Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: Gateway Center for Human Services

Provider Number: MH0133

Date (s) of Review: June 14-16, 2000

Reviewer: Dan Weigman, MS and Pam Miller, MSW

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 27 clinical charts were reviewed. Fourteen of these were Medicaid, including 9 child files and 6 adults. The non-Medicaid files consisted of 5 adult and 7 child files.

The Quality Assurance chart review consists of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.

Assessments: Adult intake assessments are fairly consistent in containing information that support the DSM IV diagnoses, provide a good relevant history, and document the mental status exam. Areas in need of improvement in the assessments reviewed include the addition of a clear summary of the mental health problems that need treatment and making clear treatment recommendations. When assessments clearly document mental health problems identified and specific treatment recommendations, it assists in the formulation of measurable treatment goals and effective interventions. It also aids in establishing a strong basis for the necessity of services. There were few assessments found that contained clear treatment recommendations. Functional assessments were strong but also need to document clears problem statements.

Assessments were the strongest area reviewed in the documentation of children's mental health services. Most comprehensive assessments were very good. All assessments reviewed were current. The children's psychiatric evaluations reviewed were considered superb. Recommended areas for improvement include: developing a clear MH problem list with tx recommendations to address those identified problems; making clear statements of eligibility for services; and clearly supporting diagnoses given.

Assessment material reflects a marked improvement from the time of the last review and evidences the incorporation of change as contracted in the agency’s 1998 Plan of Improvement.

Treatment Plans: Treatment plans for adults, overall, were fair to good. Most of those reviewed contained good problem statements. The greatest weakness found with treatment plans was in the area of goals. While they're considered measurable and observable, they appear to be service or program goals. Treatment goals need to be directly related to the problem statements from assessment material and be focused on the desired outcome for the client.

In regards to children services, the documentation of treatment planning is identified as the weakest area for this agency. Several consumer charts did not contain treatment plans. Those that did contain treatment plans documented global goals and more services being prescribed than what were recommended from the assessment material. They did not document staff interventions. These identified areas for improvement is ongoing from the last two reviews.

Progress Notes: There were progress notes found for each service delivered to adult recipients. Progress notes contained the components required per the Standards adopted in 1998. Additionally, notes generally reflect that the work being done is aimed at the goals stated in the plan, and is provided by qualified staff. Clinic service notes need to document the actual service delivery (active treatment), rather than observations of the client.

Most progress notes in the child programs consistently documented the service modality, but not staff interventions. There were many notes that were not signed credentialed and/ or titled by staff. It is important to make this a consistent practice.

Treatment Reviews: Although the score reflected in the graph below does not reflect this, adult treatment reviews tend to be good. If anything, the review document itself contains more detail than necessary. The agency is encouraged to review the Integrated Standards (1998) for the required components of this document.

Of all the child files reviewed, only one chart had review documents. The rest were discharged prior to the need for a review. The one review format was the exact same form as the treatment plan. The only difference was that the "review" box was checked off. Please note that the review document is different than the plan and requires different components. Please refer to the Standards for the required components.

Recommendations: Staff would likely benefit from a focused training or technical assistance regarding the documentation of mental health problems and recommendations. Staff would likely benefit from some focused discussion regarding writing treatment goals and documenting active treatment in progress notes

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