Documentation and Quality Assurance

Annual School of AddictionsMay 3 – 4, 2015

DOCUMENTATION REVIEWSection 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 & RiskIS YOUR CLIENT

AT RISK TO HARM SELF/OTHERS?

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

CRISIS INTERVENTION •MASTER’S LEVEL OR HIGHER•ACTS AS SCREENING/ASSESSMENT/TX PLAN

PROGRESS NOTE •PRESCRIBED SERVICES•INTERVENTIONS (PLANNED ACTVITIES)

DISCHARGE •COMPLETE FINAL PROGRESS NOTE•END OF SHORT-TERM CI/CS TREATMENT

Clinical QA & Non-Crisis Tx

CLIENT

1. REFERRAL

2. SCREENING

3. ASSESSMENT

4. TREATMENT PLAN *csr process every

90-135 days

5. PROGRESS NOTE

6. DISCHARGE SUMMARY

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 TOOLSSection 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# Yes No Type of assessment: (Clinical impressions box) Comment Regulation

A. 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# Yes No TREATMENT PLAN REQUIREMENTS Comment Regulation

A. 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)