A, L (7), (pages 15-16) And C/C Mgt. Service Descriptions If ACM services are sub-contracted by the SCA: 48. ACM case managers meet minimum experience and training requirements contained in State Civil Service Commission class specifications: D&A Case Management Specialist Trainee (L0685), D&A Case Management Specialist (L0686), D&A Case Management Supervisor (L0687) or any subsequent revisions, as approved by the Department.

10 (MET s available from DOH Bureau of Resource Management Evelyn Hunt) October Is the provider screening for emergent care needs as follows: (Review Tool to be sure it cover all four areas) Detoxification Medical Care Perinatal Care Psychiatric Care 50. Are assessments completed within 72 business hours of initial client contact? If no, why not? 51. Does the assessment tool address the following: (Review sample client ACM records, policies and procedures, etc.) Date of Referral Date of assessment Social / personal history D & A history / D&A treatment history Family history Medical history Psychiatric history Special needs assessed ICM criteria assessed 52. Does the adolescent assessment process gather the following: (Review sample client ACM records, policies and procedures, etc.) Date of referral Date of assessment History of present episode Family history D&A history / D&A treatment history Social/personal history Legal history Psychiatric history Medical history Assets, vulnerabilities, & supports assessed ICM criteria assessed Care Management Services Work Statement, Appendix A, M (1,2,3,5,6), (pages 16-17) If level of care determinations are sub-contracted: 53. Is PCPC criteria being used for level of care placement for adults?

11 54. Is ASAM criteria being used for level of care placement for adolescents? 55. Has all appropriate staff received BDAP-approved training in the use of the PCPC for adults? (Need to verify training certificates) 56. Has all appropriate staff received BDAP-approved training in the use of the ASAM for adolescents? (Need to verify training certificates) 57. Is the provider using the PCPC Summary Sheet approved by BDAP for: LOC determination and/or Admission Continuing stay ( Note: This PCPC summary form CANNOT be altered in any way. ) SCA Grievance & Appeal Process Work Statement, Appendix A, P (7), (page 20) 58. Does the provider have a procedure to inform individuals of the SCA s grievance and appeals policy? 59. How are clients informed of this process? 60. Are clients given a copy of the SCA s grievance and appeal process? How is this documented? (Verification made through client record review, policies/procedures review, etc.)

12 PREVENTION Prevention Plan Services Work Statement, Appendix A, E (2), (page 5) 61. Is the prevention provider providing all prevention services contracted for in the plan? (Review of PBPS reports) Prevention Plan Services Work Statement, Appendix A, E (7) (page 6) 62. The provider submitted PBPS data, as required, to the SCA? 63. Does the provider evaluate the effectiveness of their services? How is this information conveyed to the SCA? 64. What steps have been taken to modify the services to ensure effectiveness? Synar Amendment Work Statement, Appendix A, F (2), (page 7) If sub-contracting for tobacco compliance: 65. Merchant compliance checks are conducted, as required? SAP Services Work Statement, Appendix A, G (3) (e), (page 9) If sub-contracting SAP services/education: 66. Did the provider offer or arrange for the provision of programs offering drug abuse education, prevention, or counseling to students at compulsory school age, including: Programs to provide drug abuse counseling* in a school by trained personnel; Programs that stress the use of peers to combat student abuse of drugs and alcohol; Programs that stress community involvement in combating student abuse of drugs and alcohol; Programs that train Core Team members and teachers to encourage parent involvement in SAP; Other appropriate programs that target students and parent involvement in SAP. NOTE: Verify what is being provided and if it complies with the contractual work statement. Drug abuse counseling* is defined as treatment services provided by a licensed D&A treatment provider and can be accepted whether or not the services are provided on-site in a school.

13 FISCAL Fixed Assets Boilerplate, XI. I (page 12) 67. Has the provider made any new purchases of fixed assets not currently listed on the inventory list? If yes, verify items location. NOTE: Does not apply to fee-for-service contracts. Financial Management Work Statement, Appendix A, C (8), (page 1) The provider will comply with, and ensure, the following financial management obligations: 68. Records and administers the receipt and disbursement of all funds from the drug and alcohol program account. 69. Uses all fiscal reporting forms and procedures as indicated by the SCA. Interest Income Appendix B, (3) (a) (page 2) 70. Does the program-funded provider derive interest income from DOH funds? 71. Documentation is provided which verifies that interest income is utilized before DOH funds. ( Review bank statement to verify interest claimed check income and expenditure report. ) Third Party Liability Appendix B, (3) (b) (page 2) 72. Is the provider adhering to SCA policies and procedures related to determining third party liability, (includes client fees, private insurance, MA, food stamps)? (Verify through sample of client files that liability exists also check related invoices.) Travel and Subsistence Appendix B, (4) (page 2) Travel bound by Appendix I (Applies to ALL providers) 73. Does the provider comply with Appendix B of the DOH/SCA contract related to Commonwealth travel and subsistence? ( This requirement is applicable for BOTH program funded and fee-for-service providers) Audits Appendix B, 8 (page 4-5)

14 (Verify these three questions with SCA fiscal person.) October Was an audit submitted to the SCA? 75. Did that require any adjustment or re-submission of fiscal reports? 76. If the audit had findings, were they resolved to the satisfaction of the SCA?

15 Early Intervention Services for HIV Disease October 2002 The following SCAs receive SAPT Block Grant drug treatment funds for HIV Early Intervention (HIVEI) services and must monitor contracted providers for these funds: Allegheny, Berks, Bucks, Chester, Dauphin, Delaware, Erie, Lehigh, Montgomery, Northampton, Philadelphia, and Schuylkill. 1. Does the provider render the following HIVEI services to individuals undergoing treatment for substance abuse, at the sites where the individuals are undergoing such treatment? a. HIV prevention counseling/pretest counseling b. HIV antibody testing (oral fluid and/or blood) c. Results counseling/post-test counseling d. Therapeutic and diagnostic measures e. Linkage with health and social services HIV Prevention Counseling a. The provider has a copy of the CDC Revised Guidelines for HIV Counseling, Testing, and Referral (11/9/01). b. Counseling is done in person, in private, on a one-to-one basis. c. Client risk reduction plans are developed with the client and documented in the HIV counseling and testing record. Testing (Note: The focus of client-centered HIV prevention counseling is risk reduction. In HIV prevention counseling, counselors work with clients to commit to a specific, realistic, riskreduction step relevant to reducing the client s own risk of acquiring or transmitting HIV. The risk-reduction step should be a small, explicit, and achievable goal, as opposed to a global goal. It is usually, but not always, done in the context of HIV testing.) (Note: Universal and routine, one-on-one, HIV prevention counseling, rather than relying on clien t request, is recommended for all clients in substance abuse treatment, even if testing is declined.) a. No blood or oral fluid specimen, for HIV antibody testing, shall be collected without first obtaining an informed, written consent from the client. The Department's consent form is signed and in the HIV counseling and testing record.

16 b. Blood and oral fluid specimens are collected on-site at the treatment facilities, unless an exception is granted by prior written Department authorization. c. Blood and oral fluid specimens, for HIV antibody testing, shall be labeled with the identification number that appears on the HIV Counseling and Testing Report Form. d. Laboratory forms are completed according to procedures specified by the laboratory. e. All HIV testing shall be performed by state contracted laboratories unless prior written departmental approval is granted to use an alternative laboratory. Results Counseling a. No test results shall be revealed to the subject without individual, face-to-face results counseling. b. Positive test results counseling sessions shall include the participation of a state or local Health Department HIV Prevention Program staff member. Therapeutic and Diagnostic Intervention and Linkage a. Providers participating in this project shall establish linkages with a comprehensive community resource network of related health and social service organizations to ensure the availability of services and facilitate referral. Accurate and current referral sources for medical services, mental health, and case management services shall be documented in writing and kept on file. b. Persons who are sexually active shall be referred for or provided contraceptive information. c. All individuals with a positive HIV antibody test shall be given or referred for a complete medical history, a through physical exam, and appropriate laboratory testing. d. All persons who have positive tests for HIV antibodies shall be offered and counseled to accept a Mantoux tuberculin skin test. e. Referrals shall be documented in the client s HIV counseling and testing record or medical record.

17 2. The provider shall ensure that HIV testing services shall be undertaken voluntarily, and with the informed, prior written consent of the individual. Undergoing such services shall not be required as a condition of receiving treatment services for substance abuse or any other services. 3. Confidentiality a. All client counseling and testing information obtained by the provider shall be kept confidential. The provider shall abide by the confidentiality requirements of 71 P.S. Section , 42 U.S.C. Section 290dd-2, 42 C.F.R. Part 2, 4 Pa. Code Section 255.5,257.4 and the Confidentiality of HIV-related Information Act, Act No , 35 P.S. Section 7601 et seq. b. Counseling and testing records shall be stored in locked cabinets. c. Coded names, number sequences, and other methods, which assure confidentiality, shall be permitted. d. HIV information from these records shall not be released without the specific prior written and informed consent of the client in accordance with the confidentiality requirements contained in Act No , 35 P.S. Section 7601 et seq. 4. Reporting a. Did the provider submit a complete continuation-funding proposal by the due date? b. The CDC HIV Counseling and Testing Report Form shall be completed on each client that receives one-on-one, HIV prevention counseling, and must follow the reporting procedures as presented in the Counseling and Testing Report Form Manual. (Note: A counseling and testing report form shall be completed for each HIV prevention counseling session even if testing is declined.) c. The provider shall complete and submit, to the SCA, the quarterly HIV Early Intervention Report Form. These reports are due to the SCA on: 1 st quarter report received by October? 2 nd quarter report received by January? 3 rd quarter report received by April? 4 th quarter report received by July? d. The provider has a copy of the HIV Counseling and Testing Report Form Manual.

18 5. All HIV counselors and medical staff funded for HIV Early Intervention services shall have training on basic, accurate information about HIV/AIDS infection and the causative agent, modes of transmission and prevention, and client-centered HIV prevention counseling. (Note: Supervisory support is essential for effective prevention programs. Training in HIV prevention counseling focused on personal risk-reduction is recommended for anyone supervising HIV counselors.) 6. All HIV counselors have a DOH assigned counselor identification number. 7. All persons receiving treatment in drug treatment facilities funded for HIV Early Intervention services shall regularly receive HIV/AIDS information that they can comprehend, including translation, if necessary. 8. HIV Early Intervention Performance Objectives a. One hundred percent (100%) of the clients that are admitted to treatment at the substance abuse treatment programs receiving HIV Early Intervention Services shall receive HIV/AIDS education. b. Eighty-five percent (85%) of the clients admitted to treatment at the substance abuse treatment programs receiving HIV Early Intervention services shall receive on-on-one, client centered, HIV prevention counseling. c. Ninety percent (90%) of the clients that receive HIV antibody testing shall receive their test results and results counseling. d. State or local Health Department HIV Prevention Program staff shall be notified by the testing site of one hundred percent (100%) of the clients that test positive. e. One hundred percent (100%) of the clients who test HIV antibody positive and return for test results counseling shall be provided or referred for early intervention services. 9. Additional Non-contractual Issues a. Written quality assurance protocols should be developed and implemented by providers of HIV counseling and testing services. The protocols should address the following: 1. HIV counselor performance reviews are conducted. (Note: Staff appraisals should prioritize completion of critical counseling components over simply professionalism and completion of paperwork. Routine, periodic

19 assessments should be conducted by all providers of counseling and testing services to ensure that the counseling being conducted includes the recommended, essential counseling elements.) ( Direct observation of counseling sessions, after first obtaining client consent, can help ensure that counseling objectives are met. A supervisor may do this periodically.) (A suggested time frame for routine, direct observation of an HIV prevention counselor by the supervisor is twice monthly for the first 6 months of performing HIV counseling services, monthly for the second 6 months, and quarterly for counselors with more than one year of experience.) 2. HIV counseling & testing records are audited. (Sample audit form is available from the PA DOH, Division of HIV/AIDS) 3. Client satisfaction surveys are conducted for HIV services. (Sample survey is available from the PA DOH, Division of HIV/AIDS) (Note: Evaluations of client satisfaction can ensure that services meet client needs. Evaluations can be brief, but should address whether specific counseling goals were met, and specifics of the development of the risk-reduction. Conducting such evaluations only occasionally (e.g., for one or two weeks once or twice a year) decreases the programmatic burden and is probably sufficient to identify problems.) 4. HIV counselors receive ongoing HIV-related training. (On-site, HIV-related training is available through the PA DOH, Division of HIV/AIDS) b. The provider has developed an HIV/D&A services policy/protocol manual for this project. c. The HIV/D&A services policy manual addresses the provider s policies on HIV counseling and testing, HIV confidentiality, HIV record keeping and charting, QSOAs, TB testing, & training. d. Providers who offer HIV prevention counseling and testing services but not a full range of medical and psychological support services have developed direct, clearly delineated and formally documented arrangements with other providers who can offer needed services. (Note: Memorandum of agreements are useful in outlining provider/agency relationships and delineating roles and responsibilities of collaborating providers in managing referrals. Where confidential client information is shared between coordinating providers, such formal agreements are essential. Interagency agreements should be reviewed periodically and modified as appropriate.)