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Northeast Ohio
Behavioral Health,
Ltd.
Short-Term
Plan
July 1, 2006 -
June 30, 2007
Long-Term Goal A: NEOBH will
continue to provide
high-quality, non-medical mental health services to children,
adolescents, adults and families.
Objective 1: Achieved in FY05:
During FY
05, NEOBH created and executed at least two CQI Projects that address
issues related to the implementation of Best Practices and/or the
improvement of care to the general client population and/or to
“niche” specialty client populations.
Objective 2: Achieved in FY06:
During FY
06, NEOBH collected Ohio Consumer Outcomes Data on Medicaid-eligible
and private-pay NEOBH clients, and successfully monitored and tracked
Outcomes administration. Outcome studies were expanded to include
all NEOBH consumers receiving Diagnostic Assessment and/or Individual
Counseling Services.
Objective 3: Achieved in FY06:
During
FY 06, NEOBH created four CQI Projects based on Ohio Consumer
Outcomes Data (target: at least one project).
Objective 3 – Recommendation for FY07:
Continue Objective
3, with the
following revision: In FY07, NEOBH will use Data Mart
material to create CQI Projects, examine selected focus populations
and compare state norms with NEOBH Outcomes performance.
Timeline: Ongoing analysis of Data Mart
Outcomes data
during FY07. Initiation of first project design by September 1, 2006.
Tasks:
-
Utilize
CQI Committee recommendations to select target group (i.e. clients with
ADHD or Adjustment Disorder diagnoses)
-
Conduct
analysis of data reports re: NEOBH clients versus Data Mart state norms
for similar population
-
Report
to Consumers, Stakeholders, NEOBH Advisory Board and NEOBH Staff re:
results
Responsibility: CQI Officer, with
assistance and input
from CQI Committee, and data gathered from CQI Case Review
Financial
Consideration: None
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board
Expansion/continuation
of projects via recommendation of CQI Committee, NEOBH Advisory Board
and Executive/Clinical Director.
Objective 4: Achieved in
FY06: Revision of Objective 4, per FY06 recommendation:
During FY06, NEOBH actively utilized Outcome data in treatment
planning, as evidenced by successful CQI review of charts that
contained reference to Outcome data and ISP goals and objectives that
reflected client concerns contained within Outcome data. However,
subsequent CQI review suggested that Outcomes were not being actively
utilized at 6 month review intervals.
Objective
4: Recommendation for FY07: Continue Objective 4,
with the following revision:
In FY07, NEOBH will
develop an internal
tracking system for 6-month Outcomes submissions and reviews. It
will revise existing forms to provide review prompts and ensure data
entry regarding both 6-month Outcomes administration and review of
these Outcomes.
Timeline: Forms revision by September
1, 2006. Completion of tracking system by December 30, 2006.
Tasks:
Responsibility: Executive/Clinical
Director with
assistance from consultation Business Manager/Supervisor of Clerical
Staff
Executive Director provides reports to ODMH via methods requested by
ODMH
Financial
Consideration: None. Clerical staff has been hired to
assist with Outcomes submission to ODMH/County Mental Health Boards.
Monitoring:
Quarterly
review by CQI and NEOBH Advisory Board
Reports
to ODMH at intervals specified by ODMH
Objective 5: Not Achieved in
FY06: During FY 06, NEOBH will launch a website containing
information
regarding services available, areas of staff expertise, recommended
sources of client information regarding mental health issues, and
other data that will educate the public.
Objective 5 – Recommendation for FY07: Continuation
of this Objective, with revised timelines.
Timeline: End of FY07 (June 30, 2007)
Tasks:
-
Gather
information regarding staff specialty areas, biographical information,
and recommendations for client educational materials (partially
accomplished)
-
Compile
data in Word files
-
Create
outline for links and web design
-
Gather
information regarding costs for website design, set up and maintenance
(partially accomplished)
Responsibility: Executive/Clinical
Director, with the
assistance of NEOBH Clinical Staff
Financial
Consideration: To be determined by research
Monitoring: Quarterly review by CQI
Committee and NEOBH
Advisory Board
Objective 6: Achieved in FY06:
During FY
06, NEOBH collaborated with existing staff providers as well as
specialty providers at Akron Children’s Hospital to expand
services
to children and adolescents with Autistic-Spectrum Disorders within
the Cuyahoga Falls/Summit County office. NEOBH examined the
feasibility of expanding such services to the Canton/Stark County
office at such time when space is available. Penny Griffith and
Richard Cowan of the NEOBH staff maintained active caseloads of
autistic-spectrum clients, and developed strong linkages with medical
providers.
Recommendation for FY07:
Continuation
of this Objective, with additional emphasis on expansion of services
to other niche child/adolescent specialties, such as treatment of
children in post-adoptive placements.
Timeline:
Throughout
FY07
Tasks:
Meetings
with Autistic Spectrum Special Project Group members re: feasibility of
internal staff training, student interns, and
other ways to expand resources.
Responsibility: Executive Director,
with collaboration
from Clinical Staff experienced with Autistic-Spectrum Disorders,
staff affiliated with Kent State University and staff with
post-adoptive counseling experience.
Financial
Consideration: None
Monitoring: Executive Director, with
periodic updates
to the NEOBH Advisory Board
Objective 7: Achieved in FY06:
During FY
06, NEOBH expanded the availability of Parent Coordination Services,
Sexual Abuse Assessment and Parent Evaluation via the recruitment and
training of additional staff within these areas of specialization.
Recommendation for FY07: Continuation
of this
Objective, with the emphasis on expansion of services for victims of
trauma.
Timeline:
Throughout
FY 07
Tasks:
-
Recruitment
and support of clinical staff with an interest in trauma-focused
treatment
-
Collaboration
with the Stark County Family Court regarding client needs and referral
expectations/outcomes
-
Collaboration
with the Stark County Attention Center regarding services delivered to
incarcerated youth
-
Marketing
to Summit County Juvenile Court and Summit County Children Services
regarding trauma-focused services available at NEOBH
-
Participation
in planning meetings conducted by the Stark County Traumatized Child
Task Force
-
Executive
Director membership on the Steering Committee
-
NEOBH
leadership and planning devoted to the activities of the Learning
Collaborative and the furthering of training opportunities
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 8:
During
FY06, NEOBH participated in the development of Parent Coordination
projects with the Summit County Domestic Relations Court. NEOBH
provided at least one marketing outreach to the Stark County Family
Court. All Parent Coordination Staff participated in this project.
Recommendation
for FY07: Continuation of this Objective. Expansion of
Parent Coordination Services by the addition and training of new
staff in the Summit County office, where demand has proven to be
greater.
Timeline:
Throughout
FY 07
Tasks:
-
Recruitment
and support of clinical staff with an interest in Parent Coordination
practice
-
Collaboration
with the Summit County Domestic Relations Court/Family Court Services
and the Stark County Family Court regarding client needs and referral
expectations/outcomes
-
Participation
in meetings conducted by the Summit County DR Court.
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 9: Partially Achieved
in FY06: During FY06, NEOBH expanded programming for
child/adolescent victims
and their families via the hiring of two FT clinical staff at the
Children’s Network office, and the training of one staff to
conduct
forensic assessments. Further investigation of programming
possibilities was prevented by staff availability, due to high demand
for basic treatment/assessment services. Dr. Cassie Hornbeck and
Aimee Thomas, PC, achieved status as a CAP Fund-approved
professional, making reimbursement for time spent in expert witness
testimony a more reliable option for County prosecutors.
Recommendation for FY07: Continuation
of this
Objective, with the expansion of group treatment modalities, and the
addition of staff to fill all available office hours at the
Children’s Network.
Timeline:
Throughout
FY07
Tasks:
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 10: Partially Achieved
in FY06: NEOBH expanded programming for parents referred for
Parenting
Evaluations by the Stark County Department of Job and Family Services
and Summit County Children Services. Aimee Thomas-Chuparkoff of
NEOBH took a leadership role, and recommended format changes for
these evaluations. NEOBH also marketed these services to the Summit
County Juvenile Court and Summit County Children Services. However,
NEOBH did not accomplish the expected collaborations with other
service providers, such as the MR/DD Board, Quest Recovery Services
and Goodwill Industries.
Recommendation
for
FY07: Continuation of this Objective, with outreach to agencies
representing special parenting clients.
Timeline:
Throughout
FY07
Tasks:
-
Training
and supervision of North Canton and Cuyahoga Falls clinical staff hired
at the conclusion of FY06.
-
Discussion
of needs via consultation with the SCDJFS and SCCS.
-
Collaboration
with Stark County Goodwill Industries Parenting Skills Training Program
regarding the use of evaluation data.
-
Investigation
of assessment format revisions for parents with developmental handicaps.
-
Collaboration
with the Stark County MR/DD Board regarding services for parents with
intellectual limitations.
-
Collaboration
with Quest Recovery Services regarding parent clients with chemical
dependency concerns.
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 11: Achieved in FY06:
NEOBH
increased treatment access for Medicaid and Non-Medicaid adults in
the North Canton/Stark County office site, with particular emphasis
on the treatment needs of adult consumer parents of children in the
care of the SCDJFS. NEOBH engaged in a Non-Medicaid contract with
the Stark County Mental Health Board to assist with adult consumer
services. Financial agreements were revised, and Support Staff were
trained in the use of the Public Subsidy grid to determine
eligibility for subsidy.
Also Achieved in FY06: NEOBH
engaged in
additional program development for parents of children in the care of
the SCDJFS via the creation of Intensive Parent-Child Interaction
(IPCI) services. Ms. Tiffany Anton of NEOBH created and piloted this
service. This program was successfully marketed to the Stark County
Department of Job and Family Services in June of 2006. By the
conclusion of FY06, NEOBH had begun to consider ways to expand this
programming to the Summit County office.
Recommendation
for FY07: Continuation of this Objective, with the
expansion of adult services to include the hiring of staff with
chemical dependency and domestic violence treatment experience.
Consideration of adult group treatment services based on assessment
of community need.
Timeline:
Throughout
FY07
Tasks:
-
Training
and supervision of Stark and Summit County office clinical staff hired
at the conclusion of FY06.
-
Purchase
of training/client materials directed toward adult treatment needs.
-
Investigation
of programmatic needs of parents via consultation with the SCDJFS.
-
Collaboration
with the SCDJFS re: reunification goals
-
Collaboration
with Stark County Goodwill Industries Parenting Skills Training Program
re: integration of program goals into treatment planning.
-
Collaboration
with Community-based programs, such as WATOES and Stark Social Workers
Network re: client needs.
Responsibility:
Clinical/Executive
Director and the Business Manager
Financial
Consideration: Undetermined funds re: Training
materials and clinical staff resources.
Monitoring:
Clinical/Executive
Director
Long-Term Goal B: NEOBH will seek to
maintain the
highest level of client/ consumer satisfaction.
Objective 1: Achieved in
FY06: During FY 06, NEOBH designed and subsequently
revised a Client
Satisfaction Survey directed toward child and adolescent clients. The
CQI Committee surveyed elements of Client Satisfaction and
determined that the existing Survey was adequate; however, regular
administration and expanded distribution was arranged by Tiffany
Anton of the CQI Committee. Clients were notified of changes made
in response to Survey data via posted notice in the waiting room.
Recommendation for FY07:
NEOBH will
continue to use Client Satisfaction Survey data as part of CQI, and
will document changes made in response to client feedback.
Timeline: Throughout FY07
Tasks:
-
Collection
of Client Satisfaction Survey Data
-
Response
to client feedback, and acknowledgement via posted notices
Responsibility: Executive Director with
the assistance
of assigned CQI Committee Staff and Support Staff
Financial
Consideration: Minimal - Copying of Surveys
Monitoring: Executive Director and CQI
Committee
Objective 2: Partially Achieved
in FY06: NEOBH will refine business office practices and will
create
streamlined procedures between the Billing and Clinical offices of
NEOBH. New leadership in the NEOBH Business Office began work in
this direction as of January 2006.
Recommendation for FY07: Continuation
of the
present Objective, with increased documentation of procedures.
Timeline: Throughout FY07
Tasks:
-
Examination/audit
of all internal office procedures related to issues such as appointment
scheduling, contacts with insurance carriers, the procurement of Prior
Authorizations, Medifax verification, the completion and routing of
Phone Intakes, etc.
-
Documentation
of office procedures related to these and other facets of NEOBH office
operations not already documented in the Operations Manual.
Responsibility: Business Manager with
the assistance of
Support Staff
Financial
Consideration: None
Monitoring: Executive Director
Objective 3: Partially Achieved
in FY06: NEOBH began to develop written procedures for all
Billing functions,
per COA standards/expectations. This process was completed in basic
form at the time of the COA Site Visit, in April of 2006, but still
requires ongoing work as procedures audited internally.
Achieved
in FY06: NEOBH revised and established job descriptions for
Support Staff. NEOBH developed and refined staff roles and areas of
responsibility within staff functions related to Business Management,
clerical, billing and reception duties.
Recommendation
for FY07: Continuation of the present Objective toward
the development of a complete set of written procedures related to
both manual and electronic billing, collections, Outcomes/MACSIS,
etc.
Timeline:
Throughout
FY07
Tasks:
-
Develop
Procedure Manual for Billing and clerical procedures, according to
models already developed in compliance with COA expectations.
-
Provide
clerical staff training and updates to clinical staff re: new
procedures.
-
Redesign
clerical job descriptions to reflect segmentation of duties where
necessary
-
Gather
written procedures from staff currently assigned to Outcomes
transmission/follow-up and MACSIS data entry tasks.
Responsibility:
Business
Manager
Financial
Consideration: None
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board.
Long-Term Goal C: NEOBH will assess
service gaps and
the community assessment of service needs, as well as community
satisfaction, and will respond to this information within the
contents of its Annual/Short-Term Plan.
Objective 1: Achieved in FY06:
During
FY06, NEOBH developed and distributed a Community Survey.
Objective 2: Achieved in FY06:
NEOBH
actively used Community Survey data to increase community awareness
of NEOBH services and respond to referral source communication needs.
Marketing and presentations were made to Hudson City Schools, Summit
County Schools, Summit County Integrated Preschool and Akron Public
Schools – Pupil Services in response to information gathered from
Community Survey data regarding school personnel awareness of NEOBH
services. Information packets with Staff Lists/Specialties were
developed. Specialty and general information brochures were
completely revised.
Recommendations for FY07: Wider
distribution of the
Community
Survey and
continued identification of target audiences for data re: NEOBH
services.
Timeline:
October
1, 2006
Tasks:
-
Identify
appropriate targets for Community Survey distribution
-
Analyze
FY06 survey response to further determine targets
-
Continued
follow-up re: potential referral sources
-
Development
of further opportunities for speaking engagements to assist with
marketing services
Responsibility:
Executive
Director
Financial
Consideration: Copying/postage
for Surveys, etc.
Monitoring:
Executive
Director with reports to the NEOBH Advisory Board
Long-Term Goal D: NEOBH will create
a practice
environment conducive to the needs of our clients and to the
professional practice of our clinical and office staff members. NEOBH
will pursue the purchase of office space at the conclusion of
current rental agreements.
Objective 1: Achieved in FY06:
See Long-Term Goal A, Objective 9 re: further development of
Children’s Network office.
Recommendation
for FY07: NEOBH will participate in
planning related to the future expansion of the Children’s
Network
as a Shareholder. NEOBH will additionally participate in task force
efforts to achieve re-accreditation of the Network as a Child
Advocacy Center, streamline processes between the agencies operating
within the Network, and accomplish decision-making concerning Network
service standards.
Timeline:
Throughout
FY07
Tasks:
-
Executive
Director attendance at Shareholder meetings and submission of data
regarding NEIBH space needs, design considerations
-
Executive
Director attendance at Children’s Network leadership meetings and
Task Force meetings
-
Completion
of assigned duties regarding National Child Advocacy accreditation
standards in the area of mental health services offered by the
Children’s Network.
Responsibility:
Executive
Director
Financial Considerations: None presently. No
time-line has been
established for the expansion of the Children’s Network.
Budgetary revisions will be required as plans are formalized.
Monitoring: Executive Director, with
updates to the
NEOBH Advisory Board
Objective 2: Achieved in FY05:
During
FY 05, NEOBH will investigate and resolve questions related to chart
storage, record disposal time-frames and the feasibility of
computerized storage methods.
Recommendation for FY06: None –
This Objective was
reconsidered mid-year with the assistance of Business Manager Renee
Pittman
Achieved in FY06: NEOBH transferred its
Closed File
Database
to new computer equipment, and had queries written in a more recent
version of Access in order to determine appropriate chart disposal
dates. NEOBH obtained a scanner at the conclusion of FY06, with the
intention of scanning charts closed in FY06. NEOBH investigated
storage space for 38 filing cabinets containing closed files that
cannot yet be destroyed. At the conclusion of FY06, NEOBH began the
task of segregating charts into filing cabinets by disposal dates.
NEOBH identified legal disposal dates for other records in storage,
and had begun to pull these records. NEOBH identified an on-site
shredding service, and a place to store closed records after
segregation into cabinets.
Recommendation for FY07: NEOBH will
continue the
above
project
related to record storage, and will continue to scan
closed records to limit physical record storage.
Timeline:
Throughout
FY07
Tasks:
-
Audit
of business records currently in basement storage and identification of
those that can be legally discarded
-
Selection
of records by service end date, date of birth of client and other
parameters
-
Removal
of non-NEOBH data from records that must be kept
-
Scanning
of records closed in FY06 and onward
-
Record-keeping
of disk contents and secure storage of CD-disks.
Responsibility: Business Manager of
NEOBH with the
assistance of Support Staff
Financial
Considerations: Support
staff (afterschool helpers) hired for chart room duties. Scanner
was obtained as part of a new lease agreement with copier vendor.
Approximately 1000.00 was expended at the conclusion of FY06 to
get data transferred from old to new computer and to provide new
computer equipment dedicated to scanning.
Monitoring:
Executive
Director
Objective 3: Achieved in FY05:
At the
conclusion of FY 05, (June 30, 2005) NEOBH conducted an analysis of
its North Canton office space needs, and engaged consultation
regarding the purchase of new space at the conclusion (September
2006) of the current North Canton Office lease. NEOBH additionally
conducted an analysis of clinical utilization and billing office
needs in the Cuyahoga Falls Office.
Recommendation for FY06: Create
Objective related to
the procurement of new office space in North Canton.
Objective 4: Partially Achieved
in FY06: NEOBH began an active search to identify new and
larger office
accommodations. This Objective was not achieved in FY06, and a move
will likely not occur prior to the conclusion of the NEOBH North
Canton lease in September of 2006. Budgetary considerations related
to relocation were included in the FY07 budget.
Recommendation for FY07: NEOBH shall
continue the
active search for new space in the North Canton area. It shall
request a month-to-month or very short-term lease at the conclusion
of the North Canton office lease.
Timeline:
Ongoing
through FY07
Tasks:
-
Identification
of relocation opportunities
-
Creation
of relocation plans that will be the least disruptive to clinical
services
-
Assignment
of financial resources per FY07/FY08 budget
Responsibility:
Executive/Clinical
Director
Financial
Consideration: To
be determined as project progresses.
Monitoring:
Executive/Clinical
Director and Quarterly review by NEOBH Advisory Board
Long-Term Goal E: NEOBH will
support, attract and
retain highly motivated and highly qualified personnel within all
areas of its operation.
Objective 1: Achieved in FY06:
During FY
06, NEOBH continued to participate as a provider of Continuing
Education Units (CEU’s) for the Ohio Counselor and Social Worker
Board and the State Board of Psychology.
Recommendation for FY07: NEOBH
shall continue to
participate in CEU providership for Counselors, Social Workers and
Psychologists.
Objective 2: Achieved in FY06:
NEOBH
responded to needs identified in the Staff Training Survey and
incorporated these in the implementation of both Orientation and
Ongoing Training programs. Both programs were created according to
COA expectations and received positive reviews by the COA Site
Reviewers in April of 2006. NEOBH developed Training Modules to
accomplish evidence of training in required areas. Tracking of
training receipt was accomplished, and Personnel Files were revised
to include evidence of updated training.
Recommendation for FY07: Continuation
of Ongoing
Training procedures in compliance with COA standards and
needs/preferences/interests of NEOBH staff conveyed via Training
Survey results.
Timeline: Training throughout FY07,
with Training
Modules distributed approximately once per month, and an Annual Staff
Training Event scheduled in January 2007.
Tasks:
Financial
Consideration: None – some expenditure
expected if NEOBH sponsors training.
Responsibility:
Executive
Director
Monitoring:
Executive
Director
Objective 3: Achieved in FY05:
During FY
05, NEOBH added the Clinical and Clerical Staff necessary to enhance
its service delivery and promote smooth business operations.
Recommendation for FY06: None –
maintain Objective
Achieved in FY06: NEOBH audited office
utilization,
and hired three additional clinical staff members, two at the
conclusion of FY06. Additional clerical staff hours were added in
response to the increase in Outcomes administration.
Recommendation for FY07: NEOBH
shall monitor
office and clinical staffing needs, and hire additional staff as
appropriate, and as space is available via relocation of the North
Canton office.
Timelines: Throughout FY07
Tasks:
Financial
Considerations: The addition of new staff will require
adjustments to budget items such as NEOBH contribution to medical
insurance and 401(k).
Responsibility: Executive Director,
with the assistance
of the Business Manager
Monitoring: Executive Director, with
the assistance of
the Business Manager
Objective 4: Partially Achieved
in FY06: During FY 06, NEOBH reviewed and revised Personnel
Policies and
Procedures. It added Personnel Policies in accordance with COA
requirements. By the conclusion of FY06, NEOBH had identified and
revised additional policies that were deemed in need of
clarification.
Recommendation for FY07: Continue
Objective 4 via
a complete audit of Personnel Policies.
Timeline: Throughout FY 07
Tasks:
-
Obtain
legal consultation regarding clarification of 401K Plan terms,
Arbitration Policy and Clinical Staff reimbursement, as needed
-
Revise
Personnel Policies and Procedures according to needs identified as
policies are audited
-
Disseminate
and explain revised policies to the Staff of NEOBH as changes are made
Responsibility: Executive/Clinical
Director, with
consultation from NEOBH Advisory Board, NEOBH legal counsel, and 401K
Plan Administrator
Business Manager: Follow up regarding signed policies for Personnel
File, completion of all required elements of Personnel File, and
updated Personnel Files
Financial
Considerations: Costs associated with legal
consultation for revision of present policies to be determined, with
legal consultation engaged when appropriate.
Monitoring: Executive/Clinical
Director, with Annual
Risk Management Review by NEOBH Advisory Board and CQI Committee.
Presentation of revised policies to Advisory Board by Executive
Director
Objective 5: Achieved in FY06:
NEOBH
developed and delivered additional training modules, and adjusted
both Informal and Formal training efforts to address needs identified
in the Staff Training Survey.
NEOBH offered additional training for key staff involved in the COA
site visit.
Recommendations
for FY07: None
Long-Term Goal F: Achieved in
FY06: NEOBH achieved Council on Accreditation for Children and
Family
Services (COA) in May 2006, in advance of the September 30 2006
deadline per ODMH. NEOBH completely transformed and/or created
numerous internal structures, processes, policies and procedures.
Revision of Long-Term Goal F: NEOBH
will obtain
will continue to implement the organizational changes created by the
certification readiness process, in preparation for re-accreditation.
Objective 1: Achieved in
FY05: During FY 05, NEOBH revised its Articles of
Incorporation to
represent the withdrawal of Gary Robinson, Ph.D., as a
Partner/Member of NEOBH. The revised Articles of Incorporation
included all elements required by the Council on Accreditation.
Achieved in FY06: In
FY06, the
revisions of the NEOBH Operating Agreement were adopted by the NEOBH
Advisory Board, and were successfully used to satisfy a portion of
the requirements for General Standard 3 (Organizational Integrity)
toward the achievement of COA Accreditation.
Objective 2: Achieved in FY06:
During FY
06, NEOBH created organization structures, policies, and procedures
toward the completion of the COA Self-Study document. This was
delivered to COA in Executive Summary format in January 2006. NEOBH
had an entire traditional Self-Study available for the COA Site Visit
that was conducted April 9-11, 2006.
Recommendation for FY07: NEOBH will
determine what
changes will be required to accomplish recertification, and will
begin to compile documentation of the satisfaction of the revised COA
Accreditation Standards in advance of recertification. NEOBH will
provide COA with required Maintenance of Accreditation materials and
reports.
Timeline: Through
FY 07
Tasks:
-
Research/Obtain materials re: Revised (8th
Edition) COA Accreditation Standards
-
Create or necessary Clinical Policies and Procedures
-
Revise existing Clinical Policies and Procedures in
compliance with new COA standards
-
Revise existing Personnel Policies and create
additional Personnel Policies in compliance with new COA standards
-
Gather data from resources familiar with revised COA
standards
-
Educate Clinical, Clerical and Business Management
Staff regarding changes in policies, procedures, performance
expectations, organizational structure and long-term/short-term goals
of the agency
-
Train staff in areas related to COA standard
revisions, update areas of clinical and clerical skill
-
Develop format for compilation of evidence of ongoing
compliance with current COA Accreditation Standards, and determine how
this is related to revised standards.
Responsibility: Executive/Clinical
Director
Financial Consideration: Fees associated
with Maintenance of
Accreditation to be determined
Monitoring: Executive/Clinical
Director, with Quarterly
updates provided to the NEOBH Advisory Board, and Board approval of
policy revisions
Long-Term Goal G: NEOBH will expand
its involvement
in Managed Care, while maintaining its contracts with local Mental
Health Boards.
Objective 1: Achieved in FY06:
During FY
06, NEOBH participated in Medical Necessity audits of its Clinical
Charts, conducted by the Summit County ADMH Board and the Stark
County Mental Health Board. These were largely successful, and a
perfect score was obtained in the Summit County audit. NEOBH
completed any necessary Plans of Correction and implemented
procedural or policy changes to avoid future errors. NEOBH also
participated in audits and/or site visits required by Managed Care
organizations such as Medical Mutual, SummaCare, Value Options and
Aultcare, at the request of these organizations.
Recommendation for FY07: Continue
Objective 1, due
to the impact of Medical Necessity Reviews and the need for continued
compliance.
Timeline: Throughout FY07: Medical
Necessity audits
occur at the request of the Summit County ADMH Board and the Stark
County Mental Health Board at irregular/unpredictable intervals, but
are required annually, per contract. Clinical chart audit requests
from Managed Care organizations also appear to operate on irregular
schedules.
Tasks:
-
Utilize monthly QA/Chart Review as a method to
accomplish internal auditing of Medical Necessity requirements,
clinical chart completion and billing record accuracy, in preparation
for Managed Care and Medical Necessity Compliance Audits
-
Identify and correct any documentation problems
demonstrated within individual charts reviewed during QA/Chart Review
procedures, and identify problems encountered by staff based on
QA/Chart Review data
-
Revise QA/Chart Review Audit Tool to reflect any
changes in Medical Necessity Compliance Audit elements published by the
Ohio Department of Mental Health (ODMH)
-
Provide Mental Health Board Staff and ODMH with
clinical and financial data as required by contract
Responsibility: Executive/Clinical
Director, in
cooperation with the QA Officer and the Business Manager for NEOBH
Financial Consideration: Reimbursement
of QA Officer for time
devoted to QA/Case Review Audit Tool revision
Monitoring: Executive/Clinical
Director, reports to
NEOBH Advisory Board
Objective 2: Partially Achieved
in FY06: During FY 06, NEOBH expanded its involvement in
Managed Care by
adding qualified providers to the Aultcare panel. However, ground
gained in this direction was lost on other panels (i.e. Magellan). The
emphasis on the achievement of COA accreditation and limited
Business Office management drew attention away from efforts needed
toward Managed Care affiliations.
Recommendation for FY07: Continue
with Objective
2.
Timeline: Throughout FY 07
Tasks:
-
Compile data re: Provider Relations contacts
-
Update Personnel Files with appropriate licensure,
liability insurance and generic application data
-
Create data packets for Managed Care Provider
Relations Staff re: niche specialties of eligible providers,
organizational structure of NEOBH
-
Complete application packets as available
-
Enter data in CAQH databank as appropriate.
Responsibility: Executive/Clinical
Director, with
assistance from the Business Manager of NEOBH
Financial Consideration: Consideration
of part-time help to
assist the Business Manager with Managed Care contracting duties
Monitoring: Executive/Clinical Director
and Business
Manager
Long-Term Goal H: NEOBH will
maintain financial
solvency and meet all expectations regarding accurate and timely
financial reporting.
Objective 1: Not Achieved in
FY05: During FY 05, NEOBH will implement all recommendations
resulting from
the FY 04 financial audit conducted by the independent auditor, per
contract requirements. It will seek additional consultation from our
auditor and Advisory Board members regarding ways to safeguard the
financial health of the organization.
Recommendation for FY06: Continue
with Objective
1. Objective 1 is revised to reflect FY06.
Not Achieved in FY06:
NEOBH had
significant difficulty with the completion of the FY05 audit, due in
part to the 11-05 departure of the Business Manager, and reporting
errors that required additional accounting work and the involvement
of outside consultation. The FY05 audit was delivered in May of
2006. NEOBH made the decision to drop its Summit County UPI number,
and report all billings to the Stark County Heartland East website
for processing, as of July 1, 2006. NEOBH also engaged ADP as its
payroll service, and made substantial changes to QuickBooks.
Recommendation for FY07:
Continue with
Objective 1 with the following revision: NEOBH will utilize outside
consultation for accounting related to Medicaid contracting. It will
engage new accounting consultation for business issues related to
QuickBooks, the resolution of tax reporting issues
Timeline: Completion of FY 06 audit
data collection by
October 30, 2006
Completion of audit report by December 30, 2006, with presentation
to the Stark County Mental Health Board in early 2007
Submission of NEOBH tax data prior to April 15, 2007
Tasks:
-
Compile
financial data for independent auditor
-
Review
audit report recommendations
-
Revise
procedures to incorporate recommendations
-
Provide
financial reports to Mental Health Board staff per monthly, quarterly
and annual schedules established per contract
-
Provide
quarterly financial reports to the Executive/Clinical Director and the
NEOBH Advisory Board
-
Provide
additional financial reports to the Ohio Department of Mental Health
(ODMH) as required
-
Work
with accountant re: outstanding tax reporting issues and follow all
recommendations
Responsibility: NEOBH Business Manager
in consultation
with the Executive/Clinical Director
Financial
Consideration: Estimated cost for independent audit of
FY 06: $7,000
Estimated cost of Accounting for NEOBH: $15,000
Monitoring: Business Manager and
Executive/Clinical
Director, Mental Health Board staff in Summit and Stark counties,
independent auditor, NEOBH Advisory Board, Accounting Consultants.
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