MEDICAID QUARTERLY INTERNAL AUDIT REPORT

AGENCY: ANDERSONOCONEE BEHAVIORAL HEALTH SERVICES

QUARTER AUDITED ____3rd quarter FY-15______Total Records Reviewed _____20______

(Quarter/Year) (Admitted clients only)

ASAM LEVEL OF CARE: Indicate the total number of records reviewed in each level of care. Because some records document treatment in multiple levels of care, the sum of the records in each level may exceed the total number of records reviewed.

0.5 / I / / I-D / 1.8 / II.1 / 9 / II-D / II.5
III.1 / III.2-D / III.5 / III.7 / III.7A / III.7-D / OMT

NUMBER OF FILES IN ERROR: In the column on the left, please indicate the total number of records reviewed that were in error for each item. An item should be counted as in error if not 100 percent correct at the time of the audit, whether or not it was corrected during the audit. .

AOD SERVICES ORDERED

1)Completed assessment review within appropriate time frame.
3 / 2)Did a physician or other Licensed Professional of the Healing Arts (LPHA) certify that the Medicaid beneficiary met the medical necessity criteria per Provider Manual?
3)Client Assessment Summary’s “Admitted to Services” block is checked the form is signed dated by anLPHA.
4)If a physical exam was needed, was it ordered?
5)If services are ordered by a physician, is the Physical Exam Form annotated in Block 7, signed and dated by the physician, and filed in the chart?
6)Was the exam performed within the specified time?

CLINICAL ASSESSMENTS

7)Content comprehensively assesses biopsychosocial status
8)Content substantiates DSM-TR Axis I diagnoses
9)Content substantiates DSM-TR Axis II diagnoses and clinician is qualified to make the diagnosis
2 / 10)Axis III diagnoses are either substantiated by medical documentation or are clearly noted as client self-report
11)Content substantiates DSM-TR Axis IV
1 / 12)Content substantiates GAF scores
13)Content substantiates Master Problem List
1 / 14)Master Problem List is comprehensive
15)Interpretive Summary integrates clinical assessment information into a coherent clinical framework, which provides a rationale for treatment
16)Intensity of need identified in Interpretive Summary is appropriately matched by the intensity of service planned

INDIVIDUAL PLAN OF CARE(IPOC--formerly ITP)

17)Each service ordered is directed at specific goals
18)Orders all treatment services delivered
1 / 19)Lists frequencies of services appropriately
1 / 20)Was the IPOC reviewed 90 days after initial date and every 90 days thereafter?

TREATMENT GOALS

2 / 21)Individualized
2 / 22)Outcome specified
2 / 23)Measurable criteria for success specified

LEVEL OF CARE DECISIONS/ORDERING OF CORRESPONDING DISCRETE SERVICES

24)Initial placement is consistent with assessed client severity and diagnosis and considers client desires and capabilities.
25)All changes in level of care based upon documented changes in client status
26)Client discharge is appropriate based upon documented changes in client status
27)V-codes are used for no longer than six months.
28)For formerly bundled services, were the appropriate discrete services ordered? (Refer to the DAODAS-developed menus and crosswalk. Use small sample size)
29)Do client needs, desires and capabilities drive the mix of Community Support Services (RPS, BMOD, FS and PSS) and Therapy and Counseling Services (IT, GT, FT, SAC, CM and MM)?

SESSION NOTES

30)The focus and/or reason for the session or interventions which should be related to a treatment objective or goal listed in the IPOC are documented, unless there is an unexpected event that needs to be addressed.
31)The interventions and involvement of clinician and/or treatment staff in service provision are documented.
32)The response of the beneficiary and his or her family (as applicable) to the interventions and/or treatment is documented.
1 / 33)The general progress of the beneficiary is documented, to include observations of their conditions/mental status.
1 / 34)The future plan for working with the beneficiary is documented.
35)Is the Clinical Service Note individualized?
36)Are the assessment, IPOC, Treatment Goals, and outcome information revised in light of new information?

LEGAL DOCUMENTATION

1 / 37)Insurance Authorization
38)Client Rights & Consent to Treatment
39)If client is less than 16 years old, Parental Consent
40)All ROIs are executed properly
41)All services rendered by appropriately qualified staff
1 / 42)All clinical documentation authenticated by signature and date

BILLING

43)Were the development and/or review of Assessment Services billed as BHS (Behavioral Health Screen), DA (Diagnostic Assessment-Initial, Mental Health Assessment-Follow up, Substance Abuse Assessment-Follow up) or SAE (Substance Abuse Examination)? Note: Use a small sample size (see below for definition.
7 / 44)Were the developments and/or revision of Treatment Planning and Medical Servicesbilled as SPD (Service Plan Development, Service Plan Development-Team plus client, Service Plan Development-Team, Mental Health Service Plan Development-Non Physician) or DA (Psychological Testing and Evaluation, Psychiatric Assessment-Initial, Psychiatric Assessment-Follow up)?Note: Use a small sample size (see below for definition.
45)Is the Staff Table correct and current (all billing staff included, all staff numbers are correct, all education levels are up to date, and all certification data are accurate)?Note: Use a small sample size (see below for definition.
46)All billed services are provided by properly privileged and accredited staff.
47)To ensure that Medicaid is the payer of last resort, agency verified absence of other insurance.
48)All billed services are documented
49)All documented services are billed
50)All billed services provided within maximum units thresholds
51)All billed services are matched to a corresponding pre-authorization number
52)File organized according to UCR or other DAODAS approved guidelines

REVIEWER'S REMARKS/CORRECTIVE ACTION: Please document patterns/trends of problems and strengths found in the sample of records reviewed as well as the corrective action taken/recommended.

  • Strengths- The majority staff continues to do an above average diagnostic assessment. Session notes are timelier for most of the clinicians. I continue to observe some of the clinicians making more personalized and meaningful session notes. Our treatment team continues to be a strength as new clinicians seek and receive guidance for level of care placement, diagnosing as well as understanding AOD treatment modalities.
  • Problems-
  • This audit noted 3 files where the LPHA had not ordered services— these issues were discussed with assessing clinicians as well as their supervisors—this has been more challenging in CareLogic as the clinician must forward the assessment to the LPHA for signature—when it was in hard copy they were signed usually during the treatment team.
  • Noted mention of medical issues listed throughout the assessment then not mentioned in Axis 3 diagnosis.
  • Had 1 file where the Master Problem list was not comprehensive—but did not several where the problems were written in the form of objectives.
  • We are still having issues with an SPD note not written for each treatment plan update completed- we had 7 files with this issue found during this quarter.

Corrective Actions taken/recommended

I suggest that the supervisors focus training for the staff on the following:

  • The Master Problem list is addressing problems not needs
  • SPD notes for every update/revision of the clients treatment plan
  • More closely supervise the non-licensed staff to insure the services for each Medicaid recipient is ordered by an LPHA prior to the beginning of services.
  • We had several random errors noted, clinicians reminded to watch the details in documentation

The errors found in this quarters audit were brought to the attention of responsible clinicians- all that could be corrected were.

Reviewer:

______

SignatureDate

Kathy Parris RN-BC______864-260-4168

Name Phone

Please mail completed report to DAODAS, ATTN: Emmett Eddy

Form current as of April 2011Page 1 of 4