Last week we had our latest quarterly chart audit. As usual, the results keep getting better and better. Keep up the diligent documentation!
New this quarter is an item checking on our compliance with the Federally mandated CURES program for all appropriate patients; this is a subject worth reviewing together below. Other items that are commonly flagged in our documentation audit are also discussed below. A copy of the latest revision of the SD County “McFloop” Medication Monitoring Screening Tool used for this audit can be viewed here.
As you may know there is a Federal mandate already in effect for our clients at MHS to check the CURES system for appropriate patients. Appropriate patients are those on any schedule II-IV medication, essentially any benzodiazepine, sedative/ hypnotic, stimulant, suboxone and other opiates. After checking the CURES system all that is required is to document you have checked CURES in your note, and repeat every 4 months.
The actual CURES report is not required to be included in your charting. For any MHS client started on one of these agents on or after July 1, 2018 these steps are required. In addition, for all clients started on such agents before or after July 1 we are required to document that we have re-checked CURES at least every 4 months. If the client is not on such a scheduled agent there is no mandate to check CURES, nonetheless checking anyway may still prove enlightening. Here is a link to read more.
Each MHS program is working on a system to enlist staff to help with this task as they are able. CURES allows a designated nurse to check on behalf of providers and will obtain their own username and password sponsored by your access. It is recommended that providers provide the initial CURES check when starting new scheduled agents ourselves. And if staffing allows, nurses may be able to produce a report within every subsequent 4 months for your review and documentation. If you have not done so already, please coordinate with staff how this new workflow is accomplished at your site.
Other Common “McFloop” Items
Complete psychotropic consents, including having a range of milligrams documented on the form which includes the dose used.
Make sure to check off a box in each section of your psychotropic consents
If you have a client on dual agent therapy of any drug class then we must document a clear clinical rationale for why this is necessary
We are mandated to comply with this audit within a given time-frame. Our responses to McFloop forms will be held until the actual results are obtained. If necessary ask clients to come in and meet with someone to get forms signed, consents can occur over the phone, labs of course documenting our efforts to gain their compliance is sufficient if we have done our part. If you intend to wait to document it at your next visit please make sure that occurs within the time-frame that remains. If appropriate, a “non-billable” free text note may be entered as an addendum in the client’s chart and then referenced in our McFloop responses as an alternative.