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DMC Provider Resource Tool-Kit Common Problem

MOST COMMON AREAS OF DEFICIENCY

Below are the most common areas of deficiency that have been found during post service post payment utilization reviews by DMC Monitoring Section staff. This is by no means exhaustive, as there are many ways in which treatment documentation can be found to be deficient. However, the majority of deficiencies fall into the following categories:

1. Admission physical or waiver.

A physical exam conducted by and MD, RN , Nurse Practitioner or Physician’s Assistant must be completed within 30 days of the client’s admission to the program. The program medical director can waive this requirement after a review of the client’s medical history, substance abuse history, and/or the most recent physical examination documentation.

Some of the more common reasons recoupments are made for this part of the admission process are:

  • No record of the physical exam in the client file.
  • The physical waiver is not clearly worded to identify it as a “physical waiver.”
  • The physician fails to sign and or date the waiver.
  • The physician does not state the reason the physical exam is being waived.
    REFERENCE TITLE 22 SECTION 51341.1(h)(iii)

2. Treatment Plans.

For each client a Treatment Plan must be completed within 30 days of the date admission date. The treatment plan must include, a statement of the substance abuse problem to be addressed, the goals to be achieved for each problem, the actions steps to be taken, and the target dates that these goals are to be achieved. The plan needs to describe the services that will be provided (type and frequency of counseling), and the assignment of a primary counselor.

The treatment plan is considered complete and effective on the date of the counselor’s signature. Within 15 days of the counselor’s signature the program’s Medical Director must sign the treatment plan.

The treatment plan must be reviewed and updated within 90 days of the counselor’s signature of the previous plan. Again the Medical Director must review, approve and sign the treatment plan within 15 days of the counselor’s signature.

The treatment plan must be updated earlier than the 90 days if a change of problem or focus of treatment occurs.

Some of the reasons why recoupments are taken for the treatment plan process.

  • Late signatures by the counselor and/or medical director.
  • Signatures not dated.
  • Frequency/ type of counseling not identified.
  • Target Dates not identified.
  • Treatment plans are late.
  • Primary problem statements/action steps/goals not related to substance abuse.
    REFERENCE: TITLE 22 SECTION 51341.1 (h)

3. Individual Counseling Sessions.

Group counseling is the treatment methodology for the Outpatient Drug Free modality, individual counseling is only on an exception basis. Individual or group counseling can be used in both Day Care Habilitative and Residential Perinatal modalities since payment is on a daily rate basis.

Individual counseling for ODF can be reimbursed for only for the following reasons.

  • Intake Counseling: The process of admitting a client into a substance abuse program. This must be a one-on-one session with a counselor.
    REFERENCE: TITLE 22 SECTION 51341.1 (b)(10)
  • Treatment Planning: The development of an initial or follow up treatment plan with a client in a one on one session with the counselor.
  • Collateral Counseling: Face to face interviews with significant persons in a client’s life. Significant persons are people with a personal rather than a profession relationship with the client. Parole/probation agents, Child Protection Service or Social workers are an example of a professional relationship. These interviews must be conducted at the Drug Medi Cal certified facility.
    REFERENCE: TITLE 22 SECTION 51341.1 (b)(3)
  • Crisis Counseling: Face to face with a client in crisis. Crisis means an actual relapse or circumstance which present an imminent threat of relapse. Counseling should be limited to the stabilization of the client’s emergency situation.
    REFERENCE: TITLE 22 SECTION 51341.1 (b)(5)
  • Discharge Planning: Face to face with a client to discuss post discharge issues.

Common reasons individual counseling sessions are disallowed.

  • Session does not meet one of the above criteria.
  • Progress note does not identify which of the 5 reason is being used to justify the session.
  • Progress note fails to justify crisis intervention.
  • Collaterals held with professionals.
  • Treatment planning sessions with no treatment plans resulting.
  • Intakes being conducted by office staff rather than one-on-one session with a counselor.

4. Group Sign-In Sheets:

Group Counseling Sign In Sheet are required to maintained for all group counseling sessions conducted by all modalities. The sign in sheet must contain the date and duration of the session. The client attending the session must individually sign in on the sheet. The sheet must be maintained by the provider and it is suggested that the sheets be filed in chronological order.

Common problems encountered when examining sign in sheets.

  • Time/date/duration of the session is missing.
  • Client fails to sign in.
  • More than 10 or less than 4 clients in attendance for a group session. (This does not apply to DCH and Peri-Redisdental modalities.
  • One person signs in for all participants.
    REFERENCE: TITLE 22 SECTION 51341.1(b)(8)(,(g)(2)

5. Progress Notes.

Progress notes are individual narrative summaries that must include; a description of the client’s progress on the treatment plan problems, goals, action steps, objectives, and/or referrals. They must also contain information on the client’s attendance including the time, day, month, year of attendance at all group and individual counseling sessions.

Common progress note errors.

  • Missing year of session.
  • Client progress or lack of progress missing.
  • No progress note recorded.
  • “Crisis” individual counseling session does not meet the criteria.
  • Duration of the counseling session not noted.