Inpatient Admin Protocol

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Administration Protocol

  Date

Governing Body 580.5 (a)(1)(2)(7),580.5(b)(1), 582.5(a)(1)(2)(7), 580.5(b)(1)

• Minutes of meetings maintained as record of decisions made by the board of director, Current plan of organization, Annual written evaluation of program

  Yes

  No

  N/A

Personnel/Staffing; Administrative Staff (See Administrative Interview Form ICST p 18) 527.4, 580.5(a)(2)(4)(5)(8)(9), 580.6(a)(6)(7), 580.7, 5802.5 (a)(4)(5)(8)(9), 582.6(a)(5), 582.7, Part 27.1(c)

• Clinicial Staff, Staff Development and Training, Personnel Policies and Training, Other Staff Categories, Vacancies (See personnel Checklist ICST pg 19, See staff Interview Form ICST p 20)

  Yes

  No

  N/A

Policies and Procedures 580.5(a)(3), 582.5(a)(3), 580.5(b)(4), 582.5(b)(4)

• A current manual is available and accessible for all staff, There is a mecanism to review and revise procedures periodically at various levels, Access to regulations (See policy and procedures protocol ICST p 5-6)

  Yes

  No

  N/A

Review of affiliation agreements as applicable 580.5(b)(8), 580.9, 582.5(b)(8), 582.9

• County MH, State PC, ancillary services: ECT, Medical Consult, other services not provided by hosptial)

  Yes

  No

  N/A