Provider Name: KNA Community Counseling Center

Provider Number: MH0629

Date (s) of Review: 09/19/00

Reviewer: Connie Greco, LCSW

Introduction:

Clinical chart reviews are conducted to assist agencies in the identification of documentation needs that enable staff to generate records that reflect 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. Non-Medicaid charts are randomly selected from a list provided by the agency. The number of charts to be reviewed is determined by a Range Table based on the total number of cases supplied by DMA and/or the agency. For the chart review of this agency, a total of five (5) non-Medicaid clinical charts were reviewed. There were no Medicaid billings during the past year at this agency. The non-Medicaid files consisted of three (3) adult and two (2) child charts. The Quality Assurance chart review consists of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.

Assessments: There is an assessment at the agency that contains all of the required components to meet the requirements of the Integrated Standards. KNA is encouraged to use this form and to thoroughly complete each section. Three of the assessments were conducted by a mental health professional clinician. Assessments must be conducted by a mental health professional clinician, which requires a Master degree in a mental health field, at a minimum, in order to meet the requirements of Medical Necessity.

Progress Notes: Progress notes need to contain the components as required by the Integrated Standards.

Treatment Plans: One chart contained a treatment plan, which had the required components. Treatment plans need to consistently document goals that are specific, measurable and achievable. They also need to include interventions. Consumer signatures need to be included on all treatment plans, or attempts to obtain their signatures need to be documented.

Treatment Plan Reviews: The Integrated standards require that a treatment plan review be conducted periodically. There were no treatment plan reviews in the charts reviewed.

Recommendations: Complete and submit Plan of Improvement resulting from current review. The Division of Mental Health and Developmental Disabilities, Quality Assurance staff is available for training and technical assistance. It is recommended that this agency utilize the services of the Quality Assurance staff in order to ensure that all charts are in compliance by the end of December 2000.

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