9 26 Clinical Docmentation Auditing Procedures

							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, 1/12

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 Quality Improvement Department (QI), within the Performance
        Improvement Department, shall be conducted quarterly. The quarterly audit
        schedule shall be determined by the Quality Improvement staff. Also, site /
        program supervisors may request the Quality Improvement staff to appoint an
        auditor or auditors to conduct a special audit of particular cases.

         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 QI Dept. and will consist of
        at least 1 record per clinician each quarter. The QI Dept will also review high
        utilization services by identifying 1 clinician in 3 different sites each quarter.
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        Three (3) high utilization records will be audited from each of the identified
        clinicians’ caseload. In addition, 10 closed charts will be randomly selected and
        audited by QI.

        3. Audit Forms and Records

        The audit forms used shall be determined by the Quality Improvement
        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. Chart documentation audits
        will assess compliance in 5 different areas 1) Initial Assessment/ Reassessment
        Plan 2) Reassessment and Continued Orientation to Services Indicators 3)
        Physician Assessment and Documentation 4) Documentation Indicators. 5)
        Caseload Review. For consumers who are admitted to the crisis stabilization
        program the site manager must complete section 6 CSP of the audit tool. The
        Intake Coordinator will audit for section 1 and the Physician Coordinator will audit
        for section 3. A score is provided for each individual area. Treatment Plan audit
        results are also reviewed quarterly by the PI Committee to identify patterns of
        service utilization.

        The PI Department will prepare and the Performance Improvement Committee
        will approve a glossary of expanded definitions and explanations of how items in
        the audit form are to be interpreted and scored.

        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/QI department staff or other designated
        personnel with the approval of the Quality Improvement Manger.



        5. Determination of Audit Results
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        On receiving audit results from the QI 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
        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
        Quality Improvement Coordinator has been notified of the appeal.

        The second auditor shall notify the QI 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, once audits are completed for each site the QI staff will email audits to
        the site manager for distribution to the clinician. A conference call will be
        scheduled within 7 days with each manager to review trends and/or deficiencies
        identified. QI will create a calendar request via Outlook to confirm scheduled call.
        Any record that scores below 85% the clinician will be required to complete a
        Corrective Action Plan (CAP) indicating the actions that will be taken to bring
        record into compliance. CAP’s must be submitted to the QI dept. by the
        supervisor within 30 days of notification from the QI Dept. that audits were
        completed. Managers should review audit findings with direct care staff during
        supervision.

        For CS, any record that scores below 85% the case manager will be required to
        complete a Corrective Action Plan (CAP) indicating the actions that will be taken
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        to bring record into compliance. Supervisors should review corrections with direct
        care staff during supervision and submit the CAP back to the QI Dept. within 30
        days of notification from the QI Dept that audits were completed. In addition, the
        manager will be required to re-audit the record that scored below 85% and
        submit one (1) additional audit for that case manager to the QI Dept.

        **QI reserves the right to spot check CAP’s submitted at any time**

        A random selection of chart audit trends should be presented at the Physician’s
        meeting on a quarterly basis for review to the MD documentation results. The
        Medical Director is to use the audit results to provide clinical supervision and
        guidance to the other MD’s on staff.

        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). Staff within the PI Department will provide training at the request of
        deputy director. All audit scores, deficiencies and trends will be reviewed at PI
        Committee meeting.

        9. Audit Report

        The QI 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.