Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: COMMUNITY CONNECTIONS

Provider Number: MH3260

Date (s) of Review: June 22-23, 2000

Reviewer: Pam Miller, MSW

Introduction:

Clinical chart reviews are conducted to assist agencies in the identification of documentation needs that enable staff to generate records 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 number of charts to be reviewed is determined by a Range Table based on the total number of cases supplied by DMA. For the chart review of this agency, a total of 10 clinical charts were reviewed. Five Medicaid child files and 5 non-Medicaid child files were reviewed.

The Quality Assurance chart review consists of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.

Assessments: Overall, assessments conducted by the agency are good. They now include components that were lacking in the last chart review (1997); evidencing good follow through with the last submitted Plan of Correction. Assessments would benefit from clearly supporting the diagnoses given. The newer assessments include eligibility statements, problem lists and treatment recommendations. Documenting more specific information may refine these areas. The agency is currently using assessments that are conducted at other agencies. These assessments did not consistently meet the Standards. If an agency chooses to use documentation from other sources, they assume responsibility that the documents used meet the requirements in the Standards.

Treatment Plans: Goals for treatment need to be designed for mental health problems identified in assessment process. Some treatment plans reviewed contained goals that had not been identified. This practice calls into question the medical necessity of treating problems that have not been identified as such. Most treatment plans did a good job in recommending service modalities, but indicated a need for clarification between Activity Therapy and Family Support Services. Treatment plans also need to clearly and consistently identify staff interventions for assisting clients’ to reach their goals. All treatment plans reviewed included consumer signatures on plans. This practice was very consistent.

Progress Notes: It is a requirement that progress notes are signed per service episode. They also need to address mental health goals as identified in the assessment and prescribed for treatment in the plan. If notes are written that address goals that have not been identified, there is no medical necessity for the services provided. Activity Therapy notes clearly and consistently documented active interventions of staff. Clinic notes would benefit from adopting this practice. Family Support Services notes need to document consumer goals on them.

Treatment Plan Reviews: Treatment reviews were present in all reviewed files. They appear to be occurring consistently and in a timely manner. There were two review formats utilized by the agency. The AYI review form does not meet all the requirements of the Standards (please refer to the Integrated Standards for the requirements). The other review document format did meet the standards. The agency is encouraged to use that form consistently. Treatment reviews did an excellent job of reviewing progress toward goals and recommending changes to the treatment plan. Treatment review documents are required to be signed by the IDT members and consumers, in addition to the Mental Health Professional Clinician.