Department of Health and Social Services
Division of Mental Health and Developmental Disabilities
Quality Assurance Clinical Chart Review Summary
Provider Name: Island Counseling Center
Provider Number: MH0155
Date (s) of Review: Oct. 26-27, 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. Three Medicaid/ 3 non-Medicaid child files and 2 Medicaid/2 non-Medicaid adult 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: Assessments appear to contain the required components of the standards. All files contained current assessments conducted by Mental Health Professional Clinicians. The areas of medical necessity need to be further strengthened by clearly and consistently documenting mental health problems identified, support for diagnoses given and eligibility for services. Remember that all services to be delivered have to be recommended in assessment material.
Treatment Plans: Treatment plans are evolving to include the required components of the standards. Plans need to consistently document services prescribed per treatment goal, as opposed to a checklist of services to be provided. Remember that programs are not treatment recommendations. Intensity levels of services also need to be prescribed specifically per goal. Also, plans were recommending more services than were identified as needed in assessment material. Technically, this makes the delivery of these services not medically necessary and subject to repayment. Plans evidenced that the formulation of goals to be more measurable is occurring. Excellent job in consistently including consumer signatures as well as other required signatures on treatment plans.
Progress Notes: Notes evidenced great improvement in documenting staff active interventions. Notes are being conducted by qualified personnel. Casemanagement notes need to include the treatment goal being addressed in them. Take caution when documenting the delivery of services toward goals that are not identified as mental health goals in assessment material. These include vocational, probationary and substance abuse goals. These services are not billable under Medicaid for mental health services. You are encouraged to review the standards for the required components of progress notes.
Treatment Plan Reviews: Treatment reviews indicated an area of great improvement. Most formats included most, if not all required components of this document. The majority occurred consistently within the expected timeline. Excellent job in consistently including consumer signatures as well as other required signatures on treatment plans.
Recommendations:
-Staff at ICC may request training and/or ongoing technical assistance/consultation as needed.
