Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Policies and Procedures Protocol

  • 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.

  • Advance Directives/Health Care Proxy, Advanced Preferences: 527.6; 527.7

  • Certified Capacity/Over Census: 580.6(b)(2); 582.6(b)(2)

  • Communication/Visits: Part 21

  • Confidentiality/Access to Records: 505.7; 580.8(b); 582.8(b)

  • Discharge Planning: 580.6(a)(4)

  • ECT: Part 27.9; 527.8; OMH ECT Guidelines

  • Emergency Preparedness: 580.5(b)(7); 582.5(b)(7)

  • Patient Input: Part 27.3(b); 527.5(b)(11)

  • Grievance/Complaints: Part 27.8; 527.5(f); 527.8

  • Incident Review: 524; 580.5(b)(5); 582.5(b)(5); 580.5(a)(6); 582.5 (a)(6)

  • Infection Control: Part 27.4 (b)

  • Language Bank/Reasonable Accomodations: 527.4

  • LWOC/Escapes/Missing: Part 37, 524

  • Volunteers: 580.5(a)(5); 582.5(a)(5)

  • Medical Records: MHL 33.12; 580.6(a)(3), 580.8; 582.6(a)(3); 582.8

  • Medication: 580.6(a)(8); 582.6(a)(6)

  • Patients' Rights: 527.4-8

  • Personnel: 580.5(a)(3); 580.7; 582.5(a)(3); 582.7

  • Physical Assessments: Part 27.5 (b)

  • Quality Improvement: Part 27.3(d); 580.(c ); 582.8(c )

  • Restraint/Seclusion: Part 27.7; MHL 33.04

  • Risk Management: 580.5(b)(6); 582.5(b)(6)

  • Security/Safety: Part 27, 45, 77 (for Art 31), 712 DOH for Art 28

  • Service Agreements/Continuity of Care: 580.5(b)(8); 582.5(b)(8)

  • 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 )

  • Staff Development and Training: 580.5(a)(4); 582.5(a)(4)

  • Table of Organization:580.5(a)(2); 582.5(a)(2)

  • Treatment Planning: Part 27.3; 580.6(a)(2); 582.6(a)(2)

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