STATE OF NORTH CAROLINA IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
COUNTY OF DURHAM 10 DHR 03827
Marcell GunterAlternative Life Programs Inc.
Petitioner
vs.
North Carolina Department of Health and
Human Services Durham Center LME and DMA
(CSCEVC NC Medicaid Provider)
Respondent / )
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)))) / DECISION
THIS MATTER came on for hearing on March 30, 2011 before the Honorable Joe L. Webster, Administrative Law Judge, Raleigh, North Carolina. The petitioner was represented by Geoffrey Simmons. The Respondent, Durham Mental Health, Developmental Disabilities, and Substance Abuse Area Authority ( hereinafter referred to as the “ Durham Center”) was represented by Assistant County Attorney Marie Inserra. The North Carolina Department of Health and Human Services ( hereinafter referred to as “DHHS” ) was represented by Assistant Attorney General Charles G. Whitehead. Petitioner, Alternative Life Programs, Inc.
(hereinafter referred to as “ALP”) was represented by Geoff Simmons.
EXHIBITS
For Respondent: Exhibits: A through GG admitted
Exhibit / Description / PagesA / LME Policy & Procedure Manual: Monitoring of Facilities and Services / 1-5
B / LME Policy & Procedure Manual: Management of Complaints and Investigations / 6-7
C / Letter 2009-06-11 from LME to Gunter re: complaint and beginning investigation / 8
D / Letter 2009-07-27 from LME to Gunter re: substantiation of allegations / 9
E / Encl: Narrative of Complaint Investigation / 10-13
F / Encl: Chart: Detailed Investigation Findings and Authority References / 14-20
G / Letter 2009-08-03 from LME to Gunter re: Provider’s Concerns about Investigation / 21-22
H / E-Mail 2009-08-25 from LME to Gunter re: Voluntary Withdrawal of Services / 23-24
I / Notification of Endorsement Action: Voluntary Withdrawal / 25-26
J / E-Mail 2009-09-08 from LME to Gunter re: Additional Guidance for POC / 27
K / Letter 2009-10-05 from LME to Gunter re: 1st POC – Not Accepted by CCC / 28
L / Encl: POC Review Criteria and Determination by CCC / 29-32
M / Letter 2009-11-08 from LME to Gunter re: 2nd POC – Not Accepted by CCC / 33
N / Chart: Why Each Element of 1st and 2nd POCs Were Accepted or Not / 34-54
O / Letter 2009-12-17 from LME to Gunter re: Solicitation of 3rd POC / 55
P / Letter 2010-01-25 from LME to Gunter re: 3rd POC – Accepted by CCC / 56
Q / Chart: Reformatted version of 3rd POC / 57-74
R / Letter 2010-03-26 from LME to Gunter re: Follow-up Review of POC Implementation / 75
S / Letter 2010-04-30 from LME to Gunter re: Follow-up Review of POC Implementation / 76
T / Encl: POC Review, Explaining Findings from Two Follow-up Review Inspections / 77-81
U / Letter 2010-06-22 from LME to Gunter re: Involuntary Withdrawal / 82-83
V / Notification of Endorsement Action: Involuntary Withdrawal / 84-86
W / Letter 2010-07-26 from LME to Gunter re: Reconsideration by LME Director / 87-88
X / Two CS Notes from 2010-02-23: Ms. Terry purportedly treated two different clients at 1-2 PM / 89-90
Y / Three CS Notes from 2010-03-03: Ms. Terry purportedly treated two different clients at 9-11 AM, and Ms. Morris also treated one of them at 9-10 AM / 91-93
Z / Two CS Notes from 2010-03-09: Mr. Ingram purportedly treated two different clients from 9-11 AM / 94-95
AA / Two CS Notes from 2010-03-19: Ms. Morris purportedly treated two different clients from 12-2 PM. / 96-97
BB / Two CS Notes from 2010-04-03: Ms. Terry purportedly treated two different clients during 2-3:30 PM. / 98-99
CC / Two CS Notes, for client SB on 2010-01-04, and for client AA on 2010-03-13: The Intervention sections differ only by a few words in the middle and the Assessment section is verbatim / 100-101
DD / Two CS Notes for client SP on 2010-01-04 and 2010-01-10: The Purpose, Intervention, and Assessment sections are all verbatim / 102-103
EE / Two CS Notes for client SP on 2010-01-12 and 2010-01-13: The Purpose, Intervention, and Assessment sections are all verbatim, and the 2010-01-12 note bears dated signatures significantly earlier than the date of service / 104-105
FF / Two CS Notes for client SB on 2010-01-07 and 2010-02-01: The Purpose, Intervention, and Assessment sections are all verbatim / 106-107
GG1 and GG2 / PERSON-CENTERED DESCRIPTION/PLAN of A.A. / 108-025
For Respondent DHHS: Exhibits: 1-5
Exhibits Description
1 The Provider Enrollment Agreement Application from Alternative Life Programs
2 North Carolina Medicaid Clinical Coverage Policy 8A
3 Policy and Procedures for Endorsement of Providers of Medicaid Reimbursable Mental Health Developmental Disabilities and Substance Abuse
4 Notice of Endorsement Action from the LME to Alternative Life Programs dated June 25th, 2010 withdrawing the endorsement
5. Notice from CSC, vender of DMA, to Alternative Life Programs dated July 1st, 2010
WITNESSES
Donna Watson MacDuffie for the Durham Center, Respondent
Marcel Gunter for ALP, Petitioner
ISSUE
Whether the Durham Center, respondent, properly withdrew the endorsement for Alternative Life Programs?
FINDINGS OF FACT
1. Petitioner is Alternative Life Programs, Inc. (hereinafter referred to as ALP). From 2009 through 2010 ALP provided community support team services in Durham County to approximately six consumers. (Tr. p. 20, lines 18-25, p. 55, lines 16-23). These services provide community-based support to consumers with mental illness, substance abuse or a combined diagnosis. The services are based on goals that have been identified in the person-centered plans of the consumers and the interventions are to be client specific. ALP provided these services pursuant to endorsement by the Durham Center.
2. Respondents are the Durham Center LME, North Carolina Department of Health and Human Services, and DMA(CSCEVC NC MEDICAID PROVIDER).
3. In June of 2009, the Respondent received several complaints regarding an improper service provision provided by ALP. (Tr. p. 20, lines 1-17) In response thereto, the Respondent conducted an investigation.
4. The investigation resulted in ALP's submission of and agreement to a Plan of Correction on or about December 2010. ALP was notified in writing on January 25, 2010 that the Durham Center accepted the Plan of Correction submitted by ALP. ALP was further notified that a follow up visit would be forthcoming to ensure compliance. ( Tr. p. 20, lines 11-19 Ex. P)
5. ALP agreed through the approved Plan of Correction to address several areas of non-compliance, including issues of signatures on the person centered plans that included staff who were either not employed by ALP or who were not fully trained or qualified. ALP agreed through the approved Plan of Correction to address duplicate chart-and duplicate service notes that had been found during the investigation and review. ALP agreed to address inappropriate staffing, to ensure that the community support team was comprised of the required number of staff and also that the staff were fully trained and qualified for the particular service. ALP had agreed through their approved Plan of Correction to conduct a self-audit to assess any repayment issues to the Division of Medical Assistance. (Tr. p. 21, Ex. Q )
6. In March and April of 2010, follow up visits were conducted by the Durham Center to ensure that ALP was implementing the Plan of Correction as it had agreed to in the corrective action steps. (Tr. p. 22 ) In March and April of 2010 Donna Watson-MacDuffie, Quality Assurance Specialist and Tasha Griffin, Contract Management Specialist of the Durham Center conducted two follow up reviews. The reviewers requested records from ALP for three of its six consumers. During the follow up visits, the reviewers determined that four areas of the Plan of Correction were not implemented. The specific areas that remained uncorrected arose from findings numbered one, three, eight and nine in the approved Plan of Correction. (Ex. R, S, T, Tr. p. 22, lines 22-25, pp. 23-25 )
7. In Finding Number One of the Plan of Correction it was noted that Person-Centered Plans had been signed off by unqualified professional staff members. It also required that qualified trainers like K.Rinehart would maintain their certificate and credentials in their personnel file. (Ex. T). This finding was referenced to Service Record Manual APSM 45-2 that provides for a dated signature of the consumer or person legally responsible for the PCP.
8. The Durham Center’s review of ALP on March 16, 2010 observed signature
inconsistencies. Three of three charts had consumer signatures that appeared differently on different documents; training was not conducted by the approved trainer in the Plan of Correction; trainer qualifications did not support the specific training involved and certificates of training were not located in the personnel folders as required. (Ex. T).
9. On April 20, 2010 the reviewers observed that the signature of the person responsible for the Person Centered Plan (hereinafter referred to as “PCP”) of consumer AA had been changed from Stacia Glass to Wuillie Ingram ( Ex. GG, pp. 121, 125), although the date of 2/5/2010 remained the same. The reviewers also observed unqualified persons developing and updating PCP’s and additional signatures on PCP’s were added after the March 2010 review. (Ex. T). Training shortfalls continued as documented in the review. (Ex. T).
10. In Finding Number Three of the Plan of Correction, ALP was to address and correct the duplication of notes. ALP agreed in the Plan of Correction that lead qualified professionals would review notes and approve the content. New employees were to be trained and staff would not be allowed to write notes until completion of training. All staff were to attend an in-service training on 2/8/10 after the owner attended the council training on “Documentation - Doing it write.” Finding number three was referenced to Service Record Manual APSM 45-2. “Canned” service notes were to be avoided. Examples of canned notes are notes that are cut and posted from a personal computer or photocopied, with new dates and/or signatures attached, or notes that are copies verbatim, or almost verbatim by hand from previously-written notes. Documentation should be specific and individualized and should accurately reflect the service provided per event. Each service note deserves its own newly-composed evidence of the service provided. ( Ex. T)
11. On 3/16/10 the reviewers observed that various staff members on the team including Gunter, Ingram, Terry, and Morris had numerous examples of cut and pasted notes. There were also several examples of the wrong consumer name and agency appearing in the notes. ( Exhibits X-GG). The PCP’s had been signed by a staff member who was not a part of the Plan of Correction and who was employed by another agency until February 12, 2010. (Ex. T). There was no supporting documentation for the 2/8/10 staff training nor was there evidence that the Lead Qualified Professional reviewed the content of service notes given.
12. During the second follow up visit on 4/20/2010, there were no changes in the staff duplication of notes. Numerous examples of staff documenting overlapping time were displayed within the consumers charts and across charts. For example, Mr. Ingram provided service to two different consumers at the same time. Ms. A and Ms. P had the same date of service and same time frame, March 9, 2010, nine a.m. to eleven. (Ex. Z, p 94-95). Additionally, there were overlapping billed times that were as recent as April 3, 2010.
13. In Finding Number Eight of the Plan of Correction inadequate staffing continued as reflected in review of ALP’s organizational chart. (Ex.T). According to the Medicaid Enhanced Service Definition - Community Support Team must be comprised of a minimum of three (3) staff persons. The team leader must be a Qualified Professional according to North Carolina Administrative Code 10A NCAC 27G.0104 which states that as a leader you must function a least .5 FTE for clinical, administrative supervision and also function as a practicing clinician on the team. The review did not show compliance, (Ex. T).
14. In Finding Number Nine of the Plan of Correction, ALP was to conduct a self audit and payment plan to DMA. The reviewers did not see evidence of a self audit.
(Tr.p. 24 -25, Ex. T.)
15. On April 30, 2010 ALP was notified in writing that items one, three, eight and nine of the Plan of Correction continued to not be implemented. (Ex. S ) On June 22, 2010, ALP was notified in writing that pursuant to 10 NCAC 26C .0502, ALP’s endorsement was withdrawn. (Ex. U)
CONCLUSION OF LAW
1. The office of Administrative Hearing has personal and subject matter jurisdiction over this contested case. The parties received proper notice of the hearing in the matter. To extent that the Findings of Fact contain Conclusion of law, or that the Conclusions of law are Findings of Fact, they should be considered without regard to the given labels.
2. Petitioner bears the burden of proof by a preponderance of the evidence that the Respondent, the Durham Center, had improperly withdrawn the endorsement from the Petitioner, ALP, or had failed to act as required by law or rule when it decided to withdraw Petitioner’s endorsement to operate community support team services in Durham County. Petitioner has not carried its burden of proof in this appeal. The Durham Center followed procedure, acted cautiously, and properly followed protocol when withdraw the endorsement.
3. The undersigned finds as a matter of law that the Petitioner violated the following North Carolina Administrative Code provisions:
10A NCAC 26C .0502
10A NCAC 27G .0601
4. The undersigned finds as a matter of law that the Petitioner violated the following North Carolina General Statutes: