Clinic Administrative Interview

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Administrative Interview

  Date

• Staff attended; reviewer

  Yes

  No

  N/A

• Population Served; Current Enrollment; Length of stay; Waiting List; Referred/Not Open cases; Referrals/Admissions/Discharges; Verify sites, hours, staffing

  Yes

  No

  N/A

• Identification/response for complex, at risk individuals (4.51)

  Yes

  No

  N/A

• 1.11 Screening/triage process

  Yes

  No

  N/A

Assessment

• 1.12 Assessment process, 1.21 Comprehensive Assessment, 1.22 Substance Abuse screen/assessment; 1.23 Self harm screen; 1.24 Violence risk screen/assessment; 1.25 HealthScreen/monitoring; 1.27 Tobacco Screen/Assessment

  Yes

  No

  N/A

• 2.13 Culture/language/special needs of population and how addressed

  Yes

  No

  N/A

• 2.21 Safety Plans

  Yes

  No

  N/A

• 3.11 Complaint Process/Recipient Satisfaction; Advocates/Advisory Group; Righes and contact info provided

  Yes

  No

  N/A

• 3.12 Clinician assignment

  Yes

  No

  N/A

• 3.13 Engagement and Retention activities

  Yes

  No

  N/A

• 3.14 Efforts to develop communication with family/significant others; Communication with caregivers (C&A)

  Yes

  No

  N/A

• 3.15 Co-occuring MH and substance use

  Yes

  No

  N/A

• 3.16 Process for responding to individuals who disengage; Lost to contact

  Yes

  No

  N/A

• 3.17 Tobacco Treatment

  Yes

  No

  N/A

• 4.11 Caseload; staff coverage

  Yes

  No

  N/A

• 4.12 Treatment Services-required and optional

  Yes

  No

  N/A

• 4.13 Crisis and after hour services

  Yes

  No

  N/A

• 4.14 Cultural Competence and language access

  Yes

  No

  N/A

• 4.21 Supervision; Staff training

  Yes

  No

  N/A

• 4.41 Clinical Risk Management

  Yes

  No

  N/A

• 4.51 Recipients at Risk

  Yes

  No

  N/A

• 4.61 Premises

  Yes

  No

  N/A

• Additional Comments

  Yes

  No

  N/A