Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: ASSETS

Provider Number: MH2866

Date of Review: April 3, 2000

INTRODUCTION

The clinical chart review is conducted for the purpose of determining what information the agency needs to be able to generate documentation that reflects good clinical practice. Another reason for the review is to conduct a mini-event audit for the Division of Medical Assistance (DMA) to determine that the services delivered are reflective of the services billed to Medicaid. The Medicaid eligible charts reviewed are determined by a random sample taken from data supplied by DMA for Medicaid cases. The list of non-Medicaid eligible consumers is provided by the agency and a random selection is made from those records. The number of charts to be reviewed is determined by a Range Table based on the total number of cases supplied by DMA. The Quality Assurance chart review consists of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews. The team reviewed a total of five (5) Medicaid charts.

STRENGTHS

An overview of ASSESSMENT MATERIAL indicates that the assessments are excellent and contain, at least, the required amount of information. The current TREATMENT PLAN is superior and contains all components required by the Integrated Standards. In addition, there is a section in the treatment plan titled “Intervention Strategies” that documents case management and various methods for skills teaching, as well as how outcomes will be measured. An overview of PROGRESS NOTES show that notes were found in charts for all billings, dates and units are included, and signing and credentialing is present for each note. An overview of TREATMENT PLAN REVIEWS indicates that reviews are consistently present in the file and that the reviews are extremely thorough.

AREAS FOR IMPROVEMENT

As a way to reduce paperwork, ASSETS may wish to replace their current Screening Tool for Eligibility with an Eligibility Statement in the ASSESSMENT, as current Integrated Standards require that an eligibility statement be included in the assessment. When PROGRESS NOTES are removed from a chart, it is recommended that the chart reflect where the note can be located (i.e. accounting, case management). Please make sure that interventions and response to interventions are clearly stated; this is sometimes overlooked when a standardized progress note is being used.

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SUMMARY

ASSETS compliance with medical necessity in their mental health clinical chart documentation is depicted in the statistical summary graph below. The statistical results indicate strength in all areas of documentation. ASSETS is commended on their mental health clinical chart documentation which reflects an extremely high level of compliance with the Integrated Standards and Medicaid Regulations.