Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: Petersburg Mental Health Services, Inc.

Provider Number: MH1413

Date (s) of Review: May 25, 2000

Reviewer: 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 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. 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 10 clinical charts were reviewed. Five of these were Medicaid, including 3 child files and 2 adults. The non-Medicaid files consisted of 3 adult and 2 child files.

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

Assessments: The assessment material reviewed was very good. This included comprehensive, psychiatric and psychosocial assessments. The majority of these assessments supported the diagnoses well and contained clear statements of eligibility. Since the time of the last chart review in 1998, statements of prognosis were added to assessment formats, as were statements of consumer strengths and weaknesses. These additions evidence good follow through on the agency’s last submitted Plan of Improvement. There were a few assessments reviewed that documented the consumer’s eligibility and need for rehabilitation services. These services were not documented as being recommended or delivered. If there is a clinical justification as to why these services were not recommended or delivered, the agency is encouraged to include this information in documentation.

Progress Notes: Progress notes do a good job in documenting staff interventions and progress made toward goal. The specific goal being addressed (rather than global goals) needs to be documented on the note. All notes billed for were present in the file.

Treatment Plans: All plans were current and occurred at appropriate time intervals. 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: All reviews were current and occurred at appropriate time intervals. They now include discharge criteria as contracted in the agency’s last submitted Plan of Improvement (1998). Review documents need to assess for the identification of new mental health problems.

Recommendations: Complete and submit Plan of Improvement resulting from current review.

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