Provider Name: Address: Provider Type: Name of Reviewer: Date of Review: Residential Treatment Facility TRR Tool 2016 Member ID Auth Dates 1 Initial Assessment Areas of Review Reference Record 1 Record 2 Record 3 Record 4 Record 5 Total Total Possible % 1.1 Was the Member assessed for substance use/abuse using a formal substance abuse screening format (age 10 and up or if there is a suspicion of substance abuse at any age); and if substance abuse issues are indicated, are they being addressed either through treatment/ education or referral as appropriate? 1.2 Does the record contain evidence of trauma assessment having been completed; and if trauma is identified, is it addressed in treatment, or is appropriate referral made? 1.3 Is the Notification of Admission to Facility or Institution and School Enrollment form included in the chart? 2 Treatment Plans 2.1 Are treatment plans signed by all parties (Member, parent/guardian, therapist, other team Members) indicating participation in development and agreement with plan within 30 days? 2.2 Are the treatment plan goals specific and measurable? 2.3 Do the goals have specific and relevant target dates? 2.4 Are the methods and interventions clearly identified? 2.5 Does the treatment plan include measurable baseline information? OMHSAS-06-03; Manual p. 70, 102 Provider Manual p. 71, 102 OMHSAS-10-02 3800.224 (a); Manual p. 71 Manual p.96; 3800.226 (1) 3800.226 (1), (11); Manual p. 97 3800.226 (11); CM-006 2) 2.33.1.3; PerformCare Provider Manual p. 97 ; Manual p. 96 1
2.6 Does each goal contain an evaluation of the Member's current skill level? 2.7 Is there monthly documentation of the Member's progress on each goal? 2.8 Does the treatment plan identify symptom-free periods of time for the Member (e.g. times when symptoms were reduced or periods of wellness)? 2.9 Does the treatment plan actively incorporate supports/strategies/interventions that previously helped the Member achieve times of wellness or reduced symptoms? 2.10 Does the treatment plan include the projected aftercare services being considered? 2.11 Does the treatment plan build on the strengths of the Member? 3800.226 (2) 3800.226 (3) ; CASSP: Writing Effective Treatment Plans ; CASSP: Writing Effective Treatment Plans 3800.226 (10); Manual p. 97 OMHSAS-09-04; CASSP; Services; PerformCare Provider Manual p. 95 2.12 Are the goals and objectives updated or modified to reflect progress? 2.13 Does the treatment plan identify the supports needed by the family and Member while in residential treatment? 2.14 Does the treatment plan (identify) respect and include family strengths, needs, and cultural values? OMHSAS-09-04 2.15 Has the Family Involvement Plan been OMHSAS-09-04 developed within the first 14 days of admission - including strengths, needs, values, and supports noted by the Member and family? 2.16 Does the treatment plan contain measurable discharge criteria and clear aftercare plan? 2.17 For members with ongoing symptoms that are NOT evidencing improvement, does the record indicate that the treatment team has made changes as appropriate (i.e. assessed effectiveness of interventions, re-evaluated medications, changes to treatment plan, involvement of family/external providers, treatment team meetings, etc.)? OMHSAS-09-04; Manual p. 97 OMHSAS-09-04 ; Manual p. 97 Services 2
3 Crisis Plan 3.1 Does the crisis plan identify antecedents and triggers to a crisis for the Member? 3.2 Does the crisis plan identify early warning signs of what could be a crisis for the Member (i.e. specific symptoms or behaviors the Member may exhibit prior to a crisis)? 3.3 Does the crisis plan include steps the Member can take in order to prevent escalation of behaviors? Principle Principle Provider Manual p. 97-98 3.4 Does the crisis plan actively incorporate Member strengths and interests as a means to prevent escalation of behaviors? Provider Manual p. 97-98 3.5 Is a contact number to be used in crisis situations present? Principle 3.6 Does the crisis plan outline steps natural supports can take prior to contacting provider, crisis intervention, or police should a crisis arise? 3.7 Does the record contain evidence that, following a crisis, the treatment team has reviewed the crisis plan for effectiveness, and made changes, as clinically appropriate? 4 Progress Notes 4.1 Does each progress note clearly document what occurred during the session (i.e. the data/facts of what happened in the session)? 4.2 Do the progress notes list the person s name and role that were involved in the session? (90% compliance) 4.3 Does each progress note reflect which goals and objectives from the treatment plan are addressed? 4.4 Does each progress note clearly document which interventions were used during the session? 4.5 Does the clinician provide an assessment/analysis of the effectiveness (or lack of effectiveness) of treatment/interventions that occurred during the session? 4.6 Do the progress notes reflect the Member s response to treatment/progress towards goals? 4.7 Do the progress notes include a risk assessment which assesses suicide risk, homicide risk, and psychotic symptoms? Provider Manual p. 97-98 Principle 1101.51 OMHSAS-09-04 1101.51 1101.51 3
4.8 Does each progress note clearly document the plan for future sessions/treatment (score as 0 if it only notes the date of next session)? 4.9 Does the treatment plan specify the frequency for offering family therapy, and the progress notes provide documentation that the specified number of family therapy sessions are occurring (being offered at least 90% of RTF months)? 4.10 Does the treatment plan specify the frequency for offering individual therapy, and the progress notes provide documentation that the specified number of individual therapy sessions are occurring (being offered at least 90% of RTF months)? 5 Recovery Orientation 5.1 Does the record contain evidence of personcentered language (i.e. avoiding use of client or patient ; including Member and family names; record is individualized)? 5.2 Does the record contain evidence of shared decision making (i.e. treatment meets need of Member rather than fit Member into existing structure; evidence of collaboration/discussion between Member and treatment provider)? 5.3 Does the record contain evidence that progress is defined by the Member/family (i.e. goals should be developed and assessed by the Member/family, in collaboration with the provider; Member/family empowered to advocate for themselves)? 5.4 Does the record contain evidence that efforts were made to strengthen natural and community supports (i.e. supports used in treatment; suggestions made for increasing natural supports; review of the Member s social role or strengthening involvement with community supports)? 5.5 Does the record contain evidence that efforts were made to identify any cultural preferences of the Member/family? 5.6 Does the record contain evidence that efforts were made to be respectful to cultural preferences, in order to provide culturally competent care? Provider Manual p. 46-47, 50 Provider Manual p. 46 Provider Manual p. 46 Provider Manual p. 46-48 Provider Manual p. 51-52 Provider Manual p. 51-52 4
5.7 Does the record contain evidence that the focus is not only on symptom reduction but also addresses quality of life factors such as improving skills, relationships, living arrangements, participation in social or recreational activities, or the use of community resources? Provider Manual p. 47 6 Restraint Indicators 6.1 Was the restraint injury free? OMHSAS-02-01 6.2 If injured during the restraint, did the Member OMHSAS-02-01 receive appropriate medical follow-up to address the injury? 6.3 Is the documentation of the restraint order in OMHSAS-02-01 the record and signed? 6.4 Is the treatment team physician notified of OMHSAS-02-01 restraints? 6.5 Are the de-escalation techniques identified in restraint plans/treatment plans or previous debriefings being utilized? (or documented if they are not) 6.6 If there are 5 or more restraints within a 30 day period, is a plan to address this evident in the treatment plan or restrictive procedure plan? 6.7 Do the treatment plans include a safety plan/restrictive procedure plan for the OMHSAS-02-01 Member? 6.8 Were the treatment plans adjusted in OMHSAS-02-01 response to restraints? 6.9 Was staff debriefing completed for each OMHSAS-02-01 restraint episode? 6.10 Did debriefing with Member occur after each Restraint? OMHSAS-02-01 6.11 Were all restraints reported to PerformCare via Critical Incident Report and/or other PR-008 state/county agencies as required? 6.12 Does the restraint documentation clearly include the safety issues that were required for OMHSAS-02-01 each restraint? 6.13 Does the documentation support the use of de-escalation techniques prior to the restraint ; OMHSAS- 02-01 being initiated? 6.14 Does the documentation support a discussion or plan to prevent re-occurrence? ; OMHSAS- 02-01 5
7 Discharge Planning/ Medication Rationale/Coordination of Outpatient Follow-up: 7.1 Does the record contain evidence that discharge planning started upon admission? 7.2 Does the record contain evidence that discharge barriers were explored and resolved (if possible) in treatment, prior to discharge? 7.3 Does the record contain evidence that attempts were made to strengthen community and natural supports throughout treatment, to assist the Member in preparing for discharge? 7.4 Does the record contain evidence that aftercare plans were actively initiated at least 30 days prior to discharge (and overlap occurred, when applicable)? 7.5 Does the record contain evidence that there was collaboration between the provider and the aftercare services, if applicable (i.e. forwarded discharge summary, most recent treatment plan, communication by phone, etc.)? 7.6 Does the discharge summary include name of contact/provider, upcoming appointment date (if applicable), and contact information for all aftercare resources? 7.7 Was the rationale for prescribed medications documented in the discharge summary? 7.8 Is there a scheduled follow-up appointment with an ambulatory mental health provider clearly noted in the chart? 7.9 If there is no documentation of a follow-up appointment, is the reason documented clearly in the record (i.e. left AMA, Member/family refusal, Member/family chose to make own appointments)? (Score as 0 if no appointment scheduled and no reason documented) ; Guidelines for in Children and Adolescent Mental Health Services; Manual p. 97 Services; PerformCare Provider Manual p.97-98 1101.51; IPRO IPRO & CM-CAS- 047 6
7.10 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? IPRO 7.11 Is there documentation in the chart to support that the RTF notified the host school system (if applicable) and the resident (home) school district at least two (2) weeks prior to the anticipated discharge date for the Member? OMHSAS-10-02 8 Physical Health - Behavioral Health Coordination and Continuity of Care: 8.1 Is coordination with the PCP at the time of admission documented? 8.2 Is coordination with the PCP at the time of discharge documented? 8.3 If psychotropic medications prescribed, were reasons documented to support this intervention (90% compliance)? 8.4 Is there documentation of coordination with psychiatrist or other prescriber? 8.5 Is the management of psychotropic medication addressed (e.g., coordination with prescribing physician; linkage with case management if needed)? 8.6 Is there any evidence of medication changes documented in the chart? 8.7 Is there evidence of ongoing assessment by RTF provider of psychotropic medication? CM-006, Item 2.3; Services; PerformCare Provider Manual p. 97 CM-006, Item 2.29; Services; PerformCare Provider Manual p. 97 1101.51; IPRO CM-006, Item 2.29 CM-006 2.21-2.26 CM-006, Item 2.25 1101.51 (e) (1) (v) 7
8.8 Is there documentation in the chart to support ongoing cooperation and collaboration between the host school district and the residential (home) school district OR between the RTF and the residential (home) school district to facilitate the Member s education (i.e. providing staff from a host or residential school district or another education entity access to the facility to view the Member s program, participate in the planning process, etc.)? OMHSAS-10-02 8.9 Does the record contain evidence that discussion and support was provided related to nutrition and physical activity (i.e. provided educational materials, discussed healthy food choices, discussed increasing physical activity and wellness, etc.)? 8.10 For Members who do not currently have a Primary Care Physician, does the record contain evidence that the provider attempted to link the Member/family to a Primary Care Physician? 8.11 Does the chart contain a current physical (or document the request for one)? 8.12 Does the record contain evidence that the Member s tobacco use was assessed, and if appropriate, provided with tobacco use cessation information? 8.13 For members diagnosed with a medication responsive disorder (i.e. ADHD, Bipolar Disorder, Depression, Schizophrenia, etc.), does the record contain evidence that provider discussed with the Member/family exploring medication (e.g. discussion about member/family thoughts regarding medication, referral for psychiatric evaluation, etc.)? 8.14 Does the record contain evidence that the treatment team is monitoring medication adherence (i.e. asking Member/family on regular basis, providing education, adding as treatment plan goal, discussing during sessions, and coordination with PCP/ psychiatrist)? HEDIS Measure; Manual p. 71 HEDIS Measure; Manual p. 71 HEDIS Measure HEDIS Measure; Manual p. 71 HEDIS Measure HEDIS Measure 8
8.15 For members diagnosed with Schizophrenia or HEDIS Measure Bipolar Disorder who are using antipsychotic medications, does the record contain evidence that the psychiatrist has ensured diabetes screening has taken place? (N/A if psychiatrist is not affiliated with provider) 8.16 For members with Cardiovascular Disease and a diagnosis of Schizophrenia, does the record contain evidence that the psychiatrist ensured Member is receiving cardiovascular monitoring? (N/A if psychiatrist is not affiliated with provider) HEDIS Measure 9 Quality Indicators 9.1 Does the record contain evidence that an assessment tool (related to evidence-based recovery-oriented services) is being completed and used to inform the treatment planning process? 9.2 Does the record contain evidence that an outcome tool or measure related to evidence based recovery oriented services is being used? 9.3 Does the record contain evidence that the outcome tool or measure were utilized to inform treatment planning and clinical decision making? 9.4 Are empirically-based or evidence-based treatment packages being utilized? 9.5 Can the provider show documentation to support that they are taking steps to improve outcomes (i.e. reminder calls for appointments, interactive web-based applications to support recovery, support groups, psychoeducation groups, etc.- only score once as not related to individual records)? ; Manual p. 51 Grand Total QI Reviewer must complete boxes below for review to be complete: QOCC Referral SIU Referral YES NO IF YES, EXPLAIN 9