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Northeast Ohio
Behavioral Health,
Ltd.
Short-Term
Plan
July 1, 2007 -
June 30, 2008
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).
Partially
Achieved in FY07: Modification
of Objective 3: In FY07, NEOBH
examined Data Mart material regarding its application to CQI
Projects. NEOBH discovered major problems with this data set. Instead,
NEOBH focused its attention on the implementation of
Outcomes data within both treatment planning and within the Progress
Note documentation.
Recommendation for FY08: NEOBH will
track the use of Outcomes in individual treatment planning, and will
capture
Closing Outcomes data via modification of the Discharge Summary. This
will produce a data set unique to NEOBH clients and permit
internal comparisons.
Timeline: Modification of CQI Chart
Review Data to
include Outcomes has been completed. Modification of Discharge
Summary by November 1, 2007. Modification of Closing Data Collection
procedures by December 1, 2007.
Tasks:
-
Utilize
computer consultant to modify Discharge Summary based on best features
within the SOQIC form and data needed by NEOBH re: Outcomes comparison.
-
Revise
Closing Data Collection to reflect Outcomes versus GAF scores
-
Report
to Consumers, Stakeholders, NEOBH Advisory Board and NEOBH Staff re:
results
Responsibility: Executive Director, CQI
Officer and
Support Staff
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.
Achieved
in FY07: Continuation of Objective 4, with
revision:
In
FY07, NEOBH developed an internal tracking system for 6-month
Outcomes submissions and reviews. It revised existing forms to
provide review prompts and ensured data entry regarding both 6-month
Outcomes administration and review of these Outcomes.
NEOBH
concluded FY07 with an Outcomes Submission Rate of over 95%.
Recommendation
for FY08: Continuation of Objective 4 with Revision: NEOBH
will work with its software vendor regarding a tracking system for
subsequent Outcomes administration, as the ODMH software is
unworkable for this function.
Timeline: Completion of internal
tracking system by
June 30, 2008.
Tasks:
Responsibility: Executive/Clinical
Director with
assistance from software consultant, consultation with Business
Manager/Supervisor of Clerical Staff
Financial
Consideration: Unclear.
Monitoring:
Quarterly
review by CQI and NEOBH Advisory Board
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.
Achieved in FY07: NEOBH
Website
was launched in the Second Quarter of FY07.
Recommendation for FY08: NEOBH will
enhance
NEOBH Website with addition of employee access to Operations Manual,
Employee Handbook, new brochures created re: services, updated
employee biographies and client resources.
Timeline: April 1, 2008
Tasks:
-
Gather
information regarding new staff specialty areas, biographical
information, and recommendations for client educational materials
(partially accomplished)
-
Create
CD of final versions of Operations Manual and Employee Handbook
Responsibility: Executive/Clinical
Director, with the
assistance of NEOBH Clinical and Business Office Staff
Financial
Consideration: To be determined by research; however,
website is already created and only requires revisions.
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.
Partially Achieved in FY07:
Continuation and Modification of this of this
Objective to Include
Expansion of Other Niche Child Specialties (Treatment of Children in
Post-Adoptive Placements and Treatment for Attachment Difficulties): NEOBH
expanded services to children with autism-spectrum
disorders by the inclusion of Penny Griffith, Ph.D. as a full-time
staff member. By the conclusion of FY07, adoption-related
assessments had increased, and referrals from SCCS for post-adoptive
children with Reactive Attachment Disorder had also increased, but
had not expanded.
Recommendation
for FY08: Continuation of this Objective:
Timeline:
Throughout
FY08
Tasks:
Program
planning with responsible staff and hiring of staff with
appropriate interests/skills.
Responsibility: Executive Director,
with collaboration
from Clinical Staff.
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.
Partially Achieved in FY07:
Continuation of this Objective with Emphasis on
Trauma
Treatment and Intensive Parent-Child Intervention: NEOBH
conducted trainings re: trauma treatment in October of 2006 and June
of 2007. It devoted resources toward the training of a staff member
who could provide CBT training “in house.” New staff hired
had
appropriate interests and skills sets. However, changes in the
demand for Sexual Abuse Assessments made it impractical to expand
this program. Parent Coordination Services became a source of stress
for both Clinical and Support Staff, due to the highly litigious
nature of the clients involved. Staff resignations were marginally
balanced by hiring, making expansion of trauma treatment a moot
point.
NEOBH developed Intensive Parent-Child Intervention (IPCI), but did
not expand this service with additional staff. NEOBH was able to
continue services to incarcerated youth with trauma histories at the
MultiCounty Juvenile Attention System. (MCJAS). By the conclusion
of FY07, presentations had been made to decision-makers regarding the
expansion of these services to include youth from counties other than
Stark County. NEOBH also opened a branch office in the CARE Center
at Akron Children’s Hospital, with trauma-trained staff
available.
Recommendation for FY08: Continuation
and
Modification of this Objective:
NEOBH
will focus its
attention on enhancement of the following services:
Timeline:
Throughout
FY 08. Hiring of CARE Center staff by February 2008.
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
-
Program
planning re: IPCI, including refinement of the referral process and
pre-post assessments.
-
Hiring
of staff for CARE Center hours
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director with program updates to the NEOBH Advisory Board
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.
Achieved
in
FY07: Continuation of this Objective: Parent
Coordination Services was expanded by the addition and training
of new staff in the Summit County office, where demand has proven
to be greater. However, the feasibility of continuing this service was
hampered by the litigious nature of the clients
served. Regular collaboration with the Summit County Domestic
Relations Court was conducted, and these relationships were
strengthened. NEOBH conducted training for the Court in
September of 2006 and in April of 2007 regarding high-conflict
families.
Recommendation
for FY08: Modification of this Objective:
NEOBH will no
longer offer Parent Coordination Services. It will focus on
Custody Evaluations. NEOBH will train at least one additional
Licensed Psychologist to conduct Custody Evaluations. It will modify
existing Agreement Documents, examine fee structures and
create new Agreement Documents applicable to clients that are
involved in the legal system.
Timeline:
Creation
of Agreement Documents: October 1, 2007
Additional Staff
Training: End of FY08
Tasks:
-
Recruitment
and support of clinical staff with an interest in domestic relations
cases
-
Collaboration
with the Summit County Domestic Relations Court/Family Court Services
and the Stark County Family Court regarding client needs and referral
expectations/outcomes
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director with program updates to the NEOBH Advisory Board
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.
Not Achieved in 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. Staffing issues remained problematic
at the Network, with the resignation of key staff in early 2007. While
other NEOBH staff shifted their work toward the Children’s
Network, this created gaps in other locations. By the conclusion of
FY07, this had been only partially resolved. The addition of group
treatment at the network was not achieved, due primarily to staffing
issues.
Recommendation for FY08: Continuation of this
Objective:
NEOBH will fully staff the Network Office. It will explore
additional connections (i.e. Victim Advocates that serve domestic
violence victims) toward programming niches. NEOBH will participate
in all activates directed toward the future expansion of the
Children’s Network.
Timeline:
Throughout
FY08
Tasks:
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director with program updates to NEOBH Advisory Board
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.
Partially
Achieved
in FY07: Continuation of this Objective, with outreach to
agencies representing special parenting clients.
NEOBH
trained and hired additional staff to perform Parenting Evaluations
by the conclusion of FY07. The impending maternity leaves of both
existing and new staff hampered further program development. An
increase in the request for Parenting Evaluations was noted in the
Summit County Office. Outreach to other agencies did not formally
occur as planned, but remained “per case.”
Recommendation
for
FY08: Continuation
of this Objective
Timeline:
Throughout
FY08
Tasks:
-
Training
and supervision of clinical staff hired at the conclusion of FY07.
-
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.
Partially
Achieved in 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. NEOBH maintained its involvement with
Public Subsidy resources, but its analysis of community need did not
suggest that a movement toward greater
involvement with adult
service provision would be prudent.
Recommendation
for FY08: The essential elements of Objective 11 have been
satisfied, and Objectives pertaining to IPCI have been adequately
managed in other areas within the Short-Term Plan.
Recommend
removal
of this Objective
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.
Achieved in FY07: NEOBH
continued to use Client Satisfaction Survey data as part of CQI, and
will document changes made in response to client feedback.
Recommendation for FY08: Problems
related to the adequacy of the Client Satisfaction Form,
distribution/collection collection rates, and the need for a
Child/Adolescent Client Satisfaction Form have been resolved. NEOBH
shall continue to collect and use, and respond to Client Satisfaction
Data.
Timeline: Throughout FY08
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 –
quarterly reports
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.
Partially Achieved in FY07:
Continuation of the present Objective, with
increased
documentation of procedures: NEOBH made definite progress
toward the establishment of streamlined office procedures. These
affected every area of the office. NEOBH was able to work more
effectively with our software vendor, and devoted resources toward
the creation of special reports. It was also able to work with
Heartland East as an exclusive billing resource for Medicaid, and
established a single Provider ID for Medicaid billing. The Business
Manager of NEOBH was primarily responsible for these changes.
Recommendation for FY08: Continuation
of this
Objective:
Timeline: Throughout FY08
Tasks:
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 are 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.
Partially
Achieved in 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. Limited progress in the
documentation of these procedures was made, though rather dramatic
changes were made and improvement was definitely seen re: copay
collection, account tracking, consideration of write-offs,
examination of account balances and AR. Improved communication
between Billing Office staff and Clinical Staff was noted. However,
full documentation of procedures related to these areas of Billing
Office functioning was not accomplished.
Recommendation
for FY08: Continuation of this Objective:
Timeline:
Throughout
FY08
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.
Achieved in FY07: Wider distribution of
the
Community
Survey and continued identification of target audiences for data re:
NEOBH services.
Recommendation
for FY08: NEOBH has resolved problems related to the
Community Survey and has a more targeted approach to distribution. NEOBH
shall continue to utilize a Community Survey.
Timeline: November
1, 2008
Tasks:
-
Identify
appropriate targets for Community Survey distribution
-
Analyze
FY07 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.
Partially
Achieved in FY07: NEOBH
participated in planning related to the future expansion of the
Children’s Network as a Shareholder. NEOBH participated in task
force efforts to achieve re-accreditation of the Network as a Child
Advocacy Center, streamlined processes between the agencies operating
within the Network (i.e., SCDJFS, Victim Advocates), and accomplished
decision-making concerning Network service standards. NEOBH was
not, however, able to purchase
office space in
FY07.
Recommendation for FY08: Continuation
of
this Objective with the following Modification: NEOBH
will pursue rental or purchase agreements for office space.
Timeline:
Throughout
FY08
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
-
Negotiation
of new leases with existing landlords, if feasible.
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, due to other priorities.
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.
Partially
Achieved in FY07: NEOBH continued the above
project
related to record storage. It moved closer to the goal of storing
closed records off-site via a significant re-organization of closed
records per destroy dates, the purging of insurance and extraneous
data, and the elimination of records that no longer legally required
storage. It used computer database consultation to re-sort and
refine the existing closed file data base so that this
re-organization could take place. NEOBH did not,
however, begin to scan closed records.
Recommendation
for FY08: Continuation of this Objective
Timeline:
Throughout
FY08
Tasks:
-
Audit
of business records currently in basement storage and identification of
those that can be legally discarded
-
Selection
of “start date” for record scanning
-
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 (after school helpers) hired for chart room duties.
Monitoring:
Executive
Director and Business Manager
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.
Partially Achieved in FY07:
NEOBH
continued the active search for new space in the North Canton area,
and viewed two properties with the greatest potential. However, no
purchase was made. Lease for the Cuyahoga Falls Office remained
Month to Month. Lease for N. Canton was expired in 10-06, but issue
was not addressed by the landlord.
Recommendation
for FY08: NEOBH will execute a
Short-Term lease (1 year) for the North Canton Office. It will
utilize legal counsel to examine the terms of the lease.
Timeline: December
1, 2007
Tasks:
-
Renegotiate
lease
-
Creation
of relocation plans that will be the least disruptive to clinical
services, if necessary
-
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.
Achieved in FY07: NEOBH
continued to
participate in CEU providership for Counselors, Social Workers. The
CEU providership requirements changed for Psychologists in August
2006, making it financially untenable for NEOBH to continue
providership. Instead, NEOBH offered all FT employees $150.00 toward
outside training, and provided CEU certificates and application
materials to all psychologists that attended NEOBH-sponsored training
events.
Recommendation for FY 08:
Continuation of this
Objective, re: Support of CEU’s for NEOBH Clinical Staff.
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.
Achieved in FY07: NEOBH
Continued
Ongoing Training procedures in compliance with COA standards and
needs/preferences/interests of NEOBH staff conveyed via Training
Survey results. It provided staff training via Training Modules,
with good compliance, and held an Annual Event in January of 2007.
Recommendation for FY08: Continuation
of this
Objective, with procedural modifications to the training
module process, based on experiences re: rate of return of the
Modules.
Timeline: Training throughout FY08,
with Training
Modules distributed approximately once per month, and an Annual Staff
Training Event scheduled in January 2008.
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.
Achieved in FY07:
NEOBH
monitored office and clinical staffing needs, and hired additional
staff as appropriate.
Recommendation for FY08: Continuation
of this
Objective
Timelines: Throughout FY08
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.
Partially Achieved in FY07:
NEOBH
began, but did not complete, the audit of Personnel Policies.
It made changes to those that required clarification (i.e. Family
Medical Leave Act and definitions pertaining to eligibility for
insurance coverage. NEOBH obtained a complete copy of the handbook
template at the conclusion of FY07. NEOBH began to add policies to
the Operations manual as deficiencies were identified.
Recommendation for FY08:
Continue this
Objective via the completion of the audit of Personnel Policies, and
the creation of additional Operating Procedures.
Timeline: March 1, 2008 (Personnel
Policies)
Throughout FY08 (Policies pertaining to Operations)
Tasks:
-
Obtain
legal consultation, as needed
-
Revise
Personnel Policies and Procedures according to needs identified as
policies are audited
-
Revise
Operating Policies and Procedures as needs are identified
-
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
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
Recommendations
for FY08: 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.
Achieved in FY07: Revision of
Long-Term Goal F: NEOBH continued to implement the
organizational changes created by
the certification readiness process, in preparation for
re-accreditation.
Recommendation for FY08: Continuation
of this Objective
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.
Partially Achieved in FY07:
NEOBH
leadership attended COA Training to determine what changes will be
required to accomplish recertification. NEOBH did not begin
to compile documentation of the satisfaction of the revised COA
Accreditation Standards in advance of recertification. NEOBH
provided COA with any required information.
Recommendation for FY08: Continuation
of
this Objective:
Timeline: Through
FY 08
Tasks:
-
Create or necessary Clinical Policies and Procedures
with attention to Revised (8th Edition) COA Accreditation
Standards
-
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.
Achieved in FY07: NEOBH had successful
Medical
Necessity Reviews. It additionally conducted an internal audit of
the actual rates that it was being paid by various insurance
companies, and resigned from those that fell below the reimbursement
threshold recommended by our Medical budget consultant.
Recommendation for FY08: Continuation
of this
Objective:
Timeline: Throughout FY08: 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.
Achieved in FY07:
Internal
audit of insurance reimbursement limited pursuit of Managed Care.
Instead, NEOBH focused on expansion of self-pay services
(Psychological Evaluations, Test Reports, Custody Evaluations,
Consultation, Workshops).
Recommendation for FY08: Continue
focus on
expansion of self-pay services and maximization of both insurance and
Medicaid reimbursement.
Timeline: Throughout FY 08
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.
Achieved in FY07:
Continuation of Objective
1 with revision: NEOBH successfully utilized outside
consultation for accounting related to Medicaid contracting. It
engaged new accounting consultation for business issues related to
QuickBooks, and the resolution of tax reporting issues. NEOBH was
successful with regard to timely audit onset and completion was on
schedule at the end of FY07. NEOBH did, however, file for an
extension of 2006 federal taxes, due to some confusion regarding K-1
filing in 2005. Tax and legal consultation was successfully engaged.
Recommendation for FY08: Continuation
of this
Objective:
Timeline: Completion of FY 07 audit
data collection by
October 30, 2006
Completion of audit report by December 30, 2007, with presentation
to the Stark County Mental Health Board in early 2008
Submission of NEOBH tax data prior to April 15, 2008
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 07: $5,000
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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