Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Policies and Procedures Protocol
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Admissions/Transfers/Discharges: Parts 15, 17, 36, 57, 517, 580.5(b)(3); 580.6(a)(9), (b); 582.5(b)(3); 582.6(b) MHL Art 9.
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Advance Directives/Health Care Proxy, Advanced Preferences: 527.6; 527.7
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Certified Capacity/Over Census: 580.6(b)(2); 582.6(b)(2)
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Communication/Visits: Part 21
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Confidentiality/Access to Records: 505.7; 580.8(b); 582.8(b)
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Discharge Planning: 580.6(a)(4)
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ECT: Part 27.9; 527.8; OMH ECT Guidelines
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Emergency Preparedness: 580.5(b)(7); 582.5(b)(7)
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Patient Input: Part 27.3(b); 527.5(b)(11)
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Grievance/Complaints: Part 27.8; 527.5(f); 527.8
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Incident Review: 524; 580.5(b)(5); 582.5(b)(5); 580.5(a)(6); 582.5 (a)(6)
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Infection Control: Part 27.4 (b)
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Language Bank/Reasonable Accomodations: 527.4
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LWOC/Escapes/Missing: Part 37, 524
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Volunteers: 580.5(a)(5); 582.5(a)(5)
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Medical Records: MHL 33.12; 580.6(a)(3), 580.8; 582.6(a)(3); 582.8
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Medication: 580.6(a)(8); 582.6(a)(6)
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Patients' Rights: 527.4-8
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Personnel: 580.5(a)(3); 580.7; 582.5(a)(3); 582.7
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Physical Assessments: Part 27.5 (b)
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Quality Improvement: Part 27.3(d); 580.(c ); 582.8(c )
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Restraint/Seclusion: Part 27.7; MHL 33.04
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Risk Management: 580.5(b)(6); 582.5(b)(6)
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Security/Safety: Part 27, 45, 77 (for Art 31), 712 DOH for Art 28
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Service Agreements/Continuity of Care: 580.5(b)(8); 582.5(b)(8)
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Special Procedures: 505; 526; 580.5(a)(4);580.5(b)(6); 580.6(a)(5); 582.5(a)(4); 582.5(b)(6); 582.6(c )
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Staff Development and Training: 580.5(a)(4); 582.5(a)(4)
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Table of Organization:580.5(a)(2); 582.5(a)(2)
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Treatment Planning: Part 27.3; 580.6(a)(2); 582.6(a)(2)