RTF QI protocol

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Quality Improvement Protocol

  Date

Special Review 524, 584.17c

• Investigation and review all untoward incidents (thorough/timely), Reporting (OMH, CQC, NYS Central Child Abuse and Maltreatment Register, MHLS), Trending/Patterning Analysis, Integration of results into improved care, utilizing Sentinel Events/Root Cause Analysis

  Yes

  No

  N/A

Complaints 527.5

• Documentation (log), Investigation/Follow up, Response to Complainant (timeliness), Trending

  Yes

  No

  N/A

QI Indicators 584.17

• How conducted, How are problems identified, are outcomes relevant, Reviewed and revised periodically against attainment, progream changes, best practices, Outcomes/feedback/resolution

  Yes

  No

  N/A

Utilization Review Part 27.3(d) 584.18

• Committee compoosed of at least 3 mmebers of clinical staff including 2 physicians, Committee meets quarterly, Integrated into Qi program, Continued stay reviewe starts 30 days after admission, appropriate alternative notification followed.

  Yes

  No

  N/A

Satisfaction 527.5

• Solicited fromResident/Family/Providers (see Resident Interview), Surveys, Letters, Telephone calls, Meetings, Analysis of Information, Feedback to staff, residents, family

  Yes

  No

  N/A

Restraint 27.7, MHL 33.04 584.4 584.13 CFR 483.352-483.376

• Restraint Policy current, Policy and Procedure consistent with residents medical records and facility's restraint log, Staff training available, Staff interviews indicate staff understand issues on use of restraint, QI/QM has focused on restraint, Medical records are comprehensive including dated and signed physician orders, Physician orders based upon personal evaluations of patients done before restraints ordered, orders contain rationale, Orders written for no more than 4 hours, Documentation that patients were monitored, assessments done minimum every 30 mins, and half hour assessment notes present, Restraints approved by OMH, Documentation that residents continuously evaluated, , When released after two hours, restraints discontinued if patient does not exhibit threatening behavior. If so, is physician notified immediately, Were there any cases of an emergency requiring restraint authorized by senior professional staff where a physician was not available, Did a physician arrive within 30 mins to personally assess the patient and write the order, IF delayed, is the reason documented, Families notified, Documentation present that patients were debriefed.

  Yes

  No

  N/A

• Seclusion Policy current, Do records verify that seclusion is used only to prevent residents from serious self-injury or injury to others and that less restrictive techniques would be ineffectual, Are seclusion orders written on a daily basis and after examination by a physician, Are seclusion orders signed, dated and written for no more than two hours duration, Are patients in seclusion appropriately monitored

  Yes

  No

  N/A

Time Out 584.13

• Visual observation of intervals of no more than 15 mins, appropriate documentation in case record, Time limits within 24 hour period observed.

  Yes

  No

  N/A