Outpatient 587 Staff Interview

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Staff Interview

  Date

• Program; Reviewer; staff name and title

  Yes

  No

  N/A

*1.11 and 1.13 Medications

• Storage of medicatons at the prgoram, restricted access to med box, training provisions for recipients including self administration and info on adverse reactions

  Yes

  No

  N/A

*1.21 Incident Reporting

• incident reporting process used, knowledge of results of incident investigations and IRC recommendations

  Yes

  No

  N/A

*1.23 Incident Reporting

• ability to describe a reportable incident, reporting process to administration, incident reporting to the external proper authorities, staff awareness of incident follow up and recommendations

  Yes

  No

  N/A

*1.31 Building safety

• knowledge of safety hazards and prevention, examples of hazards observed, administrations repsonse to hazards

  Yes

  No

  N/A

2.42 Privacy

• locations where counseling is offered, space is adequate and private, location of recipeint related materials, assurance of recipients right to confidentiality

  Yes

  No

  N/A

2.13 Multi cultural training

• inservice training with regard to cultural and ethnic differences of recipients, training related to practices for ethically diverese recipients, program's treatment for the culturally and ethnic diversity of the recipients it serves.

  Yes

  No

  N/A

*2.21 Written consent

• procedures for obtaining written consent, procedure used to inform recipients.

  Yes

  No

  N/A

*2.31 Recipient Input

• examples of how the program encourages recipients to provide tehir input on improving services and other program issues, examples of how progream uses the input.

  Yes

  No

  N/A

*3.21 and 3.31 Treatment planning

• description of the treatment planning process, staff/recipients/collaterals having an opporutnity for input, procedure used to obtain input, any problems noted

  Yes

  No

  N/A

3.41 and *3.24 Discharge

• Procedure for when discharging a recipient, discharge summaries, type of information included on d/c plan, information forwarded to receiving provider

  Yes

  No

  N/A

*3.24 Service Systems

• coordination of services with other providers, opportunity to communciate with toher providers, other providers of service input into the tx planning process, dissemination of program's goals and objectives to other service providers to ensure treatment coordination of services.

  Yes

  No

  N/A

*4.11 Program services

• any service gaps noted, both internally and externally, what service gaps are there, explanation of attempts to address gaps

  Yes

  No

  N/A

*4.21 After hours accessibility

• Description of the programs after hours assistance plan, receipient awareness of this plan, communciation proces when secondary provider is used, does the plan work

  Yes

  No

  N/A

*5.11 Staffing

• adequate staffing to perform program's overall responsibilities to its recipients, examples of staffing issue in the past

  Yes

  No

  N/A

*5.11 Employee performance

• evaluation by your supervisor on work performance during past year, is it comprehensive, relevant and helpful, staff input into the evaluation process, description of staffing structure with regard to lines of accountability and authority.

  Yes

  No

  N/A