Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: COHO Mental Health Center

Provider Number: MH1878

Date (s) of Review: May 15-17, 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 Medicaid charts to be reviewed, information was obtained from the Division of Medical Assistance (DMA) For non-Medicaid cases, the random selection of charts to be reviewed, as well as clients 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

There is an assessment being used that is computer generated and appears to be thorough. The services recommended section is not precisely tied to the problem summary list (symptomatology) however, both areas are present in the assessment format. The Integrated Standards require that there be a problem list summary that includes recommendations.

TREATMENT PLANS

The treatment plans that are generated from the computer program appear to be thorough in their content. In some instances, the interventions and services being recommended are not specifically tied to a goal on the treatment plan.

PROGRESS NOTES

Progress notes were present for all episodes of services and were signed with the appropriate signature of the person who delivered the service. It is a good idea to identify which goal is being addressed for each note and to always identify the service being delivered. Also, remember that progress notes are required per service episode. If there are two different services, i.e. skills building and individual therapy, delivered on the same day, a separate note is required for each. Be careful not to document substance abuse as the service being delivered and billed in the mental health system. While it is important that we treat the whole person, these services must be delivered in the appropriate system. Mental Health and Substance Abuse have different requirements for documentation and for the credentials required to deliver services.

TREATMENT PLAN REVIEWS

This is an area that is often problematic for agencies, as content was not defined clearly until the Integrated Standards were adopted in October of 1998. While there are treatment review documents in most of the charts, they do not contain all of the necessary components listed in the Mental Health File Review Checklist of the Integrated Standards

OTHER FEEDBACK (NOT RELATED TO MEDICAL NECESSITY)

It is noted that one chart had a break in services delivered of more than 90 days. As long as a chart remains open all timelines must be adhered to as long as a chart remains open. Assessments in the charts are given various titles, "Psychiatric Intake", "Intake Note" This is an area that may be causing some confusion when filing assessments. It is noted that assessments were not always present in the area of the chart that is designated for assessments. Comprehensive assessments are due annually and some agencies have elected to use one form titled "Comprehensive Assessment" and then state whether it is the one done at intake or annually. An area that may be of concern to the agency is the number of notes that were present in the chart without a Medicaid billing to accompany the note. One chart showed no billing to Medicaid for a three-month period, although there were progress notes in the chart for that time frame.

RECOMMENDATIONS

It is recommended that you review the treatment plan for the contents required for interventions and services to be delivered. Charts that are not active should be closed within 120 days of the last service. This will allow the clinic some flexibility in billing for a new intake as well as not having to keep up a chart that is not active. Keep the focus on the goal being addressed and the interventions being used when documenting in a progress note. This will help to ensure that the notes are less process oriented and contain required elements. Your agency may want to review the Mental Health File Review Checklist located as an Appendix to the Integrated Standards. This Checklist documents all of the components necessary to comply with the Integrated Standards and the Medicaid Regulations. The Division of Mental Health and Developmental Disabilities (DMHDD), Quality Assurance (QA) department provides Technical Assistance to Providers upon request and it is recommended that C.O.H.O. arrange for a time when a representative of DMHDD QA could provide this assistance.

GRAPH