Outpatient Tiered Certification

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Standard 1.1: Programs shall control access to medication stored on premises and demonstrate safe practices regarding the prescription and administration of medication. [587.4(c)(10,11)][587.6(c)(7)(v)] [587.18(b)(11)]

• * OP 1.11 Medications shall be stored according to applicable laws in order to ensure that recipients and staff do not have unauthorized access to medications.

  Yes

  No

  N/A

• OP 1.13 Recipients shall receive medication training including: medication education and self-administration of medications.

  Yes

  No

  N/A

Standard 1.2: Programs shall have an effective incident review process. [587.6(I)][524.7(a-d)][524.8(b)]

• * OP 1.21: The program's incident review committee shall review all incidents and shall make its recommendations to the program administration for proper follow up.

  Yes

  No

  N/A

• OP 1.22: The Incident Review Committee shall maintain the required staffing composition and shall ensure that members are qualified to perform their incident review committee duties.

  Yes

  No

  N/A

• * OP 1.23: The program shall ensure that incidents which require external notification are properly reported.

  Yes

  No

  N/A

Standard 1.3: Programs shall ensure that treatment is offered in an environment that protects the safety of the patients receiving services. [587.19(a,b)][Art. 33 MHL]

• * OP 1.31: Persons (recipients, staff, and visitors) shall be safe from undue harm while they are at the program site.

  Yes

  No

  N/A

Standard 1.4: Programs shall ensure that sufficient types and arrangements of spaces are provided, including accessibility for the handicapped, as well as adequate and appropriate furnishings, which are consistent with the capacity and purpose of the program. [587.19(a)(1-5)][587.19(c)] [AD Act of 1990 and Sec 504 Rehabilitation Act (1973]

• OP 1.42: Persons (recipients, staff and visitors) with various disabilities shall have access to appropriate program areas. Programs shall adjust service environments, as needed, for recipients who are blind, deaf or otherwise impaired.

  Yes

  No

  N/A

• * OP 1.43: Programs shall have sufficient furnishings, adequate program space, and appropriate program related equipment for the population served.

  Yes

  No

  N/A

Standard 2.1: Programs shall ensure that services are humanely administered with full respect for individual dignity, personal integrity and ethnic and cultural sensitivity [MHL Art. 33] [587.6(c)(5)] [587.6(c)(7)(iv)[587.6(p)]

• OP 2.13 Program staff shall offer culturally sensitive program services to recipients of various ethnic or cultural backgrounds in a competent manner.

  Yes

  No

  N/A

• Ê 2.13C Program employs staff who are of the same or similar ethnicity or culture as the recipients served.

  Yes

  No

  N/A

Standard 2.2: Programs shall ensure that recipients give their verbal or written consent to treatment and to release information, as required, consistent with exceptions allowed under various laws, and that they voluntarily participate in treatment. [587.7(a)(3-5,12)]

• * OP 2.21: Recipients shall give the program their consent for the releasing of client specific information.

  Yes

  No

  N/A

• OP 2.22: Recipients shall be able to object to their treatment or complain about issues regarding program policies and procedures, program staff or services without fear of any retribution.

  Yes

  No

  N/A

• Standard 2.3: Recipient input shall be solicited and incorporated into the program's policy decisions. [587.6(o)]

  Yes

  No

  N/A

• * OP 2.31: Programs shall solicit recipient's opinions on the appropriateness of services and the adequacy of the program.

  Yes

  No

  N/A

• OP 2.32: Ongoing recipient input shall be used as part of program planning, service development and program review activities.

  Yes

  No

  N/A

• Ê 2.32C Recipients shall have input into the operation of the program via a recipient advisory board and/or as member(s) of the governing body.

  Yes

  No

  N/A

Standard 2.4: Clinical records and information about patients shall be accessible to those being treated, and to all appropriate others involved in their treatment. Documents shall be safeguarded for confidentiality. [587.6(c)(7)(vi)][ 587.7(a)(5)] [MHL 33.13 & 33.16]

• OP 2.41: Program recipients shall have access to their clinical records, unless it is deemed that the release of materials would be clinically contraindicated.

  Yes

  No

  N/A

• OP 2.42: Information pertaining to program recipients shall be maintained by the program as to assure confidentiality.

  Yes

  No

  N/A

• OP 2.52: The Recipients' Right Notice shall be printed in the language of the majority of the population served, conspicuously posted and include all required contact names, addresses and telephone numbers.

  Yes

  No

  N/A

Standard 3.1: Every patient shall have appropriate assessments completed that review their needs and strengths in all relevant functional areas on which recommendations for treatment are based. [587.16(b)][587.18(b)(4)]

• * OP 3.11: Initial assessments shall identify problems, strengths, recipient priorities and contain recommendations for treatment.

  Yes

  No

  N/A

• Ê 3.11C Initial assessments for persons referred by inpatient programs or emergency settings shall be completed within 5 business days of referral.

  Yes

  No

  N/A

• OP 3.12: Assessments shall be updated, as needed, to reflect current functioning levels based on recipients' response to their treatment and/or other relevant factors.

  Yes

  No

  N/A

Standard 3.2: Every patient shall have a treatment or IPRT service plan that is updated and is based on a current assessment of functioning and progress towards treatment outcomes. [587.15(b,e,g)] [587.4(c)(27)][587.17(b-c)][588.6(g)][588.7(d)][588.8(d)][588.9(d)][588.10(e)]

• * OP 3.21: Treatment / IPRT service plans shall clearly state the intended outcome(s) of the proposed treatment, including obtainable goals and objectives based on assessment recommendations.

  Yes

  No

  N/A

• * OP 3.22: Treatment plans shall be revised based on current functioning and recipient's response to current treatment/service plan.

  Yes

  No

  N/A

• Ê 3.22C COPS requires reviews "at least annually", which is less stringent than Part 587. No additional criteria above OP 3.22 is warranted for COPS providers.

  Yes

  No

  N/A

• * OP 3.23: Progress notes shall document the recipient's progress or lack thereof towards the achievement of goals and objectives noted on treatment plans.

  Yes

  No

  N/A

• * OP 3.24: Services, as stated in individual treatment plans, shall be provided at prescribed frequencies to ensure the effectiveness of treatment.

  Yes

  No

  N/A

• Ê 3.24C Program shall provide or arrange for case management, home visiting, or other clinical necessary services to maintain enrolled persons in the program or to reduce absenteeism.

  Yes

  No

  N/A

Standard 3.3: Treatment/IPRT service plans and follow-up reviews shall verify that all appropriate people have had a role in assessing patient needs and have had input in the development of goals and objectives and desired treatment outcomes. [587.7(a)(1)] [587.16(c,d)] [587.17(b,c)]

• OP 3.31: Program recipients shall have an opportunity to provide input into the development and revision of their treatment plans.

  Yes

  No

  N/A

• OP 3.32: Families members and/or collaterals, as appropriate, are offered the opportunity to provide input into the development and revision of the treatment plan.

  Yes

  No

  N/A

Standard 3.4: Ongoing discharge planning for all enrolled patients shall occur from the time of admittance into the program until formal discharge occurs. [587.4(c)(7)] [587.16(e)(5)] [587.17(c)(4)] [587.18(c)]

• OP 3.41: Discharge planning based on established discharge criteria shall be addressed throughout the length of stay.

  Yes

  No

  N/A

• * OP 3.42: Recipients shall be discharged to appropriate service levels and programs shall have arranged linkages to identified services upon discharge.

  Yes

  No

  N/A

• OP 3.43: When program recipients have been transferred to other programs discharge summaries and all other appropriate information shall be transmitted to the receiving program.

  Yes

  No

  N/A

Standard 4.1: Services shall be provided in a way which ensures continuity of care, coordination of services (emergency, health, residential, case management, etc.) and communication of information with other provider networks. [587.6(m)(4)] [587.8(i,j,k)] [587.9(h,i,j)] [587.10(h,,j,k)] [587.11(g,i,j)] [587.12(h,i,j)][587.13(h,i,j)]

• * OP 4.11: There shall be continuity of care within the mental health system and with other provider networks which meets the identified needs of the program's recipients.

  Yes

  No

  N/A

• Ê 4.11C Program shall have inpatient services readily available to them, when needed.

  Yes

  No

  N/A

• OP 4.12 Recipients shall be admitted to the program and begin treatment without unreasonable delay.

  Yes

  No

  N/A

• Ê 4.12C a) Service priority shall be given to persons with serious M I or children with serious emotional disturbance. b) Program shall provide services to persons who are part of a geographic area or target population as agreed to in the local government plan.

  Yes

  No

  N/A

• OP 4.13: The program shall ensure that people not admitted into the program are referred to other appropriate services, when warranted.

  Yes

  No

  N/A

• Ê 4.13C Program shall not deny service to anyone based on one's ability to pay for needed services.

  Yes

  No

  N/A

Standard 4.2: Programs shall arrange for around-the-clock services for critical or other urgent situations when the program is not open. [587.8(l)][587.9(k)][587.10(I)] [587.11(b)][587.12(k)]

• * OP 4.21: Services shall be available to program recipients seeking assistance when the program is not in operation, including after-hours and weekends.

  Yes

  No

  N/A

• Ê 4.21C Programs shall provide or arrange for face-to-face service 24 hours a day, as needed.

  Yes

  No

  N/A

Standard 4.3: The Utilization Review process shall assure that all active case records are systematically reviewed by authorized staff to determine if patients are receiving appropriate services and are being served at the indicated service level. [587.6(l)] [588.6(b-f)] [588.7(b-d)] [588.8(b,c)][588.9(b,c)][588.10(b,c)].

• * OP 4.31: Utilization Reviews shall be individualized and comprehensive ensuring that services are appropriate and that continued treatment is warranted.

  Yes

  No

  N/A

• * OP 4.32 Programs shall review and document an individual's need for continued service in Clinic programs for services in excess of 40 visits per benefit year.

  Yes

  No

  N/A

• OP 4.33: UR shall be performed only by properly trained professional staff that function independently, to the maximum extent possible, of clinical staff that are providing services to the program recipient under review.

  Yes

  No

  N/A

Standard 5.1: Programs shall continuously employ an adequate number and appropriate mix of staff to carry out its objectives and assure the quality of the program staff. [587.15(a-g)]

• * OP 5.11: Program shall consistently provide staffing that is adequate and appropriate for the stated services provided and for the population served.

  Yes

  No

  N/A

Standard 5.2: All programs shall be overseen by the agency’s governing body and the governing body shall be responsible for identifying lines of authority and accountability. [587.6(c)]

• * OP 5.21: The program's governing body shall be responsible for overall program oversight.

  Yes

  No

  N/A