Department of Health and Social Services

Division of Mental Health and Developmental Disabilities

Quality Assurance Clinical Chart Review Summary

Provider Name: Seaview Community Services

Provider Number: MH0167

Date (s) of Review: Oct.3-5, 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 16 clinical charts were reviewed. Four Medicaid/ 3 non-Medicaid child files and 5 Medicaid/4 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:

Strengths: Assessments appear to contain all the required components as specified in the standards. They are being conducted by MHPCs. The majority of the assessments are identifying and diagnosing MH problems, making eligibility statements and treatment recommendations. CSP files documented excellent eligibility statements.

Areas for improvement: While the above mentioned medical necessity items are added to the comprehensive assessments, they continue to need clarification and refinement. MH problems were usually identified throughout the body of the assessment document. The standards require that assessments contain a clear summary of those MH problems identified. Eligibility statements refer to what services the client is eligible for based on the MH problems and their intensity. You are encouraged to review eligibility categories for services. Lastly, diagnoses are assessment documents (comprehensive and psychiatric) need to be better supported. Clinicians may find it helpful to document the behavioral symptomology that led the clinician to a particular diagnosis. Note that these issues were identified as areas needing improvement from the last chart review 3-24-99. The Plan of Improvement (POI) submitted by your agency stated these improvements would be made by 7-30-99.

Please note that psychosocial assessments are required to be conducted every 6 months for adults receiving rehab services.

Treatment Plans:

Strengths: Most of the goals documented on the plans are related to the assessment. Tx plans are being supervised by MHPCs as evidenced by their signatures on the plan. This was an area that was identified from the last review as needing improvement. Good follow through on your POI. In addition, it appears that consumers are being included in the treatment planning process, as evidenced by their signatures.

Areas for improvement: Many treatment plans reviewed prescribe more services, or different services than were recommended in the assessment documents. Services prescribed but not recommended are not considered to be medically necessary. Goals continue to be global. The last submitted POI documented that these areas would be improved by the date of 7-30-99.

Progress Notes:

Strengths: Great improvement in this area. The majority of progress notes document service modalities and interventions. They are also directed toward goals and objectives written in the treatment plan, lending to the improvement in documenting clinically relevant information. Qualified staff is signing notes. Great follow through on the last submitted POI.

Areas for improvement: Please identify the specific goal from the treatment plan that is being addressed. Interventions utilized need to be directed toward that goal. The more specifically written, the easier it is to assess progress. Notes also need to include the client's response to the intervention. It was noted that the same internal agency code is used for Client Support Services as well as Crisis Intervention. This led to notes being billed for one service and documenting the other. It is advised to include the name of the service in addition to the code on each note.

Please note that IRS progress notes are the only services that can be documented in a weekly format.

The charts evidence more services being delivered than what are being billed. This also holds true for the amount of time being billed for. For example, a psychiatric evaluation is being billed for only 15 minutes.

Treatment Plan Reviews:

Strengths: Excellent progress in this area. The majority of files had reviews and the review documents contained all the components required by the standards. Excellent follow through with your last POI.

Areas for improvement: Please ensure that the treatment review process and the necessary documentation are included in all consumer files that require them. The lack of review documents in files that should have contained them negatively impacted your score in this area.

Other areas: Charts evidenced the need for a review of the filing system. Some were incomplete; others had documentation out of sequence. Charts had no designated area for different types of documentation, which resulted in various records being mixed in together throughout the chart. You are encouraged to develop a more organized charting system to reduce the risk of missed documentation and facilitate ease of access to information in charts.

Recommendations:

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

-Appropriate billing staff is strongly encouraged to attend training provided by the Division of Medical Assistance and their contractor, First Health to learn more cost effective billing practices.

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

- An informal chart review will be conducted within one year from date of this site review to ensure progress toward areas identified for improvement.