Department Of Health and Social Services

Division of Mental Health and Developmental Disabilities

Kenai Community Care Center

Site Review conducted September 23, 2000

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what information the agency needs in order to generate documentation that reflects good clinical practice. Another reason for the review was 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 charts reviewed were determined by a random sample taken from data supplied by DMA for Medicaid charts. The number of Medicaid charts reviewed was determined by a Range Table based on the total number of cases billed to Medicaid in the year prior to the review. Five (5) Medicaid charts were reviewed. The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.

STRENGTHS

Kenai Community Care Center charts are strong in all areas. An overview of ASSESSMENT MATERIAL indicates that the assessments are very comprehensive. TREATMENT PLANS contain well-developed goals and also include goals for the client that are not related to mental health issues in order to reflect the total care needed for the client. An overview of PROGRESS NOTES shows that notes meet all of the requirements of the Integrated Standards and Medicaid Regulations. An overview of TREATMENT PLAN REVIEWS indicates that reviews are consistently present in the file. The treatment plan reviews meet the requirements of the Integrated Standards.

AREAS FOR IMPROVEMENT

Kenai Community Care Center should make sure that a comprehensive ASSESSMENT is conducted by a Master’s level clinician annually. While it is comprehensive to list problems that are not treatable in the mental health system, be cautious that the services recommended to treat non-mental health issues are not delivered as mental health services (i.e. Family Support Services, Activity Therapy). TREATMENT PLANS are generally very well written; be cautious when listing the goals and interventions. Goals are what the client is striving to achieve and interventions are tools that the therapist uses to assist the client in meeting their goal. Make sure that the PROGRESS NOTES that reflect a mental health service, document goals for mental health issues.

Be careful to fully develop all areas of the TREATMENT PLAN REVIEW form.

SUMMARY:

KCCC has a very dedicated staff that is professional and eager to perform quality services. The Director is committed to providing training and technical assistance for the staff. KCCC has improved in their documentation from the last sight review and this improvement should continue. KCCC has a good internal quality assurance review process. This unit should continue to organize the charts to allow for easy access to staff needing to review documentation. The graph below depicts the findings of the clinical records review portion of the site-review. The overall Statistical Summary score is 98.4%. This score reflects Kenai Community Care Center’s recognition of the significance of good clinical documentation to the treatment process.