1. Documentation and Quality Assurance
Annual School of Addictions
May 3 – 4, 2015

2. Section One
Documentation Review

3. 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 ):
Substance Use Assessment
Mental Health Assessment
Integrated Mental Health and Substance Use Assessment
A Behavioral Health Treatment Plan based on the Assessment
Progress Notes
Terry

4. 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
Terry

5. 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
Terry

6. 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 (8) are included:
Kerry

7. 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
Kerry

8. 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

9. Introduction to quality assurance
Section Two
Introduction to quality assurance

10. 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
Terry

11. 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
Terry

12. 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
Terry

13. Role of quality assurance in operations
Section Three
Role of quality assurance in operations

14. Quality Assurance Components
There are two parts to Quality Assurance:
Clinical Quality Assurance
Documentation Quality Assurance
Kerry

15. 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?
Kerry

16. 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?
Kerry

17. Clinical QA & Risk Terry IS YOUR CLIENT AT RISK TO HARM SELF/OTHERS?
YES/NO
DOES S/HE HAVE A PLAN?
HOW WILL S/HE COMPLETE PLAN?
MOTIVE
MEANS
INTENT
SAFETY PLAN: 911, EMERGENCY SERVICES, DUTY TO WARN
DOCUMENT, DOCUMENT, DOCUMENT
Terry

18. 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
Terry

19. 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
Terry

20. Clinical QA & Non-Crisis Tx
CLIENT
1. REFERRAL
2. SCREENING
3. ASSESSMENT
4. TREATMENT PLAN *csr process every days
5. PROGRESS NOTE
6. DISCHARGE SUMMARY
Terry

21. 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
Kerry

22. 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
Kerry

23. 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)
Kerry

24. Quality Assurance Tools
Section Four
Quality Assurance Tools

25. Quality Assurance Toolbox
The tools for completing QA Reviews:
Integrated Medicaid Regulations
DSM
ICD-10
ASAM Guide

26. 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
clinician, using secure , 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)
Kerry

27. Checklist assessment Kerry # 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:
(b)(3); &
(c)(3)
(b)(1) B.
Does the assessment document the recipient’s mental status, social and medical history?
(b)(3)(A) C.
Does it include a review and consideration of the AST and relevant clinical information concurrently provided by the CSR?
(h)
(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)
(b)(3)(E);
(c)(3)(E); &
(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 (37)
(Clinical impressions box)
(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)
(b)(3)(C); (a)(3)(A); &
(d)(1)
Kerry G.
Does the assessment document the nature and severity of any identified mental health disorder and/or substance use disorder?
(b)(3)(B); (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)
(b)(3)(D); (a)(3)(C); (c)(3)(D); & (a)(4)(C)
(a)(3)(A) I.
Does the assessment document recipient’s eligibility for the recommended services?
70.050; & J.
Was the assessment updated as new information became available?
(d)(4)& (c)(4)

28. Checklist tx plan Kerry # Yes No TREATMENT PLAN REQUIREMENTS Comment
Regulation A.
Is there a date that TX plan implementation will begin?
Enter Date:
(a)(7)(B) B.
Does the TX plan document the recipient’s identifying information?
(b); &
(a)(7)(A) C.
Are the TX goals directly related to the findings of the behavioral health assessment?
(a)(7)(C) D.
Are the services and interventions that will be employed to address the written goals documented?
(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 ?
(7)(A)(i) F.
Do the selected services and interventions detail the frequency and duration?
(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?
(a)(5); &
(c) H.
Is the TX plan remaining current based upon the periodic client status review?
(a)(6)
Kerry I.
Are the name, signature, and credentials of the directing clinician present on the TX plan?
(a)(7)(E) J.
Is the name and signature of the recipient or the recipient’s representative present on the TX plan?
(a)(7)(F)

29. 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
Kerry

30. 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
Kerry

31. Starting a Quality Assurance Program
Section Five
Starting a Quality Assurance Program

32. 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
Kerry

33. 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
Kerry

34. Positive Quality Assurance
“I’m watching you Wazowski, always watching…”

35. 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
Kerry

36. 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
Kerry

37. Section Six
Reporting

38. 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
Terry

39. 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
Terry

40. 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
Terry

41. 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
Terry

42. Quality Assurance and Budgets
Section Seven
Quality Assurance and Budgets

43. 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
Kerry and Terry

44. 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
Terry

45. Section Eight
Common errors

46. 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

47. 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

48. 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”

49. 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

50. 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)