NYS OMH Clinic Standards of Care Survey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• NYS Office of Mental Health
  Clinic Standards of Care Survey

• Agency Name
  Clinic name
  Operating Certificate #

Assessment

• 1.11 Requests for services are addressed appropriately and in a timely manner

  Yes

  No

  N/A

• 1.12 The assessment process is responsive and coordinated

  Yes

  No

  N/A

• 1.21 The assessment is comprehensive

  Yes

  No

  N/A

• 1.22 Screening and assessment of Co-occurring disorders

  Yes

  No

  N/A

• 1.23 The assessment includes an initial risk of self harm

  Yes

  No

  N/A

• 1.24 The assessment includes an initial risk of harm to others

  Yes

  No

  N/A

• 1.25 Health screening and monitoring

  Yes

  No

  N/A

• 1.27 Screening and assessment of tobacco use

  Yes

  No

  N/A

• 1.31 The clinician pursues information from other sources, including family members, significant others and recent providers of service

  Yes

  No

  N/A

Treatment Plan

• 2.11 Every recipient has a person-centered, comprehensive treatment plan

  Yes

  No

  N/A

• 2.12 The treatment plan is developed with the recipient/family/collaterals

  Yes

  No

  N/A

• 2.14 Treatment plan revises reflect active and ongoing reappraisal of goals, objectives, and discharge criteria

  Yes

  No

  N/A

• 2.15 Documentation of treatment services

  Yes

  No

  N/A

• 2.21 Safety plan

  Yes

  No

  N/A

• 2.31 The comprehensive treatment plan is developed in a timely manner; the plan and subsequent reviews are signed by all individuals participating in the recipient's care

  Yes

  No

  N/A

Ongoing Care

• 3.11 The clinic attends to the recipient and family

  Yes

  No

  N/A

• 3.12 Identification of a primary clinician

  Yes

  No

  N/A

• 3.13 Engagement and retention

  Yes

  No

  N/A

• 3.14 Communication with families/other significant people

  Yes

  No

  N/A

• 3.15 Co-occurring mental health and substance use disorders

  Yes

  No

  N/A

• 3.16 Disengagement from treatment

  Yes

  No

  N/A

• 3.17 Treatment of tobacco use

  Yes

  No

  N/A

• 3.21 Discharge

  Yes

  No

  N/A

Clinical Administration

• 4.11 Caseload

  Yes

  No

  N/A

• 4.12 Treatment Services

  Yes

  No

  N/A

• 4.13 Crisis Services

  Yes

  No

  N/A

• 4.14 Cultural Competence

  Yes

  No

  N/A

• 4.21 Supervison and Training

  Yes

  No

  N/A

• 4.31 Information Sharing

  Yes

  No

  N/A

• 4.41 Clinical Risk Management

  Yes

  No

  N/A

• 4.51 Responsive to recipients at risk

  Yes

  No

  N/A

• 4.61 Premises

  Yes

  No

  N/A