Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

 

Provider Name: Central Peninsula Counseling Services

Provider Number: MH0156

Date (s) of Review: Sept. 26-29, 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 39 clinical charts were reviewed. Fifteen Medicaid/ 7 non-Medicaid child files and 10 Medicaid/7 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: The majority of assessments reviewed evidence the addition of required components that were found lacking in the last review. It also appears that comprehensive assessments are being conducted in a timely manner.  The current comprehensive assessment form appears to meet the requirements of the standards. When used appropriately and completely, the contents of this form should provide the basis for a clinically sound diagnosis and recommendations for treatment.  Credentials indicate that assessments are being conducted by MHPCs. Good follow through with your submitted Plan of Improvement. Diagnoses and eligibility statements need to be better supported. It may be helpful to document the behavioral symptomotology that led the clinician to assess a particular diagnosis.  You are encouraged to fully develop Axis 4 in order to better support the GAF score. Eligibility statements need to document how the individual client meets the requirements for services being recommended. The terminology for eligibility should be taken from the contents of the assessment rather than using the definition of the Medicaid Regulations. Please remember that treatment recommendations made in the assessment are the only services that will be considered medically necessary for the treatment plan and services delivered. Also be sure to follow through on the disposition of other assessments recommended.

 

Treatment Plans: It appears that most treatment plans meet the timeline requirement. The majority of treatment plans reviewed evidence the addition of required components that were found lacking in the last review. Increased efforts are noted most of the goals are related to those identified in assessment material. Objectives appear to be designed to allow for outcome measures. Good follow through with your submitted Plan of Improvement. Although charts are evidencing an improvement in refining goals to be more specific, continued efforts in this area are encouraged.  When goals and objectives are written globally, it is difficult to note progress, anticipate dates of achievement and treatment duration. Treatment plans need to consistently and accurately prescribe frequency and duration of services.  The majority of treatment plans are addressing more goals and recommending more services than what was identified in assessment material. It may be easier to see progress when efforts are directed toward fewer goals. Remember that while it is okay to list goals that are not considered MH goals, MH services may only be provided for identified MH problems. Plans indicate the need for clarification between problems v. diagnosis, objectives v. interventions v. service modalities.

 

Progress Notes: Progress notes are an area of strength. They include (at a minimum) all required components and address areas that were found lacking in the last review.  They clearly identify interventions, response to interventions and progress toward goals. Most notes contain signatures and credentials of qualified service providers. The majority of notes reviewed for were present in the file. Good follow through with your submitted Plan of Improvement. Many notes described services that were either not recommended in the assessment, or described a different level of intensity of services than was recommended. Therefore, these services delivered were not considered medically necessary for treatment. This is a significant area to attend to.  Non- medically necessary services do not meet the requirements of Medicaid Regulations and the Integrated Standards for reimbursable services. A repeat finding from last year indicates that weekly progress notes continue to be used incorrectly. At present, the only acceptable weekly note is for the provision of Intensive Rehab Services.

 

           Treatment Plan Reviews: The majority of reviews appear to be occurring according within timeline requirements. They contain most of the required components. They do a nice job of assessing progress of each goal and gathering data for outcome measurement. They appear to be supervised by a MHPC as evidenced by signatures and credentials. Consumer signatures are also present on the majority of review documentation. Good follow through with your submitted Plan of Improvement. Treatment review requirements pertain to Non-Medicaid as well as to Medicaid clients. Review documents need to include a summary of recommended changes to the treatment plan.

 

           Other areas: Charts reviewed evidenced a significant difference between the quality of the documentation found in Medicaid v. Non-Medicaid files.  Non-Medicaid charts were lacking in required documentation, most notable in the areas of treatment plans and reviews. The agency reports that these files were either closed or pending the assignment of a new clinician. It was suggested that the agency document the suspension of services for reviewers’ information.

 

It is recognized that CPCS has implemented an internal QA process that is striving to increase quality services to its consumers. They are doing so by providing uniformity in documentation throughout agency programs and ensuring that documentation meets standards. Continued training of agency staff by their internal QA staff is encouraged.

  

   Recommendations:

 

-It is recommended that the staff of CPCS receive training regarding medical necessity, requirements of the Standards and Medicaid Regulations.

 

- It is also recommended that CPCS receive consultation and technical assistance on an ongoing basis.