DIVISION OF QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT BUREAU OF STANDARDS COMPLIANCE Regulatory Compliance Site Review Instrument Chemical Dependence Outpatient Programs QA-3CD (Applicable to Outpatient Programs and Outpatient Rehabilitation Programs) Part I Patient Case Records Part II Service Management Note: Pursuant to Mental Hygiene Law and the Office of Alcoholism and Substance Abuse Services’ (OASAS) Regulations, this Site Review Instrument is designed for the express purpose of conducting OASAS regulatory compliance reviews of its certified providers. Use of this Site Review Instrument as a self-assessment tool may be a helpful indicator of a provider’s regulatory compliance. However, please note that the Site Review Instrument: (1) is not the sole basis for determining compliance with OASAS’ requirements; (2) does not supersede OASAS’ official Regulations, and should not be relied upon as a regulatory reference in lieu of the Regulations; and (3) is subject to periodic revision without notice. REVIEW INFORMATION PROVIDER LEGAL NAME SERVICE SITE ADDRESS CITY, TOWN, VILLAGE ZIP DATE(S) OF REVIEW REVIEW NUMBER OPERATING CERTIFICATE NUMBER PROVIDER NUMBER PRU NUMBER LEAD REGULATORY COMPLIANCE INSPECTOR ADDITIONAL REGULATORY COMPLIANCE INSPECTOR(S) (if applicable)
C.7. If applicable, does each Complex Care Coordination note: indicate the critical or condition leading to the need for service; identify the other service providers involved in the coordination service; and indicate the complex care service occurred within five working days of another service? [822.5(m)] ____ ____ C.8. If applicable, does each Medication Administration and Observation note: identify the type and dosage of medication administered or dispensed; and identify the condition of patient as observed to, and after, administration as appropriate to the medication? [822.5(s)] ____ ____ Number of Applicable Questions Subtotal Case Records Subtotal I. PATIENT CASE RECORDS (Active) SCORE Patient Record Numbers #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 = yes = no From Scoring Table C. DOCUMENTATION OF SERVICE (cont’d) ____ ____ ADDITIONAL SERVICES (cont’d) C.9. If applicable, does each Medication Management note document a face to face meeting with a prescribing professional identify that the service was provided for one of the following purposes: evaluation, monitoring, observation or dosage change to a patient’s medication; a comprehensive medication review of a new patient or any patient who requires a more extensive review; or the induction of a patient to a new medication requiring a period of patient observation? [822.5(u)]
9 --- C.1. progress notes - documentation 9 --- E.11. 50 percent QHPs or 10 --- C.2. services consistent with treatment plan 10 --- F.2. group counseling size ≤ 15 patients 11 --- D.3. discharge plan reviewed and approved 11 --- G.2. Justice Center background checks 12 --- D.5. discharge summary within 45 days 12 --- H.1. incident management plan 13 --- F.2. ineligible individuals - reason and referral 13 --- J.1. patient rights postings Additional Quality Indicators --- Outpatient Rehabilitation Services 14 --- A.7. admission criteria for OP Rehab. Svcs. 14 --- E.17. counselor-to-patient ratio = 1:20 # of questions ► Quality Indicator Total Score ► 15 --- E.18. half-time recreation therapist, etc. 16 --- E.19. part-time nurse practitioner, etc. 17 --- F.3. services 3-5 days/week; 4 hrs./day Quality Indicator Total Score on the Level of Compliance Determination Schedule. 18 --- F.4. additional services for OP Rehab. Svcs. 19 --- F.5. one meal per day # of questions ► Quality Indicator Total Score ► OF COMPLIANCE DETERMINATION SCHEDULE OVERALL COMPLIANCE SCORES SCORE # OF QUESTIONS FINAL SCORE LEVEL OF COMPLIANCE DETERMINATION TABLE 0.00 – 1.75 = NONCOMPLIANCE 1.76 – 2.50 = MINIMAL COMPLIANCE 2.51 – 3.25 = PARTIAL COMPLIANCE 3.26 – 4.00 = SUBSTANTIAL COMPLIANCE Patient Case Records = Service Management = QUALITY INDICATOR COMPLIANCE SCORES LEVEL OF COMPLIANCE SCORING DETERMINATION