AUDIT REPORT DEPARTMENT OF AUDITS AND ACCOUNTS
Medicaid and Local Government Audits Division
Operations of the: Community Based Mental Health, Mental Retardation,
and Substance Abuse Programs Administered by the Department of Human Resources
Community Mental Health Services Program Administered by the Department of Medical Assistance
February 1999

TABLE OF CONTENTS
LETTER OF TRANSMITTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Background of Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Audit Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Audit Scope and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Organization of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
FINDINGS AND RECOMMENDATIONS . . . . . . . . . . . . . . . . . . 24
Accountability of Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Certification Reviews of Treatment Services . . . . . . . . . . . . . . . . . . . . 28 Corrective Action Regarding Cited Problems . . . . . . . . . . . . . . . . . . . 30
Reimbursement Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Review of Claims Payment Process . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Creation, Alteration and Correction of Medical Records . . . . . . . . . . . 36 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . . . . 39 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . . . 41 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . . 47 Synopsis of Consultants' Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Intake and Assessment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Qualifications of Personnel who Conduct Client Assessments and Make . . . Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Qualifications of Personnel Who Provide Treatment Services . . . . . . . . . . 58

Appropriateness of Client Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Frequency and Duration of Treatment Services . . . . . . . . . . . . . . . . . . . . . 65 Content of Specific Treatment Services Compared to DHR Standards . . . . 68 Comparison of DHR Standards to Industry Standards . . . . . . . . . . . . . . . . 73 Assessment of Client Treatment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . 79 Outcome Measures to Evaluate Overall Program Effectiveness . . . . . . . . . 82 Adequacy of Overall Client Treatment Record Keeping . . . . . . . . . . . . . . 85 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
SUPPLEMENTARY INFORMATION (included only on enclosed compact disk) Consultants' Summary Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . 173 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Finding and Consultants' Reports on Individual Community Service Boards . Albany Area Community Service Board . . . . . . . . . . . . . . . . . . . . . . 209 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 209 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 211 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 217 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 269 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 DeKalb Community Service Board . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 296 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 298 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 303 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 354 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Gateway Community Service Board . . . . . . . . . . . . . . . . . . . . . . . . . . 382 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 382 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 384 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 390 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 452 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466 Middle Flint Behavioral Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . 481 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 481 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 483 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 488 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 557 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569 New Horizons Community Service Board . . . . . . . . . . . . . . . . . . . . . 585 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 585 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 587 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 593 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 666 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678

Ogeechee Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . 693 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 693 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 695 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 698 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 701 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 766 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
River Edge Behavioral Health Center . . . . . . . . . . . . . . . . . . . . . . . . 794 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 794 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 796 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 802 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 807 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 875 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
Three Rivers Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . 902 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . . 902 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . . 904 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . . 910 Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . . 981 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995
Tidelands Community Service Board . . . . . . . . . . . . . . . . . . . . . . . 1010 Allowability of Paid Medicaid Claims . . . . . . . . . . . . . . . . . . . . . 1010 Review of Medicaid Billing Practices . . . . . . . . . . . . . . . . . . . . . . 1012 Internal Control Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015 Substandard Treatment Documentation . . . . . . . . . . . . . . . . . . . . . 1018

Consultants' Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021 Adult Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1023 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036 Mental Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064 Attention Deficit - Hyperactivity Disorder . . . . . . . . . . . . . . . 1081 Activity Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094

CLAUDE L. VICKERS
STATE AUDITOR

DEPARTMENT OF AUDITS AND ACCOUNTS
MEDICAID AND LOCAL GOVERNMENT AUDITS
254 Washington Street, S.W., Suite 322 Atlanta, Georgia 30334-8400
Telephone (404) 656-2006 Facsimile (404) 656-7535
February 16, 1999

MICHAEL A. PLANT
DIRECTOR

The Honorable Roy Barnes, Governor Members of the General Assembly Members of the Board of Human Resources Members of the Board of Medical Assistance The Honorable Tommy C. Olmstead
Commissioner, Department of Human Resources, and The Honorable Dr. William R. Taylor
Commissioner, Department of Medical Assistance
Ladies and Gentlemen:
This report provides the results of our audit of the community based mental health, mental retardation, and substance abuse programs administered by the Department of Human Resources' Division of Mental Health, Mental Retardation and Substance Abuse; and the Community Mental Health Services Program administered by the Department of Medical Assistance. The portion of our audit dealing with these programs' service delivery focused on Community Service Boards.
This audit was conducted under the authority granted the State Auditor by O.C.G.A. 50-6-24. A copy of this report has been filed as a permanent record with the State Auditor and has been made available to the press as required by the Georgia Code.

Respectfully submitted,

CLV/er/bw

Claude L. Vickers State Auditor

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
C The DHR has not yet established a sufficient system for evaluating the overall effectiveness of these community based mental health, mental retardation, and substance abuse programs although nearly a half-billion dollars is spent each year to provide these services and although it is charged with this responsibility in state law. Since August 1993, the department has attempted to develop some types of program performance measures but has not yet implemented an overall program outcome measurement system. Meanwhile, over this five-year period, nearly $2.4 billion has been spent (based on annual CSB revenues reportedly totaling about $482 million in fiscal year 1998 alone). Consequently, one could conclude that these programs, with their significant expenditure amounts, lack accountability. (Page 24)
C The Department of Human Resources (DHR) is currently not conducting reviews of CSB's treatment services in accordance with its contract with the Department of Medical Assistance (DMA). Instead of conducting these reviews in the manner stipulated in the contract, DHR began revising its methods about two years ago. DMA, however, has not formally agreed to these revised methods and no changes have yet been made to the contract. (Page 28)
C Whatever method DHR and DMA finally agree upon to conduct on-site reviews of CSB's treatment services, the method needs to be effective in disclosing problems and in ensuring that these problems and their causes are corrected. The method which DHR formerly had in place (Certification Reviews, as discussed in the previous finding) appeared to disclose problems with CSB's treatment services but did not appear to be effective in ensuring that the cited problems and their causes were corrected. Consequently, the types of treatment service problems cited continued to be problems. CSBs were only required to prepare corrective action plans but were not held accountable for actually taking corrective action. (Page 30)
C The reimbursement methodology used by the DMA, along with the policies and procedures governing the program, has created an opportunity for providers to manipulate the system in order to maximize Medicaid payments. (Page 33)
C The control system in place at the DMA's contracted claims processor, Electronic Data Systems (EDS), detects and prevents payment of most claims that do not meet the requirements for allowability under the regulations governing the Community Mental

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
Health Service Program and Mental Retardation Waiver Program. However, our tests of the controls (edit checks) in place did show deficiencies. (Page 34)
C Four of the nine CSBs reviewed undertook massive, sometimes blatant, efforts to create, alter and correct their recipient medical records prior to or during our on-site reviews, which began in June 1998. (Page 36)
C A review of 18,276 Medicaid claims representing $1,764,457.43 paid to the nine Community Service Boards during the first six months of fiscal year 1998 showed that 12,092 (66%) of these claims were unallowable. These unallowable claims represented $1,079,229.15 in Medicaid payments to the nine providers. Additionally, there were numerous instances in which the services billed exceeded the maximum services authorized on recipients' Individual Service Plans (ISPs). (Page 39)
C All nine CSBs audited have placed Medicaid recipients in disproportionately more treatment services than other consumers. Also, 21 of the 29 CSBs have billed the DMA for various individual treatment services which should possibly be combined and billed as Day Treatment. It appears, therefore, that treatment and billing practices may have been manipulated to increase Medicaid payments. The following paragraphs further explain the reviews we conducted regarding each of these practices. (Page 41)
C We found material deficiencies in the CSBs' internal controls over intake, billing, medical records, and cash collection systems. Such material deficiencies cause accounting and management system information to be incomplete, inaccurate, and unreliable. This, in turn, severely impairs management's ability to effectively manage CSB operations. For example, management cannot accurately determine the types and levels of treatment services that are provided; the staffing levels needed to provide current or future treatment services; and whether charges for treatment services are appropriately billed and collected. Specifically, we identified weaknesses in the following controls: (Page 45)
C Documentation of treatment services in recipients' medical records at all nine of the CSB's audited was deficient, and in some instances, not recorded in chronological order. These deficiencies result in medical records which are not useful in assessing whether recipients are benefitting from prescribed treatments and for evaluating whether treatments should be modified, increased, decreased or discontinued. Erratic record keeping practices, such

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
as inserting progress notes which are completely out of date sequence with existing progress notes, may technically satisfy the requirement that a record exists for each service billed; however, it does not result in meaningful medical records which health care professionals can review to assess recipients' sequential treatments, responses, progress, or lack of progress. Our review also disclosed instances in which expensive crisis management services were billed although the only services documented involved, for example, transporting consumers to football games and department stores, listening to a guardian complain about a child's whining, and documenting a staff meeting and planning session. (Page 47)
C Client intake and assessment procedures are inadequate and, generally, diagnostic evaluations are incomplete and of relatively low quality. There is a lack of physician documentation and a lack of comprehensive, criteria-based assessments by which to determine intensity of necessary services. Generally, there is a low level of physician involvement in many assessments. Tentative diagnoses are given by unqualified individuals instead of by medical doctors or licensed psychologists. This practice, according to our Substance Abuse consultants, has resulted in erroneous substance-related diagnoses being given to consumers. Frequent inaccurate diagnoses were also noted by our consultants who evaluated Attention Deficit-Hyperactivity Disorder (ADHD) services. (Page 52)
C The qualifications of persons conducting client assessments and making diagnoses are often inadequate and there is rarely evidence that physicians supervise these assessments. Commonly, tentative diagnoses are made by unlicensed personnel without further modification by a physician. In many cases, diagnoses were not justified, were inaccurate, and/or were incomplete. Such diagnoses can result in client stigma and errors in treatment planning. (Page 56)
C Consultants expressed overall concerns regarding the lack of qualifications of individuals providing CSB treatment services. Due to grandfathering and equivalency provisions, CSB personnel are exempt from licensure requirements that would severely curtail or preclude their clinical activities in non-CSB settings. For example, although CSBs confer "Mental Health Professional Equivalencies" on staff, these staff would not be qualified to function independently or to receive third-party reimbursements for services rendered in non-CSB settings. Also, since few staff are employed who have formal training in the most effective approaches to the psychosocial management of severe mental illness, treatments provided could be less effective and, ultimately, more costly than more definitive psychosocial treatments. (Page 58)

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
C Each of our professional consultant groups found material problems with client treatment planning and resulting treatment services. Deficiencies disclosed in client treatment planning included: "individual" treatment plans which appeared to be only photocopied and identical among clients; plans lacking measurable and observable objectives and specified outcomes; plans which targeted only minor skill deficits but did not address major client challenges; and plans containing treatment objectives and outcomes which were not directly related to diagnosis and assessment results. Deficiencies disclosed in treatment services included: Day Treatment and Activity Therapy services which were found to be primarily diversional activities with little therapeutic value; Substance Abuse treatment services which have been classified as relatively ineffective treatments; and a tendency to provide treatment that was billable under existing service categories whether or not the treatment modality was logically related to the targeted outcome. (Page 61)
C Due to the cited deficiencies of CSBs' client assessments, diagnoses, treatment planning, and treatment services, a clear determination could not always be made regarding whether the frequency and duration of client treatments was appropriate. Consultants did, however, indicate problematic areas. The frequency and duration of Day Treatment was identified as a concern. Since Day Treatment programming is non-specific and there is a lack of monitoring clinical outcomes, once patients are enrolled in these services, many will remain for a long time (often years). In several cases, Mental Retardation consultants noted that services to some clients appeared excessive compared to their identified needs while other clients received insufficient treatment because the bulk of their time had not been planned as actual treatment time. As noted by the Substance Abuse consultants, CSBs could benefit if treatment plans included goals, estimated length of treatment, the rationale for each type of intervention provided, the rationale for not treating identified problems, and specific discharge criteria and plans for post-treatment care. (Page 65)
C Material deficiencies in CSBs' treatment services were noted by each group of our consultants. Day Treatment programs were identified as woefully inadequate to meet DHR requirements. Mental Retardation consultants noted that most Day Treatment programs offered the equivalent of day care; with adult clients literally being provided baby toys and with television viewing offered as a major activity. Consultants concluded that therapeutic benefits would not be expected for participating clients and that there was little instruction observed that would help clients prepare for more independent community living. Other consultants noted common weaknesses in clinical treatment processes. These included: only rarely seeing evidence that physicians participate in formulating client treatment plans; the practice of continuing clients' previous treatment plans with little or no revision;

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
progress notes usually lacking any reference to a client's level of participation or progress; poorly documented reasons for increasing or decreasing level of care; and discharge summaries lacking required information with some summaries noted as grossly inadequate. (Page 68)
C With noted exceptions, the DHR standards are generally satisfactory for those aspects of care that they address. Many areas, however, were identified in which DHR Standards should be revised to reflect what are now widely regarded as best practices in community mental health, mental retardation, and substance abuse services. As noted by the Substance Abuse consultants, many aspects of the CSB programs were found to be less than satisfactory in comparison to acceptable community standards of non-CSB offerings. This is largely attributable to the failure of the standards to require appropriate levels of education and formal training for individuals performing assessments and therapy. (Page 73)
C Pervasive deficiencies were noted regarding the assessment of client treatment outcomes at CSBs. Mental Health consultants found that, although CSBs had a policy of using a clinical outcome measure, these measures either were not useful measures or were not routinely used at the time of treatment planning to assess the effectiveness of past treatment. Mental Retardation consultants found that only slightly more than half of the client records they reviewed met the criterion for objective measurement. Substance Abuse consultants noted that there was no evidence of systematic outcome assessments found at any site reviewed and further noted that, in the absence of systematic outcome indicators, it is simply impossible to determine the extent and duration of treatment effect. ADHD consultants noted that outcomes of service instruction were poorly documented and Activity Therapy consultants stated that none of the nine CSBs they reviewed contained measurable outcomes identified in client treatment plans that were associated with activity therapy. (Page 79)
C CSBs lack sufficient outcome measures which would allow them to evaluate the overall effectiveness of their treatment programs. As our consultants reported, CSBs conduct little systematic data collection or data analysis relating to clinical care, even in the highest risk areas. None of the CSBs reviewed had a study of clinical recidivism and, with several notable exceptions, there were no data on the clinical effectiveness of CSB treatment programs. Although CSBs are sometimes required through contracting agreements with Regional Boards to gather and report data, such data is of little value in monitoring clinical care. Reliance on indicators which may be required through accrediting agencies to

Summary of Audit Findings
February 1999 Audit Report On DHR's Community Based Mental Health, Mental Retardation, and
Substance Abuse Programs and DMA's Community Mental Health Services Program
monitor CSB system performance will be unsatisfactory because: these types of indicators lack relevance to severe and persistent mental illness; CSBs may not all choose the same indicators; and not all CSBs are undergoing accreditation by the same accrediting agency. (Page 82)
C Deficiencies in client treatment record keeping preclude these records from being useful documents for assessing clients' progress and planning treatment services. Consultants noted, for example, that: documentation was often piecemeal, rather than reflecting an integrated picture; it was quite difficult to quickly ascertain from reviewing charts exactly what services a client was receiving or what programs a client was enrolled in; the evaluation of treatment interventions was greatly limited by the lack of detail in the progress notes; and that medical records were organized in such a way that clinicians would likely not find it convenient to read each others' impressions. (Page 85)

1999 Audit Report:

1

INTRODUCTION
Background of Programs
The Department of Human Resources' (DHR's) Division of Mental Health, Mental Retardation and Substance Abuse was created to establish, administer, and supervise the state programs for mental health, mental retardation, and substance abuse. The division is charged by law to direct, supervise, and control the medical and physical care, treatment, and rehabilitation provided by the institutions and programs under its control, management, or supervision; including its community based programs.
In 1993, state legislation (known as House Bill 100) was enacted to reform the mental health, mental retardation, and substance abuse programs. This legislation established regional boards for planning and coordinating community based mental health, mental retardation, and substance abuse programs at a regional level. The executive director of each regional board is appointed by the director of DHR's Mental Health, Mental Retardation and Substance Abuse Division and approved by the regional board. Prior to 1993, the community based programs were operated by community mental health centers that reported to local boards of health. The 1993 legislation created Community Service Boards (CSBs) which replaced the former community mental health centers. CSBs now are the primary contractors used by the DHR to provide the community based services.
Currently, there are 13 Regional Boards located throughout the state. These regional boards have contracted with 28 CSBs and one single county board of health (for purposes of this report the term CSB refers to all of these 29 entities) to provide community based mental health, mental retardation, and substance services in all of Georgia's 159 counties. The map and Exhibit I on pages 2 and 3 show the name, location, and service area of each of the 29 service providers within each of the 13 regions.

2

Community MH/MR/SA Programs

MAP OF COMMUNITY SERVICE BOARDS (CSBs)
WITHIN THEIR RESPECTIVE REGION

Region 1 1. Georgia Highlands Community Service Board (Dalton) 2. Haralson County Center for MH/MR/SA (Bremen) 3. Lookout Mountain Community Services (LaFayette) 4. Three Rivers Behavioral Health Services (Rome)
1
3

Region 4 10. Cobb County Community Service Board (Marietta) 11. Douglas County Community Service Board (Marietta)
Region 3 8. Georgia Mountains Community Services (Gainesville) 9. Northeast Georgia Center Community Service Board (Bogart)

Region 5

12. Fulton County Community Service Board (Atlanta) 8

4

Region 6

13. Dekalb Community Service Board (Decatur)

14 10

13

2

11

12

5

Region 2

5. Clayton Community MH, SA, Developmental Services

Board (Jonesboro)

6

6. McIntosh Trail MH/MR/SA Community Service Board (Griffin)

7. Pathways Center for Behavioral & Developmental

Growth (LaGrange) 7

20 Region 9 19. Middle Flint Behavioral Healthcare (Americus) 20. New Horizons Community Service Board (Columbus)
19
21

9
Region 7 14. GRN Community Service Board (Lawrenceville)

25

18 17

Region 12 25. Community Service Board of East Central Georgia (Augusta) 26. Ogeechee Behavioral Health Services (Swainsboro) 16
Region 8 15. Community Service Board of Middle Georgia (Dublin) 16. Oconee Community Service Board (Milledgeville) 17. Phoenix Center Behavioral Health Services (Warner Robins) 18. River Edge Behavioral Health Center (Macon)
26 15
28

29
Region 13 27. Gateway Center for Human Development (Brunswick) 28. Pineland Area MH/MR/SA Community Service Board (Statesboro) 29. Tidelands Community Service Board (Savannah)

Region 10
21. Albany Area Community Service Board (Albany) 22. The Georgia Pines Community Service Board (Thomasville)

24

27

Region 11
23. Behavioral Health Services of South Georgia (Valdosta) 24. Satilla Community Service Board for MH/MR/SA (Waycross)

22 23

1999 Audit Report:

EXHIBIT I LISTING OF COMMUNITY SERVICE BOARDS (CSBs)
WITHIN THEIR RESPECTIVE REGIONS

Regional Board Number
1

COMMUNITY SERVICE BOARDS WITHIN EACH REGION

CSB NAME
1. Georgia Highlands Community Service Board

CSB OFFICE LOCATION

COUNTIES IN CSB SERVICE AREA

Dalton

Cherokee, Fannin, Gilmer, Murray, Pickens, Whitfield

2. Haralson County Center for MH/MR/SA

Bremen

Haralson

3. Lookout Mountain Community Services

Lafayette

Catoosa, Chattooga, Dade, Walker

*

4. Three Rivers Behavioral Health Services

Rome

Bartow, Floyd, Gordon, Paulding, Polk

2

5. Clayton Community MH, SA, Developmental Services

Jonesboro

Clayton

6. McIntosh Trail MH/MR/SA Community Service Board

Griffin

Butts, Fayette, Henry, Lamar, Pike, Spalding, Upson

7. Pathways Center for Behavioral & Developmental Growth

LaGrange

Carroll, Coweta, Heard, Meriwether, Troup

3

8. Georgia Mountains Community Services

Gainesville

Banks, Dawson, Forsyth, Franklin, Habersham, Hall, Hart,

Lumpkin, Rabun, Stephens, Towns, Union, White

9. Northeast Georgia Center Community Service Board

Bogart

Barrow, Clarke, Elbert, Greene, Jackson, Madison, Morgan,

Oconee, Oglethorpe, Walton

4

10. Cobb County Community Service Board

Marietta

Cobb

11. Douglas County Community Service Board

Marietta

Douglas

5

12. Fulton County Community Service Board

Atlanta

Fulton

6*

13. DeKalb Community Service Board

Decatur

DeKalb

7

14. GRN Community Service Board

Lawrenceville

Gwinnett, Newton, Rockdale

8

15. Community Service Board of Middle Georgia

Dublin

Bleckley, Dodge, Johnson, Laurens, Montgomery, Pulaski, Telfair,

Treutlen, Wheeler, Wilcox

16. Oconee Community Service Board

Milledgeville

Baldwin, Hancock, Jasper, Putman, Washington, Wilkinson

17. Phoenix Center Behavioral Health Services

Warner Robbins

Crawford, Houston, Peach

*

18. River Edge Behavioral Health Center

Macon

Bibb, Jones, Monroe, Twiggs

3

4

EXHIBIT I LISTING OF COMMUNITY SERVICE BOARDS (CSBs)
WITHIN THEIR RESPECTIVE REGIONS

Regional

COMMUNITY SERVICE BOARDS WITHIN EACH REGION

Board

Number

CSB NAME

CSB OFFICE LOCATION

COUNTIES IN CSB SERVICE AREA

9

19. Middle Flint Behavioral Healthcare

Americus

Crisp, Dooly, Macon, Marion, Schley, Sumner, Taylor, Webster

*

20. New Horizons Community Service Board

Columbus

Chattahoochee, Clay, Harris, Muscogee, Quitman, Randolph,

Stewart, Talbot

10*

21. Albany Area Community Service Board

Albany

Baker, Calhoun, Dougherty, Early, Lee, Miller, Terrell, Worth

22. The Georgia Pines Community Service Board

Thomasville

Colquitt, Decatur, Grady, Mitchell, Seminole, Thomas

11

23. Behavioral Health Services of South Georgia

Valdosta

Ben Hill, Berrien, Brooks, Cook, Echols, Irwin, Lanier, Lowndes,

Tift, Tuner

24. Satilla Community Service Board for MH/MR/SA

Waycross

Atkinson, Bacon, Brantley, Charlton, Clinch, Coffee, Pierce, Ware

12

25. Community Service Board of East Central Georgia

Augusta

Columbia, Lincoln, McDuffie, Richmond, Taliaferro, Warren,

Wilkes

*

26. Ogeechee Behavioral Health Services

Swainsboro

Burke, Emanuel, Glascock, Jefferson, Jenkins, Screven

13*

27. Gateway Center for Human Development

Brunswick

Bryan, Camden, Glynn, Liberty, Long, McIntosh

28. Pineland Area MH/MR/SA Community Service Board

Statesboro

Appling, Bulloch, Candler, Evans, Jeff Davis, Tattnall, Toombs,

Wayne

*

29. Tidelands Community Service Board

Savannah

Chatham, Effingham

SOURCE:

Department of Human Resource records
*The above denotes the nine CSB's we audited.

Community MH/MR/SA Programs

1999 Audit Report:

5

The Department of Medical Assistance (DMA) is responsible for administering the state's Medicaid program which is jointly funded by the State of Georgia and the federal government. Through contracts with the DMA, the Community Mental Health Services Program's providers, which are primarily the CSBs, are paid for services provided to the state's Medicaid-eligible consumers.
For this Medicaid program, the DMA contracts with the DHR's Division of Mental Health, Mental Retardation and Substance Abuse to establish treatment standards, to ensure the providers' compliance with the standards and DMA Policies and Procedures, and to conduct certification and utilization reviews.
CSBs submit claims to the DMA for services that were provided to Medicaid consumers. These claims are processed by the DMA's claims payment contractor (Electronic Data Systems) and paid based on rates established by the DMA for each individual service code. There are two main categories of service (COS) within the Medicaid program which pay for Community Mental Health, Mental Retardation, and Substance Abuse Programs' services: Community Mental Health Services (COS 44) and Mental Retardation Waiver (COS 68).
As shown in Exhibit II on page 7, overall funding to the CSBs for fiscal year 1998 totaled nearly $482 million according to DHR information. Of this total, Medicaid funds accounted for 28% (about $133 million) while Grant-In-Aid funds disbursed through the DHR accounted for 51% (over $245 million). The remaining 21% (approximately $103 million) of CSB's funds came from various other sources such as local governments, Medicare, Supplemental Security Income (SSI), and consumers' private insurance and fee payments.

6

Community MH/MR/SA Programs

A dramatic increase in Medicaid funding to CSBs for the Community Mental Health Services Program (COS 44) has occurred, as illustrated in Exhibit III on page 11. Since fiscal year 1995, Medicaid funding for these services has increased nearly $40 million (67%), rising from $59 million in fiscal year 1995 to over $99 million in fiscal year 1998. A portion of this increase is attributable to an increase in payment rates by the DMA in 1997. However, according to the DHR, this rate increase only accounts for $13.5 million (34%) of the $40 million total increase. Meanwhile, as shown in Exhibit IV on page 11, the number of Medicaid recipients served at CSBs during this period has remained at a fairly constant level (about 50,000 recipients each year). Additionally, as shown in Exhibit V on page 12, the average number of units of service per Medicaid recipient has increased by 32% from January 1996 to June 1998.
Overall, CSBs served 165,867 recipients during fiscal year 1998 according to the DHR's information. As Exhibit VI shows on page 13, most of these recipients (69%) were being served for mental health disabilities while substance abuse disabilities accounted for 24% of the recipients served and mental retardation disabilities accounted for only 7%.

1999 Audit Report:

EXHIBIT II COMMUNITY SERVICE BOARDS (CSBs)
FUND SOURCES AND AMOUNTS FISCAL YEAR 1998

FUND SOURCE CATEGORIES AND RESPECTIVE AMOUNTS

Total

DHR

Medicaid

Other

Fund Source

Grant-In-Aid

Amounts $ Amount % of $ Amount % of $ Amount % of

OVERALL TOTALS Region 1: 1. Georgia Highlands Community Service Board 2. Haralson County Center for MH/MR/SA 3. Lookout Mountain Community Services 4. Three Rivers Behavioral Community Service Board

481,532,106
17,317,309 1,851,647
10,958,419 14,299,376

245,164,209
7,966,614 995,216
7,645,679 7,723,864

51%
46% 54% 70% 54%

133,355,475 28%

4,569,438

26%

440,426

24%

1,961,643

18%

4,358,194

30%

103,012,422
4,781,257 416,005 1,351,097 2,217,318

21%
28% 22% 12% 16%

Region 2:

5. Clayton Community MH, SA, Developmental

Services Board

16,332,006

8,283,468

51%

4,071,960

25%

3,976,578

24%

6. McIntosh Trail MH/MR/SA Community Service Board

16,556,425

7,596,882

46%

4,305,578

26%

4,653,965

28%

7. Pathways Center for Behavioral & Developmental Growth

14,150,548

6,970,195

49%

4,760,016

34%

2,420,337

17%

Region 3:

8. Georgia Mountains Community Services

20,285,729 12,446,239

61%

3,341,683

16%

4,497,807

22%

9. Northeast Georgia Center Community Service

Board

19,399,106 14,075,087

73%

2,631,672

14%

2,692,347

14%

7

8

EXHIBIT II COMMUNITY SERVICE BOARDS (CSBs)
FUND SOURCES AND AMOUNTS FISCAL YEAR 1998

Community MH/MR/SA Programs

FUND SOURCE CATEGORIES AND RESPECTIVE AMOUNTS

Total

DHR

Medicaid

Other

Fund Source

Grant-In-Aid

Amounts $ Amount % of $ Amount % of $ Amount % of

Region 4: 10. Cobb County Community Service Board 11. Douglas County Community Service Board

20,173,402 11,676,331

58%

4,623,811

23%

3,873,260

19%

4,458,468

2,391,424

54%

983,732

22%

1,083,312

24%

Region 5: 12. Fulton County Community Service Board

22,846,655

9,693,818

42%

3,260,755

14%

9,892,082

43%

Region 6: 13. DeKalb Community Service Board

35,317,965 17,197,119

49%

8,802,889

25%

9,317,957

26%

Region 7: 14. GRN Community Service Board

24,080,249 12,817,064

53%

5,593,701

23%

5,669,484

24%

Region 8:

15. Community Service Board of Middle Georgia 15,219,712 10,040,348

66%

3,571,372

23%

1,607,992

11%

16. Oconee Community Service Board

11,669,416

4,279,421

37%

4,322,529

37%

3,067,466

26%

17. Phoenix Center Behavioral Health Services

9,204,945

4,223,315

46%

2,085,715

23%

2,895,915

31%

18. River Edge Behavioral Health Center

17,799,520

7,319,873

41%

6,456,300

36%

4,023,347

23%

1999 Audit Report:

EXHIBIT II COMMUNITY SERVICE BOARDS (CSBs)
FUND SOURCES AND AMOUNTS FISCAL YEAR 1998

FUND SOURCE CATEGORIES AND RESPECTIVE AMOUNTS

Total

DHR

Medicaid

Other

Fund Source

Grant-In-Aid

Amounts $ Amount % of $ Amount % of $ Amount % of

Region 9: 19. Middle Flint Behavioral Healthcare 20.New Horizons Community Service Board

15,066,803

7,857,179

52%

5,310,645

35%

1,898,979

13%

21,971,689 10,709,768

49%

8,027,893

37%

3,234,028

15%

Region 10:

21. Albany Area Community Service Board

18,283,557

9,358,131

51%

5,954,633

33%

2,970,793

16%

22. The Georgia Pines Community Service Board 15,830,911

7,598,777

48%

4,568,288

29%

3,663,846

23%

Region 11:

23. Behavioral Health Services of South Georgia

15,272,070 10,405,172

68%

3,106,206

20%

1,760,692

12%

24. Satilla Community Service Board for MH/MR/SA

14,919,351

9,095,224

61%

2,756,709

18%

3,067,418

21%

Region 12: 25. Community Service Board of East Central
Georgia 26. Ogeechee Behavioral Health Services

15,147,356

7,550,978

50%

4,086,824

27%

3,509,554

23%

15,676,208

6,508,012

42%

5,508,129

35%

3,660,067

23%

9

10

EXHIBIT II COMMUNITY SERVICE BOARDS (CSBs)
FUND SOURCES AND AMOUNTS FISCAL YEAR 1998

Region 13: 27. Gateway Center for Human Development 28. Pineland Area MH/MR/SA Community
Service Board 29. Tidelands Community Service Board

FUND SOURCE CATEGORIES AND RESPECTIVE AMOUNTS

Total

DHR

Medicaid

Other

Fund Source

Grant-In-Aid

Amounts $ Amount % of $ Amount % of $ Amount % of

22,148,030

8,477,342

38%

9,473,801

43%

4,196,887

19%

14,760,366

8,843,878

60%

3,779,660

26%

2,136,828

14%

20,534,869

5,417,791

26%

10,641,274

52%

4,475,804

22%

Community MH/MR/SA Programs

1. Includes Medicaid funding to CSB's for Community Mental Health Services and Mental Retardation Waiver Programs and for othe r Medicaid programs such as Case Management and Pharmacy Services.
2. Includes serveral fund sources such as county and municipal governments, Medicare, Supplemental Security Income (SSI), consum ers' private insurance, and fees paid by consumers for services.
SOURCES: Department of Human Resources records and Department of Medical Assistance paid claim data for Community Mental Health.

1999 Audit Report:

11

EXHIBIT III Total Dollar Amount of Medicaid Claims Paid
Fiscal Years 1995-1998

$95,000,000 $85,000,000

$99,283,840 $88,604,479

$75,000,000

$65,000,000

$65,198,831 $59,313,080

$55,000,000

1995

1996

1997

Fiscal Year

1998

EXHIBIT IV Total Unduplicated Number of Medicaid Recipients
Fiscal Years 1995-1998

Recipients Served

60,000 55,000 50,000 45,000 40,000 35,000 30,000

47,915

51,004

51,838

1995

1996

1997

Fiscal Year

50,928
1998

Source: Department of Medical Assistance Note: Amounts do not include Mental Retardation Waiver (COS 68).

Average Units of Service Per Medicaid Recipient 1996 Qtr 1 1996 Qtr 2 1996 Qtr 3 1996 Qtr 4 1997 Qtr 1 1997 Qtr 2 1997 Qtr 3 1997 Qtr 4 1998 Qtr 1 1998 Qtr 2

12

Community MH/MR/SA Programs

EXHIBIT V Average Units of Service Per Medicaid Recipient
Category of Service 44 Quarterly From January 1996 through June 1998

58

55.91

56.14

56

54.95

54

53.24

52

50.28

50

49.50

49.56 48.54

48

47.40

46

44

42.50

42

40

Source: Department of Medical Assistance Medicaid claims data (COS 44)

1999 Audit Report:

EXHIBIT VI

NUMBER OF PERSONS SERVED BY COMMUNITY SERVICE BOARDS (CSBS) OVERALL AND BY TYPE OF DISABILITY

FISCAL YEAR 1998

Of Total # Served

Number of

Mental Health

Mental Retardation

Substance Abuse

Persons

Disability

Disability

Disability

Served

#

%

#

%

#

%

Overall Totals

165,867 115,224 69% 11,446

7% 39,197 24%

Region 1: 1. Georgia Highlands Community Service Board 2. Haralson County Center for MH/MR/SA 3. Lookout Mountain Community Services 4. Three Rivers Behavioral Health Services
Region 2: 5. Clayton Community MH, SA, Developmental Services Board
6. McIntosh Trail MH/MR/SA Community Service Board 7. Pathways Center for Behavioral & Developmental Growth
Region 3: 8. Georgia Mountains Community Services 9. Northeast Georgia Center Community Service Board

7,760 930
3,919 8,078
4,818 4,512 6,025
8,360 8,846

5,365

69%

812

87%

2,889

74%

6,089

75%

2,720

56%

3,337

74%

4,240

70%

5,900

71%

6,403

72%

495

6%

1,900

24%

49

5%

69

7%

214

5%

816

21%

371

5%

1,618

20%

428

9%

1,670

35%

196

4%

979

22%

298

5%

1,487

25%

543

6%

1,917

23%

464

5%

1,979

22%

13

14

EXHIBIT VI

NUMBER OF PERSONS SERVED BY COMMUNITY SERVICE BOARDS (CSBS) OVERALL AND BY TYPE OF DISABILITY

FISCAL YEAR 1998

Of Total # Served

Number of

Mental Health

Mental Retardation

Substance Abuse

Persons

Disability

Disability

Disability

Served

#

%

#

%

#

%

Region 4: 10. Cobb County Community Service Board 11. Douglas County Community Service Board
Region 5: 12. Fulton County Community Service Board
Region 6: 13. DeKalb Community Service Board

5,680 1,493
5,457
11,923

3,819

67%

1,222

82%

4,946

91%

8,458

71%

486

9%

1,375

24%

97

6%

174

12%

309

6%

202

4%

725

6%

2,740

23%

Community MH/MR/SA Programs

Region 7: 14. GRN Community Service Board
Region 8: 15. Community Service Board of Middle Georgia 16. Oconee Community Service Board 17. Phoenix Center Behavioral Health Services 18. River Edge Behavioral Health Center

7,341
3,954 2,921 3,972 7,212

4,600

63%

2,654

67%

2,245

77%

2,503

63%

4,242

59%

431

6%

432

11%

137

5%

315

8%

323

4%

2,310

31%

868

22%

539

18%

1,154

29%

2,647

37%

1999 Audit Report:

EXHIBIT VI NUMBER OF PERSONS SERVED BY COMMUNITY SERVICE BOARDS (CSBS)
OVERALL AND BY TYPE OF DISABILITY FISCAL YEAR 1998

Number of
Persons
Served

Mental Health

Disability

#

%

Of Total # Served

Mental Retardation

Disability

#

%

Substance Abuse

Disability

#

%

Region 9: 19. Middle Flint Behavioral Healthcare 20. New Horizons Community Service Board
Region 10: 21. Albany Area Community Service Board 22. The Georgia Pines Community Service Board
Region 11: 23. Behavioral Health Services of South Georgia 24. Satilla Community Service Board for
MH/MR/SA
Region 12: 25. Community Service Board of East Central
Georgia 26. Ogeechee Behavioral Health Services

3,456 4,841
5,830 6,732
6,650 4,148

2,358

68%

2,569

53%

3,972

68%

5,067

75%

4,381

66%

2,572

62%

7,194 3,087

4,542

63%

2,158

70%

448

13%

510

11%

650

19%

1,762

36%

439

8%

1,419

24%

478

7%

1,187

18%

535

8%

416

10%

1,734

26%

1,160

28%

693

10%

304

10%

1,959

27%

625

20%

15

16

EXHIBIT VI

NUMBER OF PERSONS SERVED BY COMMUNITY SERVICE BOARDS (CSBS)

OVERALL AND BY TYPE OF DISABILITY

FISCAL YEAR 1998

Of Total # Served

Number of

Mental Health

Mental Retardation

Substance Abuse

Persons

Disability

Disability

Disability

Served

#

%

#

%

#

%

Region 13: 27. Gateway Center for Human Development 28. Pineland Area MH/MR/SA Community Service
Board 29. Tidelands Community Service Board

8,337
5,134 7,257

6,661

80%

3,547

69%

4,953

68%

423

5%

1,253

15%

467

9%

1,120

22%

420

6%

1,884

26%

Community MH/MR/SA Programs

SOURCES: Department of Human Resources Records

1999 Audit Report:

17

Audit Objectives
The general objectives of this audit were to assess the operations and accountability of the programs and to assess the quality of care being provided through these programs. Specific objectives of the audit were to:
C determine the extent to which these programs are held accountable through assessment of their overall effectiveness by the DHR or the DMA;
C determine the extent to which the DHR is meeting its DMA contract obligations for ensuring that CSBs are operating in accordance with DHR and DMA policies;
C review the appropriateness of the methods used to reimburse CSBs for these program services provided to Medicaid consumers;
C determine whether claims paid by the DMA were allowable based on Medicaid policies regarding proper documentation of services in consumers' medical records, appropriate authorization of the services, and treatment service limits;
C assess whether sufficient edit checks are in place within the DMA's claims payment system to provide reasonable assurance that unallowable claims submitted by these programs' service providers for payment will be rejected;
C determine if there are indications of CSBs using manipulative treatment or billing practices which result in maximizing Medicaid reimbursement;
C assess whether CSBs have appropriate internal controls in place over intake, billing, medical records, and cash collection systems; and to
C evaluate, through the use of health professionals, CSBs' provision of mental health, mental retardation, and substance abuse services by:
< assessing the adequacy of CSB's client intake and assessment processes; < evaluating the qualifications of CSB personnel who conduct client assessments and
make diagnoses; < assessing the qualifications of CSB personnel who provide treatment services;

18

Community MH/MR/SA Programs

< determining if client treatment plans reflect services which are appropriate based on clients' diagnoses;
< determining if the frequency and duration of treatment provided to CSB clients is appropriate based on clients' diagnoses;
< determining whether the content of specific treatment services meets DHR standards;
< evaluating whether DHR standards, regarding the content of specific treatment services, meet current professional industry standards;
< evaluating whether CSBs have utilized appropriate methods to assess client treatment outcomes;
< determining whether CSBs have appropriate outcome measures in place for use in evaluating their overall effectiveness; and
< assessing the adequacy of CSBs overall client treatment record keeping.
Audit Scope and Methodology
The scope of this audit primarily focused on fiscal year 1998 operations of the DHR's community based mental health, mental retardation, and substance abuse programs and the DMA's Community Mental Health Services Program. The portion of our audit dealing with these programs' service delivery focused on Community Service Boards (CSBs). To accomplish the related audit objectives, audit teams and health professional consultant teams conducted on-site reviews at nine (31%) of the 29 Community Service Boards (CSBs). These nine CSBs are identified on Exhibit I (pages 3 and 4) and are geographically spread throughout the state with their main offices located in the following cities: Albany, Americus, Brunswick, Columbus, Decatur, Macon, Rome, Savannah, and Swainsboro. Our samples of medical records reviewed at these CSB's were randomly drawn from the DMA's Medicaid electronic claim data. For purposes of comparison to Medicaid recipient records, samples of non-Medicaid recipient records were randomly drawn from CSB's current records. As appropriate, more detailed information regarding our sample sizes, etc. is explained in the respective findings throughout the remainder of this report.

1999 Audit Report:

19

We utilized a multi-disciplinary approach to staff this audit including financial auditors, program auditors, and nurses from the Department of Audits and Accounts and five groups of health professional consultants, all of whom were heavily credentialed in their respective area of expertise. Each of these five groups of consultants (totaling 11 doctorate-level professionals and four assistant staff) and the respective area of services they reviewed is listed below:
! SUBSTANCE ABUSE TREATMENT SERVICES
Dr. Ralph LeRoy Elkins, Ph.D. Dr. Thomas Edward Orr, Ph.D. Dr. Paul Andrew Walters, Ph.D.
! MENTAL RETARDATION (MILD AND MODERATE)
Dr. Gail G. Mcgee, Ph.D. Assisted by: Sharon T. Hynes Michael J. Morrier
! ATTENTION DEFICIT - HYPERACTIVITY DISORDER (ADHD)
Dr. Arden D. Dingle, M.D. Dr. Allan M. Josephson, M.D. Dr. Sandra Sexson, M.D.
! ADULT MENTAL HEALTH SERVICES Dr. Rachel Brown, M.D., M.R.C.S., L.R.C.P. (London) Dr. Richard L. Elliott, M.D., Ph.D.

20

Community MH/MR/SA Programs

Dr. Richard A. Fields, M.D. Assisted by: Marelda Parish, M.S.
! ACTIVITY THERAPY
Dr. John Dattilo, Ph.D. Assisted by: Nancy J. Jekubovich, M.A.
In addition to their professional credentials, these consultants have substantial backgrounds of research in their respective areas of expertise which are listed above. Furthermore, all but one of these doctorate-level professionals are also professors in their respective fields at well-respected medical schools in Georgia. Given these research backgrounds and professional credentials as well as their role of teaching the profession at medical schools, we feel confident of their knowledge of industry practices, their ability to comment on these programs' services, and of the credibility of their resulting work.
As could be expected, professionals who are familiar with, and expert in, these areas of public health in Georgia are likely to have had some contact with Georgia's public health system, including these programs within DHR, DMA, and the CSBs. For example, two of the three doctorate level consultants we used to review these programs' ADHD services and the one doctorate level consultant we used to review mental retardation services periodically interact with some CSBs and their staff; two of the three consultants we used to review adult mental health services had worked at DHR in previous years; and some of our consultants occasionally provide services to Medicaid recipients. Given these circumstances, we recognized the potential for possible bias for or against these programs.

1999 Audit Report:

21

As with any such audit, we took steps during the course of the audit to ensure that bias (either positive or negative) was not manifested in the work or reports of any of our five groups of consultants. These steps are listed below.

C

Engaging multiple teams of consultants to evaluate the programs. This would discourage

blatant manifestations of bias by any single team. Additionally, if any team's reports did

manifest bias, it would be apparent when compared to the results of the other consultant

teams.

C

Ensuring that each consultant team was comprised of more than one professional to evaluate

each of the areas of program services. Also, ensuring that the consultants' reports reflected

the findings of each respective team, not just those of any one individual consultant.

C

Meeting with our consultants before they began site reviews to discuss methodologies and

ensure objectivity. This included discussing with each team the methodology and professional

standards they intended to use to conduct their evaluation. This was done to minimize the

effect of any possible bias in the methodology employed, the work done, and the results

reported.

C

Meeting with our consultant teams during the on-site phase of their work to determine if there

was any material evidence of the manifestation of bias in their approach and preliminary

conclusions.

C

Reviewing each consultant team's reports on individual CSBs and their summary reports to

determine if there was any material evidence of the manifestation of bias. Also, we compared

each team's reports to the reports of the other four consultant teams to identify any material

inconsistencies or incompatible conclusions which could be evidence of bias.

22

Community MH/MR/SA Programs

After reviewing our draft audit report of these programs' services, DHR stated that they had concerns regarding two of the 15 persons on our consultant teams since these two persons had worked at DHR in previous years and may be negatively biased. We, however, solidly conclude that we noted absolutely no manifestation of bias on the part of these two consultants or any of our other consultants which would impact their respective reports on these programs' services.
Furthermore, to substantiate our conclusion, we repeat that the steps we took during the course of the audit (as outlined in the preceding paragraph) precluded any manifestation of bias in consultants' reports. We also feel strongly that any findings or other report statements affiliated with the work of these two consultants were substantiated and were consistent with findings and conclusions presented by our other four groups of consultants.
Therefore, we definitely and affirmatively refute any contention sounded on the part of the agency whose programs we audited that there is any manifestation of bias in the work and resulting reports of any of our consultants.
In addition to our samples of medical records and our consultants' reviews as explained above, the methodology used during the course of this audit included:
C reviews of applicable laws, regulations, and policies applicable to both the Department of Human Resources (DHR) and the Department of Medical Assistance (DMA);
C reviews of DHR and DMA programmatic and financial data; C on-site reviews of medical records, billing systems, and internal controls at the nine
Community Service Boards (CSBs) listed above; C analysis of Medicaid claim data for Program services; and C interviews with personnel at the DMA, DHR, CSBs, and Regional Boards.

1999 Audit Report:

23

This audit was conducted in accordance with generally accepted government auditing standards. The entire report was discussed with appropriate personnel in the DHR and in the DMA. The DHR and the DMA were also invited to provide written comments on the report. To ensure that the DHR's contractors were given an opportunity to comment on the report before its release, we solicited their comments also. Pertinent responses from these agencies were evaluated and are reflected in the audit report as appropriate.
Organization of Report
As outlined in the Table of Contents, this printed report is supplemented with two additional sets of information which are contained only on the enclosed compact disk (located on the inside back cover of this report). The first set of supplemental information is a full copy of each of our five consultant groups' summary reports. The second set of supplemental information is a report on each of the nine individual CSBs we reviewed. Each of these CSB reports contain detailed findings from our audit review plus the detailed reports of each of our consultant groups on the respective CSB. This supplementary information is intended for readers wanting more detailed clinical information regarding the programs and services provided and for those readers interested in the findings at any one, or all, of the individual CSBs included in this audit.

24

Community MH/MR/SA Programs

FINDINGS AND RECOMMENDATIONS
Accountability of Programs
The DHR has not yet established a sufficient system for evaluating the overall effectiveness of these community based mental health, mental retardation, and substance abuse programs although nearly a half-billion dollars is spent each year to provide these services and although it is charged with this responsibility in state law. Since August 1993, the department has attempted to develop some types of program performance measures but has not yet implemented an overall program outcome measurement system. Meanwhile, over this fiveyear period, nearly $2.4 billion has been spent (based on annual CSB revenues reportedly totaling about $482 million in fiscal year 1998 alone). Consequently, one could conclude that these programs, with their significant expenditure amounts, lack proper accountability.
Initial attempts to develop overall outcome measurements for these programs began in August 1993, according to DHR officials. This was shortly after these programs were reformed through legislation in the earlier months of 1993. This attempt never materialized, however, because consumer groups and providers could not agree on what constituted appropriate outcome measurement topics.
Next, in 1996 according to department officials, the DHR entered into a $150,000 contract with a firm to develop outcome measurements for its mental health, mental retardation, and substance abuse programs. Although 18 months later this firm issued a 293-page report on performance indicators, none of these were ever implemented. The reason, according to DHR officials, was that consumer advocates and members of the regional boards were upset with this report and would not support any

1999 Audit Report:

25

of the outcome indicators which had been developed. It should be noted that this contracted firm was the Human Services Research Institute for Health Policy in Massachusetts.

Subsequently, the DHR initiated another project to develop Program outcome measures. This project is called PERMES (Performance Measurement and Evaluation System). Implementation of any outcome measures resulting from this project is not expected until fiscal year 2001. This project is costing about $100,000 per year, according to department officials.

Section 37-1-20(b) of the Official Code of Georgia Annotated (O.C.G.A.) charges the DHR with the responsibility of establishing, administering, directing and supervising the state programs for mental health, mental retardation, and substance abuse. This same Code Section also charges the DHR with coordinating the development of program outcome measures and with regularly assessing the impact of the programs. As the above paragraphs explain, the DHR has not yet fulfilled this responsibility.

Absent a sufficient system to evaluate the overall effectiveness of these programs, we asked our consultants to determine whether appropriate performance measures may exist at the local CSB level. Consultants' reports stated, for example, that:

C

There is little systematic data collection or data analysis relating to clinical care, even in the

highest risk areas...;

C

No evidence of systematic outcome assessments was found at any site reviewed. This finding

is particularly disturbing as many staff members appeared enthusiastic about their programs

and certain that their form of treatment was yielding very positive outcomes. However, they

were unable to present any data to support their assertions;

C

[The profession recognized that] there are numerous indicators of [substance abuse] treatment

gain, including duration of abstinence, amount and pattern of substance abuse, vocational

status, number of hospitalizations, emotional and social stability, physical health,

26

Community MH/MR/SA Programs

participation in criminal activities, etc. In the absence of systematic outcome indicators, it is simply impossible to determine the extent and duration of treatment effect;

C

CSBs are sometimes required, through contracting agreements with regional boards, to gather

and report data. Such data is of little value in monitoring clinical care. For example, although

CSBs conduct patient satisfaction surveys, most surveys are designed to show high rates of

patient satisfaction. Consequently, there is little value to be gained from the surveys and care

was either not improved or was only minimally impacted by survey results; and

C

It would be highly desirable if efficacy evaluations were based on common methodologies

such that results would be comparable across different CSBs.

C

Reliance on indicators which may be required through accrediting agencies to monitor CSB

system performance will be unsatisfactory because these types of indicators lack relevance to

severe and persistent mental illness, CSBs may not all choose the same indicators, and

because not all CSBs are undergoing accreditation by the same accrediting agency.

The DHR needs to expedite implementation of a meaningful outcome measurement system by which to evaluate the overall effectiveness of its community based programs. This system should allow the DHR to evaluate the effectiveness of its programs at the state, regional, and local levels. This system should also allow the DHR, as required by law, to regularly assess its programs' impact on the individuals receiving treatment. The implementation of such a system would assist the DHR in accomplishing its state mandated responsibility to establish, administer, and supervise the state programs; and its responsibility to direct, supervise, and control the medical and physical care, treatment, and rehabilitation provided by its programs. Absent such a system of measuring and managing program outcomes, the state spends nearly one-half billion dollars on these programs each year without sufficient knowledge of these programs' benefit and without an adequate gauge of their overall effectiveness.
It should be noted that the DHR in its response to this finding indicated that, during the course of this audit (November 1998), they began using a "process to review the processes associated with quality

1999 Audit Report:

27

delivery of services including service planning" and indicated that they do not have the outcome system they have been desirous of. The DHR also stated in its response that its current information system is the primary barrier to setting up overall program outcomes.

28

Community MH/MR/SA Programs

Certification Reviews of Treatment Services
The Department of Human Resources (DHR) is currently not conducting reviews of CSB's treatment services in accordance with its contract with the Department of Medical Assistance (DMA). Instead of conducting these reviews in the manner stipulated in the contract, DHR began revising its methods about two years ago. DMA, however, has not formally agreed to these revised methods and no changes have yet been made to the contract.
According to DHR's contract, it is responsible for conducting two distinct types of reviews of CSB's operations. Certification Reviews are to be comprehensive on-site reviews conducted every two years to ensure that CSB's mental health, mental retardation and substance abuse services are in compliance with DHR and DMA policies. Utilization Reviews are to be conducted to evaluate the appropriateness of clients' services and time in service. The contract requires DHR to provide DMA with quarterly reports on the results of these Utilization Reviews. It should be noted that the DMA has not provided the DHR with service utilization information as required by the contract.
DHR stopped doing Certification Reviews of CSBs in fiscal year 1997. Instead of conducting these reviews, DHR is requiring CSBs to be accredited by a national accrediting organization by the end of fiscal year 1999. To date, only nine (31%) of the 29 CSBs have become accredited.
DHR has not conducted Utilization Reviews since fiscal year 1997, according to agency officials. Instead of conducting these reviews, DHR reportedly plans to implement new guidelines and methods by the beginning of fiscal year 2000.
The DMA needs to formally determine if DHR's revised methods for conducting these reviews will sufficiently replace the methods which are stipulated in the current contract. If these methods are formally agreed upon by both agencies, the contract should be revised to reflect current practices.

1999 Audit Report:

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As explained in the next finding, regardless of what review methods are used, these agencies should ensure that CSBs are held accountable for providing services appropriately and in accordance with applicable DHR and DMA policies.

30

Community MH/MR/SA Programs

Corrective Action Regarding Cited Problems

Whatever method DHR and DMA finally agree upon to conduct on-site reviews of CSB's treatment services, the method needs to be effective in disclosing problems and in ensuring that these problems and their causes are corrected. The method which DHR formerly had in place (Certification Reviews, as discussed in the previous finding) appeared to disclose problems with CSB's treatment services but did not appear to be effective in ensuring that the cited problems and their causes were corrected. Consequently, the types of treatment service problems cited continued to be problems. CSBs were only required to prepare corrective action plans but were not held accountable for actually taking corrective action.

From our review of DHR's Certification Reviews which were done in fiscal year 1997, we found that the types of problems cited were similar to those we found during our audit reviews the next year in fiscal year 1998. CSB's had prepared and submitted corrective action plans to DHR regarding the problems cited in these fiscal year 1997 Certification Reviews. Since the same types of problems were found the next fiscal year during our on-site audit reviews of CSBs, it does not appear that CSBs actually took action to correct the cited problems and their causes.

The following list is a sample of the types of problems cited in DHR's fiscal year 1997 on-site reviews of CSBs' medical records:

C

services were billed but not documented in medical records;

C

services were documented but not billed;

C

services were billed but documentation was scratched through in the medical record;

C

"crisis management" services were billed although the services documented did not qualify

as "crisis management";

C

there were gaps in treatment service documentation - making the progress and care of the

consumer difficult to follow;

1999 Audit Report:

31

C

in a number of records the activity notes did not document progress or lack of progress in

relation to the ISP goals;

C

day treatment activity notes were uninformative and lacked documentation regarding group

and program content and consumer participation;

C

documentation was sparse and repetitive - only half of all records contained activity notes

which related to the consumer's progress or lack of progress;

C

social and medical histories were incomplete;

C

goals on consumers' individual service plans (ISPs) were not individualized or measurable

and, in many cases, were not reasonable;

C

half of all goals on ISPs reflected agency objectives (e.g., "keep all appointments") instead

of consumer-driven goals;

C

in some cases, services ordered on ISPs were not being provided (for example, in one medical

record, on-going nursing was ordered but the consumer had not been seen by a nurse as far

back as 1992);

C

one case was cited in which a consumer had been receiving the same treatment for two years

while the CSB continued to indicate that the consumer had made "no progress toward goals"

but recommended continuing the same services (DHR's review team stated that, after two

years with no progress, it appears that a new course of treatment or reassessment of goals

would be appropriate);

C

in at least one case, a consumer needed a greater level of contact than was being provided

(DHR's review team noted that this consumer attempted suicide after calling in crisis 12 days

prior to the attempt and the review team noted that this consumer was not seen between the

time of the call and the suicide attempt).

We also found these same types of problems during our on-site reviews of CSBs' fiscal year 1998 records. The problems we found are discussed in detail throughout the remaining sections of this report.

The method used by DHR to conduct on-site reviews of CSBs' operations should not only be effective in disclosing problems but should also be effective in ensuring that these problems and their causes are corrected. This concept applies regardless of the method that DHR and DMA finally agree upon. It is not sufficient to only require CSBs' to submit a corrective action plan when problems are cited. They should be held accountable for actually correcting the problems and their causes. Limiting CSBs' accountability to submitting a corrective action plan results in an ongoing and repetitive cycle of reviews citing problems, CSBs writing plans, subsequent reviews citing the same

32

Community MH/MR/SA Programs

problems, and the process continues. Such processes are not effective for ultimately improving the operations of CSBs and the care provided to consumers.

1999 Audit Report:

33

Reimbursement Methodology
The reimbursement methodology used by the DMA, along with the DMA's policies and procedures governing this Medicaid Program, has created an opportunity for providers to manipulate the system in order to maximize Medicaid payments.
The CSB providers participating in the Medicaid Community Mental Health Services Program are paid for services provided to Medicaid recipients under a cost based system. The payment rates currently in effect are based on cost reports filed by providers for fiscal year 1994 (July 1, 1993 through June 30, 1994). These payment rates are also based on the different procedures performed by the CSB, with different procedure codes paying different amounts, and each CSB being paid different amounts for the same procedure code. In addition, the service code descriptions included in the DMA Policies and Procedures for the Community Mental Health Services Program for the various procedure codes are, for certain procedure codes, so similar that the CSB could bill a single service under any one of several different procedure codes. Since payment rates are determined based on both cost and the amount of services provided, procedure codes that were billed infrequently in 1994 are paid at higher rates than those billed more often. The providers have simply changed their billing practices to bill for these higher cost procedure codes.
We recommend that the DMA establish a uniform fee structure for each type of service provided by Community Mental Health Services providers. These uniform rates should be applied consistently to all providers and should be accompanied by an effective, independent precertification and utilization review program. If this uniform fee structure is not adopted, we recommend that the cost based rates be set annually based on current utilization to eliminate some of the benefit of these manipulative billing practices. Also, we recommend that the DMA modify its service code descriptions to give more specific guidance to providers concerning what procedure codes should be billed for services rendered to recipients.

34

Community MH/MR/SA Programs

Review of Claims Payment Process
The control system in place at the DMA's contracted claims processor, Electronic Data
Systems (EDS), detects and prevents payment of most claims that do not meet the requirements for allowability under the regulations governing the Community Mental Health
Service Program and Mental Retardation Waiver Program. However, our tests of the controls (edit checks) in place did show the following deficiencies:
! DMA Policies and Procedures prohibit reimbursement for Child and Adolescent Day Treatment services rendered to persons over the age of 17. However, the existing edit check only prevents payment to a provider for this service rendered to persons older than 21 years. As a result, the DMA paid two unallowable claims during fiscal year 1998 totaling $2,911.17.
! DMA Policies and Procedures limit payment for Adult Day Treatment services to 100 units per month. However, there was no edit check in place to detect such excess billings. As a result, the DMA paid 112 unallowable claims during fiscal year 1998 totaling $22,011.72. $15,284.55 was paid to Lookout Mountain Community Service Board alone.
! Due to lack of an appropriate edit check, providers have been paid for services that are also paid for by Medicare. Because of the unreliability of the providers' information systems, (as discussed in another finding) the amount of overpayments is not easily determinable.
! The DMA Policies and Procedures for the Mental Retardation Waiver Program (MRWP) state that the maximum number of allowable hours per year for Respite Care is 312. However, the edit check designed to detect this, limits payment to 416 hours per year. As a result, the DMA paid unallowable claims during fiscal year 1998 totaling $4,677.46.
! The DMA Policies and Procedures for the MRWP state that reimbursement for Personal Emergency Response - Weekly is limited to one unit per week. There is no edit check in place to prevent payment for units in excess of this limitation. A review of claim data for fiscal year 1998 showed that no overpayments were made to providers because of this condition.
! The DMA Policies and Procedures for the MRWP provide that the maximum number of any combination of Skilled Nursing Services, Home Health Aide Services, Speech Therapy Services, Physical Therapy Services and Occupational Therapy Services which can be reimbursed under the MRWP is 290. While an assumption could be made that this limitation

1999 Audit Report:

35

is on a yearly basis, the policy does not specifically state this. Additionally, there is no edit check in place to prevent payment for units in excess of this limitation. A review of claim data for fiscal year 1998 showed that no overpayments were made to providers because of this condition.
! In October of 1997 the DMA introduced a new Mental Retardation Waiver. No policies and procedures have been formally adopted by the DMA to govern the services provided under this new waiver.
We recommend the Department of Medical Assistance recover from providers all amounts that were paid for claims that were not allowable under the programs and modify its policies and procedures to clarify the ambiguities noted above. The DMA should also, in coordination with Electronic Data Systems, implement the appropriate controls to ensure that all claims are processed in accordance with the applicable policies and procedures governing the programs.

36

Community MH/MR/SA Programs

Creation, Alteration and Correction of Medical Records
Four of the nine CSBs reviewed undertook massive, sometimes blatant, efforts to create, alter and correct their recipient medical records prior to or during our on-site reviews, which began in June 1998.
At the Albany Area CSB, management directed staff in June 1998 to review and make corrections to approximately 1,900 charts prior to our "hostile audit." These efforts were documented in management memos and in written statements which CSB staff provided to the audit team. One internal memo to CSB staff stated the following:
C "As you are aware by now the Department of Medical Assistance...is auditing many counties in the state of Georgia."
C "It is my understanding that this is a hostile audit to recoup overpayments to counties of approximately $33,000,000."
C "The last couple of days, two nights and one Saturday in Dougherty County we have worked diligently to review and make corrections in ... charts that were delinquent."
C "...this task is awesome and a challenge..." C "Case coordinators...are ultimately held accountable for... timely reviews, ISPs, ISP
recertifications and all other 40-01 (DHR) standards."
One written statement which CSB staff provided to the audit team stated:
C "To correct charts we would get missing signatures from doctors and MHPs" (Mental Health Professionals) "complete ISPs, complete reviews."
C "In June we were asked to work late and on Saturday to correct all of the closed charts..."
C "The purpose was to correct charts that you" (the audit team) "had not yet seen."

1999 Audit Report:

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At Ogeechee Behavioral Health Services CSB (Swainsboro), June 1998 board minutes contained

the following statements regarding file reviews that had been conducted:

C

CSB staff "...looked at billing, the amount of billing and if there was a progress note

to support the date that bill was made. Blank sheets of paper had been inserted with

the intentions of going back and completing at a later date..."

C

"The payback would have been approximately $155,000 if Medicaid had come in

and audited our program."

At Middle Flint Behavioral Health Care CSB (Americus), a review process was conducted on approximately 1,400 charts during June 1998. A memo from CSB management to the audit team indicated that, after learning that CSBs were being audited they knew that many more of the Americus CSB's records needed review and possible improvement. They realized that they would be unable to accomplish such a large scale review in a short time. Therefore, CSB management "instructed staff and recruited some additional help" to enable them "to review many more charts and to do so more quickly" than their internal auditor would be able to do. The CSB's memo noted that, "during this process, charts with errors or deficiencies noted were returned to the clinician involved to improve what could be improved upon..." Other internal documents and the results of our audit showed that progress notes had been inserted in medical records months after the date of service billed.

While conducting our on-site review of medical records at the Gateway CSB (Brunswick), CSB staff blatantly altered and created records for a chart which initially contained no progress notes for services which were billed during the six-month period we were reviewing. The following points explain the sequence of events which occurred:

C

In reviewing the selected sample of medical records at the CSB, the audit team

noticed that one recipient's chart contained no progress notes for the period being

audited (July through December, 1997). For this period, however, the CSB had been

paid $2,554 for services supposedly provided to this recipient. The audit team asked

CSB staff about this.

38

Community MH/MR/SA Programs

C

The following day, CSB staff provided the audit team with 15 progress notes for this

recipient. Original dates and units of service on these progress notes had been altered

using correction fluid to indicate dates of service during our review period. The

original dates of service recorded on these progress notes were for services provided

during February and March, 1997 which was prior to our review period. The new

dates of service that were written in, however, included the months of our review

period.

C

The next day, CSB staff provided the audit team with 25 more progress notes. The

skeptical point regarding these progress notes is that they were written on a form

which did not even exist at the time of the treatment service dates shown. The date

the form was last revised (November 1997) is printed on each form. Progress notes

written on these forms, however, contained much earlier treatment service dates of

April through September of 1997.

All treatments need to be documented in the medical records in a current and timely manner so that such special, massive efforts to correct recipient medical records are not necessary. CSB staff need to avoid altering medical records and creating medical records in charts which initially contain no progress notes for services which were billed.

1999 Audit Report:

39

Allowability of Paid Medicaid Claims
A review of 18,276 Medicaid claims representing $1,764,457.43 paid to the nine Community Service Boards during the first six months of fiscal year 1998 showed that 12,092 (66%) of these claims were unallowable. These unallowable claims represented $1,079,229.15 in Medicaid payments to the nine providers. Additionally, there were numerous instances in which the services billed exceeded the maximum services authorized on recipients' Individual Service Plans (ISPs).
Our review was based on all Medicaid claims paid during the first six months of fiscal year 1998 for a sample of 600 recipients. As a result of this review, we found that the 12,092 claims mentioned above were unallowable for one or more of the following reasons:
! The recipients' medical records did not contain sufficient documentation to indicate that the service was provided.
! Recipients' Individual Service Plans (ISPs) were not signed by a physician. ! Recipients' ISPs were not valid on the date of service billed. ! The service billed was not authorized on the ISP or did not state the number of
authorized units. ! The recipients' medical records did not document all the necessary clinical treatment
information required by DHR or DMA standards. ! Documentation included in the recipients' medical records did not show the treatment
was related to the goals stated on the ISP as the DHR standards require.
The table on the following page shows, by Community Service Board, a summary of Medicaid claims examined, the claims found to be unallowable, and the dollar value of these claims.

40

Community MH/MR/SA Programs

Name Albany DeKalb Gateway Middle Flint New Horizons Ogeechee River Edge Three Rivers Tidelands Total

Number of Recipients Examined
100 50 50 50 50 50 50 100 100 600

Total Dollar

Number of Value of

Claims

Claims

Examined Examined

4,295 $270,579.30

2,180

138,596.21

1,362

194,465.51

1,091

159,548.80

1,821

137,127.38

2,349

269,789.97

1,331

162,681.72

1,249

158,130.18

2,598

272,538.36

18,276 $1,764,457.43

Unallowable
Claims 3,867 1,960 1,076 272 1,032 1,057 1,136 676 1,016 12,092

Total Dollar Value of
Unallowable Claims
$230,731.47 113,005.88 159,266.31 32,002.27 74,782.82 156,491.53 139,070.40 54,507.20 116,893.27 $1,076,751.15

In addition to the conditions listed above, there were numerous instances in which the services billed exceeded the maximum services authorized on the recipients' ISPs. This occurred in 209 of the 600 recipient files reviewed. These instances were not included in the amount identified as unallowable claims.
We recommend that CSBs ensure that all Medicaid claims billed to the DMA are allowable. This includes ensuring medical records are maintained in accordance with all applicable DHR and DMA policies and procedures and treatment standards. We also recommend that the DMA recover from the providers listed above $1,079,229.15 for those claims paid which did not meet required standards.

1999 Audit Report:

41

Review of Medicaid Billing Practices

All nine CSBs audited have placed Medicaid recipients in disproportionately more treatment services than other consumers. Also, 21 of the 29 CSBs have billed the DMA for various individual treatment services which should possibly be combined and billed as Day Treatment. It appears, therefore, that treatment and billing practices may have been manipulated to increase Medicaid payments. The following paragraphs further explain the reviews we conducted regarding each of these practices.

(A) Overall, we found that Medicaid consumers received significantly more services than nonMedicaid consumers with the same diagnosis. To determine if Medicaid recipients were being placed in disproportionately more services than other consumers, we examined medical records for samples of 30 Medicaid and 30 non-Medicaid consumers in each of the nine CSBs. These samples were randomly selected from consumers who were served during a six month period in fiscal year 1998. Each sample included 10 persons diagnosed with schizophrenia, 10 persons diagnosed with attention deficit-hyperactivity disorder (ADHD), and 10 persons diagnosed with substance abuse. The results of our review are shown in the table below. This table shows the percentage of services received by Medicaid recipients in excess of services received by non-Medicaid consumers.

NAME Albany DeKalb Gateway Middle Flint New Horizons Ogeechee

Attention DeficitSchizophrenia Hyperactivity Disorder Substance Abuse

410%

330%

220%

(1)

278%

449%

396%

424%

704%

288%

(1)

472%

225%

229%

854%

401%

384%

1956%

42

Community MH/MR/SA Programs

NAME

Attention DeficitSchizophrenia Hyperactivity Disorder Substance Abuse

River Edge

942%

420%

(1)

Three Rivers

(1)

460%

276%

Tidelands

(1)

1655%

1812%

(1)Medicaid recipients received, on a monthly average, approximately the same

amount of services provided to non-Medicaid recipients with the same diagnosis.

It should be noted that the DHR and several of the CSBs, in their response to this finding, indicated that most of the Medicaid recipients who are enrolled in these programs are Supplemental Security Income (SSI) recipients and DHR cited research indicating that such persons do, in fact, need and use more treatment services than persons who are simply indigent or enrolled in Medicaid solely based on financial eligibility. Our analysis of Medicaid claim data showed that 91% of the Medicaid recipients with a diagnosis of schizophrenia were SSI beneficiaries but only 45% and 19%, respectively, of Medicaid recipients with a substance abuse or ADHD diagnosis were SSI beneficiaries. This analysis shows that there is some merit to the DHR's and CSBs' contention, but it does not fully explain the disparity between the amount of services provided to Medicaid recipients and non-Medicaid consumers; particularly for persons diagnosed with substance abuse and ADHD since less than a majority of these Medicaid recipients are SSI beneficiaries.

Furthermore, in attempting to determine the validity of DHR's contention, we also analyzed the Medicaid claim data to determine the average number of units of service provided to Medicaid recipients over a period of time. Our analysis showed that, overall, the average number of units of service provided to Medicaid recipients increased by 32% over a 2 1\2year period (January 1, 1996 through June 30, 1998). This does seem to indicate that CSBs were attempting to increase Medicaid payments.

(B) A review of paid Medicaid claims received from Electronic Data Systems for all CSBs, including the nine audited CSBs, showed that 21 of the 29 providers billed Medicaid separately for services that are considered individual components of Day Treatment (unbundling). The providers were paid $1,207,025.75 for these unbundled services during

1999 Audit Report:

43

fiscal year 1998. If these services had been billed as Day Treatment, the 21 providers would have been paid $403,434.31, a savings to the Medicaid program of $803,591.44. The results of our review are shown in the table below.

Name Albany DeKalb East Central Georgia Fulton Co. GA Highlands GA Pines Gateway Center Georgia Mountains GRN Lookout Mountain McIntosh Trail New Horizons Northeast GA Oconee Ogeechee Pineland River Edge Satilla South Georgia

Cost of Services When Unbundled
$236,751.78 1,329.76 671.71
242,740.82 2,996.20 3,689.00 3,702.36 573.18 71,103.35 50,773.24 2,323.96 23,786.38 320.94 90.50
189,556.18 45,232.42 8,210.60 3,652.77 18,475.44

Cost if Billed as Day Treatment
$91,420.95 441.96 398.82
77,255.37 800.66
1,675.56 1,024.25
136.31 24,398.68 9,063.24 1,238.25 11,460.17
217.47 54.96 33,634.53 11,954.05 2,715.60 421.85 11,536.68

Difference $145,330.83
887.80 272.89 165,485.45 2,195.54 2,013.44 2,678.11 436.87 46,704.67 41,710.00 1,085.71 12,326.21 103.47 35.54 155,921.65 33,278.37 5,495.00 3,230.92 6,938.76

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Community MH/MR/SA Programs

Name Three Rivers Tidelands TOTAL

Cost of Services When Unbundled
2,851.34 298,193.82 $1,207,025.75

Cost if Billed as Day Treatment
491.47 123,093.48 $403,434.31

Difference 2,359.87
175,100.34 $803,591.44

We recommend that Community Service Boards ensure that services are provided to all consumers based on individual needs without regard to Medicaid eligibility or ability to pay. We also recommend that the DMA implement policies and procedures to specifically identify which treatment services should be combined for billing purposes. Furthermore, the DMA should implement an effective, independent precertification and utilization review process. It should be noted that precertification should not be required for crisis intervention. After policies have been established, the DMA should conduct periodic reviews to ensure compliance.

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Internal Control Assessment

We found material deficiencies in the CSBs' internal controls over intake, billing, medical records, and cash collection systems. Such material deficiencies cause accounting and management system information to be incomplete, inaccurate, and unreliable. This, in turn, severely impairs management's ability to effectively manage CSB operations. For example, management cannot accurately determine the types and levels of treatment services that are provided; the staffing levels needed to provide current or future treatment services; and whether charges for treatment services are appropriately billed and collected. Specifically, we identified weaknesses in the following controls:

! Seven of the nine CBSs did not verify income reported by the consumer on the intake form. If income is not verified, the CSB cannot accurately determine the self-pay amount charged to the consumer based on the sliding fee scale.

! None of the CSBs had sufficient controls to ensure all services provided were documented in client medical records and correctly recorded on billing forms. Consequently, the CSBs:

<

billed for services for which the medical records contained no evidence that services

were ever provided;

<

billed for one type of service while another type of service was documented in the

medical records; and

<

did not bill for all services that were documented in the medical records.

! Six of the nine CSBs did not have sufficient controls to ensure information recorded on billing forms (such as the service code, date of service and number of units provided) was accurately entered into the billing system. Consequently, there is little assurance that information entered into the billing system is accurate.

! Six of the nine CSBs did not have sufficient controls to ensure all transactions entered into the system were billed to the appropriate payor sources for the proper amounts.

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Community MH/MR/SA Programs

! Two of the nine CSBs did not have sufficient controls to ensure payments received from payor sources were reconciled to billings and properly posted to individual patient accounts.
! Five of the nine CSBs did not have sufficient controls to ensure consumers pay appropriate amounts for services rendered. Although the CSBs have controls in place to identify amounts due from consumers, minimal efforts are made to collect these amounts at the time the services are rendered. As a result, amounts due are not collected and the CSBs have made no further efforts to collect these past due amounts.
! Five of the nine CSBs did not have sufficient controls to ensure all cash collected was properly safeguarded, recorded, deposited, and reconciled to charges for services rendered.
The Community Service Boards need to immediately address the internal control deficiencies cited above. Implementing appropriate procedures to correct these deficiencies would help to ensure reliable information is available for more effective management of the CSB's operations. Correcting these deficiencies would not only improve the reliability of financial and programmatic information at individual CSB's, it would also result in more reliable information channeled to regional and statelevel offices for use in decision making and state-level reporting.

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Substandard Treatment Service Documentation
Documentation of treatment services in recipients' medical records at all nine of the CSB's audited was deficient, and in some instances, not recorded in chronological order. These deficiencies result in medical records which are not useful in assessing whether recipients are benefitting from prescribed treatments and for evaluating whether treatments should be modified, increased, decreased or discontinued. Erratic record keeping practices, such as inserting progress notes which are completely out of date sequence with existing progress notes, may technically satisfy the requirement that a record exists for each service billed; however, it does not result in meaningful medical records which health care professionals can review to assess recipients' sequential treatments, responses, progress, or lack of progress. Our review also disclosed instances in which expensive crisis management services were billed although the only services documented involved, for example, transporting consumers to football games and department stores, listening to a guardian complain about a child's whining, and documenting a staff meeting and planning session.
To conduct this review, we randomly selected a sample of the medical records of 500 recipients who received services during a three-month period of fiscal year 1998. The following paragraphs further explain the documentation problems we found during our review.
(A) The medical records for 371 of 500 (74%) recipients sampled did not meet the DHR Quality Improvement Standards. Documentation was either nonexistent or lacked the required explanation of recipients= response to treatment services and did not describe how these services related to goals stated on recipients= individual service plans (ISPs). Consequently, the medical records are not useful in assessing whether recipients are benefitting from prescribed treatments or for evaluating whether treatments should be modified, increased, decreased, or discontinued.

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Community MH/MR/SA Programs

(B) In 32 (6%) of the 500 recipients= medical records sampled, we found a total of 151 progress notes which were out of chronological order with other progress notes. Such erratic record keeping prevents recipients= medical records from being useful documents for assessing sequential treatments and recipients= responses, progress, or lack of progress.
(C) Of the 500 recipients= medical records reviewed, 62 received crisis management services but only 22 (35%) appeared to have received legitimate crisis management. Of the remaining 40 (65%) cases, 16 had no documentation to support that crisis management occurred. In the remaining 24, crisis management was recorded and billed but the service provided did not meet the definition of crisis management. DHR standards define crisis management as, "Management of an abrupt and substantial change in behavior which is usually associated with a precipitating situation and which is in the direction of severe impairment of functioning or a marked increase in personal distress... The focus of the service is stabilization.@ In the 24 cases cited above, the types of services recorded as crisis management included, for example:
a guardian complaining about a child's whining; a client complaining of urinary incontinence (medical condition) who needed
to see a primary physician; setting up a meeting between parents and teacher; a client requesting refills of medication needed for sleep; providing transportation to such places as football games, department stores,
relatives' homes, clinics, hospitals, and pharmacies; documented staff meetings and planning sessions; meeting with teachers; having a client's mother come in to sign routine paperwork; and a client's request for a new room-mate.
A total of 367 units ($10,504.39) were billed by the nine providers as crisis management for services of this type which, if billable, would more appropriately be billed as family or individual counseling.

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The CSBs' should implement policies and procedures to ensure medical records comply with the DHR Quality Improvement Standards. Documentation of services provided should clearly record the recipient=s progress or lack of progress and should relate the recipient=s status to the goals stated on the ISP. Erratic record keeping practices need to be prevented. Medical records should be assembled in the proper date sequence. Finally, the practice of documenting and billing family and individual therapy as crisis management should be stopped.

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SYNOPSIS OF CONSULTANTS' FINDINGS
As described in the introduction to our report, we contracted with five specific groups of health professionals, each with expertise in the following specific health care areas: (1) Adult Mental Health Services, (2) Substance Abuse Treatment Services, (3) Mental Retardation Services, (4) Attention Deficit - Hyperactivity Disorder, and (5) Activity Therapy Services. We asked these consultants to review medical records and treatment service programs to assess the overall quality of services provided. Specifically, their objectives were to:
C assess the adequacy of CSB's client intake and assessment processes (page 52); C evaluate the qualifications of CSB personnel who conduct client assessments and make
diagnoses (page 56); C assess the qualifications of CSB personnel who provide treatment services (page 58); C determine if client treatment plans reflect services which are appropriate based on clients'
diagnoses (page 61); C determine if the frequency and duration of treatment provided to CSB clients is appropriate
based on clients' diagnoses (page 65); C determine whether the content of specific treatment services meets DHR standards (page 68); C evaluate whether DHR standards, regarding the content of specific treatment services, meet
current professional industry standards (page 73); C evaluate whether CSBs have utilized appropriate methods to assess client treatment outcomes
(page 79); C determine whether CSBs have appropriate outcome measures in place for use in evaluating
their overall effectiveness (page 82); and C assess the adequacy of CSBs overall client treatment record keeping (page 85).

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Based on their individual reviews of nine Community Service Boards, each of our groups of consultants prepared a program-wide report addressing these issues. The program-wide reports and reports on individual Community Service Boards are contained in Parts II and III of our report.
Overall, our consultants found significant deficiencies throughout these community based services provided by the CSBs. Deficiencies were noted in all areas evaluated, including CSB staff qualifications, consumer assessment and diagnosis processes, formulations of individual service plans, treatment delivery, treatment outcome assessments, and medical records documentation.
The following sections present our conclusions for each of the objectives stated above based on the findings of our consultants. The bulleted statements following each of our conclusions are excerpts from the consultants' reports.

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Intake and Assessment Process
Client intake and assessment procedures are inadequate and, generally, diagnostic evaluations are incomplete and of relatively low quality. There is a lack of physician documentation and a lack of comprehensive, criteria-based assessments by which to determine intensity of necessary services. Generally, there is a low level of physician involvement in many assessments. Tentative diagnoses are given by unqualified individuals instead of by medical doctors or licensed psychologists. This practice, according to our Substance Abuse consultants, has resulted in erroneous substance-related diagnoses being given to consumers. Frequent inaccurate diagnoses were also noted by our consultants who evaluated Attention Deficit-Hyperactivity Disorder (ADHD) services.
Adult Mental Health Services C Intake and assessment procedures are inadequate.... Especially needing attention is the lack of
physician documentation regarding clinical assessment, diagnosis, and input into treatment planning. Also needing attention is assessment of high risk behaviors (e.g., suicide risk, potential for child abuse) and assessment of physical condition as it relates to medication prescribing. C Also problematic is the lack of comprehensive, criteria-based assessment required to determine intensity of services necessary for individual patients. Although physicians sign forms indicating intensive services such as day treatment are necessary, there is little indication that specific criteria are used to make these judgments and, given the generally low level of physician involvement in many assessments, it is likely physicians are often not sufficiently involved to make meaningful determinations. Thus patients are enrolled in high intensity services without a clear idea of specific goals to be achieved or alternatives having been considered.

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Substance Abuse Treatment Services C According to the DHR Standards, the MD who renders the formal diagnosis can use the intake
assessment information including any tentative diagnoses or diagnostic impressions plus a face-toface interview to render a formal diagnosis. In the review of charts, modification of a tentative diagnosis or diagnostic impression by an MD was rare. C The need to properly diagnose cannot be adequately addressed through the practice of having tentative diagnoses or diagnostic impressions given by unqualified individuals. This practice was noted in the chart review to have resulted in substance-related diagnoses being given inappropriately to consumers. Diagnoses are lifetime labels. Ethically, diagnoses should not be made, let alone billed, unless they are made by MDs or licensed psychologists. The consequences of such errors are significant and could result in litigation against CSBs.
Mental Retardation Services C In general, diagnostic evaluations were incomplete and of relatively low quality. In particular,
psychological evaluations were often out-of-date or inadequate, especially with regards to differential diagnosis for clients with Dual Diagnoses. C The psychological evaluations and diagnostic intakes often failed to include specific recommendations for both current and long-term treatment goals and procedures. In addition, there was often a failure to make referrals for specialized assessments or treatment, or a lack of follow-through when referrals were made. C The documentation of client intake procedures was found to vary widely across client records. Only 59 of 160 records contained a comprehensive diagnostic evaluation that included all required components. C Based on the record review and on actual observations of the targeted clients, there was objective information to document that 131 of 160 clients were accurately diagnosed as having mental retardation. In at least 16 of these 131 cases, assessments failed to clarify whether the client was

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Community MH/MR/SA Programs

functioning at a level of mild, moderate, severe, or profound retardation. In 26 of 160 records, there was not enough information available to verify or refute the diagnosis. C There were up-to-date psychological evaluations in 67 of 160 records. Additional records had recent brief updates, but no psychological testing had been conducted within the past six years. Updates may meet the minimum requirements of DHR, but they generally did not include enough information to confirm or refute a diagnosis. C For the most part, psychological evaluations did not offer specific recommendations regarding immediate and long-term client needs. C With a range of one to six additional diagnoses mentioned in their records, 81 clients were designated as having Dual Diagnoses. The accuracy of an additional diagnosis was supported by evaluation data in 26 of the 81 case records of dually diagnosed clients. Although it is commendable that there were efforts to verify secondary disorders with psychological assessments, the use of projective tests (e.g., House-Tree-Person and Draw a Person) are inappropriate for persons with mental retardation. Very few clients had been evaluated with objective instruments that were designed for purposes of differential diagnosis (e.g., the MMPI, Beck Depression Inventory, Childhood Autism Rating Scales, etc).
Attention Deficit-Hyperactivity Disorder (ADHD) C The initial assessment process was inadequate in breadth and scope in most centers. Problems
delineated included, but were not limited to, checklist mental status examinations; no narrative history of present illness; frequent inaccurate diagnoses which were rarely changed by child psychiatrists; important social historical data such as developmental histories, family constellations and peer and social relations frequently missing. C The psychiatrists appeared to confirm ADHD diagnoses made by intake counselors and rarely changed them. A number of children initially diagnosed with ADHD appear to have subsequently developed additional psychiatric condition(s) or have been found to have another diagnosis rather

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than ADHD (e.g., bipolar disorder or psychosis). While the charts have documented the changes in diagnosis, the billings have remained for ADHD.
Activity Therapy (AT) Services C None of the nine CSBs contained an AT assessment that was clearly connected to consumer
goals and outcomes. Consequently, there were no specific objectives written in the client records connected to AT.

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Qualifications of Personnel Who Conduct Client Assessments and Make Diagnoses
The qualifications of persons conducting client assessments and making diagnoses are often inadequate and there is rarely evidence that physicians supervise these assessments. Commonly, tentative diagnoses are made by unlicensed personnel without further modification by a physician. In many cases, diagnoses were not justified, were inaccurate, and/or were incomplete. Such diagnoses can result in client stigma and errors in treatment planning.
Adult Mental Health Services C The qualifications of persons conducting assessments and making diagnoses are inadequate. C Most CSBs use a check list procedure for intake assessments. It is supposed that a physician will
supervise the assessment (as required by DHR) but there is rarely evidence that such supervision occurs. As a result, we estimated that between 25-50% of diagnoses are in error, with resulting stigma and errors in treatment planning.
Substance Abuse Treatment Services C In the majority of reviewed CSBs, intake assessments were typically conducted by non-
professionals. In many settings, the intake assessors generate a tentative diagnosis or specify a diagnostic impression. Intake assessors are not qualified or privileged under Georgia State Law to render a diagnosis. ...substance-related disorders were often not justified with the charted background information, and the diagnoses themselves were often incomplete (i.e., lacking appropriate diagnostic specifiers). C As noted, the chart review revealed tentative diagnoses made by unlicensed personnel were commonly signed by MDs without modification. In many of these cases, the diagnoses were not

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justified, were inaccurate, and/or were incomplete. In particular, co-morbid disorders not included in the tentative diagnoses were not recognized and diagnosed.
Mental Retardation Services C The qualifications of the staff conducting the evaluations most often met established DHR
guidelines, but there was insufficient supervision by licensed providers. C Experience and qualifications with the assessments used by the CET [Comprehensive Evaluation
Team] varied widely. Several teams used projective tests, with which appropriate training and qualifications for administration were not documented. There is a need for the assessment staff to gain training in the cultural bias impact of standardized tests of intellectual ability, because a number of clients present with borderline scores and conflicting results of IQ and adaptive functioning.
Attention Deficit-Hyperactivity Disorder (ADHD) C There is generally a shortage of child psychiatrists in the state system. Centers vary with respect
to level of training and licensure of all their staff and there is still a tendency in many centers to have those less well trained staff assigning initial diagnoses. These diagnoses appear unlikely to change once assigned by the staff member providing the initial assessment.
Activity Therapy (AT) Services C Although 3 of the 9 CSBs (Gateway-Coastal , River Edge, Ogeechee) employed a Certified
Therapeutic Recreation Specialist (CTRS), 0 of 9 CSBs were using a formalized AT that was clearly connected to consumer goals and outcomes.

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Community MH/MR/SA Programs

Qualifications of Personnel Who Provide Treatment Services
Consultants expressed overall concerns regarding the lack of qualifications of individuals providing CSB treatment services. Due to grandfathering and equivalency provisions, CSB personnel are exempt from licensure requirements that would severely curtail or preclude their clinical activities in non-CSB settings. For example, although CSBs confer "Mental Health Professional Equivalencies" on staff, these staff would not be qualified to function independently or to receive third-party reimbursements for services rendered in non-CSB settings. Also, since few staff are employed who have formal training in the most effective approaches to the psychosocial management of severe mental illness, treatments provided could be less effective and, ultimately, more costly than more definitive psychosocial treatments.
Adult Mental Health Services C There is a lack of psychiatrists certified by the American Board of Psychiatry and Neurology. As
a result, treatment is given and supervised by physicians who have fewer credentials, sometimes lacking formal training in psychiatry. C Counseling is often provided by staff with either a bachelors or a master's degree in a counselingrelated field. This is adequate when only supportive care is needed. However, few staff are employed who have formal training in the most effective approaches to the psychosocial management of severe mental illness, e.g., social skills training, psychosocial rehabilitation, or in behavioral modification treatment programs designed for persons with severe mental illness. As a result, treatment was less effective, and ultimately more costly, than more definitive psychosocial treatments. C Patient and family education is an area where the state has made progress in recent years. It is still greatly underutilized, and there is little evidence that patient education in Georgia is being conducted effectively, but there is growing awareness of the need to involve families.

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C Day treatment programs are an area of special concern regarding credentials. Many staff have a bachelor's degree or less, and there is usually no training on specific day treatment programs likely to be effective at treating problems of the severely mentally ill.
Substance Abuse Treatment Services C Some CSB positions are staffed with individuals deemed qualified for the duration of their
employment due to grandfathering certifications. Many such grandfathered individuals are assets to their CSBs. However, others of marginal competence work under a high degree of job security, which contraindicates their removal in the absence of a repetitive documented pattern of blatant incompetence. This problem is exacerbated by policies that render many CSB employees exempt with respect to licensure requirements that would severely curtail or preclude their clinical activities in non-CSB settings. C The designation of Mental Health Professional (MHP) Equivalent is conferred within a CSB. These MHPs would not be qualified to function independently and/or to receive third-party reimbursements for services rendered in non-CSB settings. C Our primary criticism has concerned the lack of qualifications of individuals performing assessments and therapy. C The Executive Officer of a reviewed CSB related an ongoing attempt to fill a vacant Mental Retardation supervisory position with a qualified Mental Retardation Professional (MRP). While the MRP certification would require at least a BS degree, the CSB Executive Officer deemed that the supervisory responsibilities of the position justified a more highly qualified employee and designated an MS degree as a desired qualification. Despite this explicitly stated CSB need for an employee with an advanced college degree, Georgia Merit System employees qualified an individual with a GED and six years of MR work experience to apply for the vacant position. Mental Retardation Services C The direct service staff had varied educational backgrounds ranging from High School degrees (or GED) to some college courses.

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C One of the most pressing needs for many sites reviewed is to secure technical assistance and training from someone with experience in behavior analysis.
C All of the programs would benefit from either hiring, training, or contracting for technical assistance with someone with expertise in behavioral programming.
Attention Deficit-Hyperactivity Disorder (ADHD) C All community service boards should have the services of child and adolescent psychiatrists to
evaluate children and monitor their overall treatment progress. C There appears to be no incentive to have better trained personnel in the CSBs since the
reimbursement system is based solely on the procedure provided. This system is not stratified with respect to professional discipline which is often the case in other reimbursement systems. For example, the clinical work of a less well trained clinician may be reimbursed at the same rate as the work performed by a higher trained clinician. This system provides an economic incentive to have less well trained individuals provide clinical service.
Activity Therapy (AT) Services C Although 3 of the 9 CSBs...employed a certified therapeutic recreation specialist (CTRS), the
services they provided were restricted to only one portion of services provided by the CSB. C In 6 of 9 CSBs...0 personnel who had primary responsibilities delivering AT services had a
background or certification in therapeutic recreation.

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Appropriateness of Client Treatment Plans
Each of our professional consultant groups found material problems with client treatment planning and resulting treatment services. Deficiencies disclosed in client treatment planning included: "individual" treatment plans which appeared to be only photocopied and identical among clients; plans lacking measurable and observable objectives and specified outcomes; plans which targeted only minor skill deficits but did not address major client challenges; and plans containing treatment objectives and outcomes which were not directly related to diagnosis and assessment results. Deficiencies disclosed in treatment services included: Day Treatment and Activity Therapy services which were found to be primarily diversional activities with little therapeutic value; Substance Abuse treatment services which have been classified as relatively ineffective treatments; and a tendency to provide treatment that was billable under existing service categories whether or not the treatment modality was logically related to the targeted outcome.
Adult Mental Health Services C The area of greatest concern regarding medical appropriateness and necessity of treatment is in
day treatment. As noted earlier, we found evidence that day treatment programs include a preponderance of diversionary activities, e.g., bingo, crafts, and social/shopping excursions. While such activities can be rationalized as having some (slight) therapeutic value, there are more effective activities that target specific clinical problems. C Because of the relatively nonspecific nature of day treatment activities, patients with very different clinical needs are combined into programs. Thus patients with severe mental illness, patients with diminished intellectual functioning, and patients suffering from multiple disorders are often engaged in the same nonspecific activities. Except insofar as this kind of programming keeps patients from more hazardous activities, these diversionary activities cannot be justified as medically appropriate or medically necessary.

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C Areas of special concern [regarding medical management] included:
< Failure to consistently monitor medications such as lithium and valproic acid. These medications must be monitored closely because of potentially life-threatening adverse reactions.
< Failure to record a meaningful assessment or to document change in a progress note. In one instance, a physician appeared to have used a rubber stamp to indicate that the patient had been seen. In other instances, physicians simply signed notes written by other staff.
< Failure to participate in treatment planning. Treatment plans were often signed by physicians, but there was little evidence physicians actually attended treatment planning sessions. Rather, treatment plans appeared to have been presented to physicians after meetings for signatures.
Substance Abuse Treatment Services C Based on these findings, it can be concluded that many of Georgia=s CSBs and treatment
programs in general devote considerable effort to the delivery of treatments that, on the basis of available scientific evidence, have been classified as relatively ineffective treatments. C The quality of the reviewed ISPs, in terms of meeting individual client needs, varied widely between and within the different CSBs. In the worst case, many ISPs appeared to be photocopied such that they were identical between clients. In others, the ISP goals simply restated the treatment orientation of the CSB. For example, a treatment goal may be to develop a sense of a higher power. Similarly, some ISPs stated that the client was to attend a certain number of group meeting according to the treatment schedule for all consumers. These ISPs were usually developed within in a very short time of the client's arrival, and amendments were not found. At the other extreme, some ISPs were very detailed, highly individualized, and took into account a wide range of consumer problems.
Mental Retardation Services

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C In the opinion of the evaluation team, the most serious problems pertained to the potential effectiveness of the treatment plans delivered. Difficulties in the plans began with a lack of specification of long-term and immediate outcomes, which were broken down into measurable, observable objectives. There were also significant problems in the selection of outcomes that addressed the clients' most pressing needs, with the result that minor skill deficits were often targeted while major challenges were not addressed.
C In several sites, there was a tendency to provide treatment that was billable under existing service categories, whether or not the treatment modality was logically related to the targeted outcome.
C Eighty-four of 160 Individualized Service Plans (ISPs) were found to contain outcomes and objectives that were directly related to diagnosis and assessment results. Forty-four of the 84 records scored as positive on this component were variable, with some but not all objectives corresponding to treatment. [Consequently, only 40 (25%) of 160 ISPs contained sufficient outcome objectives that were directly related to all diagnosis and assessment results.]
C Seventy-six records had no outcomes and objectives directly related to diagnosis and assessment results. Some of the targeted objectives were trivial, while serious problems went unattended.
C Only 47 of 160 plans adequately addressed long-term client needs. Further, as indicated by the numbers of records in and out of compliance, the absence of long-term goal specification was a pervasive problem in all of the CSBs evaluated.
C The treatment assignment correlated more with what services were available than with the objective with which they were associated.
C Very few treatment plans targeting social skills as an outcome broke the outcome up into objectives that specified the social behaviors to be addressed. Although field trips may be

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pleasant and desirable program activities, simply going places in the community is not likely to lead to specific social skill improvements unless social learning opportunities have been planned.
Attention Deficit-Hyperactivity Disorder (ADHD) C There is a need for interdisciplinary staffing and interaction of clinical staff with child psychiatry.
This interaction is essential to integrate biologic, psychologic and social data into effective diagnostic and treatment plans. Child staff appear to sign the same service plan but there was rarely an indication of meetings held jointly among staff. C There were common weaknesses in the clinical treatment process.... The utilization of behavior therapy and parent management training strategies to control disruptive children were absent or not clearly documented in many cases. C There may be a lack of precision regarding service delivery in that a preferred modality may not be offered whereas a less efficacious intervention is provided (e.g. activity therapy instead of behaviorally oriented parent management training). Such service delivery issues seem driven by practical concerns of available clinical expertise and available time. C Interaction with schools was infrequent. There was a general absence of interactions with teachers as well as written communications from them regarding achievement, behavioral reports and intellectual functioning. Behavior rating scales filled out by teachers were rarely present.
Activity Therapy (AT) Services C None of the nine agencies indicated systematic attempts to evaluate the impact of AT services.
The connection between AT services and the consumer's treatment plan was not specific. These activities were not clearly connected to consumer goals and objectives and there was an absence of systematic evaluation and documentation of consumer progress. C None of the nine agencies contained clear goals with measurable objectives; rather, the goals associated with AT were vague and difficult to measure. Since specific AT objectives were not developed, activities were selected which were loosely associated with more general goals.

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C When AT services were offered, documentation indicated that primarily diversional activities were provided that did not relate to client goals.
Frequency and Duration of Treatment Services
Due to the cited deficiencies of CSBs' client assessments, diagnoses, treatment planning, and treatment services, a clear determination could not always be made regarding whether the frequency and duration of client treatments was appropriate. Consultants did, however, indicate problematic areas. The frequency and duration of Day Treatment was identified as a concern. Since Day Treatment programming is non-specific and there is a lack of monitoring clinical outcomes, once patients are enrolled in these services, many will remain for a long time (often years). In several cases, Mental Retardation consultants noted that services to some clients appeared excessive compared to their identified needs while other clients received insufficient treatment because the bulk of their time had not been planned as actual treatment time. As noted by the Substance Abuse consultants, CSBs could benefit if treatment plans included goals, estimated length of treatment, the rationale for each type of intervention provided, the rationale for not treating identified problems, and specific discharge criteria and plans for post-treatment care.
Adult Mental Health Services C Most medical management occurs appropriately. The area of concern is the frequency and
duration of day treatment. As noted above, the diverse day treatment patient population and the nonspecific nature of most day treatment programming, combined with a lack of monitoring of clinical outcomes means that many patients, once enrolled in day treatment, will remain for a long time (often years). Several CSBs have begun to emphasize movement of patients into community settings such as supported or full employment, but these are exceptions.

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C The most common practice in CSBs is to enroll patients in the maximum number of hours of day treatment allowable.
Substance Abuse Treatment Services C Treatment plans should include goals, estimated length of treatment, the rationale for each type
of intervention provided, and the rationale for not treating identified problems (if the decision is made not to address these issues). In addition, these plans should contain specific discharge criteria and plans for post-treatment care. C The quality of the reviewed ISPs, in terms of meeting individual client needs, varied widely between and within the different CSBs.... some ISPs stated that the client was to attend a certain number of group meeting according to the treatment schedule for all consumers. These ISPs were usually developed within in a very short time of the client's arrival, and amendments were not found. At the other extreme, some ISPs were very detailed, highly individualized, and took into account a wide range of consumer problems.... These ISPs were usually amended during the course of treatment as other needs became apparent to the members of the treatment team.
Mental Retardation Services C Over 50 of 160 clients, including at least 25 who were in 24-hour services, received insufficient
treatment because the bulk of their time had not been designated and planned as actual treatment time. In 25 client records the level of treatment proposed in their plans appeared excessive to the individual needs identified. Inappropriate use of service delivery time also occurred when client goals were limited to services that were easily available, rather than individualizing goals to meet significant needs.
Attention Deficit-Hyperactivity Disorder (ADHD) C There were common weaknesses in the clinical treatment process. The following areas were
poorly documented: ...the reasons for increasing or decreasing level of care.

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Activity Therapy (AT) Services C Based on their diagnosis, the consumers served at all of the nine agencies are in need of AT to
help them develop knowledge and skills for them to experience leisure, enjoy their free time, improve their functional skills, and allow them to actively participate in community life. However, except for some of the AT services provided at the Emanuel SA Residential Adolescent Center, AT services at none of the nine agencies are clearly connected to the individual consumer treatment program. Consumers are either receiving extensive services identified as AT that are diversional activities (Middle Flint, Gateway-Coastal, 3 Rivers, Ogeechee, Tidelands) or AT is not being offered at a sufficient rate to have therapeutic effects (DeKalb, River Edge, Albany, New Horizons).

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Community MH/MR/SA Programs

Content of Specific Treatment Services Compared to DHR Standards
Material deficiencies in CSBs' treatment services were noted by each group of our consultants. Day Treatment programs were identified as woefully inadequate to meet DHR requirements. Mental Retardation consultants noted that most Day Treatment programs offered the equivalent of day care; with adult clients literally being provided baby toys and with television viewing offered as a major activity. Consultants concluded that therapeutic benefits would not be expected for participating clients and that there was little instruction observed that would help clients prepare for more independent community living. Other consultants noted common weaknesses in clinical treatment processes. These included: only rarely seeing evidence that physicians participate in formulating client treatment plans; the practice of continuing clients' previous treatment plans with little or no revision; progress notes usually lacking any reference to a client's level of participation or progress; poorly documented reasons for increasing or decreasing level of care; and discharge summaries lacking required information with some summaries noted as grossly inadequate.
Adult Mental Health Services C Although not strictly a treatment service, DHR standards require a quality improvement program
that would monitor the appropriateness and effectiveness of treatment services. Most of the programs we saw were inchoate and have had little influence on clinical care. One result of ineffective quality improvement programs is that services are provided which have not been shown to be medically necessary, appropriate, or effective (e.g., day treatment). Had such quality improvement programs been more effective, it is likely the clinical and resource utilization problems identified in this report would have been identified and corrected by the CSBs. C DHR standard 10.13a requires a physician to formulate a treatment plan for medical and other services. There is rarely evidence that physicians participate in such treatment planning. The

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practice is to have another, often bachelors level, mental health worker prepare a treatment plan for the physician to sign, usually without revision. C Although treatment plan reviews are required at least annually, the practice most often is to continue the previous plan with no or minimal revision. Failing to monitor medical necessity, appropriateness, and effectiveness of services results in costly high intensity services such as day treatment being used for indefinite durations. C Existing day treatment programs are woefully inadequate to meet these requirements [DHR standards]. Patients of diverse diagnostic and cultural backgrounds are often mixed (e.g., schizophrenia and mental retardation) so that individual needs are not well-addressed. Activities are mostly of the diversionary type, e.g., bingo, other recreational activities, shopping, and so forth. It is likely that of the 5-6 hours spent by a patient in a typical day treatment program, only 1 (or at most 2) hours can be called therapeutic.
Substance Abuse Treatment Services C The evaluation of treatment interventions was greatly limited by the lack of detail in the progress
notes. The failure to document therapeutic interventions and client progress may be a reflection of the level of therapist training rather than an inability to properly document treatment/client progress. Notes were not co-signed by MHPs, suggesting that supervision was minimal. C Day treatment notes were made weekly according to the DHR Standards. With few exceptions, these entries only noted the client's level of attendance to scheduled activities. The notes usually lacked any reference to the client's level of participation or progress. C Discharge summaries are expected to contain a summary of treatment, therapeutic progress, a current 5-axis diagnosis, reasons for discharge, the consumer's mental status, and recommendations for further services if needed. The information in a discharge summary should be sufficient to furnish future health care providers a synopsis of the individual's needs, prior treatment, and progress during treatment. Most of the discharge summaries reviewed lacked some aspect of a completed summary, and some summaries were grossly inadequate.

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Mental Retardation Services C With very few exceptions (i.e., Gateway, Middle Flint River, and two of three after school
programs), the day treatment programs offered the equivalent of day care.... Nearly all of these programs offered television viewing as a major activity. C Apart from providing a supportive and safe environment in which to spend one's day, the treatment function of the day treatment centers was unclear. However, there was very little instruction observed taking place, and it was unclear how participation in these programs would systematically prepare these clients for more independent functioning in the community. In the programs observed, clients were attending group counseling sessions aimed at management of psychotropic medication and stress management, as well as watching TV, completing kindergarten-level worksheets, watching videos, and participating in leisure activities. In short, therapeutic benefits would not be expected for the participating clients with mental retardation, especially in the areas of preparation for independent work and living arrangements. C The mental retardation service centers and work activity centers varied greatly within and across programs. At best, they served as a home base for clients that were supported in jobs in the community.... At worst, they resembled the day treatment programs, with adult clients receiving what amounted to day care in which the clients were literally provided with baby toys as the activity. C Programs were providing an array of DHR approved therapeutic regimens, as had been specified in ISPs. There were relatively high numbers of Supported Employment placements, and the residences were providing a high quality of living. However, there was little opportunity or instruction observed that would help clients prepare for more independent community living.
Attention Deficit-Hyperactivity Disorder (ADHD) C There were common weaknesses in the clinical treatment process. The following areas were
poorly documented: outcomes of service intervention; termination of cases; follow-up goals;

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education regarding the use of medication; and the reasons for increasing or decreasing level of care. C From our chart reviews it is difficult to ascertain compliance to these [DHR] standards because charts did not reflect an integration of professional services provided in a comprehensive, chronological manner. The frequent reliance on checklists (MSE, functional assessment, ISP) in lieu of a narrative summary limits our ability to assess compliance to DHR standards for the overall assessment and process of treatment for the individual case. C ...in the Quality Improvement (QI) standards, many of the issues our team has identified as general weaknesses, such as the need for an integrated narrative history that encapsulates the patient/family's present and past circumstances, are addressed specifically in Standard II; 2,4(e). For the most part the charts reflect the specifics of II; 4 (a-c) via checklists, but frequently fails to integrate the history in narrative form as could be interpreted in II; 2, 4e. C Similarly the description of the standards for the ISP (QI Standard III) call for a chronology and specific modification when appropriate for the ongoing assessment of the client and family. Specific areas related to patient progress and reassessment are outlined appropriately. Again, the expectation of specific documentation at times of addition and deletion of medical or clinic services is identified in the standards and, if done, in a chronological manner with a more narrative summary would address weaknesses identified by this team (QI Standard II; 2,a,b). C In Chapter 9 [DHR standards] physician responsibilities are outlined in some detail. Particularly 9.6, if followed literally, would address some of the integrated oversight problems identified in this Audit. However, frequently physician time/availability may not be adequate to address all of the responsibilities delineated in this section.
Activity Therapy (AT) Services C None of the nine agencies had documentation indicating that effects of AT on consumers
functioning were formally assessed.

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C None of the nine agencies indicated that AT services reduced or restored these conditions since there was no formal assessment related to disorientation, distraction, preoccupation, social withdrawal, physical coordination, reality orientation, social adaptation, etc.
C None of the nine agencies indicated that AT activities were clearly connected to consumer goals and indicated supportive resources. There was no indication in any of the records that there was any education of consumers connected with community outings. Staff simply planned and facilitated enjoyable outings for consumers on these occasions.

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Comparison of DHR Standards to Industry Standards
With noted exceptions, the DHR standards are generally satisfactory for those aspects of care that they address. Many areas, however, were identified in which DHR Standards should be revised to reflect what are now widely regarded as best practices in community mental health, mental retardation, and substance abuse services. As noted by the Substance Abuse consultants, many aspects of the CSB programs were found to be less than satisfactory in comparison to acceptable community standards of non-CSB offerings. This is largely attributable to the failure of the standards to require appropriate levels of education and formal training for individuals performing assessments and therapy.
Adult Mental Health Services C DHR standards are generally satisfactory for those aspects of care that they address.
Unfortunately, they fail to address a number of significant issues, such as services to incarcerated persons with severe mental illness, Assertive Community Treatment, content of day treatment programming, and outcome measures required of all CSBs. Thus DHR standards ought to be expanded to reflect new "best practices" in community mental health. C DHR has not developed medical practice policies and procedures which would standardize medical assessments and medication management. Hospitals routinely have such policies and procedures and their use in the community is highly recommended. Such policies and procedures ought to address at least such high risk areas as medication monitoring and risk assessment.
Substance Abuse Treatment Services C Many aspects of the CSB programs were found to be less than satisfactory in comparison to
acceptable community standards of non-CSB offerings. Serious deficiencies were extant with respect to staff qualifications, staff competencies, intake assessments, diagnoses, formulations of

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Community MH/MR/SA Programs

individual service plans, treatment delivery, discharge planning, treatment outcome assessments, and medical record documentation across all stages of the consumers CSB involvements. C The majority of intake assessments, group therapies, and individual therapies are presently conducted by individuals with relatively little training in assessment or psychotherapy. Individuals reimbursable for administering these services in the private sector typically have much more extensive training than those employed by the local CSBs. C The [DHR standards] fail to require appropriate levels of education for [individuals performing assessments and therapy]. For example, the Service Codes state that individual therapy, group therapy, family therapy, diagnostic assessment, and child and adolescent day treatment services are to be provided by an MHP or under the direct supervision of an MHP. [Note: the DHR Standards refer to individual, group, and family therapy as individual, group, and family training/counseling.] Yet, direct supervision is not defined and the status of MHP can be conferred on anyone who has an undergraduate degree and a specified amount of on-the-job training. Consequently, individuals with very little or no formal training in assessment or psychotherapy (i.e., CAC, SAC, HST, HSP, etc.) appear to perform these services in the absence of sufficient supervision from individuals competent in these areas. C Proper management of consumers requires accurate and timely diagnosis. The DHR standards allow 30 to 45 days between the time of admittance and the rendering of a diagnosis by an MD. This time period is inappropriately lengthy. Treatment planning is dependent upon proper diagnoses, and failure to diagnosis in a timely manner is likely to result in inadequate treatment and may harm the consumer. Review of the charts indicated that treatment was typically begun during this time period without a diagnosis. That is, consumers were treated and bills were submitted for treatment prior to the proper assignment of a diagnosis.

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Mental Retardation Services The following suggestions are compatible with what is widely regarded as best practice in the field of developmental disabilities, but may not be specifically mandated as items of compliance in the DHR Standards of Practice: C Obtain psychological evaluations that include appropriate assessments.
< ...it is highly recommended that evaluations be extended to include the use of state-of-the-art instruments that permit differential diagnoses of the emotional disorders presented by Dual Diagnosis clients.
< ...clinical planning should represent more than just identifying something for the client to work on in the assigned service delivery programs, but rather aim at remediating all significant problems that interfere with community living.
C Increase procedures used to promote independence in independent living skills. < If the goal is to prepare clients for increased independence, then a systematic teaching plan needs to be implemented.
C Prepare staff to provide parent/family training, and enhance staff awareness of the importance of parent/family-professional collaboration. < DHR standards mandate family participation in at least assessment and ISP planning, but the level and means of family participation is not specified. Family involvement should go beyond obtaining signatures on required forms. ISPs and discussions with staff suggested little effort to encourage family involvement. There also tended to be a low level of responsiveness to family concerns.
C Improve the quality of center-based programs. < DHR does not specifically mandate a method of monitoring program quality. One method that helps to identify problem areas in a program's schedule, activities, materials, or staff behavior is to monitor client engagement. The engagement data accumulated during this evaluation was variable, but often was unacceptably low.
C Increase job training and supported employment.

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Community MH/MR/SA Programs

< Although new DHR policy is increasing incentives for program participation in supported employment, the standards continue to encourage day treatment and activity therapy placements that may not be most effective for clients with mental retardation. It appeared that many of the clients receiving day treatment could be served in the less restrictive setting of an actual job site. It would also seem that if clients were trained and supported at job sites, their progress towards independence would be expedited.
C Develop specific plans for positive behavioral support. < Although it is commendable that there were no aversive therapies in evidence, the absence of comprehensive positive behavioral support plans for clients with potentially serious problem behaviors would be expected to impede their progress towards more independent community living.
C Increase the effectiveness of instruction and treatment procedures through the use of researchderived procedures for enhancing the communication and social competencies of the clients. < DHR standards detail the process of individualized service planning, and attention to the components outlined in the standards will improve the overall quality of Individual Service Plans. However, DHR regulations are more vague with regards to treatment content, with the result that just about any strategy that could logically address the target outcome and objectives will meet requirements.
C Seek out specialized consultation as needed. < One of the most apparent pressing needs for many sites reviewed is to secure technical assistance and training from someone with experience in behavior analysis. Ideally, an inhouse resource would be developed to enhance the probability of treatment success for all clients.
C Elaborate the detail in treatment plans. < Although DHR standards clearly indicate that ISPs should be aimed at promoting independent functioning, there is little specification of how this must be accomplished. When appropriate

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goals had been established, there was often inadequate, inappropriate, or no treatment method specified for achieving them. C Enhance the intensity and effectiveness of treatment. < DHR standards make reference to the provision of services that are effective, but there is no provision to prevent a common strategy of targeting two or three relatively simple goals for an indefinite period of time. However, best practice interpretations of least restrictive treatment would suggest that to justify participation in six or more hours of treatment per day, intensive and systematic treatment plans should address a comprehensive set of goals and be implemented continually throughout the treatment period. C Summary of suggestions for upgrading specific treatment services. < Although group and activity therapies are DHR approved formats of service delivery, there is no research to suggest that group counseling will increase receptive language, or decrease inappropriate behaviors. < In addition, although watching movies may be commonly interpreted as Activity Therapy, unless there is some staff interaction or use of videos for instruction, then movies should not be relied upon as a treatment intervention. < In sum, although community integration is specified in the DHR regulations, the traditional formats for service delivery are not documented to be effective means for building social skills in clients with developmental disabilities. Commercial curriculum and/or external consultation are recommended for improvement of these components of treatment plans.
Attention Deficit-Hyperactivity Disorder (ADHD) C The DHR standards for mental health services, while primarily not specific to child and adolescent
psychiatry patients or particular diagnoses, meet current professional standards both for assessment and specific treatment services. C Supervision/oversight by qualified professionals (child and adolescent psychiatrist, psychologist, social worker etc.) is implied [emphasis added] and sometimes even specifically stated.

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Community MH/MR/SA Programs

Involvement of family/caretakers is frequently specified. Appropriate reviews outside of the required annual review are also implied [emphasis added].
Activity Therapy (AT) Services C The stated focus of AT should become more related to definitions espoused by national
organizations. Therefore, AT should focus on treatment, education and recreation services designed to develop and use leisure in ways that restore, remediate or rehabilitate so that health, independence, functioning and well-being are enhanced and effects of disability or illness are reduced. C [Standards should require the providers to] establish a team of qualified personnel associated with an Activity Therapy Department that is directed by a written plan of operation.

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Assessment of Client Treatment Outcomes
Pervasive deficiencies were noted regarding the assessment of client treatment outcomes at CSBs. Mental Health consultants found that, although CSBs had a policy of using a clinical outcome measure, these measures either were not useful measures or were not routinely used at the time of treatment planning to assess the effectiveness of past treatment. Mental Retardation consultants found that only slightly more than half of the client records they reviewed met the criterion for objective measurement. Substance Abuse consultants noted that there was no evidence of systematic outcome assessments found at any site reviewed and further noted that, in the absence of systematic outcome indicators, it is simply impossible to determine the extent and duration of treatment effect. ADHD consultants noted that outcomes of service instruction were poorly documented and Activity Therapy consultants stated that none of the nine CSBs they reviewed contained measurable outcomes identified in client treatment plans that were associated with activity therapy.
Adult Mental Health Services C DHR standard 10.12a requires the use of an outcome measure which is standardized and has been
reported in the literature. In only one instance was such a clinical outcome measure used routinely to monitor the effectiveness of treatment (in Savannah, where a single physician developed a personal data base for patients). C All CSBs had a policy of using a clinical outcome measure, but these measures either were not useful measures (e.g., Global Assessment of Functioning) or were not routinely used at the time of treatment planning to assess the effectiveness of past treatment. In the DeKalb CSB there is national quality research on outcome measures and it is to be hoped the state will take proper advantage of this local resource.

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Community MH/MR/SA Programs

Substance Abuse Treatment Services C In the absence of systematic outcome indicators, it is simply impossible to determine the extent
and duration of treatment effect. C No evidence of systematic outcome assessments was found at any site reviewed. This finding is
particularly disturbing, as many staff members appeared enthusiastic about their programs and certain that their form of treatment was yielding very positive outcomes. However, they were unable to present any data to support their assertions.
Mental Retardation Services C Specifically, only 89 of 160 client records met the criterion for capacity for objective
measurement. Many of the remaining objectives were worded in vague or global terms, which precluded measurement to demonstrate that desired outcomes have been achieved. Global statements do not allow staff members providing treatment to know exactly what skills should be targeted to increase, what skills are targeted for decrease, how to determine when to move on to new skills, or when to stop teaching a skill if it is not being met. Specific criterion for mastery of a skill is a necessity if programs are to be held accountable for the services being provided to their consumers.
Attention Deficit-Hyperactivity Disorder (ADHD) C There were common weaknesses in the clinical treatment process. The following areas were
poorly documented: outcomes of service intervention; termination of cases; follow-up goals.... C Interdisciplinary clinical meetings to discuss clinical cases, particularly those children who are not
making progress, should occur on a regular basis. The child psychiatrist should interact with staff at this level and not primarily through the medium of chart communication.

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Activity Therapy (AT) Services C None of the nine agencies contained attempts to systematically evaluate effects of the recreation
and leisure-oriented activities, the impact of these services on leisure time skills, social interaction skills, functioning and physical health was not monitored or apparent. C None of the nine agencies contained measurable outcomes identified in the ISP that were associated with AT.

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Outcome Measures to Evaluate Overall Program Effectiveness
CSBs lack sufficient outcome measures which would allow them to evaluate the overall effectiveness of their treatment programs. As our consultants reported, CSBs conduct little systematic data collection or data analysis relating to clinical care, even in the highest risk areas. None of the CSBs reviewed had a study of clinical recidivism and, with several notable exceptions, there were no data on the clinical effectiveness of CSB treatment programs. Although CSBs are sometimes required through contracting agreements with Regional Boards to gather and report data, such data is of little value in monitoring clinical care. Reliance on indicators which may be required through accrediting agencies to monitor CSB system performance will be unsatisfactory because: these types of indicators lack relevance to severe and persistent mental illness; CSBs may not all choose the same indicators; and not all CSBs are undergoing accreditation by the same accrediting agency.
Adult Mental Health Services C CSBs have generally focused their data gathering efforts on the areas having the greatest financial
impact, e.g., admissions to state hospitals. There is little systematic data collection or data analysis relating to clinical care, even in the highest risk areas such as suicides. C No CSB had a study of clinical recidivism (i.e., decompensation or clinical relapse leading to rehospitalization), a measure of the adequacy of community care. With several notable exceptions (e.g., studies on the use of clozapine) there were no data on the clinical effectiveness of CSB treatment programs. Thus the effectiveness of day treatment programming is an open question, despite the high cost of such programs. C CSBs are sometimes required, through contracting agreements with Regional Boards, to gather and report data. Such data is usually of little value in monitoring clinical care. For example, all CSBs had an instrument in place to measure patient satisfaction. However, most instruments had not been standardized (DeKalb was the exception) and most results were designed to show high

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rates of patient satisfaction. Thus there was little value to be gained from the surveys, and care either was not improved or was only minimally impacted by the results of the satisfaction surveys. C CSBs choosing accreditation through JCAHO will be required, by March 1999, to have selected "at least two clinical or perception of care measures and a maximum of five acceptable measures that address 20% of its clients." JCAHO measures include diagnosis of depression, relapse among substance abusers, and suicide. Schizophrenia and bipolar disorder (manic-depressive illness) are not addressed. Because of the lack of indicators relevant to severe and persistent mental illness, because CSBs may not all choose the same indicators, and because not all CSBs are undergoing accreditation by JCAHO, reliance on JCAHO indicators to monitor CSB system performance will be unsatisfactory.
Substance Abuse Treatment Services C Serious deficiencies were extant with respect to... treatment outcome assessments, and medical
record documentation across all stages of the consumers CSB involvements. C [The profession recognizes that] there are numerous indicators of treatment gain, including
duration of abstinence, amount and pattern of substance use, vocational status, number of hospitalizations, emotional and social stability, physical health, participation in criminal activities, etc. In the absence of systematic outcome indicators, it is simply impossible to determine the extent and duration of treatment effect. C A systematic assessment of therapeutic gain during the process of treatment should be conducted for each CSB program. Additionally, each treatment modality should be periodically assessed with respect to maintenance of treatment gain following discharge. It would be highly desirable if efficacy evaluations were based on common methodologies such that results would be comparable across different CSBs.

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Community MH/MR/SA Programs

Mental Retardation Services C All of the programs reported some system for peer review of chart documentation. These
systems tended to be the ones that had been in operation for the longest period of time. On the surface, these systems appeared to cover the types of review that are tracked as part of accreditation review, with more emphasis on the mechanics of chart documentation and little attention to the quality of treatment planning or delivery. C Only three sites evaluated client outcomes in a systematic fashion.... It is strongly recommended that DHR move to an outcome-oriented system, in which reimbursements are impacted by client outcome. The current system tended to promote informal evaluations showing that clients had made no progress, which were the most frequent justifications for continuing the same program year after year. C Several programs were in the process of developing staff performance appraisal systems. C In sum, there is a need to continue development of staff performance appraisal systems. It is recommended that such systems include a component for assessing staff performance through direct observation, and through evaluation of products of their labors (e.g., client outcomes and chart documentation). C Most of the programs had a consumer evaluation system in place. Some sites sampled a portion of the consumers for each program, while others conducted satisfaction surveys twice a year.
Attention Deficit-Hyperactivity Disorder (ADHD) C Community service boards should continue to develop methods of programmatic evaluation and
consumer satisfaction.
Activity Therapy (AT) Services C None of the nine agencies indicated systematic attempts at measuring progress associated with
performance in AT.

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Adequacy of Overall Client Treatment Record Keeping
Deficiencies in client treatment record keeping preclude these records from being useful documents for assessing clients' progress and planning treatment services. Consultants noted, for example, that: documentation was often piecemeal, rather than reflecting an integrated picture; it was quite difficult to quickly ascertain from reviewing charts exactly what services a client was receiving or what programs a client was enrolled in; the evaluation of treatment interventions was greatly limited by the lack of detail in the progress notes; and that medical records were organized in such a way that clinicians would likely not find it convenient to read each others' impressions.
Adult Mental Health Services C Medical records were generally inadequate in their organization and readability. The best records
were in Columbus, where the organization of medical records into binders, and the presence of new assessment and treatment planning forms, made it easy to understand the patient's diagnosis and treatment plan. In other sites, medical records were organized in such a way that it is likely clinicians would not find it convenient to read each others impressions, so that the record would not serve as a device for communication. We saw evidence of this failure and generally found record audits were inefficient because of the organization and legibility of records. C Poor readability of records also rendered them relatively ineffective as means for communicating. Lack of transcription services required clinicians to write notes by hand, leading to illegible and overly terse documentation. Where transcription services were available (e.g., Americus), the improvement in documentation and the enhanced clinical value of the medical record cannot be overstated.
Substance Abuse Treatment Services

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C The evaluation of treatment interventions was greatly limited by the lack of detail in the progress notes. The failure to document therapeutic interventions and client progress may be a reflection of the level of therapist training rather than an inability to properly document treatment/client progress. Notes were not co-signed by MHPs, suggesting that supervision was minimal.
Mental Retardation Services C ...it was quite difficult to quickly ascertain from chart review exactly what services a client was
receiving or what program the client was enrolled. C Positive Features of Chart Documentation The following positive features of records content
reflect a summary of data: < Date of Birth [present in] 149 of 160 charts < Sex [present in] 149 of 160 charts < Race [present in] 146 of 160 charts < Address of client [present in] 147 of 160 charts < Telephone number of client [present in] 139 of 158 charts C Problems Identified in Chart Documentation < Annual medical assessment [present in] 87 of 160 charts < Most-In-Need status documented [present in] 119 of 160 charts < Critical medical issues reviewed regularly [present in] 29 of 87 charts < Physicians plan present and updated every 3 years [present in] 47 of 125 charts < Record organized according to center policy [present in] 74 of 160 charts
Attention Deficit-Hyperactivity Disorder (ADHD) C There remain significant inconsistencies in the specific documentation processes. Documentation
was often piecemeal, rather than reflecting an integrated picture. C There were common weaknesses in the clinical treatment process. The following areas were
poorly documented: outcomes of service intervention; termination of cases; follow-up goals;

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education regarding the use of medication; and the reasons for increasing or decreasing level of care. The utilization of behavior therapy and parent management training strategies to control disruptive children were absent or not clearly documented in many cases.
Activity Therapy (AT) Services C None of the nine agencies had developed a Written Plan of Operation (WPO) that contained
information about the purpose or mission of AT, goals and objectives associated with AT, or the identification of a philosophy guiding the delivery of AT services. There was no WPO that contained an identification of the scope of AT services or information on quality assurance.

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Recommendations
Based on the findings of our consultants, we make the following recommendations:
C The DHR should update its Quality Improvement Standards to address the areas noted in this finding and to reflect new best practices in community mental health, mental retardation and substance abuse programs.
C All personnel performing assessments, making diagnoses, and providing treatment services should be required to hold the necessary credentials that are expected of persons performing these functions in the private sector. For example, the continued need to grant exceptions to these requirements through the "Mental Health Professional" or similar designation should be reassessed. If this reassessment indicates that there are still substantial statewide shortages of credentialed personnel necessitating the continued use of these designations, appropriate training should be provided to all personnel to ensure the highest quality of service possible. This training should lead to CSB personnel acquiring the necessary competencies to provide the quality treatment services expected of them and to possibly become credentialed in the appropriate fields of study. In addition, if there is to be continued use of these designations, the DHR should ensure that standardized, uniform criteria are used statewide to confer these designations.
C The DMA should open its Community Mental Health Services Program to providers other than CSBs. This will create competition for the provision of these services which could result in increased quality at a decreased cost. Similarly, the DHR and regional boards should consider expanding their practice of contracting with service providers other than CSBs in order to procure the best quality service at the best available price. It should be noted that some CSBs currently subcontract with not-for-profit organizations to provide some services and retain a portion of the Medicaid or state grant-in-aid payments as an administrative fee. The regional boards and the DMA could contract for these services directly.

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C Regardless of which service providers are used, the DHR should ensure that its contractors provide the appropriate quality and quantity of services. To accomplish this, the DHR should continually monitor the quality of services provided and should implement an effective, independent precertification and utilization review process (it should be noted that precertification should not apply to crisis service).