Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: South Peninsula Community Mental Health Center

Provider Number: MH0154

Date(s) of Review: Nov. 13-16, 2000

Reviewer: Pam Miller, MSW

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 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 30 clinical charts were reviewed. Nine Medicaid/ 9 non-Medicaid child files and 6 Medicaid/ 6 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: Overall, the assessments were very good and evidenced improvement from the last chart review. Most all files contained current assessments that appeared to contain all the required components of the Standards. Areas for continued improvement include refining the mental health problem list to identify specific mental health problems rather than reiterate the diagnosis given. Diagnoses also need to be better supported. This is accomplished by listing the symptomotolgy that lead the clinician to that particular diagnosis. Many assessments documented this information, many did not. Your agency and consumers would benefit from consistent practice of this. Eligibility statements need to be more clearly stated and congruent with the information in the assessment and the level of services delivered. Assessments evidence good follow through with the POI submitted as a result of the previous chart review.

Treatment Plans: Most files contained current treatment plans that were conducted within the required timelines. Some plans evidenced the inclusion of specific and measurable goals, many of the plans continue to identify this area as a need for ongoing training in this area. Frequency and duration of goals need to be addressed as well as intensity of services. Caution: Some plans are prescribing services that were not recommended in assessment material or identified as mental health problems. Services delivered in these cases are not considered medically necessary and are therefore, may not reimbursable services. Plans evidenced good follow through with the last POI by documenting goals that address problems identified in the assessment material and that signatures included credentials.

Progress Notes: The area of progress notes proved to be the strongest area for your agency. Good improvement was noted as contracted in your last POI. Most notes were present in charts and legible. Most notes documented client goals and interventions by staff. Please note that the standards require notes to address progress toward goals and client response to interventions. You are encouraged to include this information in your progress notes and to continue your ongoing training, as your efforts in this area are apparent. An area of caution, Not all CSP notes supported the amount of time billed for. It is important to document 4 hours worth of intervention if that is what you are providing.

Treatment Plan Reviews: Excellent improvement in the area of treatment reviews. The score does not entirely reflect the strength of this area due to missing or incomplete documentation. The majority of the reviews completed met all of the requirements of the Standards and reflected a thorough understanding of the purpose for treatment reviews. The new format also evidences good follow through with your last POI. The positive outcomes of the clinical training developed and provided by your agency are apparent in the charts.

Other areas: You may find it beneficial to organize all charts in a format is easier to navigate. It may be helpful to label sections according to the type of information and to better secure the documents within the chart.

Recommendations:

- It is recommended that South Peninsula Community Mental Health Center continue to receive consultation and technical assistance upon request.