Office site visits are scheduled annually for the purpose of conducting treatment record
documentation audits of high-volume Providers in order to monitor adherence to treatment record standards and to
audit billing accuracy. The intent is for treatment records to be maintained in a manner that is current, detailed
and organized, and which permits effective and confidential care. The quality review of treatment records is based on
the applicable HealthChoices regulations governing each level of care. These indicators include the adequacy of documentation in
treatment plans, progress notes, intake assessment, continuity and coordination of care, and discharge planning.
The benchmark quality score for providers in the Capital contract (Cumberland, Dauphin, Lancaster, Lebanon, Perry) was moved
to 72% during 2009 while the benchmark quality score for providers in the NorthCentral contracts (Bedford/Somerset, Blair,
Franklin/Fulton, Lycoming/Clinton) remained at 70%.
The intent of the Treatment Record Review process is to ensure treatment records are maintained
in a manner that is current, detailed and organized, and which permits effective and confidential care.
The quality review of treatment records was based on the applicable HealthChoices regulations governing each
level of care. These indicators included the adequacy of documentation in treatment plans, progress notes,
intake assessment, continuity and coordination of care, and discharge planning. High-volume providers for the
purposes of Treatment Record Reviews were identified by meeting all three of the following conditions:
Criterion for review varies by level of care is targeted for network improvement but
includes some combination of the following specific areas:
Criterion for review varies by level of care is targeted for network improvement but includes some combination of the following specific areas:
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| Name and contact information for Primary Care Physician (PCP)
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| Coordination at the time of admission
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| Coordination at the time of discharge
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| Coordination at the time of a significant change in medication or LOC
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| History and current use of tobacco, alcohol and illicit, prescribed, and over –the-counter drugs includes kind, type, frequency and amount
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| Provider assess for Substance Abuse issues using a formal Substance Abuse Screening format
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| Appropriate referrals to Substance Abuse services, when indicated
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| Treatment Plans contain measurable goals and objectives with dates for completion
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| Therapeutic interventions/modalities are clearly identified on the treatment plans
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| Discharge criteria on the treatment plan
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| Treatment Plan has signature and agreement by Member
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| Treatment plans build on the strengths of the Member
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| Treatment plans are updated every 4 months
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| Response to treatment/progress towards goals documented in the progress notes
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| Services start within 2 weeks of accepting the authorization
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| School information is available in the record
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| The treatment record reflects continuity and coordination of care when applicable -- with other mental health providers
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| -- with substance abuse providers
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| -- with educational and/or vocational systems
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| -- with child protective services
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| -- with juvenile probation
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| Medication and changes are noted with evidence of coordination with psychiatrist or other BH prescriber
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| Initial treatment plans are completed and signed by all parties within 30 days.
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| All entries dated
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| Goals/Objectives reflect the strengths and needs of the Member - consumer specific
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| Measurable goals and objectives
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| Methods to achieving goals
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| Discharge criteria
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| Objectives and interventions change as progress is noted
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| Service plans build on the strengths of the Member
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| The activities of the service plan are reflected in the progress notes
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| Response to services/progress toward goals is documented in notes
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| DSM-IV diagnoses for axes I-V upon discharge
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| Discharge Summary sent to CBHNP within 30 days
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| Recovery Plan is documented in the chart
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| Chart contains a preventative crisis plan
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| Chart documents or acknowledges advanced directives
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| Provider assess for SA issues using a formal SA screening format
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| Appropriate referral to SA services, when indicated
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| Author of all entries is identified by name, title or degree, with signature (paper) or key identifier (electronic)
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| School information is available in the record
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| Initial treatment plan initiated within 5 days of start of services and signed by the director
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| Treatment plans have specific and measurable goals
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| Methods and interventions are clearly identified on the treatment plan
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| Behavior plan is in the chart if indicated on the treatment plan
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| Unique crisis plan for the family
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| Interagency team meeting within 30 days of acceptance of case shows conjointly written treatment plan
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| Progress notes document interventions used
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| Progress notes document the response to treatment and/or progress towards goals
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| Treatment record reflects continuity and coordination of care when applicable with Substance Abuse providers
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| Initiation of aftercare services prior to discharge
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| Proof of discharge sent to treatment team
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| Is there a scheduled follow-up appointment with an ambulatory mental health provider clearly noted in the chart?
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| Is there evidence that an ambulatory mental health provider or county mental health agency was provided materials regarding the patient's treatment at the residential treatment facility at any time near the date of discharge?
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| Treatment Plans are individualized with measurable goals and target dates for completion.
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| Treatment plans contain an evaluation of the child’s skill level for each goal
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| Charts have monthly documentation of the child’s progress on each goal.
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