Department of Health and Social Services
Division of Mental Health and Developmental Disabilities
Quality Assurance Clinical Chart Review Summary
Provider Name: REACH
Provider Number: MH7127
Date(s) of Review: Nov. 21, 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 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 3 clinical charts were reviewed. One Medicaid child file and 2 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: Comprehensive assessments reviewed were very good. They were current and contained the required components. Assessments did a nice job of supporting diagnoses, and focusing in on mental health problems and treatment recommendations. You are encouraged to continue with this practice. Developing very specific mental health problem lists sets up a smooth transition to developing specific mental health goals for treatment.
Treatment Plans: Treatment plans were present in all files. They were all related to the assessments in the charts that were reviewed. Be careful, because there were a couple of plans that prescribed more services than were recommended in the assessment material. When services are prescribed for goals that were not identified as mental health problems, there is no medical necessity for those services. Please continue to work on developing specific goals on a consistent basis. Also, frequency of services and the amount of time anticipated delivering that service is an area that needs attending to. Ensure that all treatment plans are supervised by a Mental Health Professional Clinician. Their credentailed signature on all treatment plans evidences this.
Progress Notes: Progress notes seem to be the area in need of most improvement. While most of them do document service modalities and interventions, they do not document clinical relevance. This frequently occurs when utilizing a note format that consists of mainly check-off boxes. The service provider needs to document how the intervention was targeted toward the specific mental health goal, what the progress was toward that goal, and how the client responded to the intervention. Notes also need to support the amount of time documented as service delivery. Training is strongly recommended in this area.
Treatment Plan Reviews: Most review documents were conducted within the required timelines and contained the required components. Remember that when progress is noted, especially significant progress, the treatment plan needs to reflect the change by either modifying or deleting the goal.
Other areas: Most all charts contained required documentation and service timelines were consistently adhered to. Charts reviewed were organized and easy to navigate.
Recommendations:
- It is recommended that the staff of REACH receive training regarding medical necessity, requirements of the Standards and Medicaid Regulations, with an emphasis on writing progress note for mental heath services.
- It is also recommended that REACH receive consultation and technical assistance on an ongoing basis.
