9.26 Clinical Documentation Auditing Procedures Page 1 of 4 SATILLA COMMUNITY SERVICES POLICY # 9.26 TITLE: Clinical Documentation Auditing Procedures ORIGINATION DATE: 11/03 REVISED: 04/04, 05/04, 2/05, 06/05, 09/05, 01/06, 07/07, 11/07, 04/09, 09/09, 01/11, 04/11, 10/11 POLICY STATEMENT: Satilla Community Services will conduct regular internal audits of billing and clinical documentation, required clinical assessments and treatment plans, and compliance with HIPAA privacy regulations. BACKGROUND / PURPOSE: To ensure that the agency is pursuing the highest level of professional best practice, routine sampling audits are conducted to assist agency personnel achieve optimum performance. As a by-product of this practice, the implementation of a check and balance system provides assurance against waste, fraud and abuse. Internal audit of billing against clinical documentation is also a major component of the agency's Board approved Corporate Compliance Program, designed to conform to the best practices identified in the Federal Sentencing Guidelines (2004). IMPLEMENTATION / PROCEDURE: The following procedures shall be used to conduct internal audits: 1. Auditing Schedule Audits by the Utilization Management Department, within the Performance Improvement Department, shall be conducted quarterly. The quarterly audit schedule shall be determined by the Utilization Management Coordinator. Also, site / program supervisors may request the Utilization Management Coordinator to appoint an auditor or auditors to conduct a special audit of particular cases. BH Managers will submit one audit per case manager each quarter to the UM Department. 2. Sample Selection The selection of a sample of cases for documentation auditing shall be determined by the auditor, using CareLogic reports such as the caseload reports which includes open and closed cases. The cases selected for audit may be proportionately representative of the consumer population by primary disability and by payment method (Medicaid and other) or may be, on a supervisor’s request, representative of the caseloads of one or more providers or service sites. Audit samples will be randomly selected by the UM Dept. and will consist 9.26 Clinical Documentation Auditing Procedures Page 2 of 4 of at least 1 record per clinician each quarter. In addition, the UM Dept will also review high utilization services for BH by identifying 1 clinician in 3 different sites each quarter. Three (3) high utilization records will be audited from each of the identified clinicians’ caseload. In addition, 10 closed BH charts will be randomly selected and audited by UM. 3. Audit Forms and Records The audit forms used shall be determined by the Utilization Management Department, Directors, and approved by the Performance Improvement Committee prior to each Fiscal year. Services provided under the Rehab Service Guidelines, SA Residential, Detox/CSP, and Supportive Living will be audited under the Behavioral Health Audit Tool. Medicaid Waiver programs will be audited under the Community Support Audit Tool. HIPAA audits will assess overall site compliance with privacy and information security regulations in addition to evidence in consumer charts that privacy policies have been followed at intake, and when protected health information is disclosed. Originals of individual audit checklists and summary reports shall be retained in the PI-RM file for a period of ten years, after which they will be destroyed. An electronic record (with off-site backup) shall be considered as acceptable as a paper record. 4. Personnel Assigned Audits shall be conducted by the PI/UM department staff or other designated personnel with the approval of the Utilization Management Coordinator. 5. Determination of Audit Results On receiving audit results from the Utilization Management Department, Directors should review the findings and seek further confirmation or clarification of the findings as necessary. The findings should then be communicated by the Directors to their program supervisors and case managers. Upon completion of audits each quarter, managers will receive a report of identified trends and scores for individual clinicians as well as overall site scores. 6. Appeals Mechanisms When a program or record has been determined to be non-compliant in any area(s), and the program / case manager disagrees with the determination, an appeal may be made by notifying the Director within 10 working days of the 9.26 Clinical Documentation Auditing Procedures Page 3 of 4 receipt of audit results. Failure to do so within the time specified shall result in the loss of the appeal privilege. If notified within the time specified, the Director may request that the Utilization Management Coordinator assign another auditor to review the program / record. If granted, the second review shall take place within 10 working days after the Utilization Management Coordinator has been notified of the appeal. The second auditor shall notify the Utilization Management Department of the results of the second review. If, at this point, all parties can come to agreement, proper disposition of the case will be made. If the matter cannot be resolved there; it shall be forwarded to the Executive Director for his / her review. 7. Corrective Action Mechanisms Directors for Programs will require a corrective action plan from the appropriate managers/supervisor in all cases in which agreed deficiencies have been identified. If an item cannot be corrected, this is to be noted on the checklist as well as use the findings to provide clinical guidance to staff they supervise. For BH, any direct care staff whose UM audit score falls below an 85%, the clinician will be required to complete a Corrective Action Plan (CAP) for that record. Supervisors should review corrections with that direct care staff during supervision. For CS, any direct care staff whose UM audit score falls below an 85%, the case manager will be required to complete a Corrective Action Plan (CAP). Supervisors should review corrections with that direct care staff during supervision. In addition, the manager will be required to submit one (1) additional audit for that case manager to the UM Dept. The deadline for all CAP(s) to be submitted back to the UM Department is 30 days in to the following quarter. Ex. Qtr 1 due Oct. 30th, Qtr 2 due Jan. 30th, Qtr 3 due April 30th & Qtr 4 due July 30th. A random selection of chart audit trends should be pulled and presented at the Physician’s meeting on a quarterly basis for review of the MD documentation results. The Medical Director is to use the audit results to provide clinical supervision and guidance to the MD under his supervision. The following criteria will be utilized when completing Corrective Plans for documentation deficiencies: 1) corrective plans must individually identify that corrections have been completed by placing an X in the corrected box on the audit tool 2) provide supporting documentation of corrections made (i.e. what did you do to correct this problem?) 3) Program managers must utilize the CORRECTIVE TOOL (Community Support or Behavioral Health) to document 9.26 Clinical Documentation Auditing Procedures Page 4 of 4 specific efforts performed/planned to bring site into compliance (if planned must include date and person responsible). 8. Training Needs Audit tools should be utilized by program manager to identify clinician’s/sites weak and strong areas to determine training needs (see Clinical Supervision Policy# 9.32). Program managers should utilize the corrective tool to address the training needs for each indicator listed (if not meeting compliance level). Staff within the PI Department will provide training at the request of deputy director. All corrective tools will be reviewed at PI Committee. 9. Audit Report The Outcomes Management Coordinator shall compile a summary quarterly showing documentation (and peer review) audit results by service site, by primary disability and for the SCS as a whole (as an element within the Satilla Balanced Scorecard). The summary report will be distributed to the executive director, Satilla Board of Directors, and the medical director, deputy directors, and supervisors.
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