Final Audit Report of Bonnie Brae’s Compliance with Medicaid Requirements and its Contracts with the Department of Children and Families

Final Audit Report of Bonnie Brae's Compliance with Medicaid Requirements and its Contracts with the Department of Children and Families

Table of Contents

Executive Summary

As part of its oversight of the New Jersey Medicaid program (Medicaid), the New Jersey Office of the State Comptroller, Medicaid Fraud Division (OSC) audited Bonnie Brae, a provider of out-of-home treatment services to youth, to determine whether it complied with Medicaid requirements and the terms of its contracts with the New Jersey Department of Children and Families (DCF). OSC found that Bonnie Brae violated Medicaid regulations and failed to satisfy provisions in its DCF contracts. Among other issues, OSC found that Bonnie Brae:

• Failed to maintain documentation that supported the contractually required service hours for clinical coordinators, with documented hours for clinical and case management services significantly exceeding those recorded on employees' timesheets;
• Claimed to provide on-site services to youth who, according to other Bonnie Brae documents, were off-site at the time;
• Failed to provide and/or document the amount or frequency of clinical therapy, psychiatric therapy, and case management services required by contract;
• Maintained duplicated progress notes, 93 in total, from two therapists that were nearly identical to one another and identical for all youth under their care over a span of seven weekly group therapy sessions; and
• Employed two unlicensed clinical coordinators.

Out-of-home treatment is intended to address identified behavior and underlying factors to enable vulnerable youth to safely return home or to a non-clinical setting. To meet those aims, Bonnie Brae provides clinical therapy, psychiatry, direct care, case management, nursing, and allied clinical services for youth through its contracts with DCF. During the audit period of July 1, 2019 through June 30, 2021, through these contracts, the Medicaid program paid Bonnie Brae per person rates that ranged from $350 to more than $670 per day, reflecting increases in per diem contract costs instituted over this period. In total, Medicaid paid Bonnie Brae $34.4 million during this period. During the entire five-year period of the contracts under review, Medicaid paid Bonnie Brae approximately $91.2 million.

Given the vulnerable youth population Bonnie Brae serves, the critical services that Bonnie Brae agreed to provide to them, and the considerable amount of Medicaid funds paid for these services, OSC found it concerning that Bonnie Brae did not maintain sufficient documentation to demonstrate compliance with Medicaid regulations and its DCF contracts. Equally concerning is that the documentation Bonnie Brae submitted to OSC after learning of OSC's initial findings did not reconcile with its initial submission, which further undermined the reliability of its documentation. In short, Bonnie Brae's unreliable and, at times, inconsistent documentation could not support the services it contracted to perform and for which it received Medicaid payments.

Based on the findings above, OSC determined that Bonnie Brae failed to maintain proper documentation that shows it provided contractually required services for which it received more than $1.5 million in Medicaid payments. Accordingly, OSC found that Bonnie Brae must repay these funds to the Medicaid program. In addition, OSC found that in order for Bonnie Brae to meet its Medicaid program and contractual obligations, it must significantly improve its record keeping and institute reforms.

Background

Founded in 1916 and incorporated as a nonprofit organization in 1953, Bonnie Brae specializes in delivering residential treatment services for emotionally disturbed adolescents. The organization's 100-acre main campus is located in Liberty Corner, within Bernard's Township, and includes a school, eight residential cottages, and recreational areas. Bonnie Brae also operates three community-based transitional living homes.

During the audit period of July 1, 2019 through June 30, 2021, the New Jersey Department of Children and Families (DCF) contracted with Bonnie Brae to provide out-of-home treatment services on behalf of the Children's System of Care (CSOC), DCF's division responsible for youth (under age 21) with emotional and mental health care needs, substance use challenges, and/or intellectual/developmental disabilities. The intensity, frequency, and duration of the out-of-home treatment varied based on a youth's clinical needs, age, and gender. Through two contracts, Bonnie Brae administered six programs, which provided the following levels of intensity: Residential Treatment Center (RTC) Intensity of Service (IOS); Residential Treatment Center Behavioral Health/Substance Use (RTC-BH/SU); and Specialty (SPEC) IOS.

The goal of an RTC is to establish a secure, well-rounded, stable, and therapeutically supportive environment. RTCs provide a range of services to help youth develop and enhance their behavioral, self-help, socialization, and adaptive skills. The overarching objective is to contribute to their improved physical, social, and emotional well-being and vocational potential. The therapeutic goal is to support the youth in reintegrating with their family/caregiver and community.

The RTC IOS and RTC-BH/SU programs provide 24-hour staff-supervised all-inclusive clinical services in a community-based therapeutic setting for youth with severe and persistent social, emotional, behavioral, and/or psychiatric challenges. Youth enrolled in the RTC-BH/SU program also present with co-occurring substance use treatment needs and receive specialized treatment. The SPEC program also provides 24-hour care for youth who manifest significant emotional and/or behavioral challenges that require specialized clinical intervention.

For the SPEC program, DCF and Bonnie Brae entered into a conditional five-year contract (Contract # 17BJZR) effective July 1, 2016 through June 30, 2021. The state conditioned the contract on Bonnie Brae hiring and training direct care staff to fill 11 vacancies. The state lifted the conditional status of the contract as of September 26, 2017. The contract's original terms required Bonnie Brae to provide up to 49 beds at a per diem rate of $430 billed directly through Medicaid. Effective January 1, 2018, the State raised the per diem rate to $445, and the parties extended the contract for six months to December 31, 2021. An additional increase, effective January 1, 2021, raised the per diem rate to $670.70. Over the five-year term of the contract, the final maximum reimbursable ceiling for the SPEC program contract, after subsequent rate increases, was $47,461,180. See Table I below.

Table I: Contract # 17BJZR - Per Diem Rate Increases

Similar to the SPEC program contract, for four RTC programs and one RTC-BH/SU program, DCF entered into a contract with Bonnie Brae effective July 1, 2017 for five years through June 2022 (Contract # 18FDZR). Pursuant to this contract, Bonnie Brae was required to provide up to 65 beds across the five programs at a per diem rate of $350 for the four RTC programs and $407 for the RTC BH/SU program. The parties modified this contract in June 2019, raising both rates retroactively, effective January 1, 2018, to $365 and $422, respectively. In October 2021, the parties again raised the per diem rates to $611.13 for the four RTC programs and $614.72 for the RTC BH/SU program, retroactively to the beginning of the calendar year through the termination of the contract in June 2022. The maximum reimbursable ceiling for the RTC programs contract was $53,301,087. See Table II below.

Table II: Contract # 18FDZR - Per Diem Rate Increases

RTC-BH/SU, RTC-Main Campus, and the SPEC program are located on Bonnie Brae's main campus in Liberty Corner, Bernards Township. The RTC-BH/SU and RTC-Main Campus programs are co-located, with youth sharing residential cottages, case managers, and therapists. Youth enrolled in the SPEC program reside in separate cottages, distinct from those occupied by participants in the other two programs. The three remaining RTC programs are located in community-based transitional living homes in New Brunswick, Bound Brook, and Bridgewater.

The contracts with DCF required Bonnie Brae to submit to DCF Program Staffing Summary Reports (PSSR) showing assigned staff for each program at least once per year and at other times when Bonnie Brae made significant staffing changes. Among its staffing requirements, Bonnie Brae was required to have a director and a pediatrician on call 24 hours a day for all of its contracted programs. Bonnie Brae also was required to provide the following on-site services: clinical therapy, psychiatry, direct care, case management, nursing, and allied clinical services. Table III below outlines the contractual minimum weekly service hours per youth, categorized by intensity and position.

Table III: Minimum Staffing Requirements by Intensity per Week per Youth in 2020 and 2021 for Contract # 17BJZR and Contract # 18FDZR

Pursuant to the contracts, Bonnie Brae's psychiatrists were responsible for conducting intake assessments, creating initial treatment and crisis plans, performing clinical visits, and managing medication. Licensed therapists, known as clinical coordinators, were responsible for delivering clinical services through individual, group, and family therapy. Both psychiatrists and clinical coordinators were required to allocate 75 percent of their clinical hours to face-to-face interactions with the youth. Case managers were responsible for administrative tasks related to each youth, including scheduling relevant appointments, providing financial oversight, and drafting incident reports/correspondence. A complete list of the minimum staffing credentials and requirements is provided in Exhibits 1-3 attached to this report.

DCF most recently audited Bonnie Brae's SPEC Program in October 2015, covering the period from July 1, 2013 to June 30, 2015. DCF's audit revealed several areas of non-compliance, including inadequate documentation for required therapy services and case management. The report recommended improvements in internal controls and documentation practices. In response to the 2015 audit, Bonnie Brae agreed to improve its documentation and internal controls for clinical therapy and case management, and to implement weekly audits for both.

Audit Objective, Scope, and Methodology

The objective of OSC's audit was to determine whether Bonnie Brae complied with applicable state regulations and certain provisions in its DCF contracts.

The audit scope was July 1, 2019 through June 30, 2021. OSC conducted this audit pursuant to its authority as set forth in N.J.S.A. 52:15C-23 and the Medicaid Program Integrity and Protection Act, N.J.S.A. 30:4D-53 to -64.
As part of the audit, to obtain an understanding of Bonnie Brae's controls and processes, OSC reviewed Bonnie Brae's contracts and contract modifications with DCF, PSSRs for Bonnie Brae's six programs, Bonnie Brae's 2020 and 2021 audited financial statements, and Bonnie Brae's 2020 Internal Revenue Service Form 990. OSC also conducted interviews and walkthroughs with Bonnie Brae personnel. In addition, OSC conducted a preliminary examination of progress notes for five selected youth to gain an understanding of Bonnie Brae's recordkeeping practices.

For substantive testing, OSC selected February 2020 as a sampled month because of heightened enrollment and because it predated the onset of the COVID-19 pandemic. To identify potential high-risk areas, OSC obtained staffing reports, timesheets, and payroll documents and compared the information contained in those documents to projected staffing requirements based on the number of youth enrolled at the time.

Based on its risk analysis, OSC found that clinical therapy, case management, and psychotherapy were high-risk areas and excluded RTC-New Brunswick, RTC-Bound Brook, and RTC-Bridgewater from further review. OSC obtained progress notes and documentation supporting case management, psychiatric services, and clinical therapy for each youth enrolled in the SPEC, BH/SU RTC, and RTC Main Campus programs for the substantive testing review period from February 1, 2020 through February 29, 2020. In addition, to determine whether any identified documentation deficiencies persisted after February 2020, OSC selected a smaller sample of two of eight cottages for review of case management, psychiatric services, and clinical therapy from February 1, 2021 through February 28, 2021.

Using the documents obtained from Bonnie Brae, OSC calculated the hours devoted to case management, psychiatric services, and clinical therapy for each youth and clinical coordinator to determine whether Bonnie Brae met the contracted minimum requirements. OSC also compared the number of hours recorded by clinical coordinators on supporting documentation to the number of hours worked on employee timesheets. To further test the reliability of the information received, OSC compared the following:

• Clinical coordinator absences on timesheets against dates and times recorded on progress notes;
• Medicaid billing records for youth who were recorded as absent against dates and times recorded on progress notes;
• Dates and times of individual therapy sessions by clinical coordinators to determine whether there was overlap; and
• Progress notes completed by different clinical coordinators.

Finally, OSC referenced the Division of Consumer Affairs' license verification system to assess Bonnie Brae's compliance with minimum requirements for clinical coordinators, psychiatrists, and Advanced Practice Nurses (APNs) identified within the audit samples.

Discussion of Auditee Comments

The release of this Final Audit Report concludes a process during which OSC afforded Bonnie Brae multiple opportunities to provide input regarding OSC's audit findings. Specifically, OSC provided Bonnie Brae a Summary of Findings (SOF) and OSC and Bonnie Brae, represented by counsel, held an exit conference during which the parties discussed the SOF. Following the exit conference, Bonnie Brae submitted additional records and a written response that disputed certain findings. After considering that submission, OSC provided Bonnie Brae a Draft Audit Report (DAR) and instructed Bonnie Brae to submit a formal response to the DAR including a Corrective Action Plan (CAP).

In response to the DAR, Bonnie Brae submitted a CAP to address OSC's findings (Appendix A). In its response, Bonnie Brae stated, "[w]hile we may not fully concur with all aspects of the findings, we acknowledge and respect the determinations made and will comply accordingly. Bonnie Brae remains firmly committed to maintaining full adherence to all contractual, fiscal, and documentation standards." The CAP advised that Bonnie Brae would hire additional clinicians, provide additional training, and implement updates to its procedures for completing service documentation. The CAP did not address whether Bonnie Brae would reimburse the Medicaid program the assessed overpayment of $1,528,109.

OSC addresses Bonnie Brae's arguments in more detail in Appendix B. After reviewing Bonnie Brae's submission, OSC determined that the explanations provided did not resolve the deficiencies identified in the audit. OSC found that the inconsistencies across the entirety of the records OSC reviewed limited OSC's ability to verify that Bonnie Brae delivered the contractually required services. Accordingly, OSC concluded that despite its arguments and submissions, Bonnie Brae still could not rebut OSC's findings that it had failed to comply with Medicaid regulations and provisions in its DCF contracts.

Audit Findings

Based on a review of documentation for February 2020, OSC found that Bonnie Brae's documentation for services for which it billed and was paid by the Medicaid program was unreliable and inadequate. Specifically, OSC determined that it could not rely on Bonnie Brae's documentation to support the clinical therapy, case management, and psychiatric services for youth enrolled in SPEC, RTC-Main Campus, and RTC BH/SU (on-campus). Bonnie Brae's failure to support these services violated Medicaid requirements and its contracts with DCF. In addition, based on the deficient documentation Bonnie Brae provided, OSC found that Bonnie Brae failed to provide the required number of clinical therapy hours for 13 of the 101 youth enrolled in on-campus programs. OSC also found that Bonnie Brae failed to provide the minimum number of required hours for psychiatric services for the SPEC program. Finally, Bonnie Brae did not provide the required case management hours. These findings are set forth below in more detail.

For the two cottages sampled in February 2021, OSC found that nearly all of the issues that OSC identified with Bonnie Brae's documentation from February 2020, including the lack of adequate progress notes and case management documentation, persisted to varying degrees. Based on its review of February 2021 documentation, OSC determined that 8 of 26 youth did not receive the required number of therapy hours and that youth enrolled in the SPEC program did not receive the required number of hours for psychiatric services. Finally, OSC also identified two clinical coordinators, one in February 2020 and another in February 2021, who were not licensed during the periods when they provided services.

Taken as a whole, OSC determined that Bonnie Brae failed to adequately document clinical therapy, case management, and psychiatric services. As a result, Bonnie Brae could not demonstrate that it provided the minimum level of the services required by contract. OSC's other specific adverse findings, including its determination that Bonnie Brae failed to provide sufficient levels of clinical therapy, psychiatric services, and case management, and used unlicensed clinical coordinators, highlight serious internal control failures. Because of these material and widespread deficiencies, which may have adversely affected Medicaid beneficiaries' treatment, OSC determined that Bonnie Brae must return to the Medicaid program the full amount of Medicaid funds paid to Bonnie Brae for these services for February 2020 and for the two cottages reviewed in February 2021, which totals $1,528,109.

A. Unreliable Documentation Supporting Clinical Therapy, Case Management, and Psychiatric Services

OSC found that Bonnie Brae's records involving clinical therapy, case management, and psychiatric services were materially deficient. OSC identified multiple issues with these records, as detailed below.

1. Failure to Support Hours Documented by Cottage-Assigned Clinical Coordinators Demonstrates Deficient Recordkeeping

OSC reviewed progress notes for clinical therapy and supporting documentation for case management services for February 2020 for the youth residing in all eight on-campus cottages. Bonnie Brae's contracts with DCF required it to provide at least eight hours of clinical therapy per youth per week for the SPEC program and six hours per week for the non-SPEC programs. The contracts required 75 percent of the hours to be face-to-face, which correlates to six hours for youth enrolled in SPEC and four and a half hours for youth enrolled in BH/SU and RTC-Main Campus. Bonnie Brae's contracts with DCF also required Bonnie Brae to provide five and a half hours of case management services for all youth in each program.

OSC found that certain clinical coordinators were also serving as case managers and documenting six hours of case management services per youth per week using a standardized summary form-on top of their clinical therapy responsibilities. (OSC identified significant reliability concerns with this summary form, which are addressed in finding A. 2. below.) The contracts allow clinicians to perform case management duties but explicitly state that these hours must be recorded separately from therapy hours.

When OSC examined the total hours logged for both clinical therapy and case management by the eight cottage-assigned clinical coordinators, it found that the reported service hours for February 2020 substantially exceeded the hours in a standard workweek, the clinical coordinators' logged timesheets, and the time plausibly available in their daily schedules. The documentation reflected workloads that were, in most cases, highly improbable and, in some cases, simply impossible. Table IV shows the total hours documented in progress notes by each cottage-assigned clinical coordinator in relation to the hours documented in their timesheets, and the difference between the two sets of documents.

Table IV: Differences in Clinical Coordinators' Documented Case Management and Clinical Therapy Hours (Youth Progress Notes/Case Management Summary Forms vs. Timesheets - February 2020)

The total hours documented by the cottage-assigned clinical coordinators in the month of February 2020 (leap year) ranged from a high of 436 to a low of 258 hours. Bonnie Brae claimed it did not possess clinician-staffing schedules for 2020, but its schedules for 2021 showed that therapists were scheduled to work a standard 40-hour workweek (8 hours per day). Employee timesheets for February 2020 also reflected a 40-hour workweek. OSC compared these hours to the hours listed on the employee timesheets. See Table IV for a comparison.

The large disparities between the hours recorded by Bonnie Brae's cottage-assigned clinical coordinators on progress notes and case management documentation, as compared to their timesheets, raise questions regarding the reliability of the documentation provided and whether Bonnie Brae retained sufficient staff to meet its contract requirements. Taking Bonnie Brae's documentation at face value, the aggregate hours reflected in the progress notes and case management summary form would have required approximately 10 additional clinicians to have provided these services. Specifically, the analysis of the data presented in Table IV reveals that for just eight clinical coordinators there is a collective difference of 1,654 hours for the month of February 2020 alone. To meet the claimed service hours provided to youth, as reflected in the progress notes, Bonnie Brae required an additional 10 full-time equivalent (FTE) (1,654/160 work month) positions to account for the difference in hours between what these clinicians documented in their progress notes and case management summary forms and what Bonnie Brae's timesheet records showed.^[1]

OSC reviewed documentation from two of the eight cottages in February 2021. From this review, OSC identified patterns that mimicked what it found for February 2020. In February 2021, the cottage-assigned clinical coordinators continued to perform both clinical coordinator responsibilities and case management. See Table V below.

Table V: Differences in Clinical Coordinators' Documented Case Management and Clinical Therapy Hours (Youth Progress Notes/ Case Management Summary Forms vs. Timesheets - February 2021)

Cottage (Clinical Coordinator Initials)	Hours Recorded by Clinical Coordinator on Youth Progress Notes/Case Management Summary Forms			Clinical Coordinator Timesheet Hours	Difference
	Case Management Hours	Therapy (Individual, Family, Group) Hours (Rounded)	Total Hours Logged by Clinical Coordinator in February 2021 (Rounded)
[Redacted]	282	68	350	128	222
[Redacted]	204	37	241	88	153
Total	486	105	591	216	375

As shown in Table V above, OSC determined that the total documented hours for clinical coordinators/case managers assigned to the cottages exceeded the hours recorded on their timesheets by 375 hours in February 2021. To reconcile this discrepancy and provide the hours listed on progress notes for the two cottages reviewed, Bonnie Brae would have needed to fill an additional two FTE positions (375/160 work month), assuming each full-time position contributed 160 hours per month (40 hours per week * 4 weeks).

These deficiencies, combined with the other deficiencies cited in the report, raise serious concerns that vulnerable youth may not have received the services to which they were contractually entitled. Further, based on these findings, OSC determined that Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which requires providers to certify that claim information is "true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which requires providers to "[k]eep such records as are necessary to disclose fully the extent of services provided."

2. Case Management Summary Form Did Not Reconcile with Actual Services Delivered

In a prior stage of this audit, Bonnie Brae provided OSC case management summary forms that it used as a streamlined way to support its case management services. OSC found Bonnie Brae's approach inadequate because the forms contained unreliable information that could not be used to validate case management services. Specifically, in addition to finding that these forms contained improbable and impossible claims involving clinical coordinators, OSC found that the summary forms were nearly identical for all youth and cottages and, thus, lacked sufficient details to differentiate among individuals.

OSC found that therapists produced case management notes using templates, altering only the dates. All notes typically listed Fridays between 9:00 AM and 2:30 PM as the service times for all youth. Weekly activities are summarized in Table VI below, with a total of six hours documented per youth each week consistently for all youth in all cottages.

Table VI: Weekly Activities per Case Management Notes

Tasks	Minutes per Youth
Treatment Planning	60
Progress Notes	60
Correspondence	60
Weekend Projected Plan/Home Visits	30
Incident Report	30
Phone Calls	30
Transfer Meetings	30
Monthly Treatment Plan	30
Financial Oversight (W2's, Money Requests)	15
Cottage Staff Meetings	15
Total	360 (6 hours)

Based on its review of the case management notes for both the February 2020 and 2021 samples, OSC found that Bonnie Brae did not record specific times when activities occurred but instead routinely used a summary template with generalized time blocks (e.g., 9:00 AM to 2:30 PM every Friday) and predetermined tasks as illustrated in Table VI above. The absence of variation in tasks and times raised significant concern as to whether Bonnie Brae provided the listed services as documented on the form and, if so, the effectiveness of these services given the lack of specific information about what took place.

In response to OSC's Summary of Findings (SOF) and after holding an exit conference to discuss the SOF, Bonnie Brae submitted additional information that it stated bolstered its position that the previously submitted case management notes were reliable. Through counsel, Bonnie Brae argued that its use of case management summary forms was consistent with DCF guidance, stating "DCF approved Bonnie Brae's use of a summary Case Management Checklist with standardized times (even though the standardized times were just projections) as part of their 2015 action plan."

OSC found, however, that Bonnie Brae's position was not supported by the documentation, and that OSC's initial concerns regarding the unreliability of Bonnie Brae's case management notes remained valid. OSC notes that the 2015 action plan cited in counsel's letter was in response to a DCF audit that found that Bonnie Brae's case management records were insufficient to support the required five and a half hours per youth per week. Based on that finding, DCF recommended that Bonnie Brae institute a process through which its "[d]ocumentation should clearly represent case management provided for each youth. In addition, the duration and purpose of case management services should be noted. When minimum case management services are not being attained for a specific youth, the reasons should be documented and included in the youth's case file." In response to DCF, Bonnie Brae agreed that it would do so, stating that its "Case Management services summary form identifies all Case Management services that are delivered with standardized times, when applicable, such as the times identified for preparation of treatment plans and treatment team meetings and allows for documentation of discrete times spent delivering other Case Management services." Bonnie Brae also stated it would implement an internal control system that would allow for a weekly audit of all Case Management services delivered and documented for each youth. Specifically, it would institute audits by the Assistant Clinical Director and Medical Records Technician.

However, the documentation reviewed during the audit did not demonstrate that Bonnie Brae implemented these measures in a manner sufficient to meet the expectations outlined in the DCF action plan. Bonnie Brae's summary form did not clearly identify the actual case management activities performed for each youth, the duration of those activities, or otherwise provide sufficient detail to substantiate that it had provided required case management services. Specifically, Bonnie Brae relied on the same unvarying summary form for every youth, every week, without discrete time entries or individualized information. Further, OSC found that Bonnie Brae did not provide evidence that it performed any weekly audits of its case management services, despite having advised DCF that it would do so.

Importantly, nothing in the DCF action plan eliminated Bonnie Brae's requirement to demonstrate the actual delivery of the required case management services, and DCF's acceptance of the summary form did not relieve Bonnie Brae of its obligation to maintain documentation sufficient to substantiate that those services were provided. While Bonnie Brae asserted that case management is broad or difficult to quantify, it remained contractually obligated to provide a minimum level of services and maintain documentation demonstrating compliance with those requirements. In short, OSC's review of Bonnie Brae's case management documentation shows that Bonnie Brae failed to ensure that it properly documented that it had provided the contractually required five and a half hours per week of case management services to each youth.

By failing to maintain appropriate records, Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which states that "providers shall certify that the information furnished on the claim is true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which states that providers are required "[t]o keep such records as are necessary to disclose fully the extent of services provided."

3. Case Management "Team-Based Approach" Did Not Substantiate Reported Weekly Summary Form Hours or Meet Contractual Requirements

After reviewing Bonnie Brae's case management summary forms but prior to issuing the SOF, OSC requested that Bonnie Brae explain how the clinical coordinators could feasibly perform both case management and clinical roles. Bonnie Brae initially failed to provide a substantive response to that inquiry. After OSC issued the SOF, which included findings regarding Bonnie Brae's impossible and improbable case management hours, Bonnie Brae provided supplemental documentation regarding its case management hours, claiming that these documents showed that it used a "team-based approach" to case management, with services collaboratively delivered by clinical, administrative, and program staff.^[2]

In its supplemental submission, Bonnie Brae provided a chart identifying participating staff, estimated time allocations, and categories of case management activities. Additionally, Bonnie Brae provided documentation packets for six youth selected by Bonnie Brae from the February 2020 sample to illustrate the scope of case management services provided. Bonnie Brae asserted that tracking exactly five and a half hours of case management per youth per week was not feasible due to the integrated nature of service delivery. It further argued that activities such as administrative oversight should be considered part of case management, even though the contract did not specifically reference those services as being part of case management.

OSC reviewed the supplemental documentation and determined that, taken at face value, these documents still showed large discrepancies in service hours. Moreover, more than one-third of the documents lacked time durations, which prevented OSC from fully assessing the extent of services delivered. In several instances, Bonnie Brae included non-case management staff, such as direct care staff who typically performed routine duties, as having performed case management tasks. To quantify case management hours, OSC considered only records that included time durations but applied Bonnie Brae's broad definition of case management, counting hours documented not only by the assigned case managers but also by other individuals included in the supplemental documentation. The results are presented in Table VII below.

Table VII: OSC's Recalculation of Case Management Hours - Weekly Summary Form vs. "Team-Based Approach" - Based on Bonnie Brae's Supplemental Documentation

Youth Initials	Monthly Summary - February 2020			Weekly Summary - February 2020
	Total Case Management Hours per Individual "Case Management - Checklist" per Youth	Case Management Hours per "Team-Based Approach" Supplemental Documents per Youth	Difference	Total Minimum Contractually Required Hours per Youth	Case Management Hours per "Team-Based Approach" Supplemental Documents per Youth	Difference
[Redacted]	24.00	11.75	12.25	5.50	2.94	2.56
[Redacted]	24.00	10.00	14.00	5.50	2.50	3.00
[Redacted]	24.00	8.33	15.67	5.50	2.08	3.42
[Redacted]	24.00	8.08	15.92	5.50	2.02	3.48
[Redacted]	24.00	9.75	14.25	5.50	2.44	3.06
[Redacted]	24.00	2.48	21.52	5.50	0.62	4.88
Total	144	50.89	93.11	33.00	12.60	20.40
Percentage Difference (Summary Form vs. Team-Based) (144 - 50.90 = 93.10/144)			65%	Percentage Difference (Required vs. Team-Based) (33-12.60 = 20.4/33)		62%
Average Number of Hours per Month			8.4	Average Number of Hours per week		2.1

OSC's review identified significant discrepancies between the required and recorded hours. As highlighted in Table VII above, Bonnie Brae's supplemental "team-based approach" documentation significantly differed from Bonnie Brae's previously submitted case management documentation. Taking these supplemental documents at face value, OSC quantified the durations recorded and found that on a monthly basis there was a 65 percent discrepancy between the hours documented in the beneficiaries' weekly case management summary form (signed by clinical coordinators/case managers) and the supplemental "team-based approach" documentation. According to Bonnie Brae's supplemental "team-based approach" documents, on average, Bonnie Brae provided approximately 8.4 hours of case management per youth per month, compared to the combined 24 hours in a month (6 hours multiplied by 4 weeks) Bonnie Brae documented in the case management summary forms.

OSC also recalculated the contractually required weekly case management hours (5.5 hours per week per youth) and compared them to the hours reflected in the supplemental "team-based approach" documentation. This analysis revealed a similar discrepancy of 62 percent. On average, Bonnie Brae provided approximately 2.1 hours of case management per week per youth, far below the contractually required 5.5 hours per week. See Table VII. Bonnie Brae's own documentation showed that Bonnie Brae failed to meet its contractual requirement here.

Taken together, Bonnie Brae provided OSC with two conflicting sets of records to substantiate its delivery of case management services. Given these conflicting and inadequate records, OSC found that Bonnie Brae could not support the services it contracted to perform. Combined with other deficiencies cited in this report, these failures possibly resulted in vulnerable youth not receiving the services DCF contracted and paid Bonnie Brae to provide. Furthermore, by failing to maintain appropriate records, OSC determined that Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which requires providers to certify that claim information is "true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which requires providers to "[k]eep such records as are necessary to disclose fully the extent of services provided."

4. Individual Therapy Sessions Overlap or Lacked Clear Documentation Specifying When Therapy Occurred

DCF's contracts required Bonnie Brae to perform weekly individual therapy sessions for each youth. OSC reviewed documentation for 408 contractually required weekly individual therapy sessions from February 2020. These sessions were comprised of 343 weekly individual sessions provided to youth across all programs and 65 weekly individual Mental Illness and Chemical Abuse (MICA) sessions for youth in the BH/SU program. Based on Bonnie Brae's documentation, the same two clinical coordinators managed all of these MICA sessions.

OSC determined that Bonnie Brae's records for the 343 weekly individual sessions for youth in all programs were unreliable. These records did not include the exact dates and times when the therapy occurred. The body of progress notes stated that the therapy sessions spanned the entire week and lasted for at least 60 minutes. However, that information contradicted the headers on the progress notes, which listed specific dates and times. This conflict in records raises the question of which portion of the record, if either, accurately reflected the therapy provided. In addition, OSC found that some of these individual therapy sessions overlapped with one another. For example, in [Redacted] cottage, progress notes from February 7, 2020 stated that all eight youths received individual therapy sessions simultaneously from 9:00 AM to 10:30 AM by the same therapist, resulting in overlapping sessions on the same date and time. The body of each progress note, however, stated that the therapy took place for at least an hour over the course of the week, failing to specify exactly when or for how long the youth actively participated, or if the youth participated at all. Because these progress notes were internally inconsistent and the body of each note failed to state specifically when each session took place, OSC found that these notes were not reliable. Further, the progress notes frequently failed to discuss what transpired during these sessions. The absence of these details raises concerns about the quality, duration, and reliability of the documentation of individual therapy sessions.

With respect to the 65 individual MICA sessions, the documentation was equally deficient. The scheduled times listed for all 65 individual MICA sessions were in conflict because the identified coordinators purportedly conducted multiple individual therapy sessions simultaneously, which is not possible. There was no qualifier in the documentation to clarify that these sessions spanned different times throughout the entire week, which casts further doubt as to whether the reported sessions actually took place as recorded. For example, a MICA therapist documented individual therapy sessions from 9:00 AM to 10:30 AM on Friday, February 7, 2020 for all nine youth under her care. The other MICA therapist did the same with his seven assigned youth on Friday, February 7, 2020. This occurred every Friday. Their notes stated: "[y]outh was present for a 60-minute individual session" and "[w]riter met with youth for individual session." These statements are problematic as they imply that a single therapist was conducting individual therapy sessions for multiple youth simultaneously, which, by definition, is not an individual therapy session. The conflicting schedules and overlapping sessions cast doubt on the quality, duration, and reliability of the documentation.

OSC's limited review of two cottages during February 2021 identified similar issues. OSC found that 93 progress notes failed to disclose the exact dates and times when the therapy occurred and frequently failed to describe what transpired during the sessions. Separately, 16 progress notes involving individual MICA sessions reported overlapping dates and times for the same youth and clinical coordinator, as it did in February 2020.

According to Bonnie Brae, its Electronic Health Record (EHR) system contained a configuration flaw where service date and time fields automatically populated with pre-scheduled entries rather than the actual dates and times that services were provided. This resulted in inaccurate clinical documentation, an issue that Bonnie Brae asserted has since been corrected. As a result of this flaw, during the period at issue, Bonnie Brae failed to identify the actual dates, times, or durations of individual therapy sessions. Accordingly, OSC could not verify whether or for what duration Bonnie Brae delivered required therapy services. This further supports OSC's finding that Bonnie Brae's records were unreliable.

OSC found that Bonnie Brae improperly rendered overlapping sessions and failed to maintain true, accurate, and complete records. Accordingly, OSC found that Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which states that "providers shall certify that the information furnished on the claim is true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which states that providers are required "[t]o keep such records as are necessary to disclose fully the extent of services provided." These violations demonstrate that Bonnie Brae failed to comply with regulatory requirements and raise doubts about the accuracy of its documentation and the quality and duration of services provided.

5. Discrepancies in Youth Attendance and Progress Notes Documentation

Youth receiving treatment at Bonnie Brae may take therapeutic leave for 24 hours or more as a temporary absence from the facility for a variety of reasons, including visits with parents. Bonnie Brae's treatment team must approve this leave in advance. Bonnie Brae may request reimbursement from DCF for a maximum of 14 consecutive days of therapeutic leave. Similarly, Bonnie Brae may request from DCF a "missing days" payment authorization for youth who run away or are missing for up to five consecutive days.^[3]

OSC cross-referenced Medicaid billing records with youth progress notes for clinical therapy and psychiatric services to determine whether Bonnie Brae billed for therapeutic leave in accordance with its contractual requirements. OSC found several troubling inconsistencies. In the February 2020 sample, out of 101 youth, 55 were on either therapeutic leave or missing for at least one day during the month. Of those 55 youth who were absent from the facility, 32 had at least one instance in their progress notes indicating their presence during therapy sessions, even though Bonnie Brae's own records showed they were on therapeutic leave. In total, OSC identified 109 instances when this occurred. To determine whether this continued, OSC reviewed these same documents for February 2021. From that information, OSC identified 13 instances when two youths were on therapeutic leave but their clinical documentation indicated that they were present.

The noted discrepancies between two sets of Bonnie Brae's documentation-one showing youths absent from Bonnie Brae because they were either on leave or missing, and progress notes showing that these same youths were on site for services-is another example of Bonnie Brae's deficient documentation. In one instance, a youth enrolled in the on-campus RTC program was on therapeutic leave in 2020 from February 7-8, 14-22, and 27-29 (14 days), but during those days, there were nine instances documented in progress notes stating that the youth was present for therapy sessions. The progress notes contained statements such as "[t]he youth attended group and provided his peer with feedback"; and "[y]outh joined peers for an RTR group session to discuss ways they could use sober leisure activities at home and on campus at Bonnie Brae to help reduce stress and to reduce triggers to relapse." These inconsistencies again highlight Bonnie Brae's failure to document accurately the services it provided. OSC can only conclude that one of the documents at issue-the leave documentation or session notes-is inaccurate.

In its response, Bonnie Brae attributed discrepancies between progress notes and attendance records to the same EHR system flaw previously described, explaining that pre-scheduled entries were not always updated to reflect cancellations or resident absences in the body of the note. Bonnie Brae also indicated that it has since taken corrective actions to address these issues.

By failing to maintain appropriate records, Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which states that "providers shall certify that the information furnished on the claim is true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which states that providers are required "[t]o keep such records as are necessary to disclose fully the extent of services provided."

6. Discrepancies in Clinical Coordinator Attendance and Progress Notes Documentation

OSC cross-referenced clinical coordinator timesheets with progress notes and identified 10 group therapy sessions that included a progress note stating that a clinical coordinator was in attendance during a period when the clinical coordinator was absent from work. For example, based on timesheets, OSC determined that a clinical coordinator used two personal days and one sick day from February 24-26, 2020. According to group therapy session notes, however, during this same three-day period, the clinical coordinator purportedly held a cottage group session and two specialized group sessions. The progress notes for the specialized group sessions stated, "[c]linician facilitated today's group discussion." The clinical coordinator signed each progress note for the three group sessions on March 5, 2020 within minutes of each other. In February 2021, OSC identified an additional three instances when, based on timesheets, a clinical coordinator was absent from work, and yet, according to group therapy notes, the same coordinator purportedly was present for therapy sessions. These inconsistencies cast doubt on the credibility of the reported group therapy sessions and raise concerns about Bonnie Brae's oversight of its staff members.

By failing to maintain appropriate records, Bonnie Brae failed to comply with its DCF contracts and N.J.A.C. 10:49-9.8(b)(1), which states that providers are required "[t]o keep such records as are necessary to disclose fully the extent of services provided."

7. Clinical Coordinators Duplicated Progress Notes

During the course of reviewing progress notes, OSC discovered that two cottage-assigned clinical coordinators generated identical group therapy notes for every youth and nearly every session within their respective cottages throughout the month of February 2020. The two clinical coordinators in question, assigned to [Redacted] and [Redacted] Cottages, were also the two coordinators who recorded in excess of 400 clinical hours on their progress notes for case management and clinical therapy.

The clinical coordinator for [Redacted] Cottage held group therapy sessions on February 3, 10, 17 and 24. The progress notes were identical for all four sessions for every youth in [Redacted]. The notes in part state:

All youth gathered to discuss the importance of boundary setting and treatment. There was also a discussion about accountability and it looks [sic]. Staff was able to provide each youth an opportunity to practice connecting feelings to words and sharing information with others in a way that has information examined for its content rather than its delivery. Residents were able to draw connections between interpersonal issues and treatment goals. Residents discussed the importance of respect and how to show this when change occurs.

Resident participated with minor issues and direction. Resident was able to debrief without any issues using appropriate communication skills.

Similarly, the clinical coordinator for [Redacted] Cottage held group therapy sessions on February 6, 13, and 20. The progress notes for youth attending these sessions in part state:

All youth gathered to discuss the importance of respecting peers and staff. There was also a discussion about change. Staff was able to provide each youth an opportunity to practice connecting feelings to words and sharing information with others in a way that has information examined for its content rather than its delivery. Residents were able to draw connections between interpersonal issues and treatment goals. Residents discussed the importance of respect and how to show this when change occurs.

Resident participated with minor issues and direction. Resident was able to debrief without any issues using appropriate communication skills.

Given that youth in these group therapy sessions were not the same and that therapy sessions on different dates would not be identical, the therapy notes would be expected to vary to account for differences. The fact that progress notes from two clinical coordinators covering multiple sessions were nearly identical suggests that the clinical coordinators did not produce notes based on their specific sessions, but rather used a template that may not have been based on the actual therapy provided. Equally troubling, it appears that they duplicated one another's notes rather than documenting the unique observations of the youths in their respective cottages. This repetition, observed in clinical coordinators with the highest documented hours, raises alarms regarding what appears to be a lack of individualized care. This suggests there are systemic shortcomings in providing tailored therapy and support.

The duplicated notes fail to meet the requirements of N.J.A.C. 13:44G-12.1(b), which requires clinicians to maintain signed, dated, detailed, and accurate records that document the dates and nature of services provided, and support the necessity and the appropriateness of the services provided. In addition, these notes fail to satisfy N.J.A.C. 10:49-9.8(a), which states that "providers shall certify that the information furnished on the claim is true, accurate, and complete" and N.J.A.C. 10:49-9.8(b), which requires providers to "maintain records necessary to fully disclose the extent of services provided."

B. Clinical Therapy and Psychiatric Service Hours

Although OSC determined that Bonnie Brae's progress notes for clinical therapy and psychiatric services were unreliable, OSC continued its audit testing using these same documents to assess the extent to which Bonnie Brae documented the required services. OSC accepted the recorded hours as accurate for purposes of calculating the total clinical therapy hours provided in the sample. OSC found that Bonnie Brae failed to provide minimally required services to multiple youths. These findings are discussed in more detail below.

1. Deficient Clinical Therapy Hours

OSC calculated total hours of therapy provided on a weekly basis using the hours recorded on the progress notes. As previously stated, Bonnie Brae's contracts with DCF require it to provide at least eight hours of clinical therapy per week for the SPEC program and six hours per week for the non-SPEC programs, of which 75 percent must be face-to-face with the youth. This amounts to six hours for youth enrolled in SPEC and four and a half hours for youth enrolled in BH/SU and Main Campus RTC.

To streamline the analysis, OSC focused on youth who were present in the facility for at least five of seven days each week. Since most youth taking therapeutic leave did so on weekends when official therapy sessions did not occur, OSC excluded from this review those who took extended therapeutic leave. Of the 274 weekly instances when a youth was present for five or more days, there were 94 instances when Bonnie Brae failed to meet the minimum weekly service hour requirements.

OSC also observed variations in the weekly therapy schedules, with some weeks exceeding the required therapy hours and others falling short. To assess whether Bonnie Brae compensated for these shortfalls within the sampled month, OSC aggregated the total therapy hours for each youth present for more than 20 days, ensuring they were present for at least five days per week.

The analysis identified 13 of 101 youth (10 SPEC and 3 non-SPEC programs) who did not receive the required number of therapy hours over the course of the month. The deficiencies ranged from 0.5 hours to 8.25 hours, with an average shortfall of 3.73 hours in the month.

OSC performed a similar review for February 2021 that identified similar issues. Of the 89 weekly instances when a youth was present for five or more days, OSC found 41 instances in which Bonnie Brae did not provide the minimum number of therapy hours. During that month, the analysis identified 8 of 26 youth (5 SPEC and 3 non-SPEC programs) who did not receive the required minimum hours of service. The deficiencies ranged from 3.5 to 11.95 hours, with an average shortfall of 6.58 hours.

2. Deficient Psychiatric Hours

OSC also identified a shortfall in the psychiatric therapy hours offered to youth enrolled in the SPEC program because Bonnie Brae failed to schedule enough time for each youth. Bonnie Brae's contract with DCF required it to provide a minimum of 1.25 hours (75 minutes) per week per youth of psychiatric services by a licensed psychiatrist or Advanced Practice Nurse, of which 75 percent (56.25 minutes) were required to be face-to-face. According to Bonnie Brae's progress notes, however, Bonnie Brae only provided 45 minutes of face-to-face psychiatric services per week, which is 11.25 minutes or 20 percent less than required for each youth. While this gap may appear minimal on an individual basis, when applied across the 48 youth in the SPEC program for February 2020, it resulted in approximately 34 hours of contractually required psychiatric therapy services that Bonnie Brae did not deliver that month. If this monthly shortfall persisted throughout the year, it would equate to over 400 hours of face-to-face psychiatric services not delivered annually. OSC observed almost identical shortages in the February 2021 sample. The SPEC program provides services to youth who manifest significant emotional and/or behavioral challenges that require specialized clinical intervention, which means that even modest weekly service gaps could adversely impact the affected youth.

By failing to maintain appropriate records, Bonnie Brae violated N.J.A.C. 10:49-9.8(a), which states that "providers shall certify that the information furnished on the claim is true, accurate, and complete," and N.J.A.C. 10:49-9.8(b)(1), which states that providers are required "[t]o keep such records as are necessary to disclose fully the extent of services provided."

C. Two Unlicensed Clinical Coordinators

OSC found that Bonnie Brae employed two clinical coordinators who were not licensed when they provided services to youth. DCF's contracts require clinical coordinators to be a Licensed Clinical Social Worker (LCSW), Certified Social Worker (CSW), Licensed Marriage and Family Therapist (LMFT), or Licensed Professional Counselor (LPC). Alternatively, the contracts allow Licensed Social Workers (LSW) and Licensed Associate Counselors (LAC) to work as clinical coordinators under the direct on-site supervision of a clinically licensed practitioner.

On September 9, 2019, Bonnie Brae conditionally hired an unlicensed clinical coordinator with the requirement that she pass the licensing exam to obtain LSW licensure within 90 days. Bonnie Brae representatives advised that they informed DCF's contract administrator of this arrangement on September 23, 2019 using the SPEC PSSR submission. When the clinical coordinator did not pass the exam, Bonnie Brae, without DCF's involvement, granted the clinician a one-time extension. On February 24, 2020, after the clinician again did not pass the exam and more than five months after hiring this individual, Bonnie Brae informed the unlicensed clinical coordinator that she would be reassigned immediately to a temporary case manager role.

Bonnie Brae's conduct undermined program integrity in multiple ways here. First, it was not clear that Bonnie Brae properly notified DCF because Bonnie Brae included the LSW designation in the licensing category of its PSSR, even though this person was not an LSW. Second, Bonnie Brae granted this individual a one-time extension, apparently without having first obtained DCF's approval. Third, this individual is the same [Redacted] cottage-assigned clinical coordinator who documented more than 400 hours on progress notes and case management supporting documentation, while signing progress notes using the LSW designation. Finally, based on progress notes, this clinical coordinator continued to perform group therapy sessions on February 25, 2020 and February 27, 2020, despite Bonnie Brae advising DCF on February 24, 2020 that it would "immediately" reassign this person.

Separately, on November 16, 2020, Bonnie Brae hired a clinical coordinator with an expired LSW license. OSC reviewed the Division of Consumer Affairs' licensing database, which showed that this person's license expired on August 31, 2020. Progress notes from February 2021 reveal that this clinical coordinator conducted two hours of individual therapy, three hours of family therapy, and twelve hours of group therapy during that month. Bonnie Brae terminated this employee in March 2021. OSC further learned that this clinical coordinator entered into a Consent Order with the state licensing board in June 2022, in which she acknowledged engaging in professional misconduct prior to being employed at Bonnie Brae and further acknowledged working without a license while employed at Bonnie Brae. The Order mandated the clinical coordinator to "cease and desist from advertising, offering to engage in or engaging in the practice of social work, alcohol and drug counseling, mental health therapy and/or counseling, or the provision of social work services."

Bonnie Brae's failure to provide services using licensed clinical coordinators raises significant concerns. By failing to ensure that only licensed individuals provided services, Bonnie Brae violated N.J.A.C. 13:45B-14.4(a), which states that "[w]hen licensure to perform a health care service or function is required by law, an agency shall refer or place only those health care practitioners who are currently licensed or certified and in good standing with their respective New Jersey licensing or registration boards." These actions also violated N.J.A.C. 13:45B-14.4(c), which states that "[t]he agency shall, through its health care practitioner supervisor or other designated individual, verify the license status of each individual to be placed or referred prior to the referral or placement. Licensure shall be verified by obtaining a document, which verifies licensure from the Board or Committee that registers or licenses the individual and, within 45 days of obtaining the verification, by personally inspecting the current biennial registration or license or a copy of the current biennial registration or license."

Summary of Medicaid Overpayment

OSC found that for services provided in February 2020 and February 2021, Bonnie Brae failed to maintain records that adequately documented the services that it was contractually required and paid to provide. These issues were widespread and significant. Taking Bonnie Brae's documentation at face value, OSC found that 13 youth in February 2020 and 8 youth in February 2021 did not receive the minimum required number of clinical therapy hours, and none of the participants in the SPEC program received the minimum number of required psychiatric hours in either February 2020 or February 2021, based on the documentation reviewed. Furthermore, the supplemental documentation submitted by Bonnie Brae after the issuance of the SOF confirmed that Bonnie Brae delivered case management services at levels significantly below the amounts indicated in the case management summary form and the contractually required minimums. Due to the unreliability and insufficiency of Bonnie Brae's documentation, OSC could not accurately quantify the full extent of this deficiency. Additionally, OSC found that two clinical coordinators delivered services despite not possessing appropriate licenses.

By failing to maintain accurate and reliable documentation and allowing unlicensed personnel to provide services, Bonnie Brae did not comply with N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:49-9.8(b), N.J.A.C. 10:49-9.8(b)(3), N.J.A.C. 13:45B-14.4(a), and N.J.A.C. 13:45B-14.4(c). Based on the widespread and significant failings noted above, OSC finds that Bonnie Brae must repay the Medicaid program for payments made to Bonnie Brae under the contracts for February 2020 and February 2021. Specifically, Bonnie Brae must repay a total of $1,528,109, which is comprised of 2,656 claims totaling $1,113,442 for services provided to youths enrolled in the SPEC, RTC, and BH/SU (on-campus) programs during the sampled month of February 2020 and $414,667 for 646 claims for the youth sampled in February 2021.^[4]

Recommendations

Bonnie Brae shall:

1. Reimburse the Medicaid program $1,528,109.

2. Revise its case management summary form to accurately reflect tasks performed, hours provided, and the individuals responsible. Any deviations from contractual requirements should be documented.

3. Ensure compliance with minimum required case management and clinical therapy hours.

4. In view of the similar findings in two successive audits (DCF and this one), retain and pay all costs/fees associated with an independent third-party monitor, who is approved by OSC and has no affiliation to Bonnie Brae, to conduct calendar year quarterly reviews of Bonnie Brae's case management, clinical, and psychiatric therapy documentation. The monitor shall have full access to all information needed to prepare such reports. The monitor shall prepare written reports bi-annually to OSC and DCF, which shall be submitted no later than one month after the end of each six-month period. The monitor shall remain in place for no less than three bi-annual reports (18 months), subject to OSC extending this timeframe in its sole discretion for two more reporting periods (12 months) if it determines that Bonnie Brae has continued to provide inadequate documentation.

5. Ensure progress notes accurately document the actual time, date, and duration of individual therapy sessions.

6. Implement random weekly audits of progress notes to verify completeness, accuracy, and alignment with actual services rendered.

7. Ensure compliance with minimum required psychiatric hours to meet contractual face-to-face requirements.

8. Verify licensure by obtaining and maintaining copies of valid, non-expired licenses for all positions requiring licensure, and periodically confirming ongoing validity. The verification documentation should be dated to show the date on which verification occurred.

9. Provide regular staff training on accurate and comprehensive documentation practices, emphasizing the importance of recording all significant aspects of the therapy sessions.

10. Submit a CAP to OSC outlining the steps Bonnie Brae will take to address the deficiencies identified in this report.

OSC Note - Bonnie Brae submitted a CAP outlining steps it states it has taken and intends to take to address the identified deficiencies, but its CAP did not address repayment of the identified overpayment.