LOS Angeles County

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  5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. 90 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. 92 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. 95 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. This page intentionally left blank. GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met. BACKGROUND Group homes are licensed by the California State Department of Social Services, Community Care Licensing Division under Title 22 regulations.1 The purpose of the statute is to provide support services and housing to abused and neglected youth and to juveniles on probation. The youth are placed by the Los Angeles County Probation Department (Probation) for their delinquent behaviors, and/or by the Department of Children and Family Services (DCFS) when they are removed from harmful environments resulting from neglect, abuse, or violence in the home. The general ages of group homes residents are 12–17 years old. The committee reviewed the report of the 2006–2007 Civil Grand Jury and decided to re- evaluate the group home (GH) situation. The committee inspected the living conditions of the minors, and evaluated the minors’ safety and well-being. This was done by unannounced visits to GH facilities, where the committee conducted physical inspections and private interviews with minors and staff. Special care was taken to include large and small GH facilities selected from each of the Los Angeles County supervisorial districts. DCFS and Probation are involved in managing the assigned children’s cases, including their initial placement, monitoring, and tracking their progress over time and developing their exit plans. The committee also reviewed monitoring of GHs by DCFS, Probation, and the Auditor-Controller. At the time of the 2006–2007 Civil Grand Jury review, there were 238 licensed group homes in Los Angeles County. According to the Auditor-Controller Group Home Ombudsman, there are 128 licensed group homes as of 2014. This reduction in the number of group homes could be attributed to both the court and Probation and DCFS departments having changed their focus 1 California Code of Regulations. 99 from placement in group homes to family reunification or relative (extended family) placement whenever possible. According to STEP UP—an organization that promotes relative placement rather than children being placed in foster care or group homes—43 percent of Los Angeles County’s 21,000 foster children are in the home of a relative, 23 percent are placed with a Foster Family Agency, and 5 percent are in group homes. The remaining 29 percent, not addressed by STEP UP, are in other out-of-home placements—such as adoptive homes and foster homes. STEP UP reported that foster care benefits for 100 youth in relative placement would cost the county $984,000 a year, while group homes cost would be $10.2 million a year. This means that for each youth moved out of a group home and into a relative’s home, the county saves enough money to pay the cost for 10 children in relative placement.2 An investigation titled “Why Is Grandma Worth Less?” was completed by the Los Angeles County 2013–2014 Civil Grand Jury. It addressed the disparity issue between foster-care payments for relatives and nonrelative foster parents. It was recommended that DCFS exercise its authority and pay a relative foster parent the same as a nonrelative foster parent. Group Homes Inspection Report Name of Group Home City INSPECTION COMMENTS Supervisorial District DATE Rate Classification Level3 Delilu Achievement Home Group home appeared to be adequately meeting Los Angeles 01/09/15 the needs of the residents placed there. The District:2 carpet appeared unclean. Staff stated that it RCL 12 was cleaned six months before. Dimondale Group Home Facility appeared to be in satisfactory condition. One Lancaster 01/29/15 resident stated that she appreciates the structured District: 5 environment and has positive plans for her future. RCL: 12 Eagle Rock Group Home Facility was well-maintained. All six residents were Eagle Rock 01/06/15 present at time of the inspection. Residents interacted District: 1 well among themselves and with staff. RCL 12 2 http://stepupforkin.org. The Rate Classification Level (RCL) is the monthly monetary rate assessed by the Foster Care Rates Bureau of the California Department of Social Services. The RCL ranges from $2,332 to $9,879 per child, based on the level of behavioral, mental, emotional, and physical needs of the minor. The higher the RCL number, the greater the compensation. Name of Group Home City INSPECTION COMMENTS Supervisorial District DATE Rate Classification Level Eggleston Youth Center I Facility appeared to be in excellent condition. No Baldwin Park 01/27/15 minors were present during the inspection. Staff District: 1 expressed pride in the facility and the services RCL 12 provided to the residents. Eggleston Youth Center II All required documentation was posted. Facility was Baldwin Park 01/27/15 well-maintained. Staff was truly committed to the District: 1 well-being of residents. RCL 12 Enid House Group Home Facility was well-maintained. One of the residents Azusa 01/06/15 spoke openly and appeared to be well-adjusted to the District: 1 placement. RCL 14 Girls Republic Beautiful home with many amenities, well- Monrovia 01/30/15 maintained. On the premises was a small transitional District: 5 house for girls ages 18 and older. RCL 10 Humanistic Foundation, Inc. Documents were in order and posted. Well- Los Angeles 01/27/15 maintained, with seemingly more than adequate food District: 2 supply. There were books, but no visual artwork or RCL 12 creativity. Residents were taken to a local park for outdoor activity. Long Beach Group Home Small but clean facility had had a sewage odor Long beach 01/06/15 emanating from bathroom. The committee reported District: 4 the sewage problem to DCFS and Group Home RCL 12 Ombudsman. Matter corrected. Optimist Boys South Bay Clean and well-maintained facility. School for residents Carson 02/06/15 conducted at main campus in Highland Park, Ca. District: 2 RCL 12 Pacific Lodge Group Home Facility consisted of three cottages. Spacious property Woodland Hills 12/17/14 with Olympic-size swimming pool. The staff was District: 3 courteous and caring. Facility has a wrap-around RLC 12 transition program for youth up to 21 years of age to enter the community. Penny Lane Satellite I Facility was well-maintained. Pool on site but not North Hills 01/27/15 being used because there was no lifeguard. Pool was District: 3 completely covered. RCL 12 Penny Lane Satellite 7 Facility was well-maintained. Residents help with food Northridge 01/09/15 preparation and do their own laundry. District: 3 RCL 12 101 Name of Group Home City INSPECTION COMMENTS Supervisorial District DATE Rate Classification Level Phoenix House group Home A spacious co-ed facility with a capacity of 120 Lake View Terrace 12/16/14 residents. Well-appointed with artwork created by the District: 3 residents. Focus was on substance abuse and RCL 12 behavioral problems, with seemingly positive results. Positive Path Youth Dev. Ctr. Facility was well-maintained. One resident stated her Carson 01/09/15 satisfaction with the residence. District: 2 RCL 2 Rosemary Children Services Facility was well-maintained. One resident was a Pasadena 01/23/15 runaway. Appropriate authorities notified by group District: 5 home staff. RCL 12 St. Anne’s Maternity Home One of the few homes for pregnant teens and their Los Angeles 01/16/15 infants. The residents receive parenting-skills District: 3 education. Fathers are encouraged to be an active part RCL 12 of mother and infant interaction. There is an on-site daycare and school. Silver Lake Group Home The facility was in satisfactory condition. Los Angeles 01/30/15 District: 3 RCL 10 Star View A community facility that provides services to multiple Torrance 01/15/15 counties and houses youth with extreme emotional District: 4 problems. Multiple disciplinary teams exhibited RCL N/A4 seemingly positive interaction with residents. Touch A Life Group Home Very clean and well-maintained facility in an inner-city Los Angeles 01/23/15 community. Residents were neatly dressed and District: 2 courteous. RCL 9 Turmont Home For girls Large home that was well-maintained. One resident Lancaster 01/29/15 was a runaway. Appropriate notification had been District 5 made by group home staff. RCL 8