Clinical Performance Standards

Helen Farabee MHMR

Contents:

  1. Mental Health Standards
  2. Chart Elements Complete and Current
  3. Service Package Compliance
  1. Mental Retardation Standards
  2. Person Directed Plan
  3. Individual Plan of Care
  4. Related Condition Assessment
  1. MH/MR Standards
  2. Documentation
  3. Documentation Submission
  4. Ethical Behavior/Confidentiality
  5. Productivity
  6. MAC Time Study

Mental Health Standards

  1. Chart Elements Complete and Current.
  2. Definition: Diagnosis, Uniform Assessment, and Treatment Plan are required chart elements with required update frequencies.
  3. Standard: Patients assigned to staff have current chart elements.
  4. Source: CMHC chart elements status reports.
  5. Compliance Rating: 98% or higher per element = compliance.
    Below 98% per element = non-compliant.
  6. Solution Plan: Developmental Note issued by supervisor within 1 working day of monthly review if non-compliant.Clinicians will mail a 10 day letter/Medicaid Fair Hearing Letter within one working day from the review. Failure to update the chart element or close the case on the 11th day will result in a written warning and additional training.Continued non compliance during the next 6 months will result in termination of employment.
  1. Service Package Compliance.
  2. Definition: Patients are authorized to receive state-defined amount and type of service within each service package as defined in the UM Guidelines.
  3. Standard: Patients in each service package during the previous quarter have met the minimum hours required for that package.
  4. Source: Case Manager’s Report in Report Manager.
  5. Compliance Rating: 88% compliance or above = compliant.

Below 88% = non-compliant.

  1. Solution Plan: Staff will receive performance development counseling every 10 calendar days if non compliant in previous review period and will receive supervisor mentoring. Written Counseling at 60th day of non-compliance. Termination at 80th day if non compliant.

Mental Retardation Standards

  1. Person Directed Plan
  2. Definition:
  3. Standard: All PDPs will be preparedaccording to each program schedule.
  4. Source: CMHC report.
  5. Compliance Rating: 100% = compliance; below 100% = non-compliant.
  6. Solution Plan: First non-compliant review results in a developmental note and additional training. A second non-compliant review within 3 days results in a written warning and a third within 90 days following the warning results in termination of employment.
  1. Individual Plan of Care (IPC).
  2. Definition: Annual plans that are submitted to CARE.
  3. Standard: IPC’s are completed annually and submitted to CARE at least 30 days before the annual expiration date.
  4. Source: CARE/CMHC data indicates due dates and update dates for the assessments.
  5. Compliance Rating: 100% of IPC’s are completed accurately and submitted to CARE within the expected timeframe = compliant. Below 100% = non-compliant.
  6. Solution Plan:First non-compliant review results in a developmental note and additional training. A second non-compliant review within 3 days results in a written warning and a third within 90 days following the warning results in termination of employment.
  1. Related Condition Assessment
  2. Definition: The MR/RC Assessment identifies the level of need of an individual and is entered into the CARE system annually.
  3. Standard: The assessments are completed and entered into CARE at least 30 days before the annual expiration date.
  4. Source: CARE/CMHC data indicates due dates and update dates for the assessments.
  5. Compliance Rating: 100% of MR/RC assessments are completed accurately and submitted to CARE within the expected timeframe = compliant. Below 100% = non-compliant.
  6. Solution Plan:First non-compliant review results in a developmental note and additional training. A second non-compliant review within 3 days results in a written warning and a third within 90 days following the warning results in termination of employment.
  1. MAC Time Study
  2. Definition: Medicaid Administrative Claiming (MAC) logs document the time spent in all activities during time periods defined by the MAC Coordinator, as required by the Federal MAC program.
  3. Standard: Staff will accurately code all time spent in activities during the time study period. Time study logs will be completed daily during the study period and will be sent to the supervisor for review every 3rd day.
  4. Source: MAC Coordinator and staff supervisor monitor adherence to the standards during the review period.
  5. Compliance Rating: 95% or above of MAC logs accurate and submitted by 3rd day = compliant. Below 95% of same = non-compliant.
  6. Solution Plan:Non compliance for any time study = attend the new employee MAC orientation. Non compliance for the next time study = Written Warning. Non Compliance for the next consecutive time study = termination of employment.

MH and MR Standards

  1. Documentation
  2. Definition: Documentation across center programs that indicate reasoning for medical necessity, type, frequency and duration of services provided and show evidence of working toward Treatment Plan goals and objectives.
  3. Standard: Documentation clearly identifies symptoms, severity and services that are authorized by the current plan. Notes and entries are accurate, legible, and documented within 24hrs of the event.
  4. Source: Quarterly, or as needed, Internal review of a random sample of charts by UM/QM, the Mean Documentation Time on Staff Report Card.
  5. Compliance Rating: Documentation Standard present in all documentation = compliant. Deficiencies in documentation at defined standard = non-compliant.
  6. Solution Plan: Staff will receive a written warning if non compliant in previous quarter and documentation will be updated within 5 calendar days to support services being delivered. Staff will be individually trained in correct documentation standards, however if staff are not compliant for each of the next two consecutive months, employment will be terminated.
  1. Documentation Submission
  2. Definition: The time between the documentation of the event and when the documentation is submitted to Medical Records.
  3. Standard: Documentation should be submitted to Medical Records within 24 hrs of creation.
  4. Source: Med Records review of creation date as generated electronically on documents compared to submission date as stamped by Med Records staff.
  5. Compliance Rating:
    100% of documentation submitted within 24 hrs of creation = compliance.
    Less than 100% = non-compliant.
  6. Solution Plan: Staff will receive a written warning if non compliant in previous quarter and documentation will be submitted within 5 calendar days to support services being delivered and documented. Staff will be individually trained in correct documentation submission standards, however if staff are not compliant for each of the next two consecutive months, employment will be terminated.
  1. Ethical Behavior/Confidentiality
  2. Definition: Adherence to federal, state, and center polices/procedures governing the treatment of patients and the interactions with employees through organizational business. Adherence to the ethical standards within each discipline and within the guidelines of any licensing body.
  3. Standard: No documented incidents of unacceptable behavior as identified in Federal and State laws, department guidelines, or Center Procedures.
  4. Source: Human Resources
  5. Compliance Rating: No documented incidents = compliance. Any documented incident = non-compliant.
  6. Solution Plan: Correction may vary according to the severity of the infraction and may range from a written warning followed by termination of employment to immediate termination of employment.
  1. Productivity Standard
  2. Definition: Billable hours or face to face encounters by each provider for authorized services.
  3. Standard: Productivity standard as defined in each Position Description.
  4. Source: CMHC and Report Manager reports.
  5. Compliance Rating: 100% = Compliance. Below 100% = non-compliance.
  6. Solution Plan: First month non-compliant = Developmental Note within 5 days. Second consecutive month of non-compliance = Written Warning. Third consecutive month of non-compliance = Termination of employment.
  1. MAC Time Study
  2. Definition: Medicaid Administrative Claiming (MAC) logs document the time spent in all activities during time periods defined by the MAC Coordinator, as required by the Federal MAC program.
  3. Standard: Staff will accurately code all time spent in activities during the time study period. Time study logs will be completed daily during the study period and will be sent to the supervisor for review every 3rd day.
  4. Source: MAC Coordinator and staff supervisor monitor adherence to the standards during the review period.
  5. Compliance Rating: 95% or above of MAC logs accurate and submitted by 3rd day = compliant. Below 95% of same = non-compliant.
  6. Solution Plan: Non compliance for any time study = attend the new employee MAC orientation. Non compliance for the next time study = Written Warning. Non Compliance for the next consecutive time study = termination of employment.