Program/Service Structure
How can the survey team verify that the scope of services is reviewed at least annually?
What is by reviewing QA Meeting Minutes
What is by the corporate policies
How does the program demonstrate efforts to minimize the times between first contact, screening, and admission or referral?
What is by tracking through quality assurance monthly reporting (power BI) or by manual tracking.
What is by providing input, notating what the person served is saying, by involving family members or circle of support, by showing client choice of goals and activities etc..
Where is the transition plan documented?
What is assessment/treatment plan?
When are education and training regarding medications provided to staff?
What is, at orientation and at least annually thereafter.
What is the process to inform a person that he/she is ineligible for services?
What is, inform the person and/or family/support system as to the reason and make recommendations for alternative services.
What forms/information is included in the intake/orientation process?
What is assessment, rights & responsibilities, consents, HIPAA, consumer handbook, grievance, transition and discharge criteria, access to services etc...
What is by sharing of documentation, resources, communication with a PHI form signed by client, after admit to program it would be meetings with the service/treatment team.
What items are listed in the discharge/transition plan?
What is, Progress, Gains/Achievements, Support System, Continuity of Medication (if applicable), Referral Information, etc.
What items are documented for prescription and nonprescription medications for each person served?
What is, Name of Medication, Dosage, Frequency, Prescriber Contact Information, Medication Reactions, PRN, Instructions for use, etc.
Where can the surveyors locate your written procedures?
What is in the Directors teams folder for corporate polices, and at each location for program specific policies.
How is information collected regarding advanced directives, when applicable?
What is on the assessment/treatment plan
Name 4 things that the person-centered plan should be based on?
Who can attend/develop the discharge/transition plan?
Who is, Person Served, Family/Legal Guardian, Legal Representative, Team Members, Referral Source, etc.
What number should each program have if the programs handles medication in any manner?
What is Poison Control.
Describe how the program provides and documents competency-based training to personnel providing direct services?
What is by completing the new hire orientation form and annual trainings that are documented by sign in sheets.
What is strengths, needs, interests, abilities, preferences, diagnostic history, treatment history, mental status, medication, physical health history, allergies, SDOH, history of trauma, SUD use, SI/HI etc..
How does the program ensure that information is shared in a manner that is understandable to the person served?
What is the consumer handbook is written in a school age grade level, the PCP training is in a pictorial format, forms are explained in laymen's term to the person served.
How do you ensure the person served or legal guardian receive a copy of the discharge/transition plan?
What is, Discharge/Transition plan which indicates if the person served or legal guardian received or refused a copy.
How do you show availability of consultation 24/7 from a physician, pharmacist, or qualified professional licensed to prescribe?
What is the consumer handbook and program policies and procedures?
Describe at least 3 peer support activities performed by peer support specialists?
What is:
Engagement, Support, Community Networking, Advocating, Mentoring, Self-advocacy, Wellness, Resources
What is included in the interpretive summary that is part of the assessment process?
What is disorders, data from the assessment, co-morbidities, risks for suicide, violence and other risky behaviors.
How do we share the person-centered plan with the consumer served?
What is the follow up procedure after discharge?
What is, Assessment of the consumer, QOLI, and Follow up contact 30 days post discharge.
What form states if the person served is pregnant?
What is, Nursing Assessment & Comprehensive Assessment.