PUBLIC HEARING - HUMAN SERVICES COMMITTEE · who's my executive director, both for their hard work...

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Page: 1HEARING, 4/9/2015

COMMONWEALTH OF PENNSYLVANIA HOUSE OF REPRESENTATIVES

HUMAN SERVICES COMMITTEEPUBLIC HEARING ON MENTAL HEALTH CLINIC COMPLIANCE

El Consilio 141 East Hunting Park Avenue

Philadelphia, Pennsylvania 19124

Thursday, April 9, 2 015 1:00 P.M.

BEFORE:HONORABLE GENE DiGIROLAMO, MAJORITY CHAIRMAN REPRESENTATIVE ANGEL CRUZ, MINORITY CHAIRMAN REPRESENTATIVE MICHAEL DRISCOLL REPRESENTATIVE CRAIG STAATS REPRESENTATIVE STEPHEN KINSEY REPRESENTATIVE THOMAS MURT REPRESENTATIVE LESLIE ACOSTA REPRESENTATIVE JOE HACKETT REPRESENTATIVE JASON DAWKINS REPRESENTATIVE MICHELLE BROWNLEE REPRESENTATIVE RON WATERSALSO PRESENT:MELANIE BROWN, EXECUTIVE DIRECTOR ASHLEY McCAHAN, EXECUTIVE DIRECTOR CHRISTINA CONSYLMAN, AA RACHEL ROMANOFSKY, RESEARCHER

REPORTED BY: Suzanne M. Feezle-Gigliotti, Court Reporter and Notary Public

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INDEX OF SPEAKERSBY CHAIRMAN DiGIROLAMOBY FRED RAMIREZBY HECTOR AYALABY TRACY GRIFFIN COLLANDERBY JOAN ERNEYBY DENNIS MARIONBY MS. RUIZBY DR. PRICEBY DR. POPEBY MR. MATOSBY MS. SIERRA THROUGH MR. MORALES BY MR. DeVOS BY MS. BARLEY

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CHAIRMAN DiGIROLAMO: Good afternoon and welcome to everyone.

Even though the weather outside is not quite spring-like, and in March we're usually 75 degrees, it is certainly warm and friendly in here.

So I would like to call this meeting of the Human Services Committee to order.

And I might start out by first letting the members just say hello and let you know who they are.

I'll start off with myself. I'm Gene DiGirolamo from Bucks County. I am the Republican Chairman of the Human Services Committee.

REPRESENTATIVE CRUZ: Angel Cruz, the Minority Chairman of the Committee and here from Philadelphia.

Welcome to my 180 Legislative District.REPRESENTATIVE STAATS: And I'm State

Representative Craig Staats, also from Bucks County. Welcome.

REPRESENTATIVE DRISCOLL: I'm Mike Driscoll and I represent the 173rd here in Northeast, Philadelphia.

REPRESENTATIVE KINSEY: Good afternoon.State Representative Steven Kinsey,

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Philadelphia County.REPRESENTATIVE MURT: Good afternoon.Representative Tom Murt representing

part of Montgomery County and part of Philadelphia.REPRESENTATIVE ACOSTA: Representative

Leslie Acosta representing the 197th District.REPRESENTATIVE HACKETT: Good afternoon.Joe Hackett with Delaware County.CHAIRMAN DiGIROLAMO: Okay. With that,

maybe I'll just make a few short, brief comments.I want to thank my chairman,

Representative Angel Cruz, for putting this hearing together.

And also thank Ashley and Melanie Brown, who's my executive director, both for their hard work in putting this hearing together.

This an important issue. It is really an important issue. We talk about human services, mental health and, in a lot of ways, drug and alcohol.

There's good news. I mean, Governor Wolf has just expanded Medicaid, which I think is a huge step in helping people who need services for behavioral health to get the help that they need.

It's going to be 600,000 Pennsylvanians that are going to be covered.

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And I'll remind everyone that these people who are going to be covered by the expanded Medicaid are mostly people who are in the workforce, you know, making minimum wage, $10, $12 an hour, who have no health care affordable to them, so this is going to be really, really huge.

I know there's some problems -- I see Joan Erney in the audience -- there's been some problems with getting this kicked off, but I think we're on the right path and the right trail.

So we're going to get this done and in a few months we'll have everything. So, you know, behavioral health issues.

I mean, when you look at our prison population and when you look at the crime and when you look at the violent crime that's being committed, it's not only here in Philadelphia and Bucks County, but throughout the state of Pennsylvania, many of these people have mental health problems and drug and alcohol problems.

I mean, I think it's on the order in our state prison system of about four out of five people are in prison because they've committed crimes and they had mental health issues and/or drug and alcohol issues.

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So this is a critically important issue.And again, I want to thank

Representative Cruz for holding this meeting.And, with that, just a couple simple

ground rules. I mean, we have a very ambitious agenda today.

So I thought we might ask everyone who is going to testify to come up and testify, and then at the end of the hearing -- we have to be done at 3 o'clock.

At the end of the hearing, there should be enough time to come back up and if any of the members have questions for any of the people who testify, they'll do that at the end of the hearing.

So, with that, let's call our first testifier. And that is Fred Ramirez, who is the President and CEO of Pan American Mental Health Services.

Fred, welcome.MR. RAMIREZ: Thank you, Mr. Chairman.CHAIRMAN DiGIROLAMO: You can begin your

testimony whenever you're ready.MR. RAMIREZ: Can everyone hear me?Okay. Thank you, Mr. Chairman.Good afternoon, members of the House

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Human Services Committee.As Representative DiGirolamo said, my

name is Fred Ramirez and I'm the CEO of Pan American Mental Health Services, Incorporated.

I'm also the Chair of the Board of Trustees of Aspira Bilingual Charter Schools and Co-Chair of the Latino Behavioral Health Coalition.

Pan American has been an outpatient provider of behavioral health services for the past 17 years. We offer our services mostly in the Latino community here in North Central Philadelphia.

Most of the services provided are to Spanish-speaking people, and, thus, most of our staff is bilingual and bicultural.

All of our professional -- or rather, all of our nonprofessional staff is from and lives in our neighborhoods and are products of our schools.

Although the hearings today seem to focus on the monitoring of clinics for licensing and license renewals, I wanted to come forth and speak of the experiences that we, at Pan American, have had over the past couple of years.

We operate in North Central Philadelphia out of two sites.

One is located on the 4500 block of

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North 5th Street and the other one is located at the old Episcopal Hospital Outpatient Mental Health Clinic at 2561 North Front Street.

These two sites serve approximately 1,200 people. And the 5th Street site has waiting lists since we are at full capacity. We serve every spectrum of North Central Philadelphia: children, youth, adults, and elderly people.

Our children suffer the trauma of abuse in every form. The majority of youth served by us are in special education, if they are in school, which is a nice way of saying they have behavioral health issues.

Adults and the elderly suffer the consequences of abysmal socioeconomic conditions. We have just formed and fortified our Family Services Unit and also provide faith-based services.

In the midst of this, six days a week, day to day, we work with CBH at the City level and the state Office of Mental Health and Substance Abuse.

Many years ago I was invited to testify before the City Council in favor of the creation of CBH by Estelle Richmond. I did so.

I've mentioned earlier, I do not speak of the status of other providers or the quality of

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their services. I speak of ours.I wish to emphasize to the Committee

that we, at Pan American, receive several visits a year from both CBH and the state.

Community Behavioral Health works extremely close with us. So close that our directors and senior staff often complain.

We are visited by the NIAC, which is the Network Improvement and Accountability Collaborative, oftentimes by Compliance, we add to that consumer surveys, which encompasses direct dialogue with our consumers.

Every Monday is continuing education training and seminars, often by CBH trainers. In essence, we have at a minimum three Community Behavioral Health audit-type visits a year.

The Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse also does a re-license visit once a year.

Everything from our personnel charts, in order to make sure our staff is properly credentialed, legally cleared of any wrongdoing that would prohibit them from functioning in a given capacity.

They check for any missing or expired psychiatric licenses. In short, they are very

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thorough, as well as meticulous.They also check, like CBH, consumer

records. If some deficiencies are noticed, we must send in a Plan of Corrective Action within a short time frame.

I have absolutely no knowledge of other providers. Pan American does not have a Drug and Alcohol license. Thus, we're absolutely not involved with the concern of our some of our civic leaders.

We attempt to regulate closely what our psychiatric staff prescribes through our Medical Director. We do not wish to be a pill mill.

And I personally react swiftly to any request for information, for a meeting or concern of any leader, be them elected or civic.

For us, in fact, the regulations of the authorities are sometimes too tight that we spend a large amount of agency resources addressing and correcting when we have to. I believe we do much with little.

We serve a large swath of a population living in the poorest ZIP codes of the Commonwealth.We do it as outpatient services. We do not have higher or different levels of care.

It is estimated by us that probably 65


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percent of our residents are on some type of public assistance, be it Medicaid, Medicare or SSI.

Yet, with our slender resources, we are the front-line champions of mental health and prevent, more than we know, the adverse and costly consequences of non-treatment in a neighborhood setting.

We have no knowledge of other provider locations, but are constantly striving.

Evidence of this is the fact that Pan American Behavioral Health is in the middle of seeking our CARF accreditation, which stands for Commission on Accreditation of Rehabilitation Facilities.

We have every intention of continuing our close collaboration and pursuit of excellence with both the City and the state.

In this manner, we can contribute to offer solutions to the behavioral and health problems of our community first outlined and still in existence in the 1994 report titled "Reports of Health and Healthcare Improvement Project," published by the Delaware Valley Health Education.

Thank you all for listening and paying close attention to this extremely vital issue for all of us.

CHAIRMAN DiGIROLAMO. Thank you, Fred.

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Thank you for your testimony.Next, we have Hector Ayala, who is the

President and CEO of Hispanic Community Counseling Services.

I would also like to note the presence of former State Representative George Kenney, who is with us today. George is now with Temple Hospital.

I believe that Temple Hospital does provide outpatient mental health services for this area at Episcopal Hospital, I believe.

George, welcome. It's always good tosee you.

MR. AYALA: Good afternoon.First, I would like to say to the

Honorable State Representatives Angel Cruz and Leslie Acosta, thank you for inviting me and having me here.

I would like to take this opportunity to testify today in this important hearing. My name is Hector Ayala.

And for the past ten years I have been the President and CEO of Hispanic Community Counseling Services, an outpatient mental health facility providing services in the Kensington area.

I have more than 20 years in practice devoted to community-based organizations. HCCS, as a

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community-based organization, is an integral part of the managed care solution in North Philadelphia.

Experience, wisdom, and on-the-ground expertise specializing in serving high needs consumers in community-based organizations like ours.

Community integration is the aim of consumer recovery and part of our mission. We know the communities and the neighborhoods where we operate.

I'm also the co-founder and co-chair of the Latino Behavioral Health Coalition. The Latino Behavioral Health Coalition represents eight Latino providers throughout Philadelphia.

The Coalition is the umbrella non-profit association of Philadelphia's behavioral health providers who primarily serve the Latino community.

Collectively, in a year, we serve more than 35,000 adults and children in the Latino community.

Founded in 2011, the mission of the Coalition is to improve the quality of behavioral health services to our communities through leadership and advocacy.

We are committed to coordinate the efforts of the private sector towards efficient

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delivery of quality behavioral health services to children, adults, and families.

The HCCS and Coalition promotes policies and practices that support the development and provision of community-based housing, treatment, rehabilitation, and support services to all people with mental health illness and addiction disorders, while providing urgent, unfunded social services and referrals.

The Coalition looks forward to continuing our work with DBHIDS and CBH on issues concerning the future direction of mental health and substance abuse disorder services and systems for the Latino community.

As I understand, the purpose of this hearing is to talk about the licensing and inspection process for Philadelphia mental health clinics.

However, I would like to also address challenges, as well as the ongoing efforts of the Latino providers towards improving the provision of quality of care.

For nearly half a century publicly-funded, community-based outpatient clinics have served a vital role in providing psychiatric and substance abuse treatment and related behavioral


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health supports to children and adults in the communities across Pennsylvania and Philadelphia.

Outpatient clinics have been the foundation of the public behavioral health system, serving as a safety net for the state's most vulnerable population.

Tens of thousands of low-income citizens use outpatient clinics as their primary source of behavioral health care.

Today, behavioral health outpatient clinics face serious challenges that are eroding their quality of care and threatening their very existence.

It is in the interest of all stakeholders: consumers, family members, service providers, county systems, and state government, to come together to face these challenges and transform Pennsylvania's behavioral health outpatient service system into a recovery and resilience-oriented resource for the next 50 years.

For decades, thousands of Philadelphia residents have struggled to access affordable, quality mental health services needed to lead happy, healthy lives.

They suffer from endless battles with insurance companies over coverage and limited numbers

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of facilities or providers with the necessary expertise and availability, as well as the stigma and discrimination that prevents them from seeking help and hinders their ability to recover and participate in community life.

Many public consumers and families are dealing with very complicated issues that are rooted in multi-generational, socioeconomic, emotional and psychiatric problems.

We service a community with high levels of trauma, based on domestic violence, substance abuse, high levels of incarceration, high unemployment, and lack of education or poor access to better education.

Today, we have an opportunity to critically examine the sources of the access, quality, and affordability problems in the current mental health systems and to take a comprehensive action to solve them.

There is an urgent need to rethink, reform, and restructure an archaic and inflexible system for providing publicly-funded behavioral health outpatient services in Pennsylvania.

The current system was formulated almost 50 years ago and is out of step with the philosophic,

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operational, and financial realities of the 21st century.

In order to meet the needs of this new generation of consumers needing behavioral health services and supports, and to ensure that outpatient service providers can continue to operate in a time of financial uncertainty, the behavioral health system in Pennsylvania must begin to implement a fundamental transformation of the system for providing outpatient services.

Publicly-funded outpatient clinics have been the cornerstone of the community-based behavioral health system in Pennsylvania since the enactment of Mental Health and Mental Retardation Act in 1996.

The central goal of that landmark legislation was to redirect mental health treatment away from large, crowded, and geographically-isolated state mental hospitals into community-based programs.

The 1960's movement toward deinstitutionalization in Pennsylvania was a part of the sweeping national transformation of mental health services that was inspired by the civil rights movement and a renewed commitment to individual rights and civil liberties for all Americans, including people with mental illness.

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Another seismic shift in behavioral health policy has occurred during the first decade of this century.

The 2003 President's New Freedom Commission on Mental Health posed a fundamental challenge to the behavioral health system in the United States when it concluded "...that the system is not oriented to the single most important goal of the people it serves - the hope of recovery."

The NFC defined recovery as the process in which people are able to live, work, learn, and participate fully in their communities.

For some individuals, recovery and resilience is the ability to live a fulfilling and productive life despite a disability. For others, recovery means the reduction or complete remission of their symptoms.

In 2005, the Pennsylvania Office of Mental Health and Substance Abuse Services endorsed the NFC report and made the commitment to establishing a recovery and resilience-oriented behavioral health system in the Commonwealth of Pennsylvania.

OMHSAS urged county behavioral health systems and service providers to incorporate the recovery and resilience-oriented tenets of

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self-determination, hope, empowerment, and choice into restructured services that support people reaching their full potential as individuals and community members.

The OMHSAS mandate was clear. It is time for a system change.

While Pennsylvania's behavioral health system has been an innovative recovery and resilience- oriented pioneer on many fronts, this has not been the case in regard to publicly-funded outpatient services.

The current system is rooted in an antiquated medical model that focuses almost exclusively on symptom reduction, the individual's presenting problem, and hierarchical relationships.

The system -- the rules and regulations governing Pennsylvania's patient clinics -- okay. I'm sorry.

However, many modern-day consumers and families are demanding a model of care that facilitates recovery and resilience, prioritizing self-determination, and emphasizing building a meaningful life in the community.

The Pennsylvania outpatient clinic of the 21st century needs to be transformed into a community of wellness centers that address the whole

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Page: 2 0HEARING, 4/9/2015

person through an integrated consumer-directed treatment planning, individual, family, and group therapies, case management, peer support, physical health treatment, social services, substance abuse services, vocational rehabilitation, and a variety of other supportive services.

If outpatient care is going to be aligned with the principles of recovery and resiliency that are being espoused by OMHSAS, there needs to be a comprehensive overhaul for the current regulation and funding system that creates disincentives to recovery and resilience practices.

Not only does the current system erect barriers to recovery and resiliency and community integration, it also perpetuates inefficiencies and inflexibilities that undermine the abilities of agencies to provide basic quality outpatient services.

Agencies are hindered by excessive paperwork, redundant inspections, inflexible staffing requirements, antiquated regulations, and rigid procedural policies that do not improve the quality of care, but only add time-consuming and costly diversions from the core mission of providing services to individuals.

There is a pressing need for OMHSAS,

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behavioral health managed care companies, and county behavioral health departments to collaborate and implement reforms that reduce unnecessary operational burdens on agencies providing outpatient services.

Finally, the economic realities of the current fee-for-service system for funding outpatient services to Medical Assistance recipients in Pennsylvania has resulted in agencies operating outpatient programs at a deficit.

In a time of economic downturn and government cutbacks, it is becoming increasingly difficult for agencies to tap funds from other services to counterbalance the expense of operating outpatient services.

County governments cannot afford to subsidize outpatient clinics. The status quo is simply not sustainable.

The reimbursement rates for outpatient services must be increased, essential services that are currently unfunded need to become eligible for reimbursement, and other creative options for funding outpatient services need to be seriously considered.

In conclusion, for nearly half a century, publicly-funded, community-based outpatient clinics have served as a vital role in providing

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psychiatric treatment to people in communities across Philadelphia.

Outpatient clinics have been the foundation of the public behavioral health system, serving as a safety net for the state's most vulnerable population.

Tens of thousands of low-income citizens use outpatient clinics as their primary source of behavioral health care.

Today, behavioral health care outpatient clinics face serious challenges that are eroding their quality of care and threatening their very existence.

I want to urge to make funding to neighborhood community-based agencies for outpatient mental health services a priority.

It is in the interest of all stakeholders: consumers, family members, service providers, county systems, and state government, to come together to face these challenges and transform Pennsylvania's behavioral health outpatient service system into a recovery and resilience-oriented resource for the next 50 years.

With your support and vigilance, we can continue the utilization of best practices and the continuation and expansion of most needed services.

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Thank you and all those present for your leadership and for the opportunity to present this testimony.

I will be glad to answer any questions. CHAIRMAN DiGIROLAMO: Okay. Hector,

thank you so much for your testimony here today.Next up, we have Tracy Griffin

Collander, who is the Executive Director of Behavioral Health Care Accreditation, and Jennifer Hoppe, Senior Associate Director of State and External Relations to The Joint Commission.

And before you begin, I'd like to recognize the presence of Representative Dawkins, who has joined us, Representative Brownlee, and I also believe Representative Waters is here also.

So welcome to the members.And you can begin whenever you would

like.MS. GRIFFIN COLLANDER: Okay. Thank

you.And good afternoon, Chairman DiGirolamo

and Chairman Cruz and members of the House Human Services Committee.

I'm Tracy Griffin Collander, Executive Director for The Joint Commission's Behavioral Health

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Care Accreditation program.And I'm joined today by my colleague,

Jennifer Hoppe, Senior Associate Director of State and External Relations for The Joint Commission.

We appreciate this opportunity to provide the Committee with information about The Joint Commission's accreditation process.

The Joint Commission was founded in 1951, and is a private-sector, non-profit accrediting body dedicated to improving the safety and quality of health care provided to the public.

The Joint Commission accredits and certifies over 21,000 organizations throughout the country, including 90 percent of the nation's hospitals.

In 1969, The Joint Commission began accrediting providers of programs and services for persons with intellectual and developmental disabilities, and expanded its accreditation in 1972 to include the evaluation and accreditation of organizations that provide mental health and substance abuse treatment services.

Today, The Joint Commission accredits more than 2,100 behavioral health care organizations throughout the nation and maintains deemed status with


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CMS to accredit over 445 psychiatric hospitals.Currently, The Joint Commission

accredits 212 organizations in Pennsylvania that provides behavioral health services to residents throughout the Commonwealth.

The Joint Commission Behavioral Health Accreditation provides a management framework to help manage risk and enhance the quality of care, treatment, and services to the people that behavioral health care organizations serve.

Recognized by more than 196 state authorities, accreditation can be a useful tool to demonstrate compliance with state regulations or licensure requirements.

Joint Commission accreditation is also a condition of reimbursement for certain insurers and payers. The process provides a customized, intensive review, and enhances staff recruitment and development.

The accreditation requirements of The Joint Commission's Behavioral Health Care Accreditation program address important functions related to the care, treatment or services of individuals and the management of behavioral health care organizations.

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The requirements are framed as performance objectives that are unlikely to change substantially over time.

A trauma-informed recovery and resilience-oriented philosophy and approach to care, treatment and services is embedded in all of our requirements.

The Joint Commission develops all of its accreditation requirements in consultation with behavioral health care experts, providers, measurement experts, individuals, and their families.

And, as an overview, the standards-based performance areas for all behavioral health care organizations are as follows:

We have a Care, Treatment, and Services section that provide standards related to screening, assessment, treatment planning services, and discharge planning; an Environment of Care section of standards that reviews the environment that people are served within; Emergency Management to look at emergency management systems; Human Resources Management to look at credentialing and hiring of employees, as well as ongoing training and certification; Infection Prevention and Control to look at issues such as influenza outbreaks and managing influenza within the

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facilities, amongst staffing, and population served; Information Management, Leadership.

One of the unique behavioral health accreditation offerings of The Joint Commission is that The Joint Commission works with an entire organization to accredit and other accrediting bodies who get a program, they're under the entire organization.

So that's key to our accreditation program, in that we really look at the leadership structure and how it influences the entire organization down to the quality and the -- and the safety of the services offered to the individuals in the organization.

We also have standards related to life safety, so for fire emergencies and making sure to meet standards related to safety with fire and other issues, construction, et cetera.

Medication Management, so safe prescribing, safe storage, and safe systems to manage medication for people.

And in one case related to the mental health population also have to do with looking at any kind of medications, making sure that there are the adequate number, the manner that were prescribed.

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There's a system in place for how that is managed and overseen.

We also have National Patient Safety Goals, which is unique to The Joint Commission. And the National Safety Patient -- National Patient Safety Goals are issues that are brought to us that are high-risk areas for organizations.

For example, suicide and prevention of suicide in the behavioral health care service organization.

We also have a chapter focused specifically on Performance Improvement, so really encouraging organizations to collect data on the -- on the work that they're doing to look at how it's impacting their outcomes and have an ongoing improvement process in place that we evaluate when we come out to do our surveys.

We also look at Record of Care,Treatment, and Services. Rights and Responsibilities of people served, as well as Waived testing, such as dipstick testing for urinalysis in a substance abuse treatment program.

In terms of the accreditation process,The Joint Commission's accreditation process concentrates on operational systems that are critical

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to the safety and quality of an individual's care.To earn and maintain accreditation, a

behavior health care organization must undergo an on-site survey by a Joint Commission survey team at least once every three years.

Surveys are conducted by experienced and licensed behavioral health care professionals that include psychologists, social workers, professional counselors, behavioral health care nurses, and administrators, and they are employed with The Joint Commission.

Many will survey as often as 12 times a year, as their significant experience and their length of service with The Joint Commission averages about 11 years.

So they're bringing that level of experience and expertise into the organization's survey.

The objective of the survey is not only to evaluate the organization's compliance with standards, but also to provide education and guidance that will help staff conduct and improve the organization's performance.

The survey process evaluates actual care processes through a method that is known as tracer


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methodology.This method traces individuals through

the care, treatment, and services that they receive and analyzes key operational systems that directly impact the quality and safety of an individual's care.

Surveyors will assess the organization's compliance with the standards through tracing the care delivered to individuals, on-site observations, and interviews, and verbal and written information that is provided by the organization to the surveyors.

Following the on-site evaluation, the organization will be required to submit corrective action for all standards determined to be non-compliant at the time of the survey.

The Joint Commission allows the organizations either 45 or 60 days, depending on the criticality of the requirement, to submit their Evidence of Standards Compliance.

In addition, if the issue identified is related to a quantifiable measure, the organization is also required to submit evidence that corrective action was efficient and sustained four months after approval of the Evidence of Standards Compliance.

If compliance is not resolved within the established time frames, a progressively more adverse


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accreditation decision may result.In some situations, the findings from

the survey may call for an adverse accreditation decision where it's customary to conduct a second follow-up survey to assess the organization's compliance to the standards prior to awarding the organization with full accreditation.

In the rare circumstance that an organization is not able to successfully demonstrate compliance with standards, accreditation will be denied.

We also have a process that's called intra-cycle monitoring. And The Joint Commission's intra-cycle monitoring process helps organizations with their continuous standards compliance within that three-year period.

Every accredited organization has access to an intra-cycle management profile, which is an online work space through The Joint Commission's extranet that is unique to that organization.

The profile includes a list of high-risk topics and related standards, as well as resources and solutions to contemporary health care service challenges.

Located within the profile, the Focused

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Standards Assessment provides organizations with an easy-to-use, interactive standards self-assessment scoring tool.

This tool permits an organization to develop and monitor corrective plans of action in order to sustain standards compliance.

While the tool is available to organizations on a continuous basis, The Joint Commission requires that organizations complete and submit the Focused Standards Assessment to The Joint Commission at 12 and 24 months of the triennial accreditation cycle.

In addition to the triennial on-site surveys and the intra-cycle self-assessment, The Joint Commission also conducts random, unannounced surveys at five percent of our organizations in a calendar year, and conducts extension surveys when organizations add new sites or services, and may conduct complaint surveys when warranted as well.

Once again, thank you for the opportunity to provide information on The Joint Commission's accreditation process.

In addition to my testimony today, we have brought a copy of our Standards Manual for the Committee, as well as some information in a packet.

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And we look forward to answering questions later this afternoon.

CHAIRMAN DiGIROLAMO: Thank you, Tracy.Next up, we have Joan Erney from CBH,

which is the Philadelphia Office of Behavioral Health and Intellectual disAbility Services.

Joan, good to see you again.MS. ERNEY: Nice to see you, too.CHAIRMAN DiGIROLAMO: Welcome.MS. ERNEY: But, first, I need to

apologize. I'm recovering from a cold, so, hopefully, I won't have any coughing jags here.

I have provided you testimony, although I'm going to really try to highlight the major points of that testimony for you.

My name is Joan Erney. I am the CEO of Community Behavioral Health. We are the 501(c)(3) that administers the HealthChoices Medicaid managed care program for the City of Philadelphia.

And I'm really here on behalf of Dr. Evans, the Commissioner for Behavioral Health.

We really thought I would highlight kind of our role in the review of providers and what our approach has been.

Dr. Evans has been really clear in his


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leadership that he wants us to have a very competent, a very diverse, and a very qualified provider network.

We currently contract with over 200 providers. Of those, 80 are mental health outpatient clinics and they have 185 sites across the -- across Philadelphia.

We are governed by a contract that the City holds with Philadelphia, between DHS and Philadelphia DHS -- Pennsylvania DHS.

It's taken me a little while to get accustomed to that. And we also under the guidance of our state HealthChoices standards document.

There is a large document that we are obligated to follow that has all of the standards and expectations of both the federal government and the state government.

We are also governed by all of the regulatory processes that are already in place through CMS, through DHS, and licensing currently at DHS.

So, given that our focus is on mental health and the outpatient clinics, I wanted to again identify how we approach it.

For an agency to enter our system, we do use a competitive process. When we started the HealthChoices program, it was every willing provider

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for a period of time.But over time, when Dr. Evans came, he

saw that we needed more diversity and we needed more transparency in our processes in Philadelphia, and he instituted a procurement process.

In addition, City Council in Philadelphia required that for-profits had to -- could only come into our programs if they were coming in through a competitive process -- procurement process, and so we also instituted that.

So that is a way a current provider now comes into our network if they're not part of the legacy group.

We rely, as per our standards document, on state licensure. So any agency of any service that has the ability to be licensed by either DDAP or DHS, we rely on that as really a starting place for our access into service.

We do know that some agencies seek licensure and ask for letters of support from us.That does not guarantee that they hold a place in our network.

We really can -- you know, they can seek licensure without really coming to us.

Although often the state will ask for

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some feedback and a letter of support, but that does not guarantee an actual contract with us on the Medicaid side.

There is initial credentialing that CBH actually engages in that is done by staff on the Community Behavioral Health side, and then credentialing decisions are all governed by our Board of Directors so that CBH is a very, very unique entity and there is really nothing like it in the country.

So our Board of Directors is actually City government. We have one stakeholder that also participates, but we have the Deputy Mayor, we have DHS Commissioner, that's the Philadelphia DHS, and we have Commissioner Arthur Evans, who is actually the chair of the board.

So we have a really -- a Philadelphia commitment from the City, who actually created us to do this work for Philadelphia.

So we have -- the Board will make a decision as to whether or not an agency comes in. We also have policies and procedures that we have shared with providers about their entrance and their ability to stay in the program.

The Board of Directors also must review anyone who is being asked to leave the network.

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So we have an ability in our contract with agencies to do progressive sanctions. We have, in fact, eliminated providers for quality issues over time.

We, obviously, don't like to do that.We really need the providers in

Philadelphia and we want that competency, so we work very hard on technical assistance and really offering whatever solutions we can, but there certainly have been occasions when we have had to move in that direction.

And, again, the Board of Directors really guides that as to what we can do.

We also do a lot of monitoring. I think you heard a reference from Mr. Gonzalez that we have NIAC. This is another innovation that Dr. Evans brought to Philadelphia.

NIAC is a team that is comprised of staff across the enterprise.

So it has staff from OAS, which is a county-based drug and alcohol system; it has staff from mental health; it has staff coming from Medicaid and from our CBH contingency, and it was an attempt to really streamline the processes.

So we were aware that there were state

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visits.And then, on top of that, historically,

Philadelphia would send their OAS person out and then they'd send their mental health person out, and then they would have additional requirements of credentialing.

NIAC is really overseen by the Department of Behavioral Health and is a comprehensive approach to go out and really see agencies and do a marker against what we call practice guidelines.

We have established a set of guidelines that really reflect our commitment to recovery for adults, and for resiliency and recognize resiliency for children, and that these guidelines really offer us a way to look at initial intake, engagements, you know, recovery principles, as well as what happens afterwards.

And so it's a very comprehensive look.And for some of our agencies, the NIAC staff could be there as long as a week, because they're looking at every aspect and they will also talk to recipients.

So they will talk to our members who are actually receiving services at the site.

We also have compliance. We are required by the federal government and the state

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government to have a robust fraud and abuse program at CBH. We do.

We have a compliance officer. She is actually -- was the former attorney for DHS. She is now going back as the chief counsel for DHS. We're going to miss her, but she's been our compliance officer.

And this requires our staff to go out and really look at records and look at the regulations and confirm that things have been done appropriately.

When they are not, it is actually a requirement that agencies pay us back money, and that does happen every year where we find some issues of compliance.

We also have a consumer family satisfaction team that's part of the HealthChoices program generally.

It's also part of when you close a state facility, that you create a mechanism where people who are in recovery, people who have lived and experienced family members who have children in the system, really have an opportunity to directly give us their feedback.

So these are consumers and families themselves who do the interviews.

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It's a very, again, kind of innovative practice in Pennsylvania that allows, again, people who had their own experiences at an agency tell us if there's a complaint, if there's a concern, if there's something we need to do, and they also can share with us positive information.

We have a very robust quality improvement process within CBH. It's also a required element, but we are obligated to track complaints and grievances. We do that on a regular basis and we must follow up.

So, if we get either an informal complaint or a formal complaint, whether it's a person who tells us their name or they do it anonymously, we are required to address it.

So we do what we call -- essentially, call our huddles, and we will bring folks together and say, what do we know about the organization, what did the NIAC report say, what is the allegation?

And then we will determine what needs to happen after that.

Most typically, our QI staff actually go to the agency. They will go look at records; they will go interview staff; they will do a number of things that really are, you know, to take a look to

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address the complaint that's come in.But we are obligated, particularly if

there is a name, to actually write back and address that issue immediately.

We have a contractual relationship with our agencies, and, as I mentioned, there are really levels of kind of sanctions and things that we can do.

We do everything from close admissions, if there's a serious incident, to, as I mentioned, we can terminate an agency's directive.

Another thing that we have started in the last five years is something that we call Pay-for-Performance. This is really an effort to really recognize what we think are important elements and things that we care about.

So the goals of the HealthChoices program are really to ensure access and increase access to behavioral health services.

It is to really try to enhance the quality and make sure people are getting what they need from a qualified array of services, and it's to stabilize funding.

And so we think of those things as really important elements for us to really be able to reflect, and so our P4P really does focus on those

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first two, which is access and quality. We also look at engagement.

So for every level of care that we offer, we actually do an independent P4P, Pay-for-Performance, initiative and agencies on an annual basis are able to gain money and be rewarded for evidence that they have actually accomplished and have good programs in place.

So it's been a really nice initiative that has allowed for some ongoing recognition of those providers who are really good.

I think that I will stop at that and just share with you that we are extraordinarily -- you know, we're happy to be here.

We're extraordinarily committed to our provider network. We care deeply about what happens to the members in Philadelphia.

And that is really our sole reason for existence is to make sure that we are able to have folks access and have a healthy life in our Philadelphia city.

So thank you very much.CHAIRMAN DiGIROLAMO: Thanks, Joan.Thank you for your testimony.Let's have our last testifier come up,


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and that's Dennis Marion, who is the Deputy Secretary for OMHSAS, which is the Office of Mental Health and Substance Abuse Services, and Julie Barley, who is the Director of Eastern Operations, Bureau of Community and Hospital Operations.

And they both are with our Department of Human Services. So we have a brand-new name.

And I want to recognize Representative Tom Murt, who had a lot to do with changing the name of the Department of Public Welfare to the Department of Human Services.

So, Dennis, when you're ready to begin,please do so.

MR. MARION: Good afternoon, Chairman DiGirolamo and Cruz and members of the House Committee.

It is an honor to be with you today and your staff to talk a little bit about the role of DHS, the state Department of Human Services has in working with communities to deploy, plan and operate our managed -- our behavioral health service delivery system, particularly in our case, the mental health side of that.

I'm delighted to follow Joan, who did an excellent job describing.

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One of the strengths of Pennsylvania's approach to providing human services is that, yes, there is a state role in terms of providing funding, both federal and state funding, and channeling it through to a local service of delivery.

A unique characteristic in Pennsylvania is that we have this community base.

We work very closely with counties and county representatives who are part of the organizational structure for HealthChoices, which is our Medicaid managed care program.

The City here provides a very distinctive mechanism, whereby, the Department of Human Services of the City and its affiliate, the Community of Behavioral Health, managing the behavioral health needs, brings the strength of the City compliant and keeps us connected to local need and local service delivery.

But our purpose of being here today is to talk more about the state role and that hopefully will complement what you've heard from Joan.

The Department of Human Services in the recent past consolidated a number of licensing functions that used to be distributed amongst the various program offices.


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So that's particularly true in terms of the residential services. So that was centralized within the department.

So this was consolidated into a single administrative Bureau of Human Services Licensing, known as BHSL, and that is within the Office of Administration under a separate deputy.

But -- so the light functions where each of our program offices might have had licensing duties going out to residential programs, these light programs were consolidated and are licensed by the Bureau of Human Services Licensing.

That Bureau has 71 licensing representatives and 18 regulatory technicians that work across the Commonwealth.

And they are -- work from the 5310 and 5320 Regulations, which are in the residential chapter of the 3800 regs, and so that's the basis by which they do their on-site reviews.

OMHSAS also then has four field offices.And Julie, as Director of Eastern

Operation, oversees the field offices here that serve the Philadelphia region, and those offices are directly involve in the DHS licensing, the OMHSAS licensing of programs within your community.

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So, within the field offices, we have 45 staff and who -- who are responsible for the licensing process at the community-based programs that are not governed under BHSL, but they also do the monitoring of the HealthChoices contracts.

So we work very closely with Joan and her staff, and Dr. Evans and his staff, in terms of monitoring and licensing the service delivery system in the City.

And that process takes place on an annual cycle, so we visit those programs each year and so the team is quite busy.

The DHS individually licenses and inspects all facilities and programs within the 12-month cycle. The facilities must respond to any citations that we have or violations with a Plan of Correction.

So those are submitted to our department and they are reviewed by Julie and her team, and then -- so that the Plan of Corrections are reviewed and so that it avoids that those problems will recur into the future.

The DHS then monitors the implementation of those Plan of Corrections prior to deciding on the issuance of a new license.

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To fulfill the regulatory requirements, provider agencies must submit a completed application and then meet the appropriate set of regulations in order to receive a certificate of compliance, a license.

All DHS regulations can be found at PA Code online. The online web address is there, pacode.com. These are within Title 55, Chapter 20 of the PA Code.

And that applies to all DHS facilities, and outlines the procedure for application for licensure, the frequency and content of our inspections, the conditions under which a certificate may be denied, not renewed or revoked, and DHS licensure or approval decisions that may be appealed.

So there is an appeal process for certain decisions.

In order to obtain a license, each facility must meet with the application and regulatory requirements.

And then there is a reference here in my written testimony to those documents, the documents that must be completed for the purposes of application.

Currently, DHS provides licensing for a

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variety of mental health facilities across the state. And I'll just touch upon those so you get a sense of the variety.

DHS licenses 35 Long-Term Structured Residences, LTSRs; 571 Community Residential Rehabilitation Services, CRRs; 20 inpatient mental health facilities; 274 outpatient -- psychiatric outpatient clinics, and 234 partial hospital facilities.

And then there's references to the specific codes that are utilized to govern those licenses and that monitoring process.

All of the facilities mentioned above follow the Title 55, Chapter 20 of the PA Code, for licensure and approval, and they are required to submit a Plan of Correction, as I mentioned.

In addition to the implementation of a Plan of Correction, if any, DHS also considers the number of violations that are identified during an inspection.

So the seriousness of the violation, any residential impact from the violations, whether violations are grouped in a particular area of the requirements or if they are across the whole board -the whole array of requirements, that's taken into

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consideration in the licensing decision.After considering these factors, DHS

determines whether a regular license, a provisional license, or no license at all, should be issued.

A regular license is issued if a facility is complete or nearly complete in compliance of the regulations.

If there are a number of provisions upon completion of a Plan of Correction, they may receive a provisional license. And as I've noted earlier, there is a monitoring of those licenses during the course of the subsequent year.

The license is non-renewed for substantial non-compliance with the Chapter; failure to submit a Plan of Correction or to comply with a plan; certainly in terms of reported mistreatment or abuse of a residence; gross incompetence, negligence or misconduct; fraud or deceit in obtaining a licensing; or lending, borrowing or using a certificate from another facility.

So, again, the facilities that we are looking at are the LTSRs, the residential sites for people with serious mental illness, which is primarily defined as individuals who have significant impairment in thought or mood due to a diagnosed psychiatric

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disorder.These facilities range from 8 to 20

beds. And, again, each facility is individually licensed and reviewed on an annual basis.

CRRs are small residential sites for people with serious mental illness.

Each agency operating CRRs is licensed and inspected annually as well, and no less than 30 percent of its individual sites, including all new sites added within a year, are inspected.

Inpatient mental health facilities offer intensive mental health treatment provided in a 24/7 secured hospital setting. On-site inspections are based on the 5100 regs and must be completed within a 12-month cycle.

While DHS only licenses freestanding inpatient units, those attached to a general hospital are licensed by the Department of Health as part of their inspection of the overall hospital.

Group practices of licensed professionals are not considered outpatient clinics and are not reviewed by DHS. Individual licenses are granted by the Department of State.

Psychiatric outpatient clinics are non-residential, community-based facilities, which

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typically offer individual, group, and family therapy, as well as psychiatric and psychological evaluations and mental health assessments.

Treatment is supervised and directed by a psychiatrist. Med management may also be provided. And these programs are licensed under the 5200 regs.

Partial hospital programs are day programs. They can be a step down from inpatient, but are more intensive than outpatient, and the individual usually attends several days a week.

Therapies are offered to support the individual based on a treatment plan, and these are governed under the 5200 -- 5210 regs.

Additional licensing information, again, there's a more extended website address here in the -my written minutes -- written comments, but they give you full access to the related information.

I just want to take this opportunity to thank you for the opportunity to be with you to provide this information today, and look forward to the opportunity to answer any questions you may have.

And I will note that Julie has years of direct experience in actually overseeing and conducting the on-site licensing visits.

So thank you very much.

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CHAIRMAN DiGIROLAMO: Dennis, I don't know if Representative Cruz has any -

REPRESENTATIVE CRUZ: No, no. I don't have anything to ask you just yet.

I have a couple other people here that want to testify, and we want to see if we can give them five minutes just to put whatever, and then we can go on to the questioning.

CHAIRMAN DiGIROLAMO: Go ahead.REPRESENTATIVE CRUZ: I want to call

first Nilda Ruiz from APM.MS. RUIZ: Good afternoon.I'm Nilda Ruiz and I'm the President and

CEO of APM, Asociacion Puertorriqueno en Marcha.REPRESENTATIVE CRUZ: Spell that.MS. RUIZ: Unfortunately, I do believe

it's in Spanish, so I will have to spell it.A-S-O-C-I-A-C-I-O-N, Puertorriqueno,

P-U-E-R-T-O-R-R-I -- two Rs -- Q-U-E-N-O-S, next en, E-N, and then March, M-A-R-C-A-H.

DR. PRICE: C-H-A. C-H-A, Marcha.MS. RUIZ: Let the gringo help me.

Sorry. He speaks better Spanish than I do.Today, Dr. Price is the vice-president

of our behavioral health and Dr. Pope is our

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psychologist and also another vice-president at APM that has overseen the quality assurance of behavioral health.

I wanted to testify because when we -when we get inspected, I think it is so important to have bicultural/bilingual staff that look at us.

There's a very different dynamic that gets lost in the language. And many times our notes have to be in English, and I have had CBH say that we can have them in Spanish.

The problem is that when an audit comes, we have to then translate them in English and that's an added cost, which brings us to another situation.

We've been put in this competitive environment with our psychiatrists where they're asking for a higher rate than what the Schedule A permits.

So what ends up happening is that all of the behavioral health clinics are all competing for the same folks when they're bilingual, and then they're sought after at a higher rate, but we don't have an enhanced rate for them.

So what ends up is, we end up losing them to hospitals and to others, and we have part-time psychiatrists working at different clinics.

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Then the spread of what we're able to pay the therapists, we're getting it from that, and it's a really heavy load for our therapists that are working with our clients to be able to support the rest of the agency.

So that has been a real issue with ourclinic.

Is there anything else you want to addbefore I -

DR. PRICE: Well, in a nutshell, we have to pay the psychiatrists everything we get from the Schedule A, from the billing -

CHAIRMAN DiGIROLAMO: Doctor, can I ask you to use the mic?

DR. PRICE: Yes, sir.In a nutshell, we have to pay the

psychiatrists everything we get from Schedule A for their services. There's nothing left for overhead, turning on the lights, or anything like that. So that's the issue to which Nilda is alluding.

Another thing that we were speaking of is that -- and this was mentioned in some of the earlier testimony, we are inspected by -- inspected, audited, visited by half a dozen or a dozen different people and groups of people in a year and keeping

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track of that is somewhat difficult.And what we end up doing is we look for

the hardest standard among the different standards that we have to comply with, and then we just live to -- try to live to that standard.

And then each one, each audit/inspection/visit is a little bit different, has a little bit different emphasis, and then we try to explain what we're doing in a language that that different group of people had.

Now, if there were a unified standard, and if there were some coordination or communication between the different groups of people that are coming and visiting with us, that would make our lives a whole lot easier in terms of compliance with the expectations laid upon us.

So, if you want to look at a couple of suggestions or listen to a couple of suggestions, one would be if there was a way to work towards greater coordination between the different regulatory bodies that we answer to.

And if at all possible something very close to a unified standard, so we would have one set of rules that we would have to follow, that would make it, at least on our end, our lives a whole lot more

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simple.DR. POPE: Hello, everyone, and thanks

for having us.But to Dr. Price's point, you have the

county and you have the state auditors coming in to analyze and review our practices, but there is no coordination or collaboration, because sometimes you're being reaudited on the same compliance or regulatory issues and you're getting a different response or a different audit review from each state, so when -- from each body.

So when Dr. Price is managing his program, he is adjusting in variations. So any time they come in, there's another practice or standard that they've added.

So for the therapists and for Dr.Price's clinical staff to implement the work, it becomes cumbersome because you don't know which standard you're adhering to. So you want to always adhere to the higher standard.

But, you know, every time they come in with something different, they're coming in every 90 days, you know, you're always adjusting your work versus doing your work.

So that would be very helpful to augment

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if there was some form of standardization so that, like, the state could say to the county, we've already done this piece, so when you go in, they've already scored here and this piece can go into your piece, and just, you know, kind of compile that as a state-county audit and this is the final results of that.

MS. RUIZ: I have three other recommendations.

But, along these same lines, many times the primary doctor and the psychiatrists, they don't share information.

And it would be very helpful if, instead of giving a referral, so and so, and they come to the clinic, that we could share a little bit more information.

And I think it makes it easier for the primary doctor and the psychiatrist to be able to work with those patients, and I think it will also reduce the costs of providing these for the state. So that's another one along those same lines.

Some other recommendations. If there could be an enhanced rate for the bilingual therapists and the bilingual medical doctors, that would help us -- the psychiatrists -- that would help us to maybe retain them easier.

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And if we could be allowed, as clinics -- it's not just being bilingual, it's also being bicultural.

And I give this example all the time, because I got really excited with a psychiatrist that I brought in from Montana, and he was bilingual, completely fluent in Spanish.

And the first day that we had a girl come in with a huge tattoo on her breast, and he was like outraged.

How could this -- this girl's 15 years old, she can't do that, and a lot of moral values that not having been in an urban setting, and it's really difficult. This was just one case of many.

So it's not just being bilingual, it's also being bicultural.

And it would be really helpful for us if we, as providers in the community, could be allowed to bring evidence-based practices that address the needs of our communities.

We are also a Community Umbrella Agency. And one of the practices, we work with families that we brought in from Miami, and because there's such an aspect -- I'll let Dr. Pope explain it better from Miami.

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DR. POPE: It's called strategic family therapy. It's developed in Miami to address the needs of adolescents who were engaged in substance abuse behavior.

They were from the Cuban area and, you know, it's very family oriented. It really is to address the needs of a particular culture. So we wanted to bring that to our agency.

REPRESENTATIVE CRUZ: Thank you.We'll have more time to ask questions

and you can join in the panel, but I have two more.MS. RUIZ: Okay. Well, thank you very

much.REPRESENTATIVE CRUZ: Thank you.CHAIRMAN DiGIROLAMO: Ms. Stenographer,

do you want to take a break for a minute?COURT REPORTER: Thank you, I would.CHAIRMAN DiGIROLAMO: Okay. Let's take

a minute or two just to give her a break to catch up.(Brief break taken.)MR. MATOS: My name is Carlos Matos.I am a founder -- one of the founders

for the Juniata Community Mental Health Clinic. I really want to applaud State Rep Cruz and the people who represent my area.


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I never thought that anyone could have the -- I mean, I don't like to generally say it, but the balls to do what you're doing today. Because this is such a huge problem.

It is an economic problem because that's how these organizations got started with these mental health clinics.

I believe it was on the Clinton era where they started to take people off of welfare.

And then they were saying, well, if you want to get some money, you better go into these mental health clinics, and that's how this whole epidemic started.

So people were taken off one dependency and then put into another one.

So, okay, we don't want to give you welfare, but we'll give you medication and we'll give you a check that makes you -- you know, that makes you eligible because you're disabled.

Now, you're going to say, well, you can take the medication. Then people found out that they could get more money if they could -- if they could get their kids under treatment as well.

So now you've got a family of one parent maybe and four or five children, everybody's getting

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treatment because they're all getting -- wanting to get checks.

And at that time there were real no regulations or anything as to how people were treated, or whether they were culturally sensitive or not. So people were just overly medicated. They were put on prescriptions.

They were very addicted, and on and on and on. And even children because they have a little problem behaving.

You know, I remember I used to get my butt whipped, you know, whatever, by an electric cord, or whatever, and that straightened me out. But today's solution is to put kids on medication, which opens them up to a new world.

And so what they've done for the last couple of generations is just create -- the only word I can come up with is junkie after junkie after junkie, and they're dependent on the system and they're more screwed up than ever.

I'm a product of the mental health system. I've been in treatment for 46 years and I'm 66. And I was doing -- and I was getting treatment before I even knew about these mental health clinics and all this other stuff.

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And, today, that's the biggest economic -- I want to say provider for our community, for people to come in and say they have all these issues and then become eligible to collect SSI.

And some people overstate their sicknesses, because they figure the more problematic they are, the more -- you know, the easier it becomes for them to get their income.

And it was -- it was really nice to hear Nilda say that they have these Hispanic therapists that are very culturally sensitive.

And because we speak Spanish doesn't mean that you can be -- the majority of the Hispanic patients in the mental health system are Puerto Ricans.

Because you speak Spanish doesn't mean you understand the culture. And so a lot of people are not being treated or they're being mistreated and misread, and whatever.

And so that's what causes a lot of the issues and the problems that we have in our community today, because people are not culturally sensitive and understand where we're coming from, or whatever.

And, again, and being able to see that people are overstating their illnesses because they

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really want to collect their SSI, not that we don't have problems, because we do have problems, but some of them are overstated.

They believe that the bigger the problem, the easier it is to get their checks.

And so people who are treating people should be able to see some of that and understand it and explain it to people, so that they're not overmedicated. And this is what happens today; people are overmedicated.

There are people that have gotten wise to this. So they take that medication, they don't necessarily continue to take it, they go in the streets and they sell it.

So they're providing -- I had a conversation with some people the other day and they were saying, you know, it's funny because prescribed medication is the biggest drug on our streets.

And you know who's selling it to the kids? The senior citizens, because they're getting it and they know -- some grandchild told them, oh, this is worth money.

So now they take it and they sell it in the streets. And this is the kind of stuff that's happening out there today.

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And I'm glad that -- and happy to hear that someone really has taken the interest to look out for the interest of the community.

Because people -- economics, that's the thing, man, when you need money, you need money, and so you'll do whatever it takes to make money to make sure that you can eat.

And then with that comes a host of other issues. Because if you have a family that has five or six children, you're getting a check for every one of them.

Why aren't they able to pay their electric? Why aren't they able to buy food? Why aren't they able to pay their rent?

I mean, you're talking about four or five thousand dollars a month.

Anybody should be able to -- to be able to afford the things that they need, not to pay for everything, not $200 sneakers or cable TV or a brand-new car, or what have you, but we need to show people how to better manage their money.

And one of the things that I see -- and I don't know how to pronounce her name, but Joan Erney, or Ernie Jones, the CBH CEO -- one of the things that I've seen is that she -- see, she

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started is that they're really starting to make people accountable.

One of the things is, like, prior to that, we would have therapists working for us, and they would come in and CBH would come in and say, well, they don't qualify, they're not eligible.

Then they would make us pay them back money. We would have to dismiss them.

And then they would work in the clinic down the street, and they would -- and they would clarify (sic) that same organization, saying that they're eligible to work, but, yet, they weren't eligible to work for us.

And that's a huge problem. So there's a lot of things that were being done wrong and, hopefully, they're starting to correct them, but what we need more of is accountability.

We need to be able to listen because we have the some problem in our clinic to be able to find people.

But then the problem is, let's say, if we -- if we bring people from Puerto Rico that can be therapists and they have the education and they qualify, there may be a little problem with the English language.


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So it's a question of them being able to translate it and providing good quality care that people need.

Because I think that's the biggest problem, finding the right type of people to be able to deliver the services to our people in the community.

Now, with all that, also looking at all the services that entail -- just not the mental health issue, but then there's the social services; people that have a problem with housing, people that have a problem even trying to communicate with their doctors, people who have problems with just dealing with whatever.

So case management, but they don't want to pay us for that.

And so to be able to do that, you know, we need to be able to have the monies to be able to pay people to help them, because all these problems deal around mental health issues, and there's a host of other issues.

I'm beginning to see some improvement and I think that we're heading in the right direction, but still we need to look further and figure out how to solve this problem that was caused by the

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government.And it's a money cow for some people.

But -- that's okay, but we need to do what we're supposed to do and what we're being paid for and a lot of our people aren't.

That's what I have to say.REPRESENTATIVE CRUZ: Thank you, sir. I

appreciate it.And our last speaker will be Arelis

Sierra.We'll give you five minutes. He's going

to be the translator for her.MR. MORALES: For the record, her name

is Arelis Sierra. My name is Manny Morales.She -- do you guys have any questions

that you want to ask or -REPRESENTATIVE CRUZ: Well, no. She's

here to testify and talk to us about her experience with the mental health.

MR. MORALES: She arrived with a temporary visa. She was hired by Northeast Mental Community Health Center. She received a visa with working papers for three years, another three years were renewed.

On her second renewal, halfway down the

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second renewal, she started the residential process, resident.

Because of some inconvenience out of her control, she had to move to another sponsor, which is Dr. Chubra (phonetic) from Laraveda (phonetic) that finished her process for residency.

It's been a beautiful experience because in her performance she's a doctor. Over there in the Dominican Republic, they're primary doctors.

They have the opportunity to work in health centers with all kinds of patients, even with the patients that are with depression, and over there they are authorized to prescribe.

Over here, contrary to her experience in the Dominican Republic, she has a limited authority of dealing with certain patients.

REPRESENTATIVE CRUZ: I have a question.You're telling me that you came here to

the United States on a work visa without having the education to become a therapist or being a citizen of the United States?

MR. MORALES: She arrived like approximately in 2001 and she was contracted about a month being here.

REPRESENTATIVE CRUZ: And CBH approved

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that?MS. SIERRA: Yes.REPRESENTATIVE CRUZ: Okay. Well, we'll

take care of CBH when they come up. Okay.You can finish. I'm sorry.MR. MORALES: CBH requires that you be a

professional in the industry and she was qualified.REPRESENTATIVE CRUZ: The reason why I

ask is because Puerto Rico, being a part of the United States, they don't need a visa to come to work here.

And we did a program under reciprocity of Puerto Rican -- nurses in Puerto Rico. And because they could not pass the English test, they discontinued that.

And I'm saying, how can you bring therapists here from somewhere else who has not passed an English test or any test that's here in the United States, but are working and how do I know that they're qualified therapists and not overmedicating or doing other things under CBH?

MR. MORALES: I believe that with the experience that I have and the credits that I have from the Dominican Republic.

(Representative Cruz speaking to Ms. Sierra in Spanish.)

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REPRESENTATIVE CRUZ: I asked her what background does she have medically, if she's a doctor or nurse. And she says that she's a general practitioner in Santo Domingo, not in the United States.

MR. MORALES: Thank you.REPRESENTATIVE CRUZ: Thank you for the

opportunity.Mr. Chairman, I turn it over to you.CHAIRMAN DiGIROLAMO: I want to open it

up for the remaining time for questions from the members.

And I'd like to recognize Representative Cruz first for questions.

REPRESENTATIVE CRUZ: Yes. If we can have Joan Erney from the CBH come up.

Joan, loud and clear. Joan, I've got several questions.

MS. ERNEY: Sure.REPRESENTATIVE CRUZ: If I were to open

up a mental health facility, 3501 6th Street. I open up a satellite office in the 4800 block of 9th Street.

How do I report that with the Department of CBH here in Philadelphia, but also with the Department of Human Services with the state?

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MS. ERNEY: So, the first step if you want to open up a clinic is, you have to go through the licensing process.

So the first issue would be you wouldn't be able to open it or see clients whether they were -with any payer without having some license from the state.

In addition, if you're going to do something at another location, you're also required to have a satellite -- and I'd be glad to have Julie and Dennis confirm, but that's my recollection is that you have to also have a satellite license and that would allow you to proceed.

With us, you actually have to have a contract that we put your specific services that you can bill us for on your contract.

And so you -- you know, there is a process when they come in, they'd have to be credentialed, it would go to the Board.

Now, if they already have an outpatient license and we have approved a satellite, they would not have to come back to the Board, you know, for -for those additional services, but we have -- but we would have to include any additional billing codes that they might want to bill us for.

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Does that help?REPRESENTATIVE CRUZ: Exactly.So, if I open one site, I still have to

report my second site. Because if I'm seeing patients out of my -- my main building will be 3000A, and then the other one, 3100B, to be certified to be able to see patients -

MS. ERNEY: Correct.REPRESENTATIVE CRUZ: -- in each one of

those facilities, even in the satellite, is it mandated to have general practitioners?

MS. ERNEY: In an outpatient psychiatric, it is not a requirement to have a general practitioner. You must have -- the regulations require psychiatric oversight.

It also requires therapists and the regulations are very clear about what that needs to be.

In the satellite, we actually just are -- have put in a policy clarification -- and, again, I think Julie can probably answer this -- is that you did not have to have a psychiatrist at the satellite, but part of that in good practice is, if you are seeing a high volume, you must be able to have psychiatric oversight.


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And so that practice would say, if you're seeing a high volume, you would want your psychiatrists to actually be on site, you may want a second one or you must make sure that they are signing treatment plans, they're overseeing, they're working with your therapists, et cetera.

REPRESENTATIVE CRUZ: I'm noticing a large volume of patients that are going in without a general practitioner, but walking out with a script.So who's giving people prescriptions?

MS. ERNEY: They're not permitted to have a prescription unless a psychiatrist provides them with a prescription, or if they're going to their PCP, which would not -- would be outside of the outpatient clinic, a doctor has to prescribe.

There is nobody else in our system that's permitted to prescribe. Nurse practitioners. I'm sorry, nurse practitioners.

REPRESENTATIVE CRUZ: Is it a custom also to -- does CBH allow for people to come out from -- out of the United States to come in to become therapists?

MS. ERNEY: So there is a couple of things I wanted to comment on.

One is that we do staff reviews where we

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actually go in and look at the staff requirements. We actually make sure that there is first level verification, so the staff file must actually have the documentation in it.

So we don't take someone's word that they graduated from wherever. They have to actually see it. And we go so far as to actually look at the content of their curriculum.

Because we have rules around and there is a staff document that is distributed to every provider so they know what we require.

There are -- I just asked Andy -there's a national organization that translates requirements. So we use that organization, I'll have to get you the name because I don't recall the acronym off the top of my head.

There it is. Thank you. Thank you,guys.

COURT REPORTER: What is it?MS. ERNEY: WES, W-E-S. So we use

that -REPRESENTATIVE CRUZ: That's here in

Philadelphia?MS. ERNEY: No. This is across the

country is that it's a national organization that

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takes credentials from other countries and translates them and then identifies what that person is permitted to do here.

Hence, why -- and for us, we are very conscientious, one, of trying to find a balance that we have people who are absolutely culturally relevant, who really can speak the language, but we also balance that with we want to see curriculum that is actually relevant to psychiatric or substance abuse service.

So we try to really look for that balance and we look for that teaching and that curriculum.

REPRESENTATIVE CRUZ: Okay.MS. ERNEY: I'm sorry.I would also just add, on the compliance

side, if, in fact, that we find that someone is either not qualified or they are disqualified from Medicaid, which has happened, if it is a supervisor, that person is not permitted to bill us, nor is anyone underneath them permitted to bill us, and so that would be an issue of compliance that then comes back to us.

REPRESENTATIVE CRUZ: So, let's say, Carlos Matos comes in and says, I want to hire a therapist from Puerto Rico; do I have to go through this organization or can I do it as a clinic on my

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own?MS. ERNEY: So agencies take on a lot of

different perspectives. They have to meet our standards no matter what it is.

Most agencies use and we use that national organization, but some agencies do ask us from time to time to review a particular staff file.

REPRESENTATIVE CRUZ: My last question, and then I'll turn it over to the Chairman.

Does CBH still give out the Letters of Endorsement? Does Dr. Evans still provide those Letters of Endorsements?

MS. ERNEY: If it's appropriate, he will. Again, if we do a Letter of Endorsement for an outpatient license, as an example, that does not translate into a contract with CBH.

REPRESENTATIVE CRUZ: Okay.Mr. Chairman.CHAIRMAN DiGIROLAMO: Representative

Acosta for questions.MS. ERNEY: I'm sorry. I wanted to

introduce Andy DeVos. He is our Deputy Chief Operating Officer at CBH and works with providers on a regular basis and has a long tenure at CBH.

REPRESENTATIVE ACOSTA: Thank you, Ms.

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Erney, for your testimony earlier, but I have two questions.

The first question I have is in regards to therapists.

Obviously, they get qualified by the WES program, but what is the -- what would be the threshold, right, to determine someone that comes from -- whether it comes from -- I don't care where it is, outside of the United States, CBH comes in, the file goes to the inspection -- to the credentialing folks, what criteria, what is the threshold for CBH saying this person qualifies to be a therapist; A, comes from a different country; B, does not speak the language; three, has to write notes in English?

How do you -- how do you determine the quality of the care based on those three things?

MS. ERNEY: So we do rely on the CEO and the administration of the organization to also guide us about why it is they might have selected that employee.

Typically, it is the administration who is asking us to support a candidate. Again, the guidance about what we require is laid out in a document that all providers have.

So, if you're a therapist in our system,

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you have to have a graduate level, you have to have a certain amount of experience, and you must have an educational background that includes credits that are specific to mental health if that's what your -- you know, your body of work is.

REPRESENTATIVE ACOSTA: I believe you only have to have 12 credits in mental health; is that correct?

MS. ERNEY: Correct. Correct. So you need to have that. And, again, we would rely on the administration to say what role are they going to play, what gap are they going to fill.

In some instances, where we are not clear that they -- you know, that somebody is really advocating, they feel strongly that a particular person they want them to work there, because of the language particularly, which is typically what they need, we will ask them to do an Under Supervision.

So we have done that on occasion to say we don't want them to work alone, we want someone to be with them until we can gauge whether or not they are going to be successful.

REPRESENTATIVE ACOSTA: Okay. The other question I have is in terms of the evidence-based practices of CBH.

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In terms of the evidence-based practices, how do you tailor those practices, those evidence-based? How do you -- how do you merge that within the Latino community? Because that's a -that's a big issue.

How do you include evidence-based and then tailor that to a big, larger group of Latinos?

Myself, I have 19 clinics, mental health clinics, in my district and that's a big challenge.How do you do -- how do you do the merging of that in that sense?

MS. ERNEY: I think it's a greatquestion.

Dr. Ronnie Rubin, who runs our what's called the Epic Center, which is our evidence-based practices, is really taking the leadership in getting us off the ground in evidence-based practices.

You know, an evidence-based practice in many instances has, in fact, been brought up without the benefit of having been applied in a cultural arena.

And so we think that there are definitely those practices, some of them, that aren't as relevant and that we really do have to do more work in order to make sure that they can be translatable.


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There are some, though, that really -the evidence is also as -- that there is evidence that also represents that they can, in fact, work with a culture that -- Latino or otherwise, and so I think that many of them are translatable.

We have to do more training. We have to make sure that we can train appropriately. We want to recognize that if there are cultural barriers, that we understand what those are.

So I think it's both a training component -- I do think that some are not. I have not at least -- their evidence hasn't been based on their experience in the Latino community, as an example.

We need to do more work with that to see if they are, in fact, applicable. And then, again, I think it's really the training and then understanding in conversations with agencies how to apply them best.

REPRESENTATIVE ACOSTA: One more question and then I'm done.

In terms of cultural sensitivity and to the Latino community, how is CBH doing any educational piece or even coalition to really address the needs within the Latino community?

How is CBH dealing with that issue?Because we see an influx of patients who

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are Latinos and African-Americans, but more so Latino, how are you addressing those issues within the Latino community?

MS. ERNEY: Sure. We have tried to build a relationship with the Latino community. We have worked with the Latino Coalition.

We have had our physicians, as an example, meet with the medical directors of Latino organizations to try to think through how we can do best practices. We are trying to build that.

I would say that, as with anything in Philadelphia, there's incredible diversity within that community as well, and so I don't know that we've been able to capture all the diversity, but we certainly are making efforts in that regard.

MR. DeVOS: I'm a member of the Member Services Department, which is really our lifeline to the membership.

We have about 10 to 12 staff, including some of the supervisory staff, and a number of them have been involved in community-oriented -- Aspira and other community-oriented groups to really try to get the pulse of the Latino community and think about engaging them within the Latino community.

Also, Joan has developed since she's

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come to CBH something called the Kitchen Cabinet, which is really a group of providers that really help to advise around policies of CBH, and also things that we're introducing and vet with them, and the Latino Coalition providers were represented on that.

REPRESENTATIVE ACOSTA: Is there any cultural sensitivity training at CBH regarding Latinos? Any training at that level at CBH in terms of cultural sensitivity?

MS. ERNEY: There is a general. I would not say that it is specific to the Latino community.

We do -- in an orientation, do kind of -- we do cultural sensitivity and cultural diversity in general. We certainly are very attentive to it.

We do assure that we have individuals who can relate to the Latino community, both in member services in our clinical team and in provider relations.

So we do try to make sure that we can really support the Latino community appropriately.

REPRESENTATIVE ACOSTA: Thank you.MS. ERNEY: You're welcome.CHAIRMAN DiGIROLAMO: Representative

Murt.

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REPRESENTATIVE MURT: Thank you, Mr.Chairman.

Joan, just a couple of questions.You gave some really good testimony and

you talked about compliance issues and disciplinary actions, and so forth.

And my question is, how often are there disciplinary sanctions, whether it's a closure of admissions or you also talked about a possible termination of a provider's affiliation with CBH?

MS. ERNEY: I would say terminations are much rarer. I'll start with that one. I've been here for a little over two years and we have terminated three providers.

One of the providers, we really just terminated one component of their service, but we have terminated three in the two years. So, obviously, that's a last effort and all the other sanctions are in between.

We do close admissions. Anytime there is a serious incident, we close admissions. So that could happen more frequently.

And it doesn't necessarily mean that something bad has -- you know, that they have done something inappropriate, but we want to give them and

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us time to really investigate what has happened.And it could be anything from a death;

it could be a medication mismanagement; it could be a whole host of things.

It could be that we got a complaint that we think really requires us to do something different. So that happens more frequently because we do it in order to also investigate.

And then the things in between are, we have held -- we have stopped admissions for longer periods of time. I would say that happens maybe, you know, once a month, where you have an organization -if Andy can jump in here.

But I think it's not as frequent, but we have, for example, our children's residential agency that we just -- we go back out and keep looking to see are you making the improvements we need.

If we see that they're not improving, and that the incident itself or what they've determined might have created the incident hasn't been remedied to our -- to our standards, we will keep them closed for a longer period of time.

REPRESENTATIVE MURT: One more question.MS. ERNEY: Sure.


REPRESENTATIVE MURT: How many providers

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are in the network, Joan?MS. ERNEY: How many?REPRESENTATIVE MURT: How many

providers? Yes.MS. ERNEY: There's 210. Over 200. REPRESENTATIVE MURT: Thank you, Mr.

Chairman.CHAIRMAN DiGIROLAMO: Representative

Kinsey.REPRESENTATIVE KINSEY: Mr. Chairman, my

question is for other testifiers. Do you want me to wait until they come up?

CHAIRMAN DiGIROLAMO: Why don't you ask whoever you want and then maybe Joan can sit and then bring whoever you want to ask a question, bring them up to the table.

REPRESENTATIVE KINSEY: Thank you, Mr.Chairman.

My question is for Hector Ayala and also for Tracy Griffin.

Mr. Ayala, my question is, you talked about the clinic of the 21st century.

MR. AYALA: Yes.REPRESENTATIVE KINSEY: How and if any

way will the expansion of Medicaid be helpful towards

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the services that you currently provide?And, in addition, you also talked about

fee for service and you talked about operating in an operational deficit.

The question with that is that, prior to the fee for service, the system was paying in a different formality, I believe, if I'm not mistaken, there was a different way of payment being received by provider agencies.

Was that way more effective or efficient for provider agencies as well?

MR. AYALA: That's a very good question.When I think about the 21st century

model, I'm thinking about the holistic model, the holistic approach, in which we understand the dynamics of what we're dealing with, the underlying problems that our community is facing.

I think that if we would work more in a silent mode in which we are just targeting symptoms is not the right way.

We have to understand that we have families that are being broken up by different situations. We have high levels of divorce. We have high levels of incarceration.

And when we think about mental health


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services, we have to think in how we support all those areas, how we can actually connect our clients, our community to the services that are really needed.

Part of the problems that we have found in our community is the lack of information and the lack of knowledge about what's going on out there.

It is also difficult because sometimes providers, they don't work together, and you have people working in compartments. Usually that doesn't work for our clients, either.

What I'm thinking is a model that embraces management, a model that embraces not only the mental and psychological aspects of our clients, but also the health and the wellness of our patients.

And when we look into treatment, we have to look at not only a different -- with a deficit in a different approach, but how we can actually improve that number, how we can improve the quality of life.

If you ask any parent whose child has broken an arm, they don't want to know from the doctor how you are going to fix his arm.

The first thing that, as a parent, is going to come out of my mouth is, when is my child ready to play, when is he ready to horseplay with his brothers and sisters, when is he able to go back and

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swimming and do this and that.And I think that when we -- I don't

think. I know for a fact when I talk to my clients this is what they would like to see.

Quality of life that is defined on the basis of their mental illness, or even defined in the great things that we have as illegals, as parents, as children in our community.

In respect to the fee-for-service model, it's not that it doesn't work. It is that we are providing too many services that we are not getting reimbursed for those types of services.

As a matter of fact, just last year at agencies as we provided over 1,200 units of services just for pro bono work.

These are individuals who don't have insurance. These are individuals who are not probably documented in the United States.

However, as a human rights approach, we cannot deny any of these services to none of these individuals. So that's a problem.

The problem comes when we have to spend hours on the phone speaking with a school counselor.

The problem comes when we have to help our patients with other types of services. The

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problems comes when we have to go out there and save these patients.

I think that we have to go back to a model in which we can make our services accessible, not by the amount of hours that we are open, but by the time that we spend walking on those blocks, walking in those communities, to understand what the parents, what the children, what these adults, what these families really want.

So it works, but I think that it has to be a fee-for-service system that has to be more robust that brings a holistic approach in terms of the services that we are providing.

REPRESENTATIVE KINSEY: Okay. Thankyou.

Mr. Chairman, my other question is for Ms. Tracy Griffin.

Thank you very much.Good afternoon.MS. GRIFFIN COLLANDER: Good afternoon.REPRESENTATIVE KINSEY: Ms. Griffin, you

were the organization that does accreditation.MS. GRIFFIN COLLANDER: Correct, with

The Joint Commission.REPRESENTATIVE KINSEY: I'm sorry.

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MS. GRIFFIN COLLANDER: With The JointCommission.

REPRESENTATIVE KINSEY: Okay. The Joint Commission. There's some organizations that provide services that might not be licensed.

I know that in my district -- and, again, I'm not too far from here, I have the Germantown section in Philadelphia. It's not too far from here.

However, you know, aside from the group homes that might be operated by some of the providers, there are also I think what are known as personal care homes.

MS. GRIFFIN COLLANDER: Yes.REPRESENTATIVE KINSEY: And some of

these personal care homes may not receive funding from the state, so they may not be licensed by the state as well.

Are these types of homes that are unlicensed eligible to be accredited? And if so -that's one part of your question.

And then the other part of it is, what is the cost for accreditation? Is it pretty much like a pay scale based on the size of the organization?

MS. GRIFFIN COLLANDER: Sure.


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So, first of all, if an organization has unlicensed homes or unlicensed care, we look to them and inquire about whether or not there is state regulation around that.

And, of course, if the state requires licensure, then it is required as part of the accreditation. If the state does not require licensure, then, yes, they would be eligible for accreditation.

And in terms of the cost, the cost really varies based on the size and scope of the organization. And the lowest cost that we charge, in terms of fees, is a little under $9,000 every three years.

And we break that into fees based on the survey year, which is about 60 percent of the cost, and then each of the subsequent two years it's 20 percent, 20 percent. So, overall, on a low end, $9,000 every three years.

On the average, costs for organizations, it's around 15,000 every three years, just to kind of give you a sense of what's the average, and on a larger scope about 30.

much.REPRESENTATIVE KINSEY: Thank you very

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Thank you, Mr. Chairman.CHAIRMAN DiGIROLAMO: Representative

Staats.REPRESENTATIVE STAATS: Thank you, Mr.

Chairman. And thank you to everyone for the very insightful testimony this afternoon.

Mr. Chairman, my questions are for Joan Erney. And I just had a couple of questions as it relates to compliance.

MS. ERNEY: Okay.REPRESENTATIVE STAATS: How often are

the audits completed?MS. ERNEY: We have a regular series of

audits. I believe last year we did over 500. We have an audit team and they go out every day.

REPRESENTATIVE STAATS: Is there an audit schedule or -

MS. ERNEY: Yes. There's an audit -there's an audit schedule. We do both. We do every agency at least once in a two-year cycle.

And then we also do targeted audits if we have a complaint, if we have someone who has -- if there's some challenge, then we can do a targeted audit, and -- and so either one. So we're out every day.

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REPRESENTATIVE STAATS: I see.And do these agencies know what they're

being audited on prior to?MS. ERNEY: Yes, they do.REPRESENTATIVE STAATS: You had also

mentioned that an agency would pay you back if they're not in compliance.

MS. ERNEY: Correct.REPRESENTATIVE STAATS: Does that mean

that they reimburse you for expenses?MS. ERNEY: They -- we pay claims for

services. When we find that there is a compliance issue, we actually look at the claims that were paid.

And if the area is -- you know, this is the area that we found, we take -- actually, take the money back that we paid them.

REPRESENTATIVE STAATS: I see.And if they are not in compliance, I

would assume that there's a follow-up audit to ensure compliance; and, if so, is it time bound?

MS. ERNEY: Yes. We do a -- first off, when we do the compliance, we do an exit interview at the agency level, so that we can inform them about what some of the initial findings are.

There is then a written document that

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lays out what the compliance findings are. And depending on the seriousness of the audit, typically, we ask for a meeting.

We may ask for a review, which means our clinicians will go out and do an additional research.

So there are various options and, yes, that's all done within time frames.

REPRESENTATIVE STAATS: One lastquestion.

I heard pay rates discussed today and someone talked about the need for an enhanced rate, which leads me to believe that there's no flexibility.

So is there an amount that is assigned to the position and there's no flexibility?

MS. ERNEY: So I would say that I believe that DBHIDS, particularly our Medicaid program, is a very generous payer.

I think that many agencies asked us for enhanced rates. And what we ask them to do, we have a document that's on our website that talks about what you need to do in order to get an enhanced rate.

We expect to see what your costs are and we want to look at what your outcomes are in the program, we want to look at quality indicators, and we want to look at your financial stability.

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And so there is absolutely a process by which that a rate can be enhanced, but it does need to be justified for us to be able to do it.

REPRESENTATIVE STAATS: So, otherwise, there's a pay rate assigned to the position?

MS. ERNEY: For outpatient, correct.But we -- you know, unlike the old

fee-for-service days where there was a unit cost and it was kind of a bundled cost, we actually break out by code.

There's like two pages of what you can bill us for and there is a set rate for all of those.

There are enhancements that have been done; some of them based on evidence-based practices, some of them based on a different service model, but typically it is one set rate.

REPRESENTATIVE STAATS: Thank you.Thank you for your testimony.

MS. ERNEY: Sure. You're welcome.REPRESENTATIVE STAATS: And thank you,

Mr. Chairman.CHAIRMAN DiGIROLAMO: Okay.

Representative Acosta will follow.REPRESENTATIVE ACOSTA: I have a

question for Joan Erney.


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MS. ERNEY: Okay.REPRESENTATIVE ACOSTA: Out of 2 00-plus

providers that you have, do you have a percentage where you can say, out of 2 00 providers, what's the percentage of those 200 providers that are actually providing quality care services?

MS. ERNEY: How many of them are providing quality care? I think that the question of quality is a complex one, because there is many facets, there's many components to quality.

I think that Philadelphia overall has an extraordinarily strong network. But agencies often are good in one area and maybe not as good in other areas, and so we really try to take a comprehensive approach to it.

We use P4P, or Pay-for-Performance, as one venue to look at quality. And in those instances, we do have -- you know, over half our providers get some payment.

But, again, it's by level of care and oftentimes it's very specific to what that service delivery model is.

We look also, though, at compliance; we look at complaints; we look at consumer family feedback, but we have not done a report card, per se.

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And so I would say that I can't give you -- I think that there are strong and quality providers, and there are providers who we feel need more help and need some additional technical assistance, and there are those that I would say over time probably don't need to be in our network.

REPRESENTATIVE ACOSTA: So we don't have right now a scorecard on that?

MS. ERNEY: Correct. We do not.REPRESENTATIVE ACOSTA: Okay. One more

question, and then I have a question for the Deputy Secretary.

Let me give you an example, right, of ascenario.

MS. ERNEY: Okay.REPRESENTATIVE ACOSTA: If you have a

mental health clinic that you have to give additional support because they're not complying with the requirements of CBH, and you're in this agency three times probably, or more, a year just because they need that additional support.

You see that there's no progress, you go in and tell them this is the wish list that CBH has, but you see that there's no compliance.

How long would it take CBH to actually

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say, you know what, this clinic is not going to move their barometer, they're not going to make any progress, it's time to pull the license? How would you determine that?

MS. ERNEY: So that's another very good question. Right now, we, along with most others in our industry, do not prior authorize outpatients.

So, as you know, we prior authorize, which means you have to submit information to us, we have to review it, and we have to agree that the services are medically necessary.

In behavioral health, you really want people to go to outpatient, because you don't want them using inpatient inappropriately or things that are really harder on you and your system in your recovery.

So you're really moving people and you want them to avail themselves of outpatient. You want to make it extraordinarily accessible so individuals can walk in the door.

They don't have to call us. They don't have to do anything. You want them to really avail themselves of this level of care.

What we have been discussing and have not put in place yet is that, your point, is after

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time, you know, do you want to take a look and see whether or not an individual, if they are not progressing, would you not want to try something different.

We believe our agency's good clinical practice calls upon you to do that and that our -many of our agencies do.

We do do analysis to look at how long someone has been in care. And there are definitely outliers where we see folks have been in care for years.

And when we go look at our notes on a compliance audit, we do look to see whether or not there's documentation; and if there is, then we are assuming that those clinicians, who are the ones who are seeing that client, have agreed that this is an individual who really needs the care.

We are considering whether or not over time we should institute after six months, or every six months, we may want to do prior authorization, but we have not done that up to this point.

We have really tried to encourage outpatient as the first, you know, segue into your care.

REPRESENTATIVE ACOSTA: Right.

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Do you believe, is it your assessment that a person can be in care indefinitely?

MS. ERNEY: So I would say it's more kind of my own personal experience. So I'm not a clinician. I'm a lawyer and non-practicing.

So I -- but I have worked in the field for a long time and have worked with a lot of agencies in a lot of different positions.

What I would say are two things: People who have very serious mental illnesses have a really chronic, long-term disease.

People who are in substance abuse treatment may have a chronic, long-term experience, and so they may need check-ins.

Do they need, typically, daily or even weekly interventions for the rest of their life? Not necessarily, but there have been occasions where that has been needed for some people who have some pretty significant issues.

And then they need to have -- they need to know that there is a lifeline.

So, even if they aren't getting treatment, they need to know I can go back to that outpatient clinic, I can go to that case manager, I can go to that D&A facility, and if I'm relapsing, if

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I'm not feeling well.So it can, in fact, be a very long-term

process.I think what we have to delineate is

those who really have those more serious illnesses from those that it may be another reason why they're being -- you know, they're having that experience in the -- in the clinic.

REPRESENTATIVE ACOSTA: Thank you for your testimony.

MS. ERNEY: Sure.REPRESENTATIVE ACOSTA: Mr. Chairman, I

do also have a question for the Deputy Secretary. I believe, Dennis Marion.

Thank you. Thank you for yourtestimony.

I have a question in regards to how do you license an outpatient mental health clinic?

What's the requirement for that? What's the criteria for licensing an outpatient mental health clinic from the state?

MR. MARION: If you don't mind, I'm going to defer to the person with the more specific expertise.

REPRESENTATIVE ACOSTA: Thank you,

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Julie.MS. BARLEY: Sure. That's fine.What we use to license our outpatient

psychiatric clinics are found in Chapter 5200. And I have some guidebooks if folks would like one. I brought some extras with me.

As we mentioned, and what is in our testimony, they are also on the PA Code.

So we now have all of our licensing requirements for all of our services, not just the ones mentioned in our testimony, but all licensed mental health services that have a regulatory and a statutory basis.

What we look at in terms of the licensing requirements go back to April 20th of 1981. So I just wanted to point out that, you know, the licensing regulations for outpatient clinics have been around for quite a while.

They are -- there are sections of them that are very general in nature. Joan touched on some of them. We look at staffing. We look at the number of mental health professionals, the number of mental health workers.

There are certain requirements for psychiatric coverage that is based on the number of

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mental health professionals working within the clinic. We will also look at treatment planning. We look at areas of confidentiality.

We've also applied across all of our services the 5100 Regulations, which are the Mental Health Procedures Act.

We use the same basic kind of approach where we do, if somebody is found not to be -- if a provider agency is not in compliance with any section of a regulation, they would receive a Statement of Deficiencies; they would be given an opportunity to submit back to us a Plan of Correction, which is reviewed and approved or, as Dennis mentioned in his testimony, non-renewed.

So we do have that opportunity if somebody is not submitting back to us a Plan of Correction or there are issues.

We do issue provisional licenses. I think you had asked Joan about the time frame at the state level for licensing. A provisional is, generally, a maximum of two years would be the most that a provider agency could be given.

We have Chapter 20, which is license procedures for all of DPW -- or DHS -- excuse me -providers. And the longest period of time for a

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provisional is six months.And the highest number of provisionals

any provider can receive that are concurrent is for four. So, if you receive four six-month provisionals, it roughly gives you two years to make a correction.

And we do certainly weigh certainrequirements.

I'll be very honest, one of our concerns, of course, is staff clearances, and that is -- you know, would be what we would consider a significant number -- you know, and that would be a significant non-compliance area, as opposed perhaps to, you know, not having client rights posted in the hallway.

I mean, not that that's not a serious concern, but, generally, you would expect that to be corrected, but we would not necessarily put someone on provisional, if that makes sense.

REPRESENTATIVE ACOSTA: Yes.REPRESENTATIVE CRUZ: We have to wrap up

because it's 3 o'clock and we have a bunch of kids that are coming in.

I want to thank everyone -- and I'll turn it over to the Chairman.

But I want to acknowledge Joanna Otero-


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Cruz, who's in the back, who let us borrow this beautiful place.

Thank you, Joanna, for letting us use this facility. Thank you.

Mr. Chairman.CHAIRMAN DiGIROLAMO: Thank you.It was a really good hearing. I want to

thank everyone for testifying and thank you all for being here today.

And, again, let me thank my chairman, Representative Cruz, for bringing this important issue to the attention of everyone.

So God bless each and every one of you. Thank you.(Proceedings concluded at 3:04 p.m.)


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CERTIFICATION

I, SUZANNE F. GIGLIOTTI, a Court Reporter and Commissioner of Deeds, hereby certify that the foregoing is a true and accurate transcript of the deposition of said witness who was first duly sworn by me on the date and place herein before set forth.

I FURTHER CERTIFY that I am neither attorney nor counsel for, not related to nor employed by any of the parties to the action in which this deposition was taken; and further that I am not a relative or employee of any attorney or counsel employed in this action, nor am I financially interested in this case.

SUZANNE F. GIGLIOTTI Court Reporter and Commissioner of Deeds

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