Documentation and Quality Assurance

Documentation and Quality Assurance

Annual School of Addictions

May 3 – 4, 2015

Documentation Review

Section One

Medicaid Requirements

Every clinical record must include:

The Alaska Screening Tool (AST)

All clients seeking services at a Community Behavioral Health Services clinic must complete the AST and it must be completed before are any assessments completed

The Client Status Review (CSR)

The CSR must be completed prior to any assessments then every 90 – 135 days as long as the person remains in services

Note: the 90 – 135 time frame starts from the date of the first CSR

A Behavioral Health Assessment (7

AAC

135.110):

Substance Use Assessment

Mental Health Assessment

Integrated Mental Health and Substance Use Assessment

A Behavioral Health Treatment Plan based on the Assessment

Progress Notes

Progress Notes and Medicaid

A Progress Note is written:

For every service on the day of the service was provided

Progress Notes cannot cover multiple days or multiple services

For Medicaid Regulations Progress Notes Must Include:

What service was provided

The duration in start and stop time

Who provided the service

What activities were part of the service

The active intervention provided by the clinician or clinical associate

How the client reacted and progress towards the goal on Treatment Plan

What are the next steps

The service documented in the progress note must relate directly back to the Treatment Plan

Most important remember:

NO PROGRESS NOTE = NO PAYMENT

Documentation and Accreditation

CARF, Joint Commission, Council on Accreditation (COA) all have documentation requirements that are often more restrictive than Medicaid Regulations.

For example start and stop times

It is important to learn and understand the requirements of your agency’s accrediting body as well as Medicaid requirements

Progress Note Formats

Medicaid Regulations do not specify a specific format for Progress Notes, any format is acceptable as long as all the elements from 7 AAC 135.130 (8) are included:

Documentation as Clinical Practice and Treatment

Documentation has a purpose; it’s not just busy work

It serves as a road map for clients & providers

It guides clinical care: integrated care,

staff coverage when regular provider is ill or on vacation,

transferring providers, higher

or lower level

of care

It keeps BH providers accountable

It affects lives: court, OCS, school

It saves lives: safety planning

If you didn’t document; it didn’t happen

Remember

Medicaid is Health Insurance and like all other health insurance programs Medicaid needs to know:

Service provided was a necessary service

Service was provided by an appropriate provider

Amount billed is equal to the length of service provided

Introduction to quality assurance

Section Two

What is Quality Assurance

A definition of Quality Assurance is:

The maintenance of a desired level of quality in a service or product, especially by means of attention to every state of the process or delivery or production

In a Behavioral Health Agency:

The service is the Behavioral Health Treatment

The process is the development of the treatment plan and subsequent services

The delivery is the provision of services

What is Quality Assurance cont.

Quality Assurance is the process of reviewing the components to ensure client’s are:

Diagnosed correctly

Receiving appropriate treatment

Treatment is being reviewed and updated as necessary

Quality Assurance also:

Ensures that all documentation meet State and Accreditation standards

Quality Assurance also:

Provides continuity of care from one provider to the next

Protects clinicians and counselors in proving due diligence if necessary

Teaching opportunities –internal audits, transitioning patients to other agencies for care

Consistency within the agency

Do no harm to our patients/clients when they request their records

Role of quality assurance in operations

Section Three

Quality Assurance Components

There are two parts to Quality Assurance:

Clinical Quality Assurance

Documentation Quality Assurance

Clinical QA & Diagnosis

Symptomatology & Diagnosis

Symptoms need to be identified before a diagnosis is given

What is the frequency of symptoms

What is the duration of symptoms

Are there historical diagnoses?

Who can diagnosis?

Clinical QA & Progress

Documenting a patient’s progress through

tx

Establishing “baseline”

Can progress fluctuate?

Measuring progress through

tx

plan objectives

Measuring progress through the CSR form

How to make a problem a goal

How to make a goal an objective

What is treatment success?

Clinical QA & Risk

Clinical Quality Assurance cont’

Treatment Service Options

Clinic

--

Rehab

Therapy --CCSS/TBHS

Integ

. Assess --SA Assess

MH Assess --Case Management

BH Providers can only provide services for which they are credentialed

Clinician: Master’s Level or higher

Clinical Associate: Counselor, Case Manager, BHA

Clinical QA & short term crisis

Clinical QA & Non-Crisis Tx

Documentation Quality Assurance

Agency Administration

Provides information for management and overall quality assurance

Helps drive policy and

procedure

Accountability for providers

Shows commitment to best practice to outside agencies and clients

Documentation QA cont.

Billing purposes

Agreement to follow

Medicaid Documentation

Regulations allows

an agency to

bill

Ensures payment

by allowing errors to be corrected

QA

can catch missing documentation that would

mean lost billing

Cannot bill without

documentation

Documentation QA cont.

Training

Understanding regulations, definitions, purpose of certain

documents

General documentation training/ writing skills

Timeliness/time management

Broaden clinical view (

eg

. Problem list, functional impairments, ancillary issues)

Quality Assurance Tools

Section Four

Quality Assurance Toolbox

The tools for completing QA Reviews:

Integrated Medicaid Regulations

DSM

ICD-10

ASAM Guide

Quality Assurance Checklist's

Example of a QA

work flow/process for a new

chart (similar to full chart review

):

Receipt of the signed

tx

plan from

clinician – document date

Make

a misc. note in client file with date of signature

Do QA check on

AST

CSR

BHA

TX plan

Email

clinician, using secure email,

any discrepancies that need

correcting

Mark the service as “non-billable” until corrections are made

File

tx

plan in paper

chart w/ initials

Follow up with clinician within 2 weeks for corrections

Flag potential peer review charts (if your agency uses a peer review process)

Checklist assessment

#

YesNoType of assessment: (Clinical impressions box)CommentRegulationA.  Was the assessment conducted upon admission?By a mental health professional?By a substance use counselor? Enter Date:135.110(b)(3); &135.110(c)(3)135.010(b)(1)B.  Does the assessment document the recipient’s mental status, social and medical history? 135.110(b)(3)(A) C.  Does it include a review and consideration of the AST and relevant clinical information concurrently provided by the CSR? 135.110(h)135.100(c)D.  Does the assessment document functional impairments? (that substantially interferes with or prevents them from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills) 135.110(b)(3)(E);135.110(c)(3)(E); &135.990(92)E.  Does the written report document the presenting problems and related symptoms, and service needs for the purpose of establishing a diagnoses and a treatment plan. 7AAC 160.990 (37)(Clinical impressions box) 135.130(a)(3)(B)F.  Is there a complete DSM diagnosis consistent with multi-axial classification? (If a diagnosis exists) (both mental health & substance use diagnoses if applicable) 135.110(b)(3)(C); 135.130(a)(3)(A); &105.230(d)(1)

G.

Does the assessment document the nature and severity of any identified mental health disorder and/or substance use disorder?

135.110(b)(3)(B); 135.110(c)(3)(B)

H.

Are treatment recommendations that include services identified as treatment needs, which form the basis of a subsequent behavioral health treatment plan documented within the assessment? (In relation to both mental health and substance use)

135.110(b)(3)(D); 135.130(a)(3)(C); 135.110(c)(3)(D); & 135.130(a)(4)(C)

135.010(a)(3)(A)

I.

Does the assessment document recipient’s eligibility for the recommended services?

70.050; &

135.020

J.

Was the assessment updated as new information became available?

135.110(d)(4)&135.110(c)(4)

Checklist tx plan

#YesNoTREATMENT PLAN REQUIREMENTSCommentRegulationA.  Is there a date that TX plan implementation will begin?Enter Date:135.130(a)(7)(B)B.  Does the TX plan document the recipient’s identifying information?  105.230(b); &135.130(a)(7)(A)C.  Are the TX goals directly related to the findings of the behavioral health assessment? 135.130(a)(7)(C)D.  Are the services and interventions that will be employed to address the written goals documented? 135.130(a)(7)(D)E.  Does the TX plan identify the goals, objectives, services, and interventions selected to address a recipient's behavioral health needs identified by a professional behavioral health assessment under 7 AAC 135.110? 135.990(7)(A)(i)F.  Do the selected services and interventions detail the frequency and duration? 135.990(7)(A)(ii)G.  If the recipient is under 18 years of age, did the TX plan document the treatment team members and their ability to participate in the TX planning session? 135.120(a)(5); &135.120(c)H.  Is the TX plan remaining current based upon the periodic client status review? 135.120(a)(6)

I.

Are the name, signature, and credentials of the directing clinician present on the TX plan?

135.130(a)(7)(E)

J.

Is the name and signature of the recipient or the recipient’s representative present on the TX plan?

135.130(a)(7)(F)

Checklist: Existing chart for billing

Previous QA (

misc

note)

Current CSR and updated BHA

Progress note

Service code

Date – compare to scheduler/encounter number

Start and stop time and duration

Goal, Intervention, Progress

Any information not included in

tx

plan or Assessment

QA checklists cont

Quarterly random chart reviews

Follows same full checklist as new chart + progress notes

Flags for possible peer review

Quarterly Peer Review

Same checklist

Looks for both documentation QA and clinical QA

Starting a Quality Assurance Program

Section Five

Buy-In

Part of starting a Quality Assurance program in an agency requires:

Buy-In from Leadership as Quality Assurance:

Makes the organization more professional and more efficient

Produces meaningful information

Increases accountability

Increases revenue

Buy In

Buy-In from Staff

Every

field has a QA

process

Aircraft maintenance

Editors

IRS audits

Balancing your checkbook is QA!

It’s

not personal, “to err is human”…

QA

exists because everybody makes

mistakes

QA can help you stress less about your documentation because you are supported

Positive Quality Assurance

“I’m watching you Wazowski, always watching…”

Positive Quality Assurance

Quality Assurance and chart reviews do not have to be scary.

Agencies can use Quality Assurance as a positive action that leads to professional development.

Creates a collaborative environment with shared accountability.

Must have consistent procedure and communication with plenty of follow-up and

follow through

Positive Quality Assurance cont’

Everyone learns from Quality Assurance

Your client will thank you for it

Positive QA allows you to grow in your profession

It builds better integration between clinicians and clinical associates

Reporting

Section Six

Report Audiences

You will share your Quality Assurance findings with different audiences:

Agency management and even the Board of Directors

State and Federal Agencies

Staff

Confidentiality

Client confidentiality must be maintained when reporting any findings, except in the following situations:

Sharing results with the individual staff member who took the action

The staff member’s supervisor so he/she can also provide follow-up

It is important to tailor your reports to specific audiences

Reporting to Staff

Use the sandwich technique (+, -, +)

Ask for the provider’s understanding of the document before pointing out negative findings

Provide opportunities for training if needed or requested

Remind providers that we are always learning

Demeanor should be very matter- of- fact and non-critical

QA should make you feel safe not scrutinized

Reports to Management

When writing or presenting Quality Assurance findings to management it is important to:

Do not mention specific clients – maintain confidentiality

Start with the positive findings

Then mention the deficiencies

End with positive findings and what steps are being taken to address deficiencies

Summarize results in the following way:

Out of 20 files 18 had completed Alaska Screening Tools, 2 did not and we could not bill Medicaid

Out of 20 files reviewed – 10 had co-occurring disorders, 6 had severe mental illness, and 4 had substance use disorders

Keep the summaries simple and in bullet form

Quality Assurance and Budgets

Section Seven

How Quality Assurance can Help with Budgets

A strong Quality Assurance program can actually increase revenue by:

Catching correctible errors

Quickly retrieving information required by payers

Finding missing notes that may lead to missed services billed

Identifying Service Authorization needs

Documenting the QA process for auditors

Quality Assurance Prevents Paybacks

Periodically agencies are audited. When this happens and deficiencies are found the agency may be required to pay back money.

The payback is often an extrapolation of the results, for example:

If 15% of the files are found to be deficient, your agency may be required to pay back 15% of revenue received in that time frame

Common errors

Section Eight

Most Common Errors Found

AST and CSR:

AST and CSR results are not documented in the body of the assessment (check box at the end does not count)

AST and Initial CSR responses are not integrated into the assessment as potential treatment needs

CSRs

outside of the 90 – 135 day time frame

CSRs

are not used or documented in measuring client progress

CSR changes are not used to update the treatment plan or assessment

Most Common Errors Found

Assessments:

Missing Functional Impairments (Hint: AST and CSR results often provide evidence of Functional Impairments)

Diagnosis often does not match the narrative of the mental status, social and medical history

Missing treatment recommendations or treatment recommendations do not match the diagnosis or narrative

Missing treatment recommendations/referrals for medical or social needs

Not updated as circumstances / needs / diagnosis change

Most Common Errors Found

Treatment Plans:

Goals/Objectives often do not match the treatment recommendations from the assessment

Treatment plan is not updated as treatment needs change

Treatment plan is not updated with CSR nor is there documentation stating “no change needed at this time”

Common Errors cont.

Progress Notes:

Through the course of treatment Progress Notes reflect different diagnosis, service modalities, services provided, etc. and:

There is no record of an update to the assessment

There is no record of an update to the treatment plan

Progress Notes do not document the “active treatment” provided

Progress Notes do not document the client’s reaction to treatment or progress toward the goal that is the focus

Group Progress Notes are not individualized

Progress Notes miss the start, stop and duration

Contact / Questions

Terry Hamm

Terry.Hamm@alaska.gov

(Correct also given to Kerry Halter and Vickie Miller who assisted in the development of the original training in November 2014 for the Behavioral Health Aide Forum at

ANTHC

)