Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: 4Rivers Counseling Services

Provider Number: MH4211

Date (s) of Review: April 12-14, 2000

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what the agency must know in order to be able to generate documentation that reflects good clinical practice. For non-Medicaid cases, the random selection of clients to be reviewed, as well as those to be interviewed was derived from a client list provided by the agency. The number of charts to be reviewed was determined by a Range Table based on the total number of clients served. The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews. The file review team analyzed a total of five (5) non-Medicaid charts. There were no services delivered to Medicaid eligible clients during the period reviewed.

ASSESSMENTS

While the current assessment (Bio-Psychosocial) is generally well written, there are areas that are required to be included in the assessment by the Integrated Standards that are missing. The presenting problem should be a separate area of the assessment and should discuss the symptoms of the problem, as the symptoms are the basis for the goals of the treatment plan, as well as the justification for the diagnosis. There should be an Eligibility Statement that documents eligibility for Clinical/ Rehabilitation Services. The diagnosis must be well supported by the contents of the assessment. There should be a prognosis statement that discusses the rationale for the prognosis. The assessment should contain an area that summarizes the problems and makes recommendation for services. The Recommendation section should clearly state which services are recommended i.e. individual, family or group, case management; skills building. The Integrated Standards require that a Comprehensive Assessment be conducted at intake and annually, thereafter.

TREATMENT PLANS

The Treatment Plans in the charts generally provided measurable and achievable goals. There is a good relationship between problems identified in assessments and the goals written in the treatment plan. The person receiving services (or their guardian) signed the plans reviewed and the person who is delivering services signed and used their credentials. The Integrated Standards require that the services and levels of services (frequency and duration), as well as the person responsible for delivering the services be identified in the treatment plan.

PROGRESS NOTES

The Integrated Standards require that the services delivered during a session be stated in the progress note and that there be a progress note in the chart per each service episode. This progress note should include 1) the service provided and the2) length of the service 3) the goal addressed, 4) the intervention used by the therapist, 5) the consumers response to the intervention and 6) progress of the consumer toward the goal.

TREATMENT PLAN REVIEWS

There were no treatment plan reviews present in the charts that were examined. The Integrated Standards require that there be a treatment plan review conducted within 90 days after entry into treatment and thereafter in accordance with the Integrated Standards Service Timeline Requirements.

OTHER FEEDBACK (NOT RELATED TO MEDICAL NECESSITY)

The Integrated Standards require that charts be closed no later than 120 days after the last service. As long as the chart remains open it must be updated using the timeline provided in the Integrated Standards. The Division of Mental Health and Developmental Disabilities Quality Assurance staff is available for technical assistance upon request.

RECOMMENDATIONS

Please refer to the Integrated Standards Mental Health File Review Checklist (page 4 of 7) for the requirements of a progress note. Please refer to the criteria for Eligibility for Services located in the Alaska Administrative Code, 7 AAC 043.470 (d) and 7 AAC.043.1990. (7)(18)(65)(66). 4Rivers may wish to review the Standardized Progress Note form. Your agency has been provided with a disk that contains this form. It is recommended that the agency review the required service timelines (page 5 of 7), as well as the specific documentation required of treatment plans and treatment plan reviews (pages 3,4,5 of 7), as documented in the Mental Health File Review Checklist Section in the Integrated Standards.

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