ACT Record Review

ACT 1.11 Recieves contacts from 3 or more different team members per month

ACT 2.11 Program staff directly provides the required ACT services (assertive engagement and outreach, psychiatric, IDDT, Supported Employment, community reintegration and rehabilitative services, housing procurement and support, family psychoeducation and support, and WSM), At least 80% of the contacts take place in the community, Team directly provides 24 hour coverage for crisis services, Team has direct involvement in at least 70% of hospital admissions and discharges.

ACT 2.12 Service Frequency: A minimum of 6 face to face contacts montly per recipient is required, one of which may be a collateral contact. Additional contacts are provided as clinically indicated, including evenings and weekends.

ACT 3.11 Consents for release of information, program's policy and practice conforms to OMH requirements regarding consents for the release of information.

ACT 3.12 Recipients are informed of their rights and their rights are respected. The program incorporates recipient input into program practices and provides full, immediate access to their charts. Recipients shall be albe to object to their treatment, or complain or dsicuss issues related to program policies and procedures, program staff or servies without fear or retribution. (Greivance procedure). Recipients have a right to culturally sensitive and competent treatment and services.

ACT 4.11 An immediate needs assessment is completed within 7 days of the receipt of referral. Documentation of services to meet immediate needs is present. The Comprehensive Assesssments are: strengths based, reflect recipient needs and preferences, reflect all the areas identified in the OMH ACT guidelines, include recommendations for treatment and rehabilitative services and supports, are completed within 30 days of admission and are updated every six months or as needed. The Comprehensive Assessment is approved and signed by the Team Leader or designated Clinical Supervisor.

ACT 4.12 Service Plans are completed within 30 days of admission; plans contain goals and measurable objectives that are based on the comprehensive assessment and are person centered. The program demonstrates that recipient choice and participation is an integral part of all treatment planning and service delivery decisions; service plans and reviews much demonstrate a shared decision making process involving the team, the recipient, and/or family support network. The plans include a crisis/relapse prevention plan developed with the recipient. The plans are reviewed and updated at least every six months based on changes in recipient needs and preferences. The plans and reviews are approved and signed by the physician and team leader or designated clinical supervisor.

ACT 4.13 Progress notes: document all service contacts and attempted contacts, services delivered, duration, signifcant events and any progress or lack of progress towards the achievement of goals and objectives noted in the service plan. The psychiatrist and/or PNP documents information, including the provision of medicationeducation, on each recipient on at least a monthly bases, the psychiatrist/PNP documents contacts made on the recipients behalf during hosptialization.

ACT 4.14 The program has a discharge planning process in place; the process is individualized and based on the recipients needs, preferences, readiness and goals. Documentation is present that identifies the ongoing efforts to engage the recipient in planning and the progress toward recovery and goal attainment. The agency has a discharge procedure in place which includes: discharge criteria, a 90 day follow up period, discharge summary requirements, a description of the discharge process, and a procedure for transmission of discharge summaries to the receiving program. Charts that document that the procedure is fully followed. The agency has a systematic UR plan in place. The agency adheres to the plan. The individual conducting the UR is appropriately credentiald and trained and does not provide direct care to ACT recipients under review. In addition, the agency participates in the development of any state or LCU utilization management process.

Additional Information