Medicaid Record Review

Item 
Number
Item
Description 
Level 1  Level 3 Level 5
1

The current Individual Treatment Plan (ITP) reflects the individual's assessed needs and has been updated per consumer's progress and changing needs.

Note: look at one individual's chart (even if only one ITP to review)-not across charts

Goals and services do not respond to individual's assessed needs. ITP's are all duplicates of prior ITP's, with the only changes being the anticipated achievement dates and/or staff, if that. Treatment plans are completed only at 6- month intervals and not as progress is made or changing needs occur. Goals and services somewhat respond to the individual's assessed needs. ITP's are nearly identical: only some items of progress or changing needs are modified. Goals and services responsive to almost all/all of the individual's assessed needs. Almost all/all ITP's are updated from the prior versions, reflecting all consumer progress and changing needs.
2 There is evidence of changes in or re-evaluation of treatment needs and/or services during periods of sudden changes in functioning or symptoms. There is no evidence of changes or re-evaluation of treatment needs and/or services during periods of sudden changes in functioning or symptoms. There is evidence of changes or re-evaluation of treatment needs and/or services during some periods of sudden changes in functioning or symptoms There is evidence of changes or re-evaluation of treatment needs and/or services during almost all/ all periods of sudden changes in functioning or symptoms
3 Treatment is consumer driven as evidenced in clinical documentation

None of the clinical documentation reviewed shows evidence of treatment being consumer driven.

(e.g., clinical documentation reflects that the consumer does as told or is 'compliant'; there is no evidence of consumer's own words or consumer participation in decision-making; all documentation is centered on the clinician's opinions and decisions).

Some clinical documentation reviewed shows evidence of treatment being consumer driven.

(e.g., SOME clinical documentation reflects that the consumer is involved in his/her treatment and the consumer is actively a part of decision-making),

Almost all/all clinical documentation reviewed shows evidence of treatment being consumer driven.

(e.g., clinical documentation reflects that the consumer is very involved in his/her treatment and the consumer is actively a part of decision-making; for example, treatment goals are in the consumer's own words, service notes show the consumer brings up issues to discuss and work on).

4 Treatment provided builds on the identified strengths of the consumer. There is no evidence of strengths being discussed or identified (includes listing strengths as 'none' or 'unknown'). As evidenced by ONE or TWO of the following:
  1. Individual strengths are identified in the MHA
  2. The ITP uses identified strengths to address identified needs.
  3. The ITP reviews and/or progress notes continue to build on identified strengths (new and/or previously identified)
As evidenced by all THREE of the following:
  1. Individual strengths are identified in the MHA
  2. The ITP uses identified strengths to address identified needs.
  3. The ITP reviews and/or progress notes continue to build on identified strengths (new and/or previously identified)
5 All treatment needs as identified on the Mental Health Assessment are being addressed in the ITP and in the actual service and are prioritized based on importance/severity.

The treatment needs/ recommendations identified in the MHA are: (1) listed in the treatment plan or justification not to address a need is not documented most of the time and/or (2) addressed in the service delivery via progress notes, and/or (3) are addressed according to importance.

(Recommendations identified meet none or 1 above points)

The treatment needs/ recommendations identified in the MHA are: (1) addressed in the treatment plan or justification not to address a need is documented some of the time, and/or (2) observed in the service delivery via progress notes, and/or (3) are addressed according to importance.

(Recommendations identified meet 2 above points)

The treatment needs/ recommendations identified in the MHA are: (1) addressed in the treatment plan or justification not to address a need is documented most of the time, and (2) observed in the service delivery via progress notes, and (3) are addressed according to importance.

(Recommendations identified needs meet the above 3 points).

6 There is congruence between the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia Scales. There is congruence between none of the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia Scales. There is congruence between some of the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia Scales. There is congruence between Almost all/all of the information in the Mental Health Assessment and the Functional Assessment/ LOCUS/Ohio/Columbia
7 There is evidence in the clinical record that primary health care coordination is occurring with the primary physical health care provider.

There is no evidence in the clinical record that primary health care coordination is occurring with the primary physical health care provider.

If consumer refuses coordination with primary health care, there is no documentation of discussion of potential benefits.

There is some evidence in the clinical record that primary health care coordination is occurring with the primary physical health care provider.

If consumer refuses coordination with primary health care, there is documentation of at least one discussion of potential benefits.

(e.g., release to PCP, etc.)

There is good evidence in the clinical record that primary health care coordination is occurring with the primary physical health care provider.(PCP)

If consumer refuses coordination with primary health care, there is documentation of repeated periodic discussion of potential benefits.

[e.g., Correspondence with PCP, medical reports, participation of PCP in meetings, staff participation during medical appointments, etc.]

8 There is documentation that the provider is assisting the consumer with utilizing natural supports in the community. There is no documentation that the provider is assisting the consumer with utilizing natural supports in the community.

There is limited documentation that the provider is assisting the consumer with utilizing natural supports in the community.

[e.g., occasional attempts seen, but not on a regular basis]

There is consistent documentation that the provider is assisting the consumer with utilizing natural supports in the community.

[e.g., there are consistent and regular attempts seen at assisting with getting set up with clubs, activities in the community, attempts to involve family and friends in treatment, or independent activities.]

NON-MEDICAID RECORD REVIEW

Item # Item Description Yes/No
9 There is documentation that the provider is working to connect the consumer with benefits / entitlements (such as Medicaid benefits).
10 There is documentation that the provider is assisting the consumer with utilizing natural supports in the community.