Provider Name: Wrangell Community Services

Provider Number: MH1010

Date(s) of Review: Feb. 6-7, 2001

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 reflects good clinical practice. 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. Three Medicaid/ 3 non-Medicaid adult files and 2 Medicaid/ 2 non-Medicaid child 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: Assessments appear to be strength for your agency. All comprehensive assessments were current and present in the files reviewed. They evidenced follow through on the last submitted POI. Qualified staff conducted all assessments reviewed. A great majority of those revised assessments did a very nice job of supporting a multiaxial diagnosis. Also eligibility for services was nicely supported. An area that can use continued refinement is clearly documenting specific mental health problems and treatment recommendations. This includes psychiatric evaluations. Also, please make sure that comprehensive assessments are documenting the need for further assessments, I.e. psychiatrics and functionals to determine the psychiatric/rehab services to be delivered. Functional assessments need to be completely filled out, signed and credentialed. These assessments (functionals) do not need to be conducted by mental health professional clinicians.

Treatment Plans: Treatment plans were present and current in all files reviewed. They evidenced supervision by mental health professional clinician. Obtaining client signatures, or documenting attempts/reasons why they are not on the plan, needs to be a more consistent practice. The majority of goals on treatment plans were related to assessment material. Some plans did not include services recommended in assessment material, such as psychiatric services that were provided or other clinic services. Service modalities are included in the plans, evidencing follow through from your last submitted POI. Areas that need continued refinement are to consistently document interventions on plans and continue designing goals to be measurable and specific.

Progress Notes: Progress notes reviewed documented service modalities. Some notes evidenced the need for clarification between the different categories such as case management services being called psychosocial development and vise versa. Interventions were being documented pretty consistently. Some interventions that did not appear to be aimed at mental health goals lost clinical relevance. Notes need to include client's response to interventions. All notes reviewed were signed and credentialed by qualified staff.

Treatment Plan Reviews: Treatment reviews were present in all reviewed charts that required them. They were current and timely. Reviews did a nice job of evaluating goals for progress. They continue to need to reflect the lessening of services. This will become easier to do once goals are designed to be more specific. Treatment reviews continue to require that they address any new mental health problems that have been identified and a summary of changes to the treatment plan. This was an area that was identified as needed in the last chart review conducted in January 1999. Review documents were consistent in documenting the signature and credentials of qualified staff. Obtaining the signature of consumers (or attempts/reasons why they are not signing the document) needs to be a more consistent practice.

Other areas: It was noted that reviewed charts evidenced current documentation and the required timelines were adhered to.

Recommendations:

-It is recommended that the staff of Wrangell Community Services receive training regarding medical necessity, service modalities, interventions, and designing treatment goals to be specific and measurable. This training should occur once policies regarding the newly adopted Medicaid Regulations for mental health have been clarified.

- It is also recommended that Wrangell Community Services may receive consultation and technical assistance from DMHDD QA staff on an ongoing basis as needed.