Columbus, Georgia

NEW HORIZONS COMMUNITY SERVICE BOARD





January 28, 2002 Nurses? Classroom, Columbus Health Department, Columbus,

Georgia



Members Present: Vickie Allen, Roxann Daniel, Sandra Gill, Anne Hopp, Linda

McElroy, Nancy Schroeder, Wesley Shorter, Lawrence Young



Members Excused: David McCall, Earetha Tymes



Guests: Greg Hoyt (Region 9 Board), Carlton Bain and Peggy Crowe, University of

Georgia, Carl Vinson Institute





1. Call to Order: Mr. Wesley Shorter, Chairperson, called the meeting to order

at 3:37 p.m.



2. Recognition of Guests: All guests attending today?s meeting were recognized.



3. Meet Our Staff: As a means of empowering staff, division directors are

inviting staff to attend board meetings to learn more about New Horizons

Community Service Board?s operations. Jan Shippey (C&A Day Services) and

Andrea Winston (The Millennium Center) attended today?s meeting.



4. Secretary?s Minutes: M/S/P Lawrence Young/Nancy Schroeder that the minutes

of the September 10, 2001 and November 5, 2001 meetings are approved.



5. Board Member Resignation: M/S/P Lawrence Young/Roxann Daniel that the board

accepts the resignations submitted by Carol Ingram (Talbot County) and Shirley

Christian (Clay County), as requested.



6. Performance Improvement Report: Mr. Wesley Shorter reported that the board

normally received a quarterly report on the activities of the various

Performance Improvement Committees. Today?s report will be different as New

Horizons Community Service Board has just completed the JCAHO survey from

January 14 ? 18, 2002. Mr. Shorter reported that he and Nancy Schroeder

attended the Leadership Performance portion of the JCAHO survey. Mr. Shorter

requested a report of the JCAHO survey.



Cyndy Pattillo provided the preliminary results of the JCAHO survey and stated

that New Horizons Community Service Board received ten Type 1 recommendations

which are as follows with corrective actions:



1. Rights and Responsibilities: New Horizons Community Service Board was using

a level system at a mental health group home that was approved by the division

director but had not received approval by the Performance Improvement

Committee. CORRECTION: The Consumer Rights Committee will review and approve

the level system and will present this level system at the next Performance

Improvement Committee for review and approval. A new policy will state that

all levels, points, and behavioral programs must be approved at the Performance

Improvement Committee level.



2. Initial Screening and Clinical Assessment: JCAHO surveyors cited that New

Horizons Community Service Board?s Biopsychosocial is not detailed enough

regarding Pain Management for consumers. CORRECTION: An action group will

develop a more detailed Pain Assessment and Follow-through Procedure. The

current Nursing Assessment will be amended to include the approved new

section. Nurses will receive training on the new assessment.



3. Assessment of Abuse and Neglect: JCAHO cited that New Horizons Community

Service Board?s Abuse and Neglect Assessment was not detailed enough.

CORRECTION: An action group has developed a more detailed assessment. After

approval at an upcoming Performance Improvement Committee meeting, the

assessment will be added to the Biopsychosocial. All clinicians will receive

training on this new section of the Biopsychosocial.



4. Medication Use: JCAHO surveyors cited a program for medications and

hazardous materials (Clorox) being stored together at a program site.

CORRECTION: On-site corrections have already been made regarding storage of

medications and hazardous materials. Program staff will receive training on

correct storage requirements.



JCAHO surveyors cited that when consumers self-administer their medication with

staff supervision at a program site (residential or day services) this

self-administration of medications must be ordered by the physician.

CORRECTION: A policy has been drafted to ensure that physicians order

self-administration with or without observation. A policy will be considered

for review at the next scheduled Performance Improvement Committee meeting.

Also, this physician order of self-administration of medications will be added

to the Medical Record?s audit and the Corporate Compliance audit to ensure

follow-through.



5. Continuum: JCAHO surveyors cited that some consumers have been discharged

from the local hospital and emergency rooms and returned to New Horizons

Community Service Board programs without written aftercare instructions.

CORRECTION: All New Horizons Community Service Board staff will be instructed,

through a memorandum, that if a New Horizons Community Service Board consumer

is picked up at the hospital and returned to a New Horizons Community Service

Board program, written aftercare instructions must be obtained, and the written

instructions must be placed in the consumer?s medical record. For those

consumers in outpatient services who obtain hospital treatment, they will be

requested to sign a release of information for New Horizons Community Service

Board to obtain the hospital discharge summary. If the consumer refuses to

sign a release of information form, this will be documented in the medical

record.



6. Aggregation and Analysis: JCAHO surveyors cited that critical incidents

resulted in an investigation not a systems review. CORRECTION: New Horizons

Community Service Board staff will complete a systems review on two critical

incidents. We will complete systems reviews in the future on critical

incidents.



7. Environment of Care: JCAHO surveyors cited that two doors at Alchemy are not

acceptable. CORRECTION: New Horizons Community Service Board will purchase

and replace the two doors at Alchemy. We will ensure that the doors open

outward and have panic bars.



JCAHO surveyors cited that housekeeping chemicals stored at one program site

were not properly labeled on the bottle. CORRECTION: New Horizons Community

Service Board staff at this program site will contact the contracted cleaning

company to ensure that all chemicals stored on site are properly labeled. New

Horizons Community Service Board site inspectors will receive re-training on

this issue.



JCAHO surveyors cited that New Horizons Community Service Board program?s fire

drills are not adequately monitored. CORRECTION: From this point forward,

fire drill completion will be monitored by the Performance Improvement

Committee rather than through division directors.



JCAHO surveyors cited that New Horizons Community Service Board needs to

identify a specific person whose responsibility area would be Safety. New

Horizons Community Service Board needs to ensure completion of the annual risk

assessment; completion of the annual assessment of safety management plan,

security management plan, emergency management plan, equipment management plan,

utility systems management plan. CORRECTION: The New Horizons Community

Service Board staff identified as being responsible for Safety will have their

Performance Management Form revised to specifically state that function. New

Horizons Community Service Board staff will be trained on annual evaluation

requirements. Annual risk assessments and annual review of management plans

will be added to the Performance Improvement calendar to ensure completion.



8. Qualifications, Competencies and Clinical Responsibilities: JCAHO surveyors

cited that competency checklists were not aggregated and trended and are not

measurable. CORRECTION: An action group will be created to expand the

competency checklist format to include data collection and analysis.



JCAHO surveyors cited that Performance Management Form evaluations were

completed late on four out of ten personnel files reviewed: CORRECTION: New

Horizons Community Service Board?s Executive Director will enforce Performance

Management Form deadlines.



9. Clinical Data and Information: JCAHO surveyors cited that discharge

summaries that were reviewed did not contain enough information. CORRECTION:

The Medical Record?s Committee will revisit the current discharge summary form

for possible modification.



JCAHO surveyors cited that when verbal orders are given that the physician is

not dating them. CORRECTION: A policy will be drafted to be reviewed/approved

at the next scheduled Performance Improvement Committee meeting. This item

will then be added to the Medical Record?s audit, the Corporate Compliance

audit and the Utilization Management audit.



JCAHO surveyors cited that consumer physical examinations received from outside

agencies are not authenticated. CORRECTION: The Performance Improvement

Committee will revisit the agency policy on accepting outside physicals ?

whether to accept them or not ? if so, a procedure for authentication will be

developed. We will add review of authentication of outside physical exam to

the Medical Record?s audit, the Corporate Compliance audit and the Utilization

Management audit.



10. Surveillance, Prevention and Control of Infection: JCAHO surveyors cited

that the staff?s responsibility for Infection Control is not specified in the

staff?s contract or Performance Management Form. CORRECTION: New Horizons

Community Service Board will revise the staff?s contract to include Infection

Control responsibilities, including expectations of time requirements.



Cyndy Pattillo reported that this is JCAHO?s preliminary report of New Horizons

Community Service Board?s survey. The official JCAHO report is expected to be

received within 45 days and New Horizons Community Service Board has six months

to provide a corrective action plan on all Type 1 recommendations.



7. Financial Reports: Mr. Wesley Shorter reported that as an agency, New

Horizons Community Service Board has struggled for quite a while financially

and continues to struggle. Mr. Shorter shared that he is aware of some board

members being concerned about New Horizons Community Service Board remaining in

debt, going forward, and requested that a report be provided on where New

Horizons Community Service Board is and where it is going.



Valerie Bowden provided the financial report for the six months ended December

31, 2001 that reflected a $719,126 deficit for New Horizons Community Service

Board. Primarily, implementation of Revenue Maximization has caused this

deficit as credentialed staff have been employed to provide correct staff to

consumer ratios to meet standards. At the June 11, 2001 board meeting, a

report was provided that reflected the cost of implementing the new Revenue

Maximization initiative/realignment at New Horizons Community Service Board to

be approximately $1.8 million. The actual cost of implementing Revenue

Maximization was $1.3 million which is ? million dollars less than what was

projected. New Horizons Community Service Board?s Residential Services

Division has increased the number of consumers from 105 to 145 (a 37%

increase), has added fifteen new housing sites and employed additional staff to

provide services to these additional Residential Services Division consumers.



Valerie provided a graph that reflected the total Medicaid billing received

from July 2001 through January 2002. This graph also reflected the Medicaid

Revenue Per Day for this same period. New Horizons Community Service Board has

experienced a positive increase in the total Medicaid billing and continues to

monitor this activity on a daily basis. Projecting the budget through June 30,

2002, New Horizons Community Service Board is expected to have a projected

$752,117 deficit for the fiscal year.



New Horizons Community Service Board has a new block grant development building

in Harris County that is ready for occupancy. However, this building must be

furnished from New Horizons Community Service Board?s budget funds before it

can be occupied. Program staff continue working on this effort.



Board members requested information on how New Horizons Community Service Board

would balance its budget by the end of the fiscal year. Information was also

requested on employing staff to assist those consumers who are

Medicaid-eligible registering for Medicaid. Perry Alexander reported that this

is a collaborative effort between New Horizons Community Service Board and the

Department of Family and Children Services. One Medicaid Eligibility staff

person has been selected for Muscogee County and we continue working on the

selection for Randolph County.



8. Bridge Money: Mr. Wesley Shorter reported that bridge money is money the

state division may be/is making available to struggling community service

boards. Mr. Greg Hoyt, Region 9 Executive Director, was introduced and

reported that Perry, Valerie and he met with Karl Schwarzkopf and Carroll

Benson from the Division of Mental Health, Mental Retardation, and Substance

Abuse in December 2001 regarding New Horizons Community Service Board?s

implementation of Revenue Maximization and the financial situation of the

agency. Mr. Hoyt reported that New Horizons Community Service Board?s Mental

Retardation Division?s Budget 400 would receive a $150,000 advance (this money

must be paid back) in January 2002. Mr. Hoyt also reported that New Horizons

Community Service Board is expected to receive $600,000 in ?new? money in

February 2002. It has not been determined if and when these funds ($600,000)

must be paid back.



9. DACE: Mr. Wesley Shorter reported that DACE is a standing report as the

board is concerned about the number of consumers in the hospital because New

Horizons Community Service Board wants to serve people in the community and

avoid financial penalties. Mr. Shorter requested a DACE report. Valerie

Bowden reported that for the period July 2001 through December 2001, New

Horizons Community Service Board?s allowable DACE was 8,094. New Horizons

Community Service Board used 7,878 bed days for this same period and was 216

days under our available bed day rate. To-date, January 2002 is under the

available bed day rate.



10. Annual Signature Event: Mr. Wesley Shorter reported that for quite a while,

New Horizons Community Service Board has been interested in community awareness

and the board believes there is an opportunity to receive some charitable

dollars from the community. Mr. Shorter requested that board members Nancy

Schroeder and Vickie Allen provide an update on the activity regarding the

planning for New Horizons Community Service Board?s annual signature event that

will be held on March 19, 2002 at Green Island Country Club.



Vickie Allen reported that Former First Lady Rosalynn Carter will be the

keynote speaker for this event and the event?s focus will be on ?Building

Better Lives?. This event is a fundraiser and is ?by invitation only?.



Nancy Schroeder reported that the reception would begin at 6:00 p.m. Mrs.

Carter would attend the reception for about 30 minutes. The dinner would begin

at 7:00 p.m. and Mrs. Carter will be scheduled to speak beginning at 7:15

p.m. Nancy reported that New Horizons Community Service Board is developing a

video to be shown at this fundraiser and recommends that we include the story

of the NHEAT Program.



Paul Fike reported that a corporate table could be purchased for $400 per

table. Each board member is requested to invite community leaders to attend

and support this fundraiser. Also, the 2002 NHEAT Campaign had 97% employee

participation and a total of $21,404.96 was pledged.



11. Corporate Compliance Report: Mr. Wesley Shorter reported that Corporate

Compliance is a standing agenda item of the board and asked for a brief

report. Susan Gallagher reported that the Medical Record?s follow-up audits

continue and provided a combined December follow-up audit that reflected the

percentage of improvement for each item audited. The Business Practice Audit

subcommittee is working on an audit tool to use at the programs that would exam

how effectively the business aspects of the program are running. Closed-event

ticketing and scheduling will be examined as well as procedures for ensuring

service tickets are accurate. The subcommittee expects to begin using this new

audit tool beginning February 18, 2002. The Corporate Compliance Office has

provided compliance training to ten employees on December 5, 2001, to nine

employees on December 9, 2001 and to seventeen employees on January 24, 2002.



The HIPAA subcommittee members are scheduled to attend training in March 2002

at the Trade Center with a speaker from the Georgia Department of Human

Resources and an attorney who specializes in HIPAA and privacy issues. The

HIPAA GAP analysis will begin in March 2002 in preparation of a HIPAA plan

expected to be completed by October 2002. HIPAA compliance is required by

April 2003 although legislation may push that date back.



The Corporate Compliance Office has not received any corporate compliance issue

complaints through the Hotline number.



12. Georgia Therapy Associates: Mr. Wesley Shorter reported that several months

ago the board learned that the State Methadone Authority or the Division of

Mental Health, Mental Retardation and Substance Abuse, changed the policy and

standards for Methadone Maintenance. The board has determined that it is in

the best interest of New Horizons Community Service Board to find a

subcontractor to provide Methadone services. Mr. Shorter requested a status

report of this service delivery program.



Perry Alexander reported that New Horizons Community Service Board would

contract with Georgia Therapy Associates beginning February 1, 2002 to provide

Methadone Maintenance services. New Horizons Community Service Board staff has

been meeting with DEA Office staff to ensure a smooth transfer of this

service.



13. Accident: Perry Alexander and Carolyn Ryder reported that an automobile

accident occurred with a New Horizons Community Service Board employee on

today. This employee was en-route to pick up and transport a consumer home

from work. An accident occurred on I-185 where the New Horizons Community

Service Board vehicle hit a stalled vehicle and there were two fatalities. The

New Horizons Community Service Board employee was not injured. All necessary

agencies have been informed of this accident, according to policy/procedure.



14. Community Service Board Meeting Time: The board reviewed the meeting time

for board meetings and agreed that the meeting time would remain as it is.



15. Training and Technical Assistance Summary on Readiness to Implement Revenue

Maximization: Perry Alexander reported that this document was pre-mailed and

indicated that New Horizons Community Service Board is organized to effectively

implement Revenue Maximization.



16. Carl Vinson Institute Survey/Interview ? Board Governance: Perry Alexander

reported that Peggy Crow and Carlton Bain from the Carl Vinson Institute would

be contacting board members to participate in a telephone interview as they

complete their board governance review. Also, the surveys previously provided

to board members by the Carl Vinson Institute are due to be returned by

February 1, 2002.



17. Public Comments: Greg Hoyt reported that the Mental Retardation Division

has responded cooperatively to consumer issues especially with the Bainbridge

closure. The service provided to mental retardation consumers is commendable.



Greg requested that Larry Stephens be contacted as New Horizons Community

Service Board staff begins the task of aggregating and trending requested

information for JCAHO.



Greg offered assistance in helping JCAHO and American Psych Systems to review

each agency?s standards being used and possibly avoid difficulties in meeting

more than one set of standards.



Paul Fike reported that New Horizons Community Service Board is the recipient

of a $10,000 gift from a local foundation through the Development Advisory

Board.



18. Adjournment: M/S/P Lawrence Young/Roxann Daniel that the January 28, 2002

meeting is adjourned at 5:30 p.m.













________________________________________ ____________________________________

Vickie Allen, Secretary Wesley Shorter, Chairperson





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