Quality Assurance Peer Review Training
For individuals enrolled after 3/1/2012, is the Receipt of the Orientation Handbook &HIPAA Privacy Act 1 Acknowledgement signed by the individual in Carelogic? 2 Is the Receipt of the Orientation Handbook & HIPAA Privacy Act Acknowledgement signed by the individual on an annual basis? Reminder: CARF requirement- this should be completed upon Intake and annually for programs/services lasting more than 12 months. 3 Is the Consent for Services signed by the individual on VPH enrollment date? (For GRAN- see AD Residential Consent for Services. For CSUs and Court Services - also check scanned documents) 4 Are all Consents updated at least annually? (Includes: Consent for Contact, Consent for Services, Application for Financial Assistance- if applicable based on SCS or Medicaid payers, Release of Informationif applicable, etc.) Also check scanned documents. 5 For IDD programs, are all consents signed by the individual and his or her legal guardian? 6 7 8 9 10 Is there a Comprehensive Assessment or Updated BPS completed in accordance with payer requirement (6 months or at least annually)? (For Court Services: at least 1 assessment on file= see DUI/Drug Court Assessment Note- also check scanned documents) Is the Interpretive Summary comprehensive and individualized? Includes information from ALL sources - including central themes, medical problems, family history, current functioning, etc. Are acute and chronic medical/physical conditions noted in the individual s assessments? (For Adult CSU, review CSU Comprehensive Nursing Assessment) If the individual has a medical/physical condition, is there evidence of appropriate medical referrals, if needed? (review assessments, progress notes, case mgmt note, correspondence of a referral to medical provider) (For CSU, review Nursing Assessments) Is there evidence of a medical/health & wellness screening at least annually? (review Health & Wellness Assessment) 11 For IDD programs, does documentation reflect follow up to medical care or assessments? 12 For IDD programs, is there evidence in the record indicating timely medical follow up post hospitalization? Last Revised: 4/18/14 1 of 9
Is there a focus on the individual s strengths, needs, abilities and preferences (SNAP) towards their goal 13 of recovery? 14 15 16 Is the Transition/Discharge plan SMART? (Specific, Measurable, Achievable, Realistic & Time-Limited-all elements must be met for scoring of 2) Does the Transition/Discharge plan contain specific step-down service? Important: stating step down or lower level of care is not a specific step down service = score of zero, if not specific). Is C-SSRS Screener - Lifetime/Recent Version or C-SSRS Screener - Pediatric/Cognitively Impaired Recent/Lifetime Version completed at intake? (Score N/A for CSUs) 17 Is there a Safety Plan signed by individual (with printed name) at Intake? (For CSUs, check for safety plan completed at discharge from CSU). 18 Is the Safety Plan updated at least annually and/or as clinically necessary? (Score N/A for CSUs) 19 20 Are the Goals and Objectives listed on the Treatment Plan, related to the assessment, services, individual needs and reflected in the progress notes? Is the Treatment Plan signed and dated ON or less than 30 days prior to its Start Date by the individual and/or Guardian WITH printed name included? (for C&A, tx plan must include signature of indivual served and parent/legal guardian unless refusal/inability is clearly documented). 21 For individuals who refuse to sign or are unable to sign their treatment plan (e.g. due to medical instability/incoherence, psychosis/paranoia), is there documentation stating why the individual is unable to sign AND is there a message posted on the face sheet indicating the missing signature on the treatment plan? (also check Progress Notes, Case Mgmt Notes, addendums on assessment) Are all of the Treatment Plan Goals outcome based and reflect the individual s hopes for recovery? 22 23 Are the Objectives in the Treatment Plan SMART? (Specific, Measurable, Achievable, Realistic & Time- Limited-all elements must be met for scoring of 2) Last Revised: 4/18/14 2 of 9
If Moderate or High Risk - Suicide History is noted on message board/face sheet, is the Treatment Plan 24 updated to reflect appropriate interventions to address suicidality? 25 Do the interventions on the Treatment Plan support the individual s goals and objectives? 26 27 If the individual is dually diagnosed, are interventions for both diagnoses included on the Treatment Plan? Reminder: dual diagnosis may include any combination of MH, AD and/or IDD diagnoses. If the individual is dually diagnosed and there are no interventions addressing dual diagnoses, is there documentation noted in the assessment, case mgmt note or in the Explanation of Exceptions indicating why it is not on the treatment plan? Example, individual refuses recommendations for substance abuse treatment or type of service/loc or individual already receives IDD services from another provider. Reminder: dual diagnosis may include any combination of MH, AD and/or IDD diagnoses. 28 29 30 31 If the individual is dually diagnosed and willing to address, is there documentation that services have been provided that address both diagnoses (progress notes)? Reminder: dual diagnosis may include any combination of MH, AD and/or IDD diagnoses. Is there evidence of goals and interventions in the IRP/treatment plan that include whole health and wellness (e.g. advocacy, skills training/development and education)? Is the Treatment Plan updated to reflect significant changes in the individual s symptoms and needs? Look for an updated treatment plan signed by individual & clinician. Is there a Goal, Obj & Intervention listed on the Treatment Plan for every service that is listed on the Order for Services? 32 IDD/IE individuals only: Has the ISP been reviewed quarterly? (see ISP Review) 33 34 Is there an Order for Services signed and dated ON or less than 30 days before services are provided with a qualifying signature for medical services? (For Court Services: enter N/A) Is there an Order for Service that is signed and dated ON or less than 30 days before services are provided with a qualifying signature for clinical/non-medical services? (For Court Services: enter N/A) Last Revised: 4/18/14 3 of 9
For CSUs, if the Order for Services was a verbal order (see comment section on form), was it accepted by nursing staff, date and authenticated by the ordering practitioner s signature within seven (7) calendar 35 days of the issuance of orders? This may be an original signature, electronic signature or faxed signed order. 36 37 38 39 40 If an ordered service has not been provided since the last authorization has that service been removed from the Treatment Plan? (Look for treatment plan in Carelogic that is signed/dated by individual& clinician) (For Court Services: enter N/A) IDD/IE individuals only: Is the DMA (6 or 7) scanned to the record? (must be completed annually-similar to Order for Service). If the individual is currently receiving medication, have they been re-evaluated by the psychiatrist/aprn as medically necessary? **Minimum Requirement for MD/APRN contact is every 3 months** (see MD Progress Notes & check Service History) Is there documentation of accurate delivery of medications (e.g. size of needle/canula, trained/educated individual, injection site, individual response/reaction to injection) for individuals who receive on-site medications? (Review the MAR & Nursing Progress Notes). If individual is NOT receiving on-site medications mark N/A. ACT Program individuals ONLY - Is there documentation of accurate delivery of medications (e.g. size of needle/canula, trained/educated client, injection site, individual response/reaction to injection), for individuals who receive out of clinic IM medications? See ACT Note signed by RN 41 42 Are Progress Notes signed within the appropriate time frame according to agency standards? (IDD/IE: progress notes must be signed at the end of shift/time of contact. All other VPH programs signed within 24 hours). For GRAN & Court Services only: are the Progress Notes of Level 5 (paraprofessional staff with no listed certification) co-signed by a licensed staff? (Note: Court Services- certified group facilitators do not require 2nd signature from licensed staff). Last Revised: 4/18/14 4 of 9
Are all Individual, Family and Group Psychotherapy/Counseling provided by licensed staff? (Licensure and other credentials are noted after staff signature. For ACT, review ACT Progress Note). Note: Certified Addiction credential is allowed to provide counseling and skills training for AD related 43 services; however this does not include psychotherapy- review content of note and interventions to determine how to score). 44 45 46 47 48 49 50 If receiving both CM & PSR-I services (replaced Adult CSI as of 6/1/2013), are staff interventions documented independently as Progress Notes to describe service activities? CM activities may include service linking/coordination, engagement, collaboration with internal/external providers, resource planning, referrals, facilitating & assisting. PSR-I activities may include skills training/building, teaching and coaching ways to develop environmental and recovery supports, modeling and teaching self-advocacy. Do Progress Notes document that Interventions listed on the Treatment Plan are being implemented? (verifies health service delivery) Do Progress Notes indicate specific Interventions to address the individual s symptoms, behaviors, and/or skill deficits? Do Progress Notes indicate the individual s response to the intervention provided by staff/clinician? (Tip: response should describe how the individual reacted to interventions from staff/clinician---e.g. was the individual responsive---did the individual participate---was the individual resistant to education or skills training/activities or did the individual willingly engage/practice? Also, quotes can be included to further describe the individual s response to the intervention). Do Progress Notes document progress or lack of progress of the individual toward achieving their treatment objectives? Do Progress Notes document that each service listed on the Treatment Plan is being provided consistent with the frequency noted on the Plan of care? (range of contacts or specific frequency) Do Progress Notes document the next clinical step(s) that will be taken? For example, next steps are similar to a "lesson plan" what will staff do to support individual in reaching goals and objectives identified on the treatment plan? (Nursing notes may refer to MD as next step) Last Revised: 4/18/14 5 of 9
Do Case Management Notes for missed or cancelled appointments (status: DNS, CBC, or CBT) include specific details/documentation (e.g. date of rescheduled appointment, effort made by staff/clinician to 51 follow up or provide service to individual and/or strategies to avoid future missed appointments)? Blank notes= 0 52 53 Cancellations/ No shows (within 2 week time frame or 2 missed appointments)- was a follow-up contact made and documented? (Contact by phone documented or letter sent is indicated in chart/progress notes or scanned documents). If receiving CM (Case Management replaced CSI as of 6/1/2013), are 50% of the services face to face over an authorization period? (180 days) (# of face to face contacts divided by # of total contacts) 54 If receiving PSR-I, are services provided at a minimum of twice each month? 55 If receiving ADSS (Addictive Disease Support Services), are services provided at a minimum of twice each month? (Note: at least one of these contacts must be face-to-face and the second may be either face-toface or telephone contact depending on the individual s support needs and documented preferences). 56 If individual is receiving Independent Residential Services, was the required minimum of at least 1 weekly, in home, face-to-face individual contact, provided? (Weekly Summary Note must be signed within 7 days of service). (If note is missing, check case mgmt notes, memo to chart and program history for absentee dates- to verify reason for no documentation (e.g. individual hospitalized, incarcerated, etc.). 57 If receiving Semi-Independent Residential Services, was the required minimum of 3-4 hours of skilled training and/or support, which is relevant to the individual s IRP, provided each week? (Residential Skills Training Note). (If note is missing, check case mgmt notes, memo to chart and program history for absentee dates- to verify reason for no documentation (e.g. individual hospitalized, incarcerated, etc.). 58 If receiving Intensive Residential Services, was the required minimum of 5 hours skilled training provided, which is relevant to the individual s IRP, provided? (Residential Skills Training Note). (If note is missing, check case mgmt notes, memo to chart and program history for absentee dates- to verify reason for no documentation (e.g. individual hospitalized, incarcerated, etc.). Last Revised: 4/18/14 6 of 9
If individual has been discharged from a program, was a Discharge/Transition Program completed? (Reminders: Effective date/time must match last date/time of service provided by program from which 59 individual was discharged-verify last service by viewing service history) Review assigned quarter only. I certify that I have not been directly involved with the services delivered to the clients above. Reviewer Name, Licensure/Credentials and Date Please enter your name, credentials, and the date in the cell to the left of this arrow after reading the certification statement FOR ADMINISTRATIVE USE ONLY Average Quality Score #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Average Billing Score #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Average Score Overall #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! # of responses with score of "0" 0 0 0 0 0 # of responses with score of "1" 0 0 0 0 0 # of responses with score of "2" 0 0 0 0 0 # of questions with no response 51 51 51 51 51 # of responses % of Total Not Compliant (0) 0 #DIV/0! Partial Compliance (1) 0 #DIV/0! Full Compliance (2) 0 #DIV/0! Total 0 #DIV/0! Last Revised: 4/18/14 7 of 9
- Scoring Comments Reviewer Name: 0 Client ID Question # Comment on any score less than 2 Last Revised: 4/18/14 8 of 9
- Additional Reviewer Notes Reviewer Name: 0 Client ID # Note: Last Revised: 4/18/14 9 of 9
Peer Review Tool Comment tab Client ID Question # Comment on any score less than 2 99999 15 44444 24 33333 35 88888 36 2 most recent tx plans (dated 1/17 & 3/28) do not include client's signature; tx plan is not valid without client signature. Active tx plan does not include interventions to address AD (e.g. relapse prevention planning) despite dual diagnosis-cannabis Abuse. Progress notes mostly indicate clinical next step; however there are weekly notes which show identical next steps/plan despite varying bxs displayed by client. Clinical next steps should be individualized and reflect the plan for staff interventions that will assist the client in reaching identified goals and objectives (see notes dated 3/8, 3/15, 3/22, 3/29, 4/12, 4/19 for identical next step/plan) No shows & cancellations are briefly noted in case management documentation. For ex) case mgmt note dated 4/12/2013 states "Client did not show" and case mgmt note dated 3/22/2013 states "Client did not come in this week, no return call"; however there are no specific details noting how staff attempted to follow up with client (e.g. notes about efforts to call client, no scanned letters from staff to client, etc.).
Peer Review Tool Additional Reviewer Notes Client ID Note: 99999 Client is assigned to VPH Org. POE needs correction. 44444 There are multiple unsigned notes observed in service history. Program hx shows active and inactive programs but there are no 33333 discharge/transition programs in ECR.
TIPS & REMINDERS: Peer Reviews are conducted quarterly Scoring tools with comments are due on or before the assigned date DO NOT LEAVE BLANK SCORES OR COMMENTS Scores less than 2 require a comment Comments should be substantive and objective Additional Reviewer Notes (last tab on peer review tool) should be included for clinical feedback and suggestions which are not addressed on scored questions Chart reviews will consist of services documented within the assigned review cycle (exceptions are assessments, tx plans) If reviewer is affiliated with assigned chart, reviewer must notify QA to receive alternate chart assignment Post all completed scoring tools to the Peer Review share folder LATE OR INCOMPLETE REVIEWS IMPACT QUALITY MEASURE SCORES/ INCENTIVES AND REPORT DATA - SUBMIT COMPLETED REVIEWS ON TIME! Peer Review Cycle: Quarter Assignments sent Assignments due 1 July- September September 15 October 15 2 October December December 15 January 15 3 January- March March 15 April 15 4 April June June 15 July 15