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The Contractor’s Quality Management (QM) Program shall improve Contractor’s established outcomes through structural and operational processes and activities that are consistent with current standards of practice.

  • The Contractor shall have a written description of the QM Program which clearly defines the QM Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement. The QM Program shall be evaluated annually and updated as necessary per Title 9, CCR, Section 1810.440(a)(6) and Title 42, CFR, Section 438.240(e).

  • The QM Program shall conduct performance monitoring activities throughout the Contractor’s operations.  These activities shall include but not be limited to, client and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of beneficiary grievances.





    1. The Contractor shall ensure continuity and coordination of care with physical health care providers. The Contractor shall coordinate with other human services agencies used by its beneficiaries. The Contractor shall assess the effectiveness of any MOU with a physical health care plan.




    1. The Contractor shall have mechanisms to detect both underutilization of services and overutilization of services, as required by Title 42, CCR, Section 438.240(b)(3).




    1. The Contractor shall implement mechanisms to assess beneficiary/family satisfaction. The Contractor shall assess beneficiary/family satisfaction by:




    1. Surveying beneficiary/family satisfaction with the Contractor’s services at least annually;

    2. Evaluating beneficiary grievances, appeals and fair hearings at least annually; and

    3. Evaluating requests to change persons providing services at least annually.

    The Contractor shall inform providers of the results of beneficiary/family satisfaction activities.




    1. The Contractor shall implement mechanisms to monitor the safety and effectiveness of medication practices. The monitoring mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs. Monitoring shall occur at least annually.




    1. The Contractor shall implement mechanisms to address meaningful clinical issues affecting beneficiaries system-wide.




    1. The Contractor shall implement mechanisms to monitor appropriate and timely intervention of occurrences that raise quality of care concerns. The Contractor shall take appropriate follow-up action when such an occurrence is identified. The results of the intervention shall be evaluated by the Contractor at least annually.




    1. The Contractor shall have a QM Work Plan covering the current contract cycle with documented annual evaluations and documented revisions as needed. The QM Work Plan shall include:




      1. Evidence of the monitoring activities including, but not limited to, review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review as required by Title 9, CCR, Section 1810.440(a)(5) and Title 42, CFR, section 438.416;




      1. Evidence that QM activities, including performance improvement projects, have contributed to meaningful improvement in clinical care and beneficiary service;




      1. A description of completed and in-process QM activities, including performance improvement projects. The description shall include:




    1. Monitoring efforts for previously identified issues, including tracking issues over time;




    1. Objectives, scope, and planned QM activities for each year; and,




    1. Targeted areas of improvement or change in service delivery or program design.




      1. A description of mechanisms Contractor has implemented to assess the accessibility of services within its service delivery area. This shall include goals for responsiveness for the Contractor’s 24-hour toll-free telephone number, timeliness for scheduling of routine appointments, timeliness of services for urgent conditions, and access to after-hours care.




      1. Evidence of compliance with the requirements for cultural competence and linguistic competence specified in Title 9, CCR, Section 1810.410.




    1. Quality Improvement (QI) Program.




    1. The Contractor’s QI program shall monitor the Contractor’s service delivery system with the aim of improving the processes of providing care and better meeting the needs of its clients. 




    1. The Contractor shall establish a QI Committee to review the quality of specialty mental health services provided to beneficiaries. The QI Committee shall recommend policy decisions; review and evaluate the results of QI activities, including performance improvement projects; institute needed QI actions; ensure follow-up of QI processes; and document QI Committee meeting minutes regarding decisions and actions taken.




    1. The QI Program shall be accountable to the Contractor’s Director as described in Title 9 CCR, Section 1810.440(a)(1).




    1. Operation of the QI program shall include substantial involvement by a licensed mental health staff person, as described in Title 9 CCR, Section 1810.440(a)(4).




    1. The QI Program shall include active participation by the Contractor’s practitioners and providers, as well as consumers and family members in the planning, design and execution of the QI Program, as described in Title 9 CCR, Section 1810.440(a)(2)(A-C).




    1. The Contractor shall maintain a minimum of two active Performance Improvement Projects (PIPs) that meet the criteria in Title 42, CFR, Section 438.240(b)(1) and (d). Each performance improvement projects shall focus on a clinical area, as well as one non-clinical area.




    1. QI activities shall include:




    1. Collecting and analyzing data to measure against the goals, or prioritized areas of improvement that have been identified;




    1. Identifying opportunities for improvement and deciding which opportunities to pursue;




    1. Identifying relevant committees internal or external to the Contractor to ensure appropriate exchange of information with the QI Committee;




    1. Obtaining input from providers, consumers and family members in identifying barriers to delivery of clinical care and administrative services;




    1. Designing and implementing interventions for improving performance;




    1. Measuring effectiveness of the interventions;




    1. Incorporating successful interventions into the Contractor’s operations as appropriate;




    1. Reviewing beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review as required by Title 9, CCR, Section 1810.440(a)(5).




    1. Quality Assurance (QA).

    The Contractor shall set standards and implement processes that will support understanding of, and compliance with, documentation standards set forth in this section and any standards set by the Contractor.  QA activities may include monitoring performance so that the documentation of care provided will satisfy the requirements set forth below.  The documentation standards for client care are minimum standards to support claims for the delivery of specialty mental health services.  All standards shall be addressed in the client record; however, there is no requirement that the records have a specific document or section addressing these topics.




    1. Assessment.




    1. The following areas shall be included, as appropriate, as part of a comprehensive client record when an assessment has been performed. For children or certain other beneficiaries unable to provide a history, this information may be obtained from the parents/care-givers, etc.




    1. Presenting Problem. The beneficiary’s chief complaint, history of the presenting problem(s), including current level of functioning, relevant family history and current family information;




    1. Relevant conditions and psychosocial factors affecting the beneficiary’s physical health and mental health; including, as applicable, living situation, daily activities, social support, cultural and linguistic factors and history of trauma or exposure to trauma;




    1. Mental Health History. Previous treatment, including providers, therapeutic modality (e.g., medications, psychosocial treatments) and response, and inpatient admissions. If possible, include information from other sources of clinical data, such as previous mental health records, and relevant psychological testing or consultation reports;




    1. Medical History. Relevant physical health conditions reported by the beneficiary or a significant support person. Include name and address of current source of medical treatment. For children and adolescents: Include prenatal and perinatal events and relevant/significant developmental history. If possible, include other medical information from medical records or relevant consultation reports;




    1. Medications. Information about medications the beneficiary has received, or is receiving, to treat mental health and medical conditions, including duration of medical treatment. The assessment shall include documentation of the absence or presence of allergies or adverse reactions to medications, and documentation of an informed consent for medications;




    1. Substance Exposure/Substance Use. Past and present use of tobacco, alcohol, caffeine, CAM (complementary and alternative medications) and over-the-counter, and illicit drugs;




    1. Client Strengths. Documentation of the beneficiary’s strengths in achieving client plan goals;




    1. Risks. Situations that present a risk to the beneficiary and/or others, including past or current trauma;




    1. A mental status examination;




    1. A complete five-axis diagnosis from the most current DSM, or a diagnosis from the most current ICD-code shall be documented, consistent with the presenting problems, history, mental status examination and/or other clinical data; and,




    1. Additional clarifying formulation information, as needed.




    1. Timeliness/Frequency Standard for Assessment. The Contractor shall establish written standards for timeliness and frequency for the elements identified in item A of this section.




    1. Client Plans.




    1. Client Plans shall:




    1. Have specific observable and/or specific quantifiable goals/treatment objectives;




    1. Identify the proposed type(s) of intervention/modality;



    1. Have a proposed frequency and duration of intervention(s);

    2. Have interventions that focus and address the identified functional impairments as a result of the mental disorder (from Title 9, CCR, Section 1830.205(b));




    1. Have interventions that are consistent with the client plan goal;




    1. Be consistent with the qualifying diagnoses;




    1. Be signed (or electronic equivalent) by:




      1. The person providing the service(s), or,




      1. A person representing a team or program providing services, or




      1. A person representing the Contractor providing services;




      1. By one of the following as a co-signer, if the client plan is used to establish that services are provided under the direction of an approved category of staff, and if the signing staff is not of the approved category:




          1. A physician,




          1. A licensed/waivered psychologist,




          1. A licensed/registered/waivered social worker,




          1. A licensed/registered/waivered marriage and family therapist,




          1. A registered nurse;




    1. Include documentation of the beneficiary’s participation in and agreement with the client plan, as described in Title 9, CCR, Section 1810.440(c)(2)(A)(B).




    1. Examples of acceptable documentation include, but are not limited to, reference to the beneficiary’s participation and agreement in the body of the plan, beneficiary signature on the plan, or a description of the beneficiary’s participation and agreement in the client record;




    1. The beneficiary’s signature or the signature of the beneficiary’s legal representative is required on the client plan when:




    1. The beneficiary is expected to be in long term treatment as determined by the MHP and,




    1. The client plan provides that the beneficiary will be receiving more than one type of specialty mental health service;




    1. When the beneficiary’s signature or the signature of the beneficiary’s legal representative is required on the client plan and the beneficiary refuses or is unavailable for signature, the client plan shall include a written explanation of the refusal or unavailability.




    1. The Contractor shall offer a copy of the client plan to the beneficiary.




    1. Timeliness/Frequency of Client Plan. The client plan shall be updated at least annually, or when there are significant changes in the client’s condition.




    1. Progress Notes.




    1. Progress notes shall describe how services provided reduced impairment, restored functioning, or prevented significant deterioration in an important area of life functioning outlined in the client plan. Items that shall be contained in the client record related to the client’s progress in treatment include:




    1. Timely documentation of relevant aspects of client care, including documentation of medical necessity;




    1. Documentation of client encounters, including relevant clinical decisions, when decisions are made, alternative approaches for future interventions;




    1. Interventions applied, beneficiary’s response to the interventions and the location of the interventions;




    1. The date the services were provided;




    1. Referrals to community resources and other agencies, when appropriate;




    1. Documentation of follow-up care, or as appropriate, a discharge summary; and




    1. The amount of time taken to provide services;




    1. The signature of the person providing the service (or electronic equivalent); the person’s type of professional degree, licensure or job title; and the relevant identification number, if applicable




    1. Timeliness/Frequency of Progress Notes. Progress notes shall be documented at the frequency by type of service indicated below:




    1. Every Service Contact:




    1. Mental Health Services;

    2. Medication Support Services;

    3. Crisis Intervention;

    4. Targeted Case Management;




    1. Daily:




    1. Crisis Residential;

    2. Crisis Stabilization (1x/23hr);

    3. Day Treatment Intensive; and

    1. Weekly:




    1. Day Treatment Intensive: a clinical summary reviewed and signed by a physician, a licensed/waivered psychologist, clinical social worker, or marriage and family therapist; or a registered nurse who is either staff to the day treatment intensive program or the person directing the service;




    1. Day Rehabilitation;




    1. Adult Residential.




    1. Other.




    1. All entries to the client record shall be legible.




    1. All entries in the client record shall include:




    1. The date of service;




    1. The signature of the person providing the service (or electronic equivalent); the person’s type of professional degree, licensure or job title; and the relevant identification number, if applicable.




    1. The date the documentation was entered in the client record.




    1. Utilization Management (UM) Program.




    1. The Utilization Management Program shall be responsible for assuring that beneficiaries have appropriate access to specialty mental health services as required in Title 9, CCR, Section 1810.440(b)(1-3).




    1. The Utilization Management (UM) Program shall evaluate medical necessity, appropriateness and efficiency of services provided to Medi-Cal beneficiaries prospectively or retrospectively.




    1. The Contractor shall implement mechanisms to assess the capacity of service delivery for its beneficiaries. This includes monitoring the number, type, and geographic distribution of mental health services within the Contractor’s delivery system.




    1. The Contractor shall implement mechanisms to assess the accessibility of services within its service delivery area. This shall include the assessment of responsiveness of the Contractor’s 24 hour toll-free telephone number, timeliness of scheduling routine appointments, timeliness of services for urgent conditions, and access to after-hours care.

    The Contractor shall implement mechanisms to assure authorization decision standards are met. Authorization of services shall include all of the following:




    1. Pursuant to Title 42, CFR, Section 438.210(b)(1), the Contractor and its subcontractors must have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services.

    2. Pursuant to Title 42, CFR, Section 438.210(b)(2), the Contractor shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions, and shall consult with the requesting provider when appropriate.

    3. Pursuant to Title 42, CFR, Section 438.210(b)(3), any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested shall be made by a health care professional who has appropriate clinical expertise in treating the beneficiary’s condition or disease.

    4. Decisions must be made within the timeframes outlined for service authorizations in Title 42, CFR Section 438.210(d), and notices of action related to such decisions must be provided within the timeframes set forth in Title 42, CFR, Section 438.404.(c).




    1. Compensation for Utilization Management Activities.: Pursuant to Title 42, CFR, Section 438.210(e), compensation to individuals or entities that conduct utilization management activities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any beneficiary.
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