• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Standard 1.1: Medications are stored and monitored in accordance with OMH approved policies and procedures. 595.6(d)(7)(v), 595.12(b)(5)

  • * CR 1.11:​ Medications storage and monitoring assures resident safety.

  • CR 1.12:​ Residents are trained and assisted, as needed, in self-administration of medication.

Standard 1.2: Program has an effective incident reporting, investigation, and management process. 595.6(d)(8)(iii) 595.13(a)(2), Part 524

  • * CR 1.21: Incidents are reported and investigated in accordance with the program’s approved incident reporting plan.

  • *CR 1.22: ​Incident reviews result in appropriate changes to policies and practices.

Standard 1.3: The program maintains a safe environment. 595.15(a)(1), (a)(2), (a)(4), 595.16

  • * CR 1.31: ​Residents meet requirements for self-preservation.

  • CR 1.32: The building, its equipment and fixtures are free from fire and safety hazards.

  • *CR 1.33 Smoke detectors and firefighting equipment are located and maintains as required by regulation.

Standard 1.4: Living spaces are adequately furnished and well maintained. 595.16(b)(1)(v)(vi)

  • CR 1.41: Personal living spaces meet regulatory requirements for furniture and linen. The rooms are clean and properly maintained.

  • CR 1.42: ​Common living spaces are appropriately furnished. Furniture and spaces are properly maintained.

Standard 1.5 The program ensures residents has access to emergency and crisis services. 595.12(b)(4)(12), & (f)

  • *CR 1.51 Emergency health care services are provided to residents as needed.

  • *CR 1.52 Crisis Intervention services are available to residents as needed.

Standard 2.1: Program exhibits respect for I dividual rights, dignity, personal integrity and the various ethnic and cultural backgrounds of its residents.

  • CR 2.11 Program is sensitive to the culture and ethnicity of the residents served.

  • *CR 2.12 Residents are informed of and aware of their rights, Resident rights are respected.

Standard 2.2 Resident input is solicited and incorporated into policy decisions.

  • CR 2.21 Resident input is incorporated into residence operation.

  • CR 2.22 Resident grievances are reviewed and resolved in a timely manner.

Standard 2.3: Resident information is safeguarded for confidentiality.

  • CR 2.31: The confidentiality of resident records is maintained.

  • CR 2.32: Resident consent is obtained prior to the release of identifying or clinical information regarding the resident.

Standard 3.1: The service planning process identifies resident needs, goals and objectives. The service plan identifies services and interventions designed to address these needs and attain resident objectives. The plan is based upon resident input and reflects the priorities of the resident.

  • CR 3.11: Assessments identify resident needs.

  • *CR 3.12: Service plans identify specific, measurable goals and objectives and discharge criteria. Methods and time frames for attaining objectives are explicit.

  • CR 3.13: With resident consent, families (when clinically appropriate) and/or collaterals are part of the service planning/review process.

  • *CR 3.14: Service plans are periodically reviewed and revised as needed.

  • CR 3.15: Progress notes are timely and reflect residents' progress toward attaining agreed upon objectives.

  • CR 3.16: Agreed upon services are available and provided as stated in the service plan.

Standard 3.2: Program ensures that there are systematic, independent, ongoing reviews of appropriateness of services for each resident.

  • *CR 3.21: Residents shall be appropriately admitted and retained.

  • CR 3.22: The utilization review process is carried out by staff who do not have primary responsibility for the resident under review.

Standard 3.3: The discharge planning process ensures that residents are discharged to appropriate settings.

  • CR 3.31: Discharge planning shall be based upon resident preferences and shall include input from relevant staff, community service providers and, where clinically appropriate, family members.

  • CR 3.32: Discharges of residents who are not discharge ready adequately safeguard the rights of all residents of the program and the community.

  • *CR 3.33: Connections to necessary community support services are, with the resident's consent, made prior to discharge.

Standard 4.1: The program's administration ensures that staffing is sufficient to carry out the mission of the program and to ensure that quality services are provided.

  • *CR 4.11: Staffing is adequate to provide the program's stated services.

  • CR 4.12: Training is regularly provided to all program staff to enhance their ability to effectively provide program services.

Standard 4.2: the governing body effectively oversees the operation of the program.

  • *CR 4.21: Program operation is regularly monitored against the goals and objectives established by the program and approved by OMH.



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