Audit Information: It's all paperwork

On Wednesday, May, 9, 2007, Steve Puckett, PhD puckettste@smokymountaincenter.com, Clinical Operations Director forwarded to me a powerpoint presentation given on May 3, 2007, by Sandy Resnick Compliance Unit Leader for NC DD/MH/SA. These are some of the important points in those slides.

These were the 4 criteria utilized to evaluated providers: I am waiting for answers to my questions re: problematic weighting of the 4 criteria from jim.jarrard@ncmail.net, @ DHHS, who is the person Dr. Puckett advised me to contact.

Valid Service Order; Valid Service Plan; Valid Authorization; Valid Service Note : 4 Audit questions weighted in order to obtain critical % audit results/ provider.
(Overall): Results indicate poor understanding of Service Definition and Documentation Requirement (slide 23)

QUESTION #1: how were these 4 criterion weighted? There is no information in the slides indicating the weighting of the criteria. I assume they were weighted equally. There is no good reason to do this and indeed, the data is skewed if the statistician has done this. This quite possibly means that the (naughtiest) Category 3 may not have been quite so naughty if the criteria had been weighted in a manner in keeping with the face validity. (see below: face validity: "A test is said to have face validity if a reading of the items appears to reflect the areas that the test purports to measure. Face validity alone is insufficient to judge the value of the test. It is but one aspect of content validity, which can be evaluated by a panel of experts." http://www.google.com/search?hl=en&rls=GGLR,GGLR:2006-43,GGLR:en&defl=en&q=define:Face+validity&sa=X&oi=glossary_definition&ct=title


There were very obviously, best I know, no 'experts' who stated that the measurement of these 4 paper-work criteria were an adequante measurement of the work done as associated with the clients). These are not silly, statistical points to be dismissed: the audit hinges on these matters.

And in that the audit hinges on these matters, the defunding of Community Support hinges on these matters. If there is no good research to indicate that Community Support was being 'wrongly' applied, then there is no reason to: 1. diminish the number of CS hours from 28/ wk/client to 12/wk/client and neither is there reason to diminish the hourly rate/ CS/ Client.

Were they all given the same weight (were they all assumed to be equally important)? I think not as associated with viewing the EXCEL file sent to me by DHHS personnel, Brad Deen, which indicated that Category 3 (the naughtiest) had lacking notes as associated with 7 of the providers, such that "4 or more were missing." If this was not the most heavily weighted criterion, then why was a note made of it in the EXCEL file? Would not one assume that the 'heaviest billers' would more possibly have more missing notes as associated with the sheer volume of notes submitted/ client?

Valid Service Order is easily obtained; the signature of a psychologist, nurse practitioner, psychiatrist, will suffice. Valid authorization is obtained via Value Options and is readily obtained----though it takes some time----by submitting a 1 page request to Value Options. Valid Service Plan (and what is 'valid'---what were the criteria for judging all the myriad items associated with a Valid Service Plan?) and 'Valid Service Note' is much more complex. The Service Plan is a long, drawn-out process, associated with interviewing the client, the family, obtaining signatures. 'Valid' service note is more complex. Again, what is the definition used by the raters of 'valid' as associated with the Service Note?

Bear in in mind here that there is NO witnessing of the actual work here---there is only the testimony of the paperwork.....an indirect witness. So, am I to understand that the 4 variables----2 quite easy, 2 quite difficult----are weighted the same?? Bear in mind that there is no 'weight' given to what the consumer/ client perceived as helpful or not. If this is to be a consumer driven service, then why is it that the assessment of the consumer is not included? (It won't do to state that it was too much trouble to obtain).

There is no reason to weight the intensive work of creating the Service Plan (most difficult item here) and the creation of the service note (2nd most difficult item) with the easiest item, Service Order, and then second in difficulty, the Service authorization. In creating a model associated with they all being weighted identically, there is a skewing of the data. The more complex matters are at the same level as the simpler items. There is no research to indicate that these are the same and as associated with face validity, and as associated with a good familiarity with these processes, there is no reason for these all to be weighted equally.

The fact that the paperwork, alone, is being utilized in order to gig the Community Support companies (Endorsed Providers) is troublesome. There is an implicit assumption here that the paperwork is a true reflection of the work done.

Providers in Category 1: 88 Providers in Category 2: 63 Providers in Category 3: 16 (Category 3 is associated with compliance rate less than 50% critical measures OR 4+ Service Notes missing).
Issues found:
1. 30 day window for those new to services not understood
2. Signatures not obtained for documented plan reviews
3. Missing service notes
4. Missing or very weak intervention in service notes
5. Poor understanding of focused skill-building to address the MH or SA needs of people receiving CS
6. Canned service notes
7. Service notes did not reasonably represent the hours billed
8. Missing authorizations and/ or no verification request was submitted.
I can understand the necessity of the paperwork. But let's be clear here: there was no evaluation of the hands-on work of ANY provider here. This is simply an overview of the quality of the paperwork submitted.