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Home My WebLink Aboutfy2024-2025-mental-health-audit-tool-equidox-adaStrengths Quality Improvement Recommendations Total Compliance 71 0 0 100% Chart Overview 8 0 0 N/A Discharge 4 0 0 N/A Specialized Services 4 0 0 N/A ICC, IHBS, &/or TFC 13 0 0 N/A Problem List 4 0 0 N/A Progress Notes 20 0 0 N/A Consents & Other Documentation 7 0 0 N/A Assessments 11 0 0 N/A Below you will find our quality review findings for your review and consideration. Our goal in sharing quality findings with agencies is to improve the quality and outcomes of care for clients. It is our hope that you will find this feedback of value. The overall Quality Compliance Score for this audit for your program was [enter total compliance]. The Quality Review determined if the standards for documentation of Medi-Cal Specialty Mental Health Services had been met. For this audit, we analyzed eight (8) Quality Review Categories, with seventy one (71) Quality Review Items. They included the following categories: Consents & Other Documentation, Assessments, Problem List, Progress Notes, Specialized Services, ICC, IHBS, &/or TFC, Chart Overview and Discharge. The table below titled “Compliance Rate by Category” provides your overall score for each Quality Review category. The following pages include your scores for each question within the categories that were reviewed, as well as relevant comments for consideration and follow up. Your Claims Summary, which highlights any applicable disallowances, is included at the end of this report. Please refer to your individualized provider letter for next steps. Compliance Rate by Category Category Total QRIs Total Scored QRIs Non-Compliant Findings Compliance Rate of Scored QRIs Disallowance Rate (%) #DIV/0! Action Plan Required Corrective Action Plan (CAP) Client Number Review Period Number of Disallowed Services 0 CHART REVIEW RESULTS Provider Name Program Name and RU Number Total Services Provider: Provider/Program Name Page 1 of 7 ! " #$%&' ()*+, -./0 1 2 3 4 5 6 7 8 9 :; <=>?@ A B C D E F G H I J K L M N O P Q R S T QRI# RESULT 1 2 3 4 5 6 7 QRI# RESULT 8 9 10 11 12 13 14 15 Domain 5: Social and Life Circumstances, Culture/Religion/Spirituality Domain 6: Strengths, Risk Behaviors and Safety Factors Domain 7: Clinical Summary and Recommendations, Diagnostic Impression, Medical Necessity Determination/Level of Care/Access Criteria ASSESSMENTS Was the assessment completed within a reasonable time and in accordance with generally accepted standards of practice? This includes a typed or legibly printed name, signature of the service provider, and date of signature. Domain 1: Presenting Problem(s), Current Mental Status, History of Presenting Problem(s) and Beneficiary-Identified Impairment(s) Domain 2: Trauma Domain 3: Behavioral Health History, Comorbidity Domain 4: Medical History and Medications (Physical Health Conditions, Current and Past Psychotropic Medications, Developmental History) Are valid Releases of Information on file, as appropriate? For members whose primary language is not English, is there evidence of informing materials provided to the member in their primary language or documented evidence that informing materials were explained to the member in their primary language with acknowledgement of understanding? If applicable, are outcome measures (e.g., Child and Adolescent Needs and Strengths (CANS) and Pediatric Symptoms Checklist 35 (PSC-35) completed as required? Link to SMHS Supplemental Documentation Guide: https://bhcsproviders.acgov.org/providers/QA/docs/qa_manual/7- 2_Doc_Manual_Post_CalAIM_11.6.24.pdf If applicable, does the record include a copy of the member's Screening Tool or Transition of Care Tool? Link to DHCS Screening & Transition of Care Tools: https://www.dhcs.ca.gov/Pages/Screening- and-Transition-of-Care-Tools-for-Medi-Cal-Mental-Health-Services.aspx Consents & Other Documentation Comments (if none, enter "N/A"): Fill in Provider Name/Program Name **Items in bold are requirements identified by DHCS as reasons for recoupment if not compliant and/or in certain conditions.** Has the ACBHD Informing Materials/Consent to Treat Acknowledgement of Receipt page for the audit period been completed and signed by the due date? Link to ACBHD Informing Material: https://bhcsproviders.acgov.org/providers/QA/General/informing.htm If telehealth services are provided, is there documented consent (written or verbal) specific to the provision of telehealth services prior to initial delivery of services? If the member receives Medication Services, were medication consent requirements followed? Link to Medication Consent Form: https://bhcsproviders.acgov.org/providers/QA/docs/qa_manual/7-9- medication-consent-form-2023.pdf Provider/Program Name Page 2 of 7 U V W X Y Z [\] ^_` a b c d e f g h i j k l m n o p q r s t u v w x y z {| }~ ﾀﾁﾂﾃﾄﾅﾆﾇﾈ 16 17 18 QRI# RESULT 19 20 21 22 QRI# RESULT 23 24 25 26 27 28 29 30 31 Do group Progress Notes include required elements? 1) description of the member's response to the service, 2) participant list, 3) for services involving one or more providers also include: (a) total number of providers and their specific involvement in delivering the service, (b) time involved in delivering the service for each provider (includes travel and documentation) Are Progress Notes signed (or the electronic equivalent) and dated by the person providing the service? For members diagnosed with a co-occurring Substance Use Disorder (SUD), do Progress Notes document specific integrated mental health treatment approaches, when appropriate? If clinically relevant, were appropriate SUD treatment referrals provided and documented in a Progress Note? Assessments Comments (if none, enter "N/A"): PROBLEM LIST Is there a Problem List present in the chart? Link to CalMHSA Documentation Guides: https://www.calmhsa.org/clinical-practice/ Does the Problem List include diagnosis/es and problems? Are problems or illnesses identified by the member and/or significant support person included on the Problem List? Are diagnoses and ICD-10 codes established by staff according to their scope of practice, or do they have required co-signatures? Are all applicable behavioral health diagnoses, including any substance use disorders, present and consistent with the information noted in the assessment? Is the diagnosis consistent between the billing system and the EHR? Were the majority of Progress Notes finalized within three (3) business days (with the exception of Progress Notes for crisis services, which shall be completed within one (1) calendar day)? Do all Progress Notes include required elements? 1) date of service, 2) service type rendered, 3) contacts made, 4) duration of direct patient care for the service, 5) location of service (indicate telehealth when applicable), 6) evidence based practice, and 7) if the service is provided in a language other than English, the language is noted. Do the Progress Notes document the SMHS interventions delivered and demonstrate individualized, clinically relevant interventions that address the member’s current needs? Problem List Comments (if none, enter "N/A"): PROGRESS NOTES Do the Progress Notes refrain from using copy-and-paste language, such as repeated sections or interventions carried over from prior notes without meaningful updates aligned with the member's current condition and needs? Do all Progress Notes include a brief summary of next steps to be taken by the provider? Does the Problem List include the date, name, and title of the provider that identified, added, or resolved the problem? Are the diagnosis/es and problems identified by a provider acting within their scope of practice? Has the Problem List been updated on an ongoing basis to reflect the member's current condition and within a reasonable time? Has the Problem List been updated any time there is a relevant change to the member's condition? Provider: Provider/Program Name Page 3 of 7 ﾉﾊﾋﾌﾍﾎﾏﾐﾑﾒﾓﾔﾕﾖﾗﾘﾙﾚﾛﾜﾝﾞﾟﾠﾡﾢﾣﾤﾥﾦﾧﾨﾩﾪﾫﾬﾭﾮﾯﾰﾱﾲﾳﾴﾵﾶﾷﾸﾹﾺﾻﾼﾽﾾ﾿￀ 32 33 34 35 36 37 38 39 40 41 42 QRI# RESULT 43 44 45 46 Specialized Services Comments (if none, enter "N/A"): If member received ICC, IHBS, and/or TFC services during the audit period, click on (+) button on the left. Do individual and/or group Progress Notes with multiple providers clearly identify the number of providers and the specific involvement and interventions of each provider? SPECIALIZED SERVICES If the member receives Targeted Case Management (TCM) services, is there a completed care plan documented within the clinical record? Link to ACBHD Documentation Requirements: https://bhcsproviders.acgov.org/providers/QA/memos/2022/CalAIM%20Documentation%20MH%20 and%20SUD%20QRG.docx If the member receives Peer Support Services (PSS) from a Certified Medi-Cal Peer Support Specialist (CMPSS), do the services meet all required PSS documentation standards? Link to PSS Requirements: https://www.dhcs.ca.gov/services/Pages/Peer-Support-Services.aspx If the program is a Full Service Partnership (FSP), is there a completed Individual Services and Supports Plan (ISSP) in the clinical record? Link to ISSP Requirements: https://www.dhcs.ca.gov/Documents/BHIN-23-068-Documentation-Requirements-for-SMH-DMC- and-DMC-ODS-Services.pdf If member receives Therapeutic Behavioral Services (TBS), is there a completed client plan documented within the clinical record? Link to TBS Manual: https://file.lacounty.gov/SDSInter/dmh/176042_TBS_Documentation_Manual_10_26_09.pdf Progress Notes Comments (if none, enter "N/A"): Do the dates of service listed on the Progress Notes match the dates of service listed on all claims? Are all documented services within the scope of practice of the provider? Were all services billable according to Title 9; with no services claimed that were solely academic, vocational, recreation, socialization, transportation, clerical, or payee related? For members with medical/physical health needs related to their mental health treatment, do Progress Notes document that appropriate medical care is integrated into treatment through education, resources, referrals, symptom management and/or care coordination with medical care providers? Did the service that was claimed (procedure code) align with the service activities documented in the Progress Note? Did the amount of time claimed match the amount of time documented in the progress note? Was the CPT/HCPCS code (or codes) (e.g., primary, add-on, or supplemental) in the Progress Notes used according to rules in place on the date of the service? Do the services documented in the Progress Note justify the amount of time billed? Are any gaps in service delivery supported by non-billable notes or explained elsewhere in the clinical record? For members with safety risks, do progress notes document ongoing assessment, clinical monitoring, and intervention(s) that relate to the level of risk, when appropriate? Provider: Provider/Program Name Page 4 of 7 ￁ￂￃￄￅￆￇ￈￉ￊￋￌￍￎￏ￐￑ￒￓￔￕￖￗ￘￙ￚￛￜ￝￞￟￠￡￢￣￤￥￦￧￨￩￪￫￬￭￮￯￰￱ ￲ QRI# RESULT 47 48 49 50 51 52 53 54 55 56 57 58 59 QRI# RESULT 60 61 62 Does the clinical record clearly demonstrate that the member meets medical necessity criteria for Specialty Mental Health Services (SMHS), appropriate to their age and clinical needs? Did the audit confirm that the chart contains no evidence of fraud, waste, and abuse? Were services confirmed not to have provided while the member was in a Medi-Cal lockout place of service (e.g., Psychiatric Inpatient, Institution for Mental Disease (IMD), juvenile hall*, jail)? *For dependent minors in juvenile detention, Medi-Cal services can be provided prior to disposition, if there is a plan to make the minor’s stay temporary and after adjudication for release into community. Does the member's record contain documentation that a Child and Family Team (CFT) meeting has occurred within 30 days of intake and at a minimum of every 90 days thereafter? Is there a completed CFT Client Care Plan documented within the member's record and does the Client Care Plan reflect all the services provided to the member? Link to ICC/IHBS Child and Family Team (CFT) Care Plan Instructions & Form: https://bhcsproviders.acgov.org/providers/QA/memos/2023/ICC-IHBS-Care-Plan-Memo-2023.2.27- Care-Plan.pdf Does the CFT Client Care Plan & Meeting Minutes include all sections? 1) meeting attendees, 2) hope statement, 3) strengths, 4) challenges, 5) previous task review, 6) safety/risk, 7) discussion items (review of CANS ratings and updates as needed), 8) transition plan? Does the CFT Client Care Plan & Meeting Minutes include a goals section with these elements? 1) area of need, 2) goals/objectives, 3) date added, 4) task/next steps, 5) person responsible, and 6) progress status Does the CFT Meeting Minutes review the need for IHBS and/or TFC services during required intervals and is a request for re-authorization documented? If during a Child and Family Team (CFT) meeting, it is determined that IHBS services are needed, is there documentation of a referral to IHBS services being made in a progress note or in the CFT meeting minutes? If the member is receiving IHBS services, does documentation reflect accurate use of procedure codes, including the appropriate HK modifier? If the member is receiving TFC services, did the TFC parent complete and sign a Progress Note for each day of service, and was each Progress Note reviewed and co-signed by an LMHP? If the member is receiving TFC services, did the TFC parent receive the required training and supervision in accordance with program requirements? CHART OVERVIEW ICC, IHBS and/or TFC Services Comments (if none, enter "N/A"): If the member is receiving TFC services, did the provider complete all required Medi-Cal related reports? If the member is receiving TFC services, did the TFC parent comply with all service limitations and lockouts, including not claiming for non-billable services or services provided in lockout settings? INTENSIVE CARE COORDINATION (ICC), INTENSIVE HOME-BASED SERVICES (IHBS), AND/OR THERAPEUTIC FOSTER CARE (TFC) SERVICES Has an individualized screening been completed for ICC, IHBS, and/or TFC services? Does the member's most recent Assessment substantiate the need for ICC, IHBS, and/or TFC services? Provider: Provider/Program Name Page 5 of 7 ￳￴￵ ￶￷￸ ￹￺￻ � !"# $%& '() 63 64 65 66 67 QRI# RESULT 68 69 70 71 If member was discharged during the audit period, click on (+) button on the left. DISCHARGE Did the provider engage in discharge planning activities prior to the date of discharge? Was a comprehensive discharge plan shared with the individual in care and include 1) how the person's needs may be addressed after discharge, 2) information on prescribed medications, 3) the type of care the individual is expected to receive and by whom, and 4) referrals or information on available community services and supports If the member was discharged to another level of treatment, including other treatment providers, was a warm handoff facilitated? Does the discharge date in the clinical documentation match the discharge date in CG? Discharge Comments (if none, enter "N/A"): Was Medi-Cal eligibility documented on a monthly basis in the clinical record for the full audit period? Chart Overview Comments (if none, enter "N/A"): Does the chart as a whole include evidence of care coordination across providers, agencies, county systems (e.g., child welfare and Behavioral Health (BH)), significant support person(s) and/or between delivery systems (Managed Care Plan (MCP) and Mental Health Plan (MHP))? Based on the documentation as a whole, is there evidence that treatment is person centered, culturally responsive, and aligned with the member's needs? Does the medical record contain evidence that services were coordinated with other service providers to prevent duplication of services? Is the CQRT Tracking Tool (and CQRT Checklist if applicable) received and demonstrate compliance with CQRT process? Link to CQRT Procedures: https://bhcsproviders.acgov.org/providers/QA/docs/qa_manual/8-2-CQRT-Procedures.pdf Provider: Provider/Program Name Page 6 of 7 *+, -./ 0 1 2 3 4 5 6 7 8 9 :;< =>? @ A B C D E F G H I Service Date Client Name Client Number Date of Birth Procedure Name Treatment Location Service Staff Full Name Time in Min 0 CLAIMS SUMMARY 0 #DIV/0! Provider Name Program Name and RU Number Total Services Review Period Number of Disallowed Services Disallowance Rate (%) 0 0 Disallowed Reason by QRI# Provider: Provider/Program Name Page 7 of 7 J K L M N O P Q R S T U V W X Y Z [\]^_