ACT Policies and Procedures

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Program Policies & Minutes Worksheets

  Date

2.11 Admission Criteria: Progream should have clearly identified mission to serve a particular population and has and uses measurable and operationally defined criteria to screen out inappropriate referrals.

• Are admission criteria clear and precise? That is, if a criteria is that recipients have a psychiatric diagnosis, does it specify an Axis I diagnosis or a schizophrenia spectrum disorder?

  Yes

  No

  N/A

• Are admission criteria operationalized? That is, if creiteria specify severe and persistent mental illness, do they have an objective standard, such as number of hospitalizations in the last year, to measure that criteria.

  Yes

  No

  N/A

2.14 Responsibility for Crisis Services: Team should directly provide 24 hour coverage for psychiatric crises.

• Do policies specify the kind crisis coverage? Is it 24 hour? Do calls go directly to a staff member or is there an intervening step? Are policies consistent with reports of staff?

  Yes

  No

  N/A

4.15 Self Help Resources: Program has a system in place to ensure that recipients are made aware of self help and receive self help referrals for self help in resources in the community.

• Does the program have policy on identifying self help resources in the community and providing them to recipients who are interested in self help?

  Yes

  No

  N/A

5.11 Commitment to Cultural Competence: Program should have a management level person responisble for cultural competence, a dedicated budget for cultural competence activities, and a comprehensive cultural competence plan.

• Does policy specify specific plan?

  Yes

  No

  N/A

• Does it mention the manner in which it will be implemented, including a time table and objectives?

  Yes

  No

  N/A

• Does it indicate that a person has responsibility for the plan?

  Yes

  No

  N/A

• If a person is designated with specific responsibility for the plan, where is that person in the hierarchy of the agency or the team?

  Yes

  No

  N/A

• Is there a budget for cultural competence activities?

  Yes

  No

  N/A

5.12 Culturally Relevant Service Delivery

• Does program have policies regarding culturally relevant services, including requirements for necessary language skills and interpreter services?

  Yes

  No

  N/A

• Does program have policies regarding training in culturally relevant service delivery?

  Yes

  No

  N/A

• Does program have policies about its commitment to diversityat all levels of organization?

  Yes

  No

  N/A

5.13 Consent for release of information: Program should have policy on obtaining written consent from the recipient for the release of information.

• Does program's policy on consent specify that consents should be time limited and not used for blanket purposes?

  Yes

  No

  N/A

• Does the program policy discuss how and when consents should be obtained.

  Yes

  No

  N/A

5.14 Recipient Input: Program should have policy and formal mechanism for incorporating ongoing recipient input into program planning, service development, and program review activities.

• Does program have policies on the importance of incorportating recipient input into its operations?

  Yes

  No

  N/A

• Does program policy specify the method by which recipient input will be obtained?

  Yes

  No

  N/A

• If so, is the method formal and systematic or informal and ad hoc?

  Yes

  No

  N/A

5.15 Recipients' Rights: Program should have policy and procedure for ensuring recipient's rights.

• Is program's policy on grievance procedure relatively straightforward or overly complicated?

  Yes

  No

  N/A

• Does program specify recipients right to refuse treatment in its policies?

  Yes

  No

  N/A

• Does program specify that rights notices must be handed out to all recipients?

  Yes

  No

  N/A

• Is there a policy regarding changes that should be made, when warranted, in response to specific grievances?

  Yes

  No

  N/A

• Is there a policy regarding the systematic tracking grievances?

  Yes

  No

  N/A

• Is there a policy regarding follow-up to grievances to ensure that recipients are satisfied with their resolution?

  Yes

  No

  N/A

• Are minutes from any relevant proceedings consistent with policy?

  Yes

  No

  N/A

5.16 Recipient Access to Records: Program should provide recipients' full access to their charts.

• Is there a policy regarding recipients' right to access their own charts?

  Yes

  No

  N/A

• Is the procedure straightforward or complex and burdensome?

  Yes

  No

  N/A

• Does program, through its policies, promote recipients' right to access their own chart?

  Yes

  No

  N/A

• Does program permit recipients' to write in their own charts?

  Yes

  No

  N/A

6.16 Discharge Summaries: Program should have policy on discharge and should transmit appropriate discharge summaries to receiving programs.

• Does program have a policy of allowing any discharged recipient to return for at least 90 days after date of discharge?

  Yes

  No

  N/A

• Does program have criteria specifying under what conditions discharge is appropriate?

  Yes

  No

  N/A

7.11 Quality Improvement: Program should have systematic approach for ensuring ongoing quality assurance regarding treatment practices.

• Does program have policies on quality improvement that specify: What kind of supervision should be provided to practitioners? How ACT will be monitored to ensure fidelty to the model? How outcomes will be reviewed from ACT 6 month forms to identify deficiencies in care? HOw the delivery of care will be modified in response to identified deficiencies?

  Yes

  No

  N/A

7.12 Staff Development & Core Competencies: Program staff should receive appropriate and ongoing professional training.

• Does program have policies on the provision of training for evidence based practices and cultural competence?

  Yes

  No

  N/A

7.13 Utilization Review: Programs should have systematic approach for utilization review of appropriate service provision conducted by independent reviewer.

• Inspect programs policies on UR for the following issues: Requirements for professional background of UR reviewers, Requirements for frequency of UR, Requirements for independent review, so that reviewers are not involved in program under review, Rold of governing body in UR.

  Yes

  No

  N/A

7.14 Incident Review Committee: Program has appropriate incident review committee that investigates and reports on incidents, makes and follows up on recommedations.

• What re policies regarding the professional makeup of the committee?

  Yes

  No

  N/A

• Does policy specify that committee must meet at least 4 times a year?

  Yes

  No

  N/A

• Do minutes support the program leaders description of the process?

  Yes

  No

  N/A

• Do minutes support that incidents are quickly investigated and properly reported?

  Yes

  No

  N/A

• Do minutes support that the committee makes specific recommendations?

  Yes

  No

  N/A

7.15 Governing Body: Program shall have a governing body that is responisble for all aspects of program oversight.

• Do program policies grant oversight responisbility for all program operations?

  Yes

  No

  N/A

• How stong is the monitoring function as expressed in the policies?

  Yes

  No

  N/A

• Do minutes support program policies about the functioning of the governing body? In particular, the scope of its oversight for operations.

  Yes

  No

  N/A

• Do minutes support that the governing body responds to recipient or family concerns?

  Yes

  No

  N/A