Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: Maniilaq Counseling Services

Provider Number: MH4353

Date (s) of Review: April 18-20, 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 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

Overall, the assessments are well developed. There are some components that are required by the Integrated Standards and Medicaid Regulations that are missing from some assessments. The Recommendation section should clearly state which services are recommended i.e. individual, family or group, case management; skills building. The Integrated Standards require that a Comprehensive Assessment be conducted at intake and annually, thereafter.

TREATMENT PLANS

While later treatment plans are better developed, some treatment plans do not contain all of the components that are required by the Integrated Standards and Medicaid Regulations. The Integrated Standards require that the services and levels of services (frequency and duration), as well as the person responsible for delivering the services be identified in the treatment plan.

PROGRESS NOTES

Progress notes are generally well developed and meet requirements. Keeping the focus on the goal being addressed and the interventions being used will help to ensure that the notes are less process oriented and contain required elements.

TREATMENT PLAN REVIEWS

The charts reviewed did not have any treatment reviews due so there is no information to be shared in this area. The Integrated Standards require that there be a treatment plan review conducted within 90 days after entry into treatment and thereafter in accordance with the Integrated Standards Service Timeline Requirements.

OTHER FEEDBACK (NOT RELATED TO MEDICAL NECESSITY)

The Division of Mental Health and Developmental Disabilities Quality Assurance staff is available for technical assistance upon request.

RECOMMENDATIONS

It is recommended that your agency review the Mental Health File Review Checklist portion of the Integrated Standards to ensure that assessments and treatment plans contain all of the required elements. Please refer to the standardized forms for treatment plan reviews and to the time lines for due dates which are listed in the Mental Health File Review Checklist.

GRAPH