chapter 9 provider monitoring policies
TRANSCRIPT
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Monitoring Contractor andSubcontractor Sufficiency 9.01 Page 1 of 2
Policy Name: MONITORING CONTRACTOR AND SUBCONTRACTOR SUFFICIENCY Policy Number: 9.01
Reference: 42 CFR 438.206; 42 CFR 438.207; DSHS Contract
Effective Date: 8/2004
Revision Date(s): 12/2011; 4/2016
Reviewed Date: 4/2016; 6/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors• Policy: Provider and Subcontractor Administrative Review• Policy: Subcontractual Delegation and Assessment Plan
PURPOSE
The Salish Behavioral Health Organization (SBHO) will monitor provider network and subcontractor sufficiency and provide reports to the state.
PROCEDURE
1. SBHO providers will complete a report detailing current staffing.a. Report will be updated as per contract.b. Report will detail number of network staff and areas of specialty employed by
each network provider. Specialties include:• Credentials, such as psychiatrists, MHPs, MSWs, CDPs, etc.• Age, such as child and geriatric• Minority• Disability and hearing impaired• Evidence Based Practice training, and• Bilingual skills
Salish BHO Policies and Procedures
Monitoring Contractor andSubcontractor Sufficiency 9.01 Page 2 of 2
2. SBHO subdelegated contractors will provide evidence of how previous fiscal year activities outlined in the contracts were met during the regularly scheduled Administrative Reviews.
3. SBHO staff will monitor contractor reports and delegation agreements through the
following activities: a. Conduct a GEOACESS mapping, with significant alternations to population
and/or public transportation routes, to ensure adequate capacity for the expected enrollment in our service area in accordance with state standards for access to care travel times, as required.
b. SBHO will monitor the report for losses or additions of individuals with
particular specialties. c. The SBHO will work with network providers to ensure continued access to
specialists. d. If a network provider loses internal access to a particular specialist, the SBHO
will work with the provider to: • Encourage the hiring of replacement staff or train existing staff to meet
qualifications • Maintain access via referrals for outside-agency contracts or
arrangements with other network providers e. The SBHO will conduct regularly scheduled formal reviews of contractors and
subcontractors with Subdelegation Agreements, using the SBHO Subcontractual Delegation and Assessment Plan.
MONITORING
1. Policy Monitoring. The SBHO will conduct resource management of network sufficiently through:
• Grievance Reports and system tracking of concerns and grievances to assess if there is a pattern that suggests inadequacy in network sufficiency or gaps in service capability. The reports will be reviewed by SBHO staff and the Quality Improvement Committee.
• Regularly scheduled SBHO Provider and Subcontractor Administrative Review
• Monthly Provider Chart Reviews • Reference existing GEOACESS maps to analyze gaps in meeting state
standards. 2. If a provider performs below expected standards during any of the reviews listed
above a Corrective Action will be required for SBHO approval.
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Monitoring of Contractors 9.02 Page 1 of 2
Policy Name: MONITORING OF CONTRACTORS Policy Number: 9.02
Reference: 42 CFR 438.206, 207; WAC 388-865-0268; DSHS Contract
Effective Date: 8/2004
Revision Date(s): 2/2013; 4/2016; 6/2017
Reviewed Date: 4/2016; 6/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Provider and Subcontractor Administrative Review
PURPOSE
The Salish Behavioral Health Organization (SBHO) shall monitor contracted providers for compliance with contract requirements and state and federal regulations.
PROCEDURE
1. The SBHO monitors contractor compliance and performance by a variety of means
• Contractor licensing and certification is monitored during the routine SBHOadministrative reviews.
• Statistical monitoring is performed quarterly in the SBHO performance reports.• Contractor performance is compared to statewide standards on specific performance
measures.• Timely access to services is monitored through MIS data reports.• A random sample of clinical files is reviewed annually, at a minimum totaling 500
charts in a year.• A standardized clinical chart review is utilized, as well as targeted/ focused chart
reviews such as Practice Guidelines and zero PRATs.• Files are reviewed for data accuracy against the SBHO database.
Peninsula RSN Policies and Procedures
Monitoring of Contractors 9.02 Page 2 of 2
• Grievance reports are compiled quarterly and monitored for patterns of grievances that bears investigation by SBHO staff and the Quality Improvement Committee.
• SBHO monitors and oversees the agency semi-annual revenue and expense reports submitted to the SBHO.
• SBHO conducts annual delegation agreement/plan reviews.
2. The SBHO conducts regularly scheduled SBHO provider and subcontractor administrative reviews, targeting areas of trend and corrective action from previous reviews. The SBHO will:
• Deliver to the provider copies of the format of the review at the time of review, or earlier.
• Report the results of the review in writing to the provider, including areas needing improvement or other acts of non-compliance, within 30 calendar days of the completion of the review.
• Identify required redress or repair and the time limits, and the form or format or other evidence that the provider is required to submit in order to be considered compliant.
• Report to the provider the possibility of punitive response as may result from failure to comply.
MONITORING
1. This policy is a mandate by contract and statute. This policy is monitored through use of SBHO:
• Regularly scheduled SBHO Provider and Subcontractor Administrative/ Subdelegated Review
• Annual Provider Chart Reviews • Grievance Tracking Reports • Biennial Provider Quality Review Team review • Quality Management Plan activities, such as review targeted issues for trends and
recommendations. • Review of previous provider corrective action plans related to the Age and Cultural
Competence policy, including provider profiles related to performance on targeted indicators.
2. If a provider performs below expected standards during any of the reviews listed above a
Corrective Action will be required for SBHO approval. Reference 9.11 SBHO Corrective Action Plan Policy.
Salish BHO Policies and Procedures
Monitoring Table 9.02a Page 1 of 2
SBHO MONITORING TABLE FY 2017-18 Activities
Monitoring Activity SBHO Contractor Due Date
Date Activity
Completed
SBHO Provider Admin. Review True Star Annual
SBHO Provider Admin. Review KRC Annual
Grievance Tracking Reports analysis and network grievances submitted to Department SBHO July 30
SBHO Gaps Analysis SBHO
SBHO Provider Admin. Review WEOS Annual
Provider R & E Reports September
Clinical chart reviews: Network Annual
SBHO Subcontractor Admin. Review Ombuds Annual
Provider Performance Reports – (previous FY Totals) October
SBHO Provider Admin. Review BOH Annual
1st QRT On-Site Provider Review Fall
Grievance Tracking Reports analysis and network grievances submitted to Department SBHO October 31
SBHO Provider Admin. Review Cascadia Annual
Provider Performance Reports- 1st Qtr of current FY December
SBHO Provider Admin. Review Cedar Grove Annual
SBHO Provider Admin. Review OPG Annual
SBHO Provider Admin. Review KMHS Annual
Grievance Tracking Reports analysis and network grievances submitted to Department SBHO January 31
Provider R&E Reports February
SBHO Provider Admin. Review PBH Annual
Salish BHO Policies and Procedures
Monitoring Table 9.02a Page 2 of 2
SBHO Provider Admin. Review Spec. Srvcs. II Annual
SBHO Provider Admin. Review Spec. Srvcs. III Annual
Provider Performance Reports- 2nd Qtr of current FY March
2nd QRT On-Site Provider Review Spring
SBHO Provider Admin. Review WSTC Annual
Grievance Tracking Reports analysis and network grievances submitted to Department SBHO April 30
SBHO Provider Admin. Review Agape Annual
SBHO Provider Admin. Review DBH Annual
Provider Performance Reports-3rd Qtr of current FY June
Grievance Tracking Reports analysis and network grievances submitted to Department SBHO July 30
Provider Performance Reports- 4th Qtr of current FY and Yearly Totals September
QUIC Review Provider QM Plans and QA Reports Annual
SBHO Fiscal Review of each Provider Agency Annual
SBHO Subdelegated Admin. Review: ASO ASO Biennial
SBHO Subdelegated Admin. Review: KMHS IS IS Biennial
SBHO Review of E&Ts AIU & YIU Annual
SBHO Review of Residential Programs KMHS & PBH Annual
Provider Performance Reports- 4th Qtr of current FY and Yearly Totals September
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Provider – Subcontractor Administrative Review 9.03 Page 1 of 2
Policy Name: SBHO PROVIDER AND SUBCONTRACTOR ADMINISTRATIVE REVIEW Policy Number: 9.03
Reference: 42 CFR 438.230; WAC 388-865-0264, -0268
Effective Date: 8/2004
Revision Date(s): 2/2013
Reviewed Date: 4/2016; 6/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Monitoring of Contractors• Policy: Standard Chart Reviews
PURPOSE
It is the policy of the Salish Behavioral Health Organization (SBHO) to establish a standardized process for network provider and subcontractor administrative reviews. This administrative review is in addition to the existing monthly SBHO chart reviews, Quality Review Team (QRT) on-site, and other monitoring activities.
PROCEDURE
1. The SBHO Administrative Reviews will:a. Monitor the PIHP and state contracted delegated administrative activities,
as well as agency administrative activities.There is a focus to ensure recent changes to state laws (WACs and RCWs),contracts, and federal regulations are implemented.
b. Conduct routine administrative reviews of network providersc. Use measurement standards consistent with industry standards (i.e.
Corrective Action benchmarks).2. For identified area of deficiencies or areas of improvement, a final report and
corrective action plans will be required within 30 days.
Salish BHO Policies and Procedures
Provider and Subcontractor Administrative Review 9.03 Page 2 of 2
MONITORING
1. This policy is a mandated by contract or statute. This policy will be monitored through use of SBHO:
• Routine SBHO Provider and Subcontractor Administrative/ Subdelegated Review
• Review of previous provider corrective action plans related to policy, including provider profiles related to performance on targeted indicators.
2. If a provider performs below expected standards, a corrective action will be
required for SBHO approval. Reference SBHO Corrective Action Plan policy.
SBHO Administrative Review - Chart
Items
ReviewID
Reviewer
Agency
Date of Review
1. Evidence of agency purchasing
services if not able to provide
medically necessary behavioral health
services.
2. Ensure MH Intake packet or SUD
assessment process includes current
version of outpatient rights.
3. Medicaid only - Evidence of client
notified of primary clinician
terminated/no longer employed at
agency) within 15 days of separation.
4. Evidence in chart how advanced
directive information was made
available/distributed/tracked.
5. Evidence that request for second
opinion appointments occur within 30
days,when requested.
6. Evidence of choice or change of
provider is effected when requested.
7. Review process for agency securing
"restricted access" or unauthorized
access clinical charts.
8. Clients have access and right to
review clinical file and be told cost for
copying.
9. Review ROI and ROI process in client
file; request a staff member to describe
agency process.
10. Review charts for evidence of PIPs
and new program development
SBHO Administrative Review -
HIPAA/42 CFR
ReviewID. Please input the first 3 of
Agency Name and year of review (eg.
CAS2017, WES2017).
Reviewer
Agency
Date of Review
1. Provide policies and procedures that
show the agency aligns with federal regs
and SBHO policies.
2. Demonstrate that a HIPAA log exists and
that it is up-to-date.
3. Provide documentation and describe
process which demonstrates how Breach
vs Violation is determined.
4. Review agency ROI(s) for adherence to
HIPAA (and 42 CFR Part 2, if SUD).
6. Provide agency policy which identifies
permitted uses and disclosures of client
records or client information.
5. Provide information regarding methods
which would be used for any breach
notification.
7. Provide agency policies which clearly
define and identify authorized disclosures.
8. Ensure agency has a policy which
reflects that only necessary minimum
information will be disclosed.
9. Revew policy and procedure that
demonstrates the patient's right to access
their records.
10. Review policy and procedure that
demonstrates a patient's right to amend
their record.
11. Review policy and procedure that
demonstrates the patient's right to receive
an accounting of disclosures regarding
their records.
12. Provide policy and procedure which
demonstrates the patient's right to restrict
access to their records.
13. Provide policy and procedure which
demonstrates patient's right to recieve
agency's notice of privacy practices.
14. Provide visual verification that interview
rooms are secure and private.
15. Provide visual verification that the front
reception area has reminders that there is
limited or no privacy in that area.
16. Provide visual verification that
computer screen and monitors are
maintained as secure, including the use of
privacy settings.
17. Provide visual verfication of secure and
privacy log-in access, including password
management and that staff can report
clear understanding of need and use of
this practice.
18. Review agency risk assessment and
discuss with administration to ensure it is
up-to-date and has identified high,
medium, and low risks.
19. Review agency log to ensure provision
of effective risk training (this can be part of
Compliance training).
20. Observe files to ensure patient content
is in locked container - either locked files
and/or locked shred bin.
21. Observe office doors are locked or
office does not have patient content
available to unauthorized persons.
SBHO Administrative Review -
Information Systems
Review_ID. Please input value with first
3 of Agency Name and Year of
Review. (e.g. PEN2016, AGA2017)
Agency
Reviewer Date of Review
1. Provide evidence that the provider's
Disaster Plan is up to date.
2. Provide evidence that a copy of
provider's Disaster Plan is stored off-site.
3. Demonstrate Disaster Plan has been
tested.
4. Provide evidence that the provider's
Disaster Plan contains agency's mission
or scope.
5. Provide evidence that that there is
an appointed disaster recovery team.
6. Provide evidence that provider's
Disaster Plan has provisions for back-up
of key personnel.
7. Provide evidence that provider's
Disaster Plan includes identification of
emergency procedures.
8. Provide evidence that provider's
Disaster Plan contains procedures for
allowing effective communication.
20. Data on disks mounted to servers are
located in area accessible only to
authorized personnel, access by key, card
key, combination lock or comparable.
21. Paper documents stored in secured
area only accessible to authorized
persons, storedd in locked container.
22. Evidence that data stored on optical
disks will not be transported out of secured
area and must be kept in secure storage.
23. Evidence that access to State data
controlled by DSHS staff who issue
authentication credentials. Notice to DSHS
immediately when staff leaves employ or
no longer needs access.
24. Data storage on portable
media/devices transported outside
secured area - encrypt data and devices
to 128 bits.
25. Data storage on portable
media/devices transported outside
secured area - access control with
password or stronger authentication.
26. Data storage on portable
media/devices transported outside
secured area - manual locking devices
whenever left unattended; auto lock after
< 20 minutes.
27. Data storage on portable
media/devices transported outside
secured area - physical protect portable
devices/media - kept in locked storage,
using check-in, frequent inventories.
9. Provide evidence that provider's
Disaster Plan contains visibly listed
emergency telephone numbers.
10. Provide evidence that provider's
Disaster Plan contains application
inventory, e.g. Office software.
11. Provide evidence that provider's
Disaster Plan contains prioritization for
business recovery.
12. Provide evidence that provider's
Disaster Plan contains hardware and
software vendor list.
13. Provide evidence that provider's
Disaster Recovery Plan contains
confirmation of updated system and
operations documentation
14. Provide evidence that provider's
Disaster Plan contains process for
frequent backup of systems and data.
15. Provide evidence that provider's
Disaster Plan contains offsite storage of
system and data backup files.
16. Provide evidence that provider's
Disaster Recovery Plan contains
designated recovery options that may
include use of a hot or cold site.
17. Provide evidence that provider's
Disaster Recovery Plan contains
evidence that disaster recovery tests
have been performed.
28. Evidence that devices/media with
DSHS data must be in physical control of
authorized agency staff.
29. Evidence that DSHS data not stored on
any portable devices or media unless
specifically authorized.
30. Evidence that DSHS data may be
stored on portable media as part of
contractor's existing documnted bakc
process for business continuity/disaster
31. Evidence that DSHS data may be
stored on non-portable media as part of
contractor's existing documented bakup
processes for business continutity or
disaster recovery. If backup media retired
while containing DSHS information media
will be destroyed.
32. Evidence that DSHS data is
segregated/distinguishable from non-DSHS
data. Includes procedures for data
storage on media, in logical container,
within shared database, and paper
documents.
33. Evidence that media stored on server
or workstation hard disks or removable
media is disposed using wipe utiltiy,
degaussing, and/or physical destruction.
34. Evidence that paper documents with
sensitive or confential information is
disposed by recycling through a
contracting firm or onsite shredding,
pubping or incineration.
35. Evidence that optical discs are
disposed by incineration, shredding, or
defacing readable surface with a coarse
abrasive.
36. Evidence that magnetic tape is
disposed by degaussing, incinerating,
orcrosscut shredding.
18. Data stored on local stations hard
disks have restricted access to
authorized users, requiring unique user
IDs and hardened passwords.
19. Data stored have restricted access
using control lists using unique user ID
and hardened password.
37. Provider sends timely certifications that
attest, based on best knowledge,
information and belief, to the accuracy,
completeness and truthfulness of the
information and/or data.
Personnel
Agency Name
SBHO Staff Reviewer
1. Ensure number of qualified agency personnel, age
appropriate, sufficent number, and access/travel standards.
Measure - Review caseload numbers, availability to specialists,
and travel standards.
2. Verify primary source verification for education and
credentials (state slicensure can substitute primary source
documents). Measure - Reandom review of 10% of personnel
files of recently hired staff for primary source verification check.
(See Personnel checklist).
3. Random sample review of agency employee files for training
and evaluation plans. Measure - Random review of 10% of
recently hired staff (See Personnel checklist).
4. Signed statements are maintained on file acknowledging
understanding and agreement to abide by HIPAA
requirements. Measure - Random review of 10% of recently
hired staff (see Personnel checklist).
5. Agency staff have received annual HIPAA training. New staff
receive training within 30 days of start date. Measure - Random
review of 10% of recently hired staff (see Personnel checklist).
6. Verify Medicaid fraud and abuse training. Measure - Random
review of 10% of recently hired staff (see Personnel checklist).
7. Verify Safety and Violence Prevention training occurs
annually. Measure - Random review of 10% of recently hired
staff DMHPs (see Personnel checklist).
Review ID: AGA2017
BEA2017
8. DMHPs only: Evidence of deputized date for recently hired
(previous 12 months) DMHPs. Measure - 100% review of all
recently hired DMHPs (see Personnel checklist).
10. Random sample of Exit Interviews from recently departed
staff (within the past 12 months). Measure - Random review Exit
Interviews for trends.
11. Verify Agency provides Cultural Diversity training twice a
year to staff. Measure - Random review of 10% of recently hired
staff (see Personnel Records Checklist).
9. Verify no Physician Incentive Plan(s). Measure - Random
Review
SBHO Administrative Review -
Personnel Records Checklist
ReviewID. Please input value with first 3 of Agency Name and
Year of Review. (e.g. PEN2016, AGA2017)
Agency Staff Name
Date of Review
Agency
Staff Name
Position
Medicaid Fraud and Abuse Training
HIPPA training within first 30 days of hire
Signed HIPPA statement
WSP or other background check
Board Certification, state licesnure, or agency affiliated
School training certificate/Specialists Training log
Current Training Plan
Current Evaluation Plan
Attended annual safety and violence prevention training
SUD - Blood Born Pathogen Training
Evidence of date deputized
SUD - TB Test on file
SUD - Control of disease
Cultural Diverstiy Training provided twice a year
Evidence that personnel file contain signed attestation to abide
by Code of Conduct
SBHO Administrative Review -
Program Integrity
Reviewer
Agency
2. Demonstrate policy and procedures
that providers follow for reports of
allegations of Medicaid Fraud or Abuse
from agency/staff in the past 12 months in
log.
3. Review policy and procedure, as well as
observe evidence that ensure Federal
Exclusion website searches are conducted
upon hire, continue every month following
(inclucing view ongoing files which can be
paper or electronic).
4. Ensure monthly Federal Exclusion
attestations are submitted in a timely
manner.
5. Evidence provided that provider has
maintained a current list of management
staff that includes name, DOB, and SS
number.
6. Provider has mechanism that if an
employee or subcontractor is found to
have a conviction or sanction or found to
be under investigation for criminal offense
related to healthcare are to be removed
from direct responsibility for, or
involvement with the Salish BHO/PIHP
funded services.
22. Provide evidence that provider is in
compliance with non-discrimination policies
(such as Title IV or the Civil Rights Act of 1964,
Age Discrimination Act of 1965, Rehabilitation
Act of 1973, Title II and II of American with
Disabilities Act) and DSHS Administrative
policies.
23. Agency has been responsive to SBHO
CAP requests - e.g. Admin Rev, chart
reviews, UMC, Fiscal audit, QUIC.
24. Provide evidence of policy which
ensures enrollee is notified of changes in
state law related to direct services.
25. Agency is able demonstrate how they
identify/confirm payer at time of service.
26. Provide evidence that agency
policies, procedures, and form
demonstrate an effort to ensure sliding fee
scale payments.
27. Provide evidence that policy and
procedure regarding all non-Medicaid
individuals seeking services are assisted
with accessing Medicaid to determine if
they qualify for that program.
1. Provide evidence that provider has
current Medicaid Fraud Abuse (MFA) Plan.
Comply with SBHO Medicaid Fraud and
Abuse Plan. Measure - Review agency
plan for updates, such as SBHO
Compliance Committee participation, risk
assessment, method of reviewing
subcontractors.
Review ID: AGA2017
14. Observe and verify accurate method
of exclusion check.
7. Provide evidence of provider's
Compliance Committee meetings and
available trainings to staff. Measure -
Review of agency Compliance
Committee meeting notes and training
logs.
15. Ensure agency administration is familiar
with CLAS (HHS website) expectations.
8. Review of agency cultural diversity
goals and how the goals are assessed.
9. Provide evidence of provider's
participation in SBHO Compliance
Committee.
10. Provide evidence of Compliance
training, e.g. listed in training log. Training
must occur at least annually.
11. Provide evidence of Agency Code of
Conduct. Ensure content adhere's to
SBHO Code of Conduct content.
12. Ensure agency has an identifed
Compliance Officer.
13. Provide evidence that provider has
adequate retention policy, in line with
SBHO policy and contract.
16. Provide evidence that ensures staff is
aware of types of disasters/emergencies
and what agency protocols are in the
event of such.
17. Ensure emergency exit routes are
posted.
28. Medicaid clients only: Provide
evidence of policy that client receives
notification (within 15 days) that primary
clinician is no longer working there, e.g.
terminated.
29. Medicaid client only: Ensure there is
policy procedure that allows agency
clinician to advocate for Medicaid clients
so that they are not denied, limited, or
discontinued medically necessary
behavioral health services.
30. Demonstrate agency has effective
Critical Incident Policy.
31. Review Critical Incident Log for
adequate content and process.
32. Ensure there is a designated person(s)
to process/log all critical incidents.
33. Review smoking Policy - in light with
WAC 388-877-0420(16) 388-877-020(12).
34. Identify all, if any, civil monetary
penalties and assessments of vendors,
providers, or subcontractors.
35. Review provider safety policy and
ensure it includes adequate safety, e.g.
Marty Smith safety outreach protocols.
36. After review of broad spectrum of policies
and procedures - clear evidence is present off
current practice/acronyms and review dates in
policies.
37. Medicaid clients - Review Policy to
ensure second opinions occur within 30
days, when requested. Non-Medicaid - as
resources available.
38. Provide evidence that policy and
procedure ensures client choice and
change of providers is done, when
requested.
18. Provider is able to demonstrate
agency alternative communication
methods for persons with visual or hearing
impairment or limitation.
19. Provider is able to
demonstrate/describe plan to evacuate
all persons, including person with mobility
impairment and children if child care
offered.
20. Provide evidence of policy to ensure
emergency phone access when power
outage and/or phone service is out.
21. Overall review of policies and
procedures shows compliance with all
applicable state and federal laws.
39. Provide evidence that agency
policy/procedure includes securing
"restricted access" of clinical charts.
40. Provide evidence of provider policy
regarding client right to have access and
review their clinical file.
41. Review ROI Policy to ensure
appropriate procedure how disclosure is
processed.
42. Provide evidence of policy reflecting
compliance with SBHO Seclusion and
Restraint policy; Also evidence in incident
reports.
SBHO Administrative Review - Quality
Assurance
Review ID. Please input as first 3
of Agency Name and Year (eg.
KIT2017, OLY2017)
Reviewer
Agency
Date of Review
1. Provide evidence of an
existing Quality Management
Plan.
2. Provide evidence that the
provider is actively
implementing their Quality
Managaement Plan.
3. Ensure evidence that
provider participates in the
SBHO Quality Improvement
Committee.
4. Provide evidence that
services are offered/provided
to improve the treatment of
consumers regarding the
quality of intake evaluations.
5. Provide evidence that
services are offered/provided
to improve treatment of
consumers regarding
effectiveness of prescription
medications.
6. Review of policy/procedure
which reflects - training plans,
who funds trainings, required
trainings, and frequency.
14. Provide evidence of agency
policy/procedure which reflects the
enrollee's rights during the grievance
process.
15. Provide evidence of agency
policy showing what is applicable
content in written notices involved in
the grievance process.
16. Provide evidence of agency
policy which reflects that record
retention of grievances is 10 years.
17. Provide evidence of agency
policy/procedure which outlines the
appeal process and timelines.
18. Provide evidence of agency
policy/procedure which outlines
requirements and process of Adverse
Benefit Determinations.
19. Provide evidence of adequate
policy/procedure regarding rights and
process for administrative hearings.
7. Provide agency
policy/procedure which
reflects adequate clinical
supervision (at least annually.
8. Provide policy/procedure
which reflects credential
requirments and prohibits staff
from providing clinical services
if not adequately credentialed.
9. Demonstrate that the
agency collects, maintains,
and uses information to correct
deficiencies and improve
services, including sentinel
events.
10. Provide evidence that
agency has and uses a clear
definition of grievance which
aligns with the WAC grievance
definition.
11. Provide clearly written
policy showing enrollee rights
which align with WAC enrollee
rights.
12. Provide evidence that
clients are informed of Ombuds
services, including contact
information given to client.
13. Provide evidence of
agency policy/procedure
which reflects who and when a
grievance may be filed with
agency or SBHO.
20. Provide evidence of accurate and
substantive policy/procedure which
outlines process for grievance
reporting. Include who, what, when,
where.
21. Provide evidence of ongoing data
collection by the agency. Data is
actively used to discern objective
measures aimed at examining clinical
services.
22. Provide evidence that the agency
has valid method to identify areas
warranting improvement.
23. Provide evidence of that agency is
implementing plans to improve areas
identified as warranting improvement.
24. Provide evidence that agency
culture includes consumer choice and
participation in Quality Management.
25. Provide evidence that family and
other natural supports identified by
enrollee are a part of the enrollee's
evaluation and treatment process.
Walk-throughSBHO Administrative Review -
ReviewID.
Reviewer
Agency
Date of Review
1. Evidence of brochures/flyer in
reception/main lobby, treatment
rooms, satellite sites.
2. Evidence of Point to your Language
sign in lobby/reception.
3. Evidence of Posted Advanced
Directives in reception/lobby -
brochure.
4. Evidence of posted enrollee rights in
all prevalent languages in public
areas.
5. Evidence of SBHO Member
handbook or agency comparable
information sheet explaining all
benefits for enrollee.
6. Evidence of DSHS Benefits Booklet
available in conspicuous areas of
agency.
7. Agency staff can explain process
when an individual requests to review
their own medical record.
8. Confirm by observing - agency has
all necessary licnses, cerfications
and/or permits as required by law.
9. Observe Medicaid Fraud Control
Unit Hotline Reporting Flyer in common
Staff area.
10. In ET - Observe posted client rights.
11. In ET - Observe HIPAA privacy
practices - private interview rooms,
privacy screens, locked files/doors.
12. In ET - Observe Ombuds
brochures/flyers in client areas.
13. In ET - Observe inpatient policy
regarding security and safety.
14. Observe agency call logs which
contains date and type of call (e.g.
grievance, information,requesting
services) and date of attempted
resolution.
15. Evidence of log for use of
interpreters.
16. Observe layout to determine ADA
accessibility; consider ADA checklist
completed by agency.
17. www.ada.gov/racheck.pdf - Ensure
ADA assessment is done.
FY 2017 BRIDGES Ombuds Program
SBHO Administrative Review Tool Date:
Conducted by: Scoring range: 1-absent, 2-partially developed, 3-evidence of full compliance
# ITEM SCORE COMMENTS
1. Administrative Services
a Ombuds program Information is made available Measure- Review marketing/informational materials.
b Comply with SBHO Fraud and Abuse Plan Measure– Review staff training to identify and report possible fraud/abuse.
c Provide evidence of Code of Conduct. Ensure elements adhere to SBHO Code of Conduct content.
d Identify all, if any, civil monetary penalties and assessments of vendors, subcontractors.
e Advanced Directives written information is provided and available (42 CFR 438.6.i.3, SBHO Rights) Measure- Review written information
f Programs comply with all applicable state and federal laws. Measure – Audit contract compliance and review policies and procedures.
g ADA self-assessment of building completed Measure- ADA self- assessment tool completed
h Programs submit required SBHO reports in a timely manner. Measure- Submission of monthly program activity, quarterly concerns and bi-
annual Exhibit N reports 2. General Services
a Maintain confidentiality. Measure- Review Ombuds case records, documentation, and verify ROIs
b Direct concerns through formal and informal channels for grievances Measure- Review staff training records. Review records for compliance with
SBHO Grievance policy. Protocol for addressing client dissatisfaction with Ombuds services.
c Remain accessible to consumers, including a toll free phone number. Measure- Verify toll free number and accessible
FY 2017 # ITEM SCORE COMMENTS
d Receive and investigate concerns at the request of an individual. Measure- Review call log, ROI process, and investigation process
e Assist in conflict resolution to resolve concerns and grievances at the lowest/ most local level. Measure- Ombuds Manual for Investigation and Resolution P&P, review
informal grievance process
f Assist and advocate for clients and family members in voicing concerns/ grievances with the provider, SBHO, or DSHS (DBHR). Measure- Review case notes
g Responds to issues of concerns in a timely manner; close cases in a timely manner. Measure- Review logs for response times, Exhibit N for closed cases status.
h Tracks data and trends regarding dignity and respect issues Measure- Review data collections and tracking trends
i Review agency cultural diversity goals and how the goals are assessed. Is agency administration familiar with CLAS (HHS website) expectations.
j Actively outreaches to consumers and family members to inform them of services and provide assistance with issues of dissatisfaction. Measure- Review outreach activities, how services are publicized
k Coordinates and collaborates with allied system advocacy and Ombuds services to improve the effectiveness of advocacy and to reduce duplication of efforts for shared clients (WAC) Measure- Review case examples
l Refer matters to mediation, when possible and appropriate. Measure- Review case record that was referred to mediation services.
3. Quality Assurance Activities
a
Participate on the SBHO Quality Improvement Committee, Quality Review Team activities, and monthly SBHO Advisory Board meetings. Make recommendations to improve the quality of services provided through the network, based on investigation and reporting trends. Measure- Review participation in QUIC and QRT
b
Program improvements. Efforts to target and improve BRIDGES program services or areas needing improvement. Able to demonstrate steps to address issue(s). Measure- Review staff meeting notes or other documentation
FY 2017
# ITEM SCORE COMMENTS
4. Enrollee Rights
a Posted general enrollee rights in all prevalent languages. Measure- Has rights available in prevalent languages.
b Ombuds is aware of client rights regarding a second opinion. Measure- Staff interview
c Ombuds is aware of a client’s rights regarding choice and change of providers. Measure- Staff interview
5. Utilization and Resource Management a Demonstrate understanding of authorization requirements and process.
Measure- Staff interview
b Demonstrate knowledge of appeal process for clients when services have been denied or reduced. Measure- Staff interview.
6. Personnel a Ensure number of qualified staff to provide age and culturally appropriate
services. Measure - Review monthly activity reports for program.
b Ombuds staff have not been employed by a service provider two years previous to hire, unless with SBHO notification or DSHS approval Measure – Personnel records.
c Review of agency employee files for supervision, training, and/or evaluation plans Measure- Review all personnel files for evidence of training (state
sponsored Peer Support or BHC, ect) documents, evaluation plans, and supervision logs.
d Review of Exit Interviews from recently departed staff (within the past 12 months) Measure- Review Exit Interviews if applicable.
e Signed statements are maintained on file acknowledging understanding and agreement to abide by HIPAA requirements. Measure – Review all personnel files, HIPAA training
f Staff interviews (see staff interview questions) Measure- Conduct Staff interview(s)
FY 2017
Staff Interview Questions
Staff interviewed: ________________________________________________
1. True or False. An individual can request a Fair Hearing, prior to exhausting the local Grievance process.
2. Do you know how to access Interpreters/ Hearing Impaired services, if they were needed for a
client requesting your services?
3. True or False. A client with special health care needs shall have unencumbered access to a MHP.
4. If a client or family member requested a second opinion, what are the next steps?
a. For an intake assessment b. Regarding diagnosis or treatment strategy
5. If a client requested a change of providers, what are the guidelines (timeframes) listed on the
SBHO Client Rights form?
6. Are you aware of your roles, responsibilities, and communication channels when you are concerned of agency or staff Medicaid Fraud and Abuse?
7. Please give an example of when you had the opportunity to advocate for a client so that they
were not denied, limited, or discontinued medically necessary behavioral health services? 8. Please explain the Ombuds role in the appeal process for a client whose behavioral health
services have been denied or reduced.
9. From your perspective, what are the top three behavioral health service delivery issues most commonly addressed through the Ombuds program?
10. Please provide the SBHO feedback about how our office could assist in the quality improvement of services provided through the Ombuds program?
11. What is the approximate time between when records are requested by a provider (Profiler) and
when records are received?
# Scoring Source Monitoring Process
Manual – Pg. 11EMR, Intake Assessment,
Client Info
WAC 388‐877A‐0130
Salish Behavioral Health Organziation WISe Review Tool
Assess/Engagement
Criteria
1WISe Manual Sec. 3, Pg.
10
2 WAC 388‐877A‐0130
Met, Not Met, N/A
Met, Not Met, N/A
6WISe Manual Assessing
Phase, Pg. 16
3
4WISe Manual Sec. 2 &3,
Pg 8, 10
5WISe Manual Sec. 2, Pg.
8
Met, Not Met, N/A
Met, Not Met, N/A
Met, Not Met, N/A
Met, Not Met, N/A
There is a CANS screen documenting eligibility for WISe services by someone certified in performing CANS screens and assessments and completed within 10 days of the request, documenting eligibility.
An intake assessment is available in the record and was completed by a mental health professional.
There is documentation that the individual met Access to Care Standards.
A full CANS assessment was completed within 30 days of the WISe screen (enrollment into WISe)
A full CANS Assessment was completed every 90 days after the initial Full CANS Assessment.
A Family Narrative has been completed
EMR, OP Reviews
EMR, OP Reviews, Client Info.
EMR, Client Info, BHAS reporting &/or WISe
reviewsEMR, Client Info, WISE
reviewsEMR, WISe team
reviews, Supervisor review
# Scoring Source Monitoring Process
WISe Manual Sec. 4, Pgs. WAC 388‐877A‐0135
Y/N Family Vision Statement Y/N Team Mission Statement Y/N Useful Strengths (CANS) Y/N Additional Strengths (Team) Y/N Background Needs (CANS) Y/N Targeted Needs (CANS) Y/N Needs Statements (Team) Y/N Anticipated Outcomes (CANS) Y/N Targeted Outcome Statements (Team) Y/N Strategies and Interventions (Team) Y/N Useful Strengths Activities (Team) Y/N Action Steps for Team Members (Team) Y/N Strengths to Build (CANS) Y/N Strengths Building Activities (Team)
7WISe Manual Sec. 4, PG.
3, 8
Met, Not Met, N/A
Met, Not Met, N/A
Met, Not Met, N/A
Cross System Care Plan (CSCP)/Individual Service Plan (ISP)
Safety/Crisis Plan was completed and a copy was given to the youth and family
The Cross System Plan includes the following:
Criteria
11
EMR, WISe review, CSCP, Scanned documentsEMR, CFT, ISP, Note review, WISE review
EMR, CFT Notes, ISP and Scanned Documents; WISe Clinical Team
Review
EMR, Incidental Notes, WISe review
There is evidence of family and youth voice in the Cross System Planning. Are there signatures and evidence a dopy of the CSCP and all revisions were given to family? Quotes? Verbiage for the youth and family? The Cross System Plan incorporates the Individual Service Plan (ISP) or there is a separate ISP in the chart. It was competed with 30 days after the first routine appointment.
8
9WISe Manual Sec. 4, Pgs. 8, 55; WAC 388‐877A‐
0350 5 (B) & (vi)
10WISe Manual Sec. 2 & 4, Pg. 8, 21‐22; WAC 388‐
Met, Not Met, N/A
WAC 388 877A 0350 5(A)EMR, Incidental Notes,
WISe reviewA complete list of participants and their contact information is included in Cross Systems Planning and is documented. Met, Not Met, N/A
# Scoring Source Monitoring Process
WISe Manual Sec. 2, Pg. 8,
WAC 388‐877‐0620
Y/N Evaluates progress towards meeting needs and the effectiveness of indicated strategies.
Y/N The CFT adjusts strategies to meet changes in the needs and outcomes, creating the most effective mix of services and supports.
Y/N The CFT evaluates whether there is progress towards the designated outcomes. The team adjusts the outcomes to guide next steps.
Y/N The CFT adds members and strives to create a mix of formal, informal and natural supports. Y/N The CFT acknowledges successes and adds to strengths as they are identified.
14WISe Manual Sec. 4, Pg.
14, 36
15WISe Manual Sec. 2, Pg.
7
12WISe Manual Sec. 2, Pg.
8, 17, 19
13WISe Manual Sec. 2 & 4,
Pg. 8, 17, 19
16
17WISe Manual Sec. 4 & Appendix C, Pg. 17, 42
18WISe Manual Appendix C
& H, Pg. 42‐45, 55 Met, Not Met, N/A
21 WAC 388‐877‐0640
Met, Not Met, N/A
Met, Not Met, N/A
Met, Not Met, N/A
19WISe Manual Sec. 4 & Appendix C, Pg. 22, 23,
44
20WISe Manual Sec. 2 &3,
Pg. 3, 5, 13,
Met, Not Met, N/A
Met, Not Met, N/A
There is documentation of transition planning within the CFT meetings to address successful transition away from formal supports as informal supports are in place and providing needed support. Evidence is found in CFT meeting notes, CSCP and Crisis plan.
Services are provided in the location preferred by the youth and/or family. Evidence of this will be demonstrated in regular participation and meeting notes.
Child and Family Teams (CFTs)
The chart includes all necessary releases of information
CFT notes include a list of attendees. (Attendees are those invited as preferred by the youth and family and as indicated on the CANS assessment and intake assessment as relevant to the youth and family.
CFTs are facilitated by a WISe trained Care Coordinator, who typically facilitates and coordinates services and supports.
Notes document that the family and youth were offered the support of a Peer Certified Youth and/or Family Partner.
Documentation that CFT meeting notes were shared with all members of the CFT within a week of each meeting.
CFTs include the youth, parents/caregivers, relevant family members, and natural and community supports as identified in # 10 or address why they were not present.
CFT notes indicate CFTs occurred at least every 30 days
Criteria
EMR, CFT Meeting Minutes, WISe reviews,
Incidental Documentation
Met, Not Met, N/A
The CFT: (Evidence should be found in updated Cross System Care Plan and meeting notes)
Met, Not Met, N/A
Met, Not Met, N/A
Met, Not Met, N/A
Date:
Reviewer:
Provider:
Client Name:
Client ID:
Adult or Child:
Diagnosis:
Systems Present or Involved:
Comments(Improvements Discussed, themes, Strengths in care, Notable
Outcomes, etc .)
Coordination of Care:
Appropriate involvment of Natural Supports?
Appropriate Coordination of Systems?
Strengths and Recovery:
Strengths noted and incorporated in treatment?
Treatment team includes voice of Client/parents/caregiver?
Treatment Effectiveness
Treatment approach is appropriate and reflects clincially sound methods?
Utilization
Client assignment consistent with Level of Care guidelines?
Service Intensity appropriate for needs of client?
SBHO Resource Management Review of Care
Comments:
Review Period
Reviewer
Provider
Client ID
Date of Service
Documentation includes source of referral/identity of caller. 0 #DIV/0!
Documentation includes nature of the crisis. 0 #DIV/0!
Documentation includes the outcome including, basis for decision to not respond in person, follow-up contacts made,
referrals made.0 #DIV/0!
If the consumer has an Advance Directive, it is followed as nearly as possible considering the circumstances.
0 #DIV/0!
Did follow-up services recommended by the crisis worker/DMHP occur as evidenced by documentation?
0 #DIV/0!
The outcome of the intervention/crisis response is clearly documented.
0 #DIV/0!
Evidence of collaboration with consumer and others identified by the consumer as needed.
0 #DIV/0!
Is there appropriate referral/coordination with other systems/settings?
0 #DIV/0!
There is a written plan delineating how to resolve the crisis if the client was not hospitalized. N//A if person was
hospitalized.0 #DIV/0!
Were safety needs and risk factors adequately addressed? 0 #DIV/0!
Were services provided in the least restrictive setting? 0 #DIV/0!
Clinical Record (All Face to Face Reviews)
SBHO Review Tool: Crisis Services
Documentation for Phone Call Only Crisis Contacts
Children only: If NOT detained: o Documentation that a minor’s parent (if child age 13-17) was informed of the right
to request a court review of the decision not to detain.0 #DIV/0!
Was the person detained or hospitalized voluntarily, or was an LRA revoked?
#DIV/0!
Is the presence of a mental disorder adequately justified? 0 #DIV/0!
Is the cause for detention/hospitalization adequately identified?
0 #DIV/0!
Less restrictive alternatives were adequately investigated and documented.
0 #DIV/0!
Contact with the liaison or hospital treatment team occurs within three working days of an enrolled consumer’s
admission to the hospital. Contact must include a provisional placement plan for the enrollee to return to the community that can be implemented when the enrollee is
determined to be ready for discharge.
0 #DIV/0!
There was a non crisis contact within 7 days of discharge and there was an effort to ensure a medication appointment
within 30 days of discharge. 0 #DIV/0!
Were services between hospitalizations adequate to the person's needs?
0 #DIV/0!
Did the person have a follow-up medication management appointment?
0 #DIV/0!
The person has a crisis plan (2 if yes, 0 if person meets SBHO criteria for crisis plan requirements but does not have
one. Otherwise, N/A)0 #DIV/0!
N/A if not present. If present, does the crisis plan describe interventions that include resources of 1) the individual (such as coping skills), 2) natural supports (i.e. friends
family,neighbors), and 3) institutional/systems (i.e. calling crisis clinic) as appropriate?
0 #DIV/0!
If the client has a crisis plan, is there evidence it was utilized?
0 #DIV/0!
Additional Questions (High Utilizer Reviews Only)
Inpatient Justification and Follow-up (Inpatient Reviews Only)
Have intensive community based treatment modalities been fully exhausted?(i.e. wraparound, PACT)
0 #DIV/0!
Comments:
Date of Review
Reviewer
Provider
Client ID
Admit Date
Actual ScorePossible
ScorePercentage Comments
The consumer received a medical evaluation within 24 hours of admit (licensed physician, ARNP, PA-
C). WAC 388-865-0541 (2)0 #DIV/0! Progress Notes/H&P
There is a psychosocial evaluation by a MHP WAC 388-865-0541 (2)
0 #DIV/0! Progress Notes/H&P
There is an initial treatment plan WAC 388-865-0541 (2)
0 #DIV/0!
For inpatient treatment plan you have to go to the drop down menu at the bottom where it says Cost Ctr. Loc. Click on inpt KMHS,
then cklick on profile of treatment plan
There is an admission diagnosis and information that the diagnosis was based upon. WAC 388-865-
0541 (2)0 #DIV/0! Progress Notes/H&P
Authorization from a physician was obtained within 1 hour of initiating seclusion or restraint. WAC 388-
865-0545 (1)0 #DIV/0!
This is documented on the seclusion and restraint forms which are scanned into the
file. They will be in attachments.
The consumer was informed of the reasons for use of seclusion or restraint and the specific behaviors which must be exhibited in order to gain release from these procedures. WAC 388-865-0545 (2)
0 #DIV/0! same as above
There is documentation of staff observation of the consumer at least every fifteen minutes and
observation recorded in the consumer's clinical record. WAC 388-865-0545 (3)
0 #DIV/0! same as above
If the use of restraint or seclusion exceeds twenty-four hours, a licensed physician assessed the
consumer and write a new order if the intervention will be continued. This procedure is repeated again
for each twenty-four hour period that restraint or seclusion is used. WAC 388-865-0545 (4)
0 #DIV/0! same as above
All assessments and justification for the use of seclusion or restraint are documented in the
consumer's medical record. WAC 388-865-0545 (5)0 #DIV/0! same as above
SBHO E&T Chart Review Tool
E&T Admission and Intake
Adult Seclusion and Restraint (complete only if there was an episode of seclusion or restraint)
Authorization from a physician was obtained within 1 hour of initiating seclusion or restraint. WAC 388-
865-0546 (1)0 #DIV/0! same as above
The child was not restrained or secluded for a period in excess of two hours without having been
evaluated by a mental health professional. The child was directly observed every fifteen minutes and the
observation recorded in the consumer's clinical record. WAC 388-865-0546 (2)
0 #DIV/0! same as above
If the restraint or seclusion exceeded twenty-four hours, the consumer was examined by a licensed
physician. The facts determined by his or her examination and any resultant decision to continue restraint or seclusion over twenty-four hours was
recorded in the consumer's clinical record over the signature of the authorizing physician. This
procedure must be repeated for each subsequent twenty-four hour period of restraint or seclusion.
WAC 388-865-0546 (3)
0 #DIV/0! same as above
There is evidence the plan was developed collaboratively with the consumer (consider if client
is voluntary/involuntary). 388-865-0547 (2)0 #DIV/0!
There is a discharge plan including plan for follow-up where appropriate. 388-865-0547 (4)
0 #DIV/0! Attachment
There is documentation of the course of treatment. 388-865-0547 (5)
0 #DIV/0!
Progress Notes (Contains Med Provider and Group Notes); Reports: Inpatient MHP
Daily Note, YIU/AIU Shift Note Report, YIU/AIU Inpatient Nursing Daily Note
Involuntary Consumers: There is documentation of daily contact with a MHP for the purpose of
observation, evaluation, release from involuntary commitment to accept voluntary treatment, and discharge from the facility to accept voluntary
treatment upon referral. 388-865-0547 (6)
0 #DIV/0!
Inpatient MHP Daily Note (called "IMHP") or for weekends the nursing note in the
regular progress note report has an MHP note at the end.
Children: Seclusion and Restraint (complete only if there was an episode of seclusion or restraint)
E&T Documentation and Treatment Planning
Med Rights: (a) The prescriber attempted to obtain informed consent for medications. 388-865-0570 (1)
0 #DIV/0! In dr's prog note or attached form.
(b) The consumer was asked if he or she wishes to decline treatment during the twenty-four hour period prior to any court proceeding wherein the consumer has the right to attend and is related to his or her continued treatment. 388-865-0570 (1)
0 #DIV/0! Attachment "24HR"
(c) Of the reasons why any anti-psychotic medication is administered over the consumer's objection or lack of consent. 388-865-0570 (1)
0 #DIV/0! Proress Notes/Med Provider
If the physician administered anti-psychotic medications over a consumer's objections or lack of consent all of the following were present: A second opinion is documented OR, an emergency existed requiring the involuntary medication (likelihood or
hard to self/others, AND no alternative to anti-psychotic medications). 388-865-0570 (2)
0 #DIV/0! Proress Notes/Med Provider
Is there documentation that a Children's MH Specialist evaluated the child within 24 hours of
admit? WAC 388-865-0575 (3)0 #DIV/0! MHP progress note in reports
If child was voluntarily admitted without parent consent, the parent is notified within 24 hours of
admit. WAC 388-865-0575 (8)0 #DIV/0! Same as above
The child was evaluated by the facility, including the need for CD treatment, need for restricting the right to communicate with parents. WAC 388-865-0575
(10)
0 #DIV/0! Progress Notes/H&P
The child was advised of their rights in accordance with RCW 71.34. WAC 388-865-0575 (10)
0 #DIV/0! Attachment
Information concerning treatment of the child was only disclosed only in accordance with RCW
71.34.340 WAC 388-865-0575 (16)0 #DIV/0! Attachment
Consumer Rights and Medication Rights
Children: Special Considerations
Comments:
Review Period
Reviewer
Provider
Client ID
Date of Service
ScorePossible Points
Percentage Comments
The intake includes the presenting problems as described by the individual and others providing
support to the individual, with consent if age13 or older (under age 12 with agency discretion).
0 #DIV/0!
There is sufficient information to demonstrate medical necessity.
0 #VALUE!
The intake includes sufficient clinical information to justify the provisional diagnosis using diagnostic and
statistical manual (DSM) criteria.0 #VALUE!
The intake includes a recommendation of a course of treatment.
0 #DIV/0!
The intake includes input from people who provide active support to the individual, if the individual so
requests, or if the individual is under thirteen years of age.
0 #DIV/0!
The intake is culturally and age relevant. 0 #VALUE!
Children only: The intake contains a devlopmental history.
0 #DIV/0!
The intake includes the current physical health status, including any medications the individual is taking.
0 #DIV/0!
If the individual does not have a PCP, they are referred to one. If there is a PCP, the name is
documented. 0 #VALUE!
The intake documents history of substance abuse (including tobacco) or problem gambling and
treatment.0 #DIV/0!
The intake documents any previously accessed inpatient or outpatient services and/or medications to
treat a mental health condition.0 #DIV/0!
The intake indicates whether they are under the supervision of the department of corrections.
0 #VALUE!
SBHO Review Tool: Intake
Intake Report
There is an identification of risk of harm to self and others, including suicide/homicide and referral to crisis
services if appropriate. 0 #VALUE!
The plan was initiated with at least one goal identified by the individual, or their parent or other legal representative if applicable, at the first session
following the intake evaluation.
0 #DIV/0! First goal may be in prog note instead.
The full plan must was developed within thirty days from the first session following the intake evaluation.
0 #DIV/0!
Date of Request for Services
Date of Intake
Days Between Request and Intake 0
Date of First Routine service
Days Between Request and First Routine Service 0
The first service occurred within 28 days.
If routine service did not occur within 28 days there is adequate documentation explaining why (0, 2, or n/a).
0 #DIV/0!
If the client did not receive a first routine appointment within 28 days, engagement efforts were adequate
and appropriate to the Consumer0 #DIV/0!
A specialist consultation was completed when required:
1. Ethnic Minorities: In all cases. 2. Children: In all cases.
3. Geriatric: When clinically indicated. 4. Developmental Disability: In all cases.
Treatment Plan Report/DLA-20 Report
Progress Notes Report
If the current PRAT is an initial one completed upon client enrollment, rate this item. Assigned
Level is appropriate for client’s diagnosis, GAF/CGAS score (intakes prior to 10/1/15), symptomatology, and
service needs and adheres to the guidelines in the current PRSN's Levels of Care.
0 #VALUE!
Evidence that facilitation of EPSDT services occurred for all children (0-21) adhering to the periodicity schedule, while brokering with multiple system providers to meet the identified needs of the
child/family.
0 #DIV/0!
Documentation exists that demonstrates communication with referral source (EPSDT medical
provider), specifically written notice provided that includes at minimum: date of intake, diagnosis and
level of care assignment.
0 #VALUE!
Written notification to child’s medical provider (for children referred without EPSDT) requesting that documentation be provided that a Healthy Child
screening has been completed or that one will occur. NA if client does not have a PCP.
0 #VALUE!
If no medical care provider is identified by enrollee, then a copy of EPSDT rights contained in the MHD
benefits booklet is provided as well as assistance with selection/accessing of medical provider. NA if client
has PCP.
0 #VALUE!
Develop an Individual Service Team (IST) including identified formal systems and natural supports for
children authorized for Level II services and involved in two or more service systems (cross-system
involved.)
0 #VALUE!
There is a cross-system Individual Service Plan (ISP) which addresses overall needs of both the child and family across life domains for cross-system Level II
clients.
0 #VALUE!
Either the individual service plan or a separate plan specifically addresses the conditions of the LRA order
and plan for transition to voluntary treatment. 0 #VALUE!
Consumer has signed LRA rights. 0 #VALUE!
PRAT Report
EPSDT (Complete this section if client is under age 21)
Community Support (LRA) Scores (Only Consumers on LRAs)
If the consumer is on a 90-day or a 180-day LRA, the consumer has been evaluated monthly by an MHP
with regard to release from or continuation of an involuntary treatment order.
0 #VALUE!
If the consumer is on an LRA they receive receives psychiatric medication services at least once ever
seven days for the first 14 days following discharge from the inpatient facility, unless the attending
physician determines another schedule is more appropriate and documents this in the record and at least once every 30 days after that (unless otherwise
changed by the prescriber).
0 #DIV/0!
Other Comments:
Review Period
Reviewer
Review Type: Bipolar/Schizophrenia
Provider
Client ID
Diagnosis(es)
ScorePossible Points
Percentage Comments
If the client has a MH diagnosis in addition to Bipolar Disorder is there evidence that condition is being
addressed or treated (e.g. goal on tx plan, involved in COD tx, etc.) Not applicable if client has no MH
diagnoses other than bipolar disorder.
0 #DIV/0!
Is the client being prescribed a mood stabilizer medication, either by the MH agency prescriber or by
his or her primary care provider?0 #DIV/0!
If in crisis, have risk factors for suicide been evaluated?
0 #DIV/0!
If warranted, is the importance of maintaining regular sleep/wake cycles and consistent patterns of
daily activities in preventing relapse of mania reflected as a goal on the treatment plan based on
documentation in the chart?
0 #DIV/0!
If the client has a crisis plan, are the identified early markers of manic episodes on the plan and are
possible interventions listed?0 #DIV/0!
SBHO Review: Practice Guidelines
Bipolar Practice Guidelines (Bipolar Only)
If the client has a MH diagnosis in addition to schizophrenia is there evidence that condition is being addressed or treated (e.g. goal on tx plan,
involved in COD tx, etc.) Not applicable if client has no MH diagnoses other than schizophrenia.
0 #DIV/0!
Is the client being prescribed an antipsychotic medication, either by the MH agency prescriber or by
his or her primary care provider?0 #DIV/0!
IF the client has disengaged or missed two or more consecutive appointments in the previous six months, has the client been called or has an outreach attempt been made to where the client resides? (Enter n/a if
not applicable)
0 #DIV/0!
Is the client receiving or been offered at least one of the following psychosocial treatments (as evidenced
by notes from clinician, prescriber, or other care providers?): Family intervention, supported
employment, ACT, social skills training, CBT, stress management training.
0 #DIV/0!
If in Crisis: Have risk factors for suicide been evaluated?
0 #DIV/0!
If in Crisis: Have risk factors for behavior dangerous to others been evaluated?
0 #DIV/0!
Comments:
Schizophrenia Practice Guidelines (Schizophrenia Only)
Review Period
Reviewer
Provider
Client ID
ScorePossible Points
Percentage Comments
Treatment plan goals based on the intake assessment and diagnosis (or based on an updated assessment of
consumer). 0 #DIV/0! N/A if no treatment plan
The treatment plan was reviewed every 180 days. 0 #DIV/0! N/A if no treatment plan
The 180 day review includes a narrative justification for continued treatment at the level of care requested.
0 #DIV/0! N/A if no treatment plan
Demonstrates the individual's participation in the development of the individual service plan using
quotes from the individual. 0 = No evidence, 1 = Quotes in review only, 2 = Quotes in treatment plan
problem statement or goal.
0 #DIV/0! N/A if no treatment plan
Includes treatment goals that are measurable. 0 #DIV/0! N/A if no treatment plan
Identifies medically necessary interventions, mutually agreed upon by the individual and provider, for this
treatment episode.0 #DIV/0! N/A if no treatment plan
The person has a crisis plan (2 if yes, 0 if person meets PRSN criteria for crisis plan requirements but does not have one. Otherwise, N/A if not required)
0 #DIV/0!
Adult: Any of these in last 2 years: Inpatient stay, suicide attempt, violent act; Or, ITA eval in last 6 months; Or, current S/I or H/I; Or in
residential services; Or assigned clinician/assessor believed it is necessary.
Child: Same as above or child's living situation is at risk.
N/A if not present. If present, does the crisis plan describe interventions that include resources of 1) the individual (such as coping skills), 2) natural supports
(i.e. friends family, neighbors), and 3) institutional/systems (i.e. calling crisis clinic) as
appropriate?
0 #VALUE!
The plan addresses the overall identified needs of the individual, including those that best met by another service delivery system, such as education, primary
medical care, child welfare, drug and alcohol, developmental disabilities, aging and adult services,
corrections and juvenile justice as appropriate.
#DIV/0!
Coordination for those with complex medical needs is tracked through the treatment plan and progress
notes. 0 #VALUE!
N/A if no treatment plan (no longer a 1x year requirement for all consumers. Instead focuses on those with complex medical
needs).
Treatment Plan Report/DLA-20 Report (Review after reading intake)
SBHO Review Tool: Reauth
If a service occurs, the service is an intervention on the treatment plan.
0 #DIV/0!
Notes identify treatment goal being addressed, and this goal is reflective of treatment plan.
0 #VALUE!
The notes document the consumer's response to treatment and their progress toward the goals on the
treatment plan. 0 #VALUE!
The consumer is receiving other services listed in WAC 388-877A-0100 (2) and is therefore not "meds
only".0 #DIV/0! MEDICAL SERVICES
The individual or if applicable, their parent/guardian provided informed consent for new medications.
0 #VALUE! MEDICAL SERVICES
The clinical/medical record contains both the name and purpose of the medication prescribed, and clinical support for any change in medication and/or dosage.
0 #VALUE! MEDICAL SERVICES
The medical provider assessed the individual for side effects of prescribed medications and interactions
between medications. 0 #VALUE! MEDICAL SERVICES
The medications prescribed have been reviewed by the prescriber at least every 3 months.
0 #VALUE! MEDICAL SERVICES
Progress Notes Report
If the current PRAT is for a continuing/renewed benefit, rate this item. Assigned level is appropriate for client's diagnosis, GAF/CGAS score (for review periods before 10/1/15), symptomatology, and service. Criteria used to determine re-authorization of an existing benefit adheres to guidelines in current PRSN Levels of Care. Continuation of service at assigned level is justified by documentation in chart of the client's clinical presentation as described in the treatment notes.
0 #VALUE!
The frequency of service and type of service utilized is the best fit for this client, given the
documented description of their clinical presentation in the treatment notes, and in the intake if it was
completed within the previous year.
0 #VALUE!Note: Can be used to indicate under/over
utilization, even when the PRAT is adequate.
Evidence that facilitation of EPSDT services occurred for all children (0-21) adhering to the periodicity schedule, while brokering with multiple system providers to meet the identified needs of the
child/family.
0 #DIV/0!
Documentation exists that demonstrates communication with referral source (EPSDT medical
provider), specifically written notice provided that includes at minimum: date of intake, diagnosis and
level of care assignment.
0 #VALUE!
Written notification to child’s medical provider (for children referred without EPSDT) requesting that documentation be provided that a Healthy Child
screening has been completed or that one will occur. NA if client does not have a PCP.
0 #VALUE!
If no medical care provider is identified by enrollee, then a copy of EPSDT rights contained in the MHD
benefits booklet is provided as well as assistance with selection/accessing of medical provider. NA if client
has PCP.
0 #VALUE!
Develop an Individual Service Team (IST) including identified formal systems and natural supports for
children authorized for Level II services and involved in two or more service systems (cross-system involved.)
0 #VALUE!
There is a cross-system Individual Service Plan (ISP) which addresses overall needs of both the child and family across life domains for cross-system Level II
clients.
0 #VALUE!
Either the individual service plan or a separate plan specifically addresses the conditions of the LRA order
and plan for transition to voluntary treatment. 0 #VALUE!
Consumer has signed LRA rights. 0 #VALUE!
If the consumer is on a 90-day or a 180-day LRA, the consumer has been evaluated monthly by an MHP withregard to release from or continuation of an involuntary
treatment order.
0 #VALUE!
EPSDT (Complete this section if client is under age 21)
PRAT Report
Community Support (LRA) Scores (Only Consumers on LRAs)
If the consumer is on an LRA they receive receives psychiatric medication services at least once ever
seven days for the first 14 days following discharge from the inpatient facility, unless the attending physician determines another schedule is more
appropriate and documents this in the record and at least once every 30 days after that (unless otherwise
changed by the prescriber).
0 #DIV/0!
Comments:
Facility Name and Type (RTF/BH)
Reviewer
Provider
Client ID
Review Date
Date of Admission to Facility
Actual PointsPossible Points
Percentage Comments
Is the resident involved in activities at the facility? #DIV/0!
There is evidence of coordination between the outpatient provider and the facility. #DIV/0!
Client voice is incorporated into his or her care at the facility. #DIV/0!
There is evidence that efforts are being made to help the resident learn independent living skills in order to eventually move to a lower level of care. #DIV/0!
The treatment plan includes a goal addresing the residential treatment needs, interventions, and
outcomes. #DIV/0!
The individual has a current crisis plan. #DIV/0!
Is there a current PARS for the consumer? #DIV/0!
Do the consumer’s clinical presentation demonstrate a need for this residential level of
care? #DIV/0!
SBHO Residential Review
Resident Care/Treatment
The individual has a history or recent episode of failing to live independently in the community due
to his/her psychiatric illness. #DIV/0!
The individual is currently enrolled in outpatient services or is in the process of being authorized
and assigned to outpatient services. #DIV/0!
#NAME?
Comments:
1 SBHO 1/23/17
Salish BHO, SUD Clinical Review Tool
Agency/Provider name
Clinician name and credential
Clinical chart identifier Chart is active or closed Active Closed (Date): Review date
SBHO clinical reviewer SUD Assessment Review
Requirements for SUD assessments are referenced in WAC 388-877-0610, and, WAC 388-877B, Medicaid contract, BHSC Contract Item
# Requirement In File
Yes/No/NA Comments
1 Date of request for SUD assessment
2 Face to face assessment has been completed within 14 calendar days of the individual’s request.
3 Reason for assessment is documented.
4 Alcohol & other drug, and tobacco use history is documented.
5 • Type of substance6 • Route of administration7 • Amount, frequency, and duration of use
8 Individual’s PCP is documented.
9 History of self-harm is documented.
10 A history of problem pathological gambling (PPG) is documented.
11 Record of prior treatment history is documented.
2 SBHO 1/23/17
12 DOC supervision is documented.
13 GAIN-SS completed at time of assessment and is included in determining medical necessity.
14
HIV brief risk intervention is documented.
15
DSM-5 diagnosis is documented with appropriate supporting evidence.
16
Individual ASAM dimensions document applicable information, risk ratings, and recommended levels of care. Medical necessity has been determined and documented.
17
Recommended ASAM level of care and duration of treatment are documented.
18
Individual has been informed of assessment results (individual’s signature is verification).
19
Assessment is co-authenticated by CDP if assessment is completed by CDPT.
20
Supporting documentation has been reviewed (court documents, police report, BAC results, etc…).
21
Urinalysis done if required, results documented.
Comments (Link comments to specific item # above):
3 SBHO 1/23/17
Individual Service Plan (ISP) Review
Requirements for Individual Service Plans (ISP’s) are referenced in WAC 388-877-0620, and, WAC 388-877B
Item #
Requirement
In File Yes/No/NA
Comments
1
An ISP has been created and signed by the individual before treatment services are received (Outpatient).
2
An ISP has been created and signed by the individual within five days of admission (Intensive Inpatient).
3
Patient’s name is documented on all ISP’s.
4
ISP’s are strength based. The Individual’s strengths have been identified and included in the development if the ISP.
5
ISP’s indicate the ASAM dimension and current level of care specific to the individual’s needs.
6
ISP’s include a problem statement specific to the individual’s identified needs.
7
ISP’s include a goal statement indicating the desired outcome of the ISP.
8
ISP’s include objectives, with assigned dates or conditions, addressing accomplishment of the goal.
9
ISP’s are updated to reflect changes in the individual’s treatment needs, and achievement of goals and/or objectives.
10
ISP’s address referral to PCP for coordination of complex medical needs if applicable.
11
ISP goals and objectives are Specific, Measureable, Attainable, Realistic, and Time sensitive (SMART).
12
The individual’s voice is reflected (quoted) in the ISP. The individual’s participation is documented.
13
ISP’s have been reviewed and signed by the individual.
4 SBHO 1/23/17
14
ISP’s document the name, credential, and signature of the CDP/CDPT who worked with the individual to create it.
15
ISP’s have been co-authenticated by a CDP if it was developed by a CDPT.
16
The chart documents mutual agreement of the ISP and that the individual received a copy.
Comments (Link comments to specific item # above):
5 SBHO 1/23/17
Clinical Record Content and Documentation Review
Requirements for Clinical Record Documentation are referenced in WAC 388-877-0640, and, WAC 388-877B Item
#
Requirement In File
Yes/No/NA
Comments
1 The clinical record documents the date and time of the individual’s first contact with the agency.
List date and time:
2
The clinical record documents the date and time of the individual’s assessment.
List date and time:
3
The clinical record documents the date and time of the individual’s admission to treatment.
List date and time:
4
The clinical record documents the date and time when the individual began receiving services.
List date and time:
5
The clinical record documents the date and time of the individual’s discharge from treatment services.
List date and time:
6
The clinical record documents the individual has been informed of HIPAA.
7
The clinical record documents the individual has been informed of confidentiality requirements under 42 CFR Part 2.
8
The clinical record documents demographic information specific to the individual.
9
The clinical record documents the individual is under civil or criminal order for Mental Health or Substance Use Disorder treatment.
10
The clinical record documents a court order exempting the individual from reporting requirements.
11
The clinical record documents the individual has signed a consent to treatment if not court ordered.
12
The clinical record documents the individual has signed a counselor disclosure form IAW RCW 18.19.060, and WAC 246-811-090.
13
The clinical record documents the individual has received a copy of their individual patient rights.
14
The clinical record documents the individual is aware of agency grievance procedures.
6 SBHO 1/23/17
15
The clinical record documents the individual has received a copy of treatment rules and responsibilities.
16
The clinical record contains medication records for the individual if applicable.
17
The clinical record contains laboratory and/or urinalysis reports if applicable.
18
The clinical record contains properly completed Releases of Information (ROI’s), IAW 42 CFR Part 2 signed and dated by the individual for the release of confidential information.
19
The clinical record documents the individual has had a TB test or screen.
20
The clinical record documents individual counseling sessions as required by WAC 388-877B. Requirements vary with level of care (LOC).
21
The clinical record documents the individual began receiving services within 28 days of request. If not, the reason is documented.
22
Progress notes indicate coordination with other service delivery systems if applicable. (Mental Health, PPW services, etc…)
23
Progress notes document referral to PCP, and coordination of care with PCP if the individual has complex medical needs.
24
Individual service plan reviews are completed per WAC 388-877B requirement based on the level of care the individual is receiving.
25
The clinical record documents ISP’s are updated/modified to reflect progress (or lack of), adjustments, or completion of the ISP.
26
The clinical record contains copies of status reports to courts, DOC, DOL, DSHS, etc… Reports are signed and dated by agency CDP/CDPT.
27
ASAM level of care (LOC) and continuing stay requirements are documented.
7 SBHO 1/23/17
28
Justification for level of care (LOC) change is documented when transferring an individual from one LOC within the same agency at the same location.
29
The clinical record documents progress notes that include date, time, duration, participant name, summary of the session, and the name of the CDP/CDPT who provided it.
30
The clinical record documents that staff met with individual at time of discharge, unless individual left without notice, to;
31
Determine care recommendations and finalize a continuing care plan.
32
Assist the individual in making contact with necessary agencies or services.
33
Provide and document the individual was provided a copy of the plan.
34
The clinical record documents that a discharge summary was completed within seven days of the individual’s discharge date.
35
All clinical record content and documentation requirements completed by a CDPT are co-authenticated by a CDP.
Comments (Link comments to specific item # above):
8 SBHO 1/23/17
______________________________________________________________________________ _______________________________ Signature of Salish BHO Reviewer Date
# Item Score Notes / Comments
1 Is a criminal background check and an excluded provider check through the Office of Inspector General (OIG) conducted for all agency staff members?
Evidence: P & P, sample checks. Once demonstrated, review every other year (or next contract cycle).
2 Are background checks conducted for all agency volunteers, board members, and interns? Evidence: P & P, sample checks. Once demonstrated, review every other year.3 Is a background check conducted for all subcontractors? Evidence: P & P, sample checks. Once demonstrated, review every other year.4 Does the agency ensure employees are trained in: The skills each employee needs to effectively perform the
functions included in their job description and the population in which they directly serve;Safety and violence prevention per RCW 49.19.030;Personnel training consistent with WAC 388-877-0500(6);HIPAA compliance and confidentiality of records and Enrollee information;Utilizing natural supports, building on Individual strengths, and recovery and resiliency;Suicidal risk identification and intervention;Basic Life Support (CPR and first aid) and prevention and control of communicable disease, including HIV/AIDS, blood borne pathogens and tuberculosis (TB);Psychotropic medications (if applicable).
Evidence: Job description review, P&P new employee orientation and staff training, training sign-in sheet, personnel record sample. Once demonstrated, review every other year.
5 Does the agency provide training in treatment methods that address individual age, gender, language, literacy, culture, ethnicity and sexual orientation?
Evidence: P&P, staff training, Sample training
6 Does the agency have established referral relationships with the assessment entities, outpatient individual providers, vocational or employment services, and courts which specify aftercare expectations and services including procedure for involvement of referents in treatment activities?
Evidence: P&P care coordination and ISP. Sample chart review.
7 Does the agency have internal policies and practices to measure and improve the quality of services? Quality Plan elements list
Evidence: P&P quality improvement. QM plan. Sample of initiative. Once demonstrated, review every other year.
8 Does the agency have internal policies and practices to accept and make necessary adjustments to continue treatment for any clinically appropriate individual taking opiate substitution medication?
Evidence: P&P. Once demonstrated, review every other year.
9 Does the agency have policy and provide training for staff to implement person-centered techniques, such as motivational interviewing, to assist the individual in completing recommended level of care?
Evidence: P&P AMAs & Staff Training. Once demonstrated, review every other year.
10 Does the agency have policy and procedure for notifying the responsibile BHO and any other required agencies of critical incidents including serious injury requiring medical attention, alleged sexual abuse, serious physical assaults between individuals, alleged abuse of a youth by a staff member, or other instances of suspected individual abuse in accordance with state law?
Evidence: P&P Incident reporting and CPS/APS reporting
11 Does the agency allow individuals to leave the facility for the purposes of obtaining medical treatment not available at the center, conducting personal business, visiting with family members or significant others, and for other reasons that may be beneficial to the individuals treatment program?
Evidence: P&P temporary pass
12 Does the agency have specific criteria for therapeutic and rule violation discharges? Evidence: P&P Discharges
Instructions: Please score each item in the Contract Review based on a Three (3) point rating: "0" = Not in Compliance; "1" = Partially in Compliance; "3" = Fully in Compliance. Select N/A if not applicable.Name of BHO conducting Review:
City / State / Zip:Home BHO of Residential Facility:Primary Contact Name:Dates of Review:
Residential Facility Name: Address:
Comprehensive SUD Residential Review: Contract Review
All Contracts
Name of Reviewer:
13 Is the agency in compliance with contract requirements relating to maintenance of records? Evidence: P&P records maintenance. Site review. Once demonstrated, review every other year.
14 Is the agency following requirements related to the permitted and required uses or disclosures of protected health information?
Evidence : P&P, Review HIPPA tracking sheet of releases
#DIV/0!
1 Does the agency make continuing education services available to staff? Evidence: P&P and personnel record review2 Has the agency ensured that information on the priority populations was publicized? Evidence: P&P and sample of methods of publication (brochures, website, community
presentation, etc.)3 Did the agency ensure that the following order of priority was followed for admission to treatment: (a)
Pregnant injecting drug users; (b) Pregnant substance users; (c) Injecting drug users; (d) Parenting women?
Evidence: Admission P&P
#DIV/0!
1 Were all potential Medicaid-eligible individuals screened for Medicaid eligibility? This is only applicable for direct admits. Evidence: P&Ps admission and financial eligibility. Sample of records.
2 Are potential Medicaid-eligible persons referred to the Health Care Navigators to apply for medical coverage?
Evidence: P&Ps admission and financial eligibility. Once demonstrated, review every other year.
3 Once enrolled in the program are all individuals screened for financial eligibility no less than once each month?
Evidence: P&Ps admission and financial eligibility. Once demonstrated, review every other year.
4 Does the agency have policies and procedures on income eligibility for DBHR, Medicaid, and third party insurance individuals?
Evidence: P&Ps admission and financial eligibility. Once demonstrated, review every other year.
5 Is the agency charging any fees to Medicaid-eligible individuals (with the exception of ADIS)? Evidence: P&P. Once demonstrated, review every other year.
#DIV/0!
1 Do CDPs who are working with youth have 10 hours of their 40 CEU’s specific to youth? Evidence: Personnel record review. Review annually.2 Does the agency meet “supervised care” requirements for program site and in public places? Evidence: Site review and P&Ps
3 For level II programs, is the agency providing specialized treatment groups addressing co-existing mental health concerns that may complicate substance use disorder treatment? (hours for these groups may be a part or in addition to the 20 hours required in WAC)
Evidence: Program schedule. Review annually
4 Does the agency provide recreational, leisure, and free time that are appropriate to the ages, abilities, and individual interests of the individual? (Minimum of 7 hours/weekly of supervised recreational activity)?
Evidence: Programming description
5 Is the agency following contract requirements regarding individual age for admission and exceptions for youth under age 13 and for 18, 19, or 20 year old admissions?
Evidence: P&P admission/intake. Chart review. Again, the regional BHO could use its population as a proxy. WAC 388-877B-0280
6 Does the agency ensure compliance with contract restrictions on nicotine products? Evidence: P&P admission paperwork describing compliance with nicotine products.7 Does the agency meet the contract requirements for required number of hours and content for treatment
modality?Evidence: Data report- level to hours. Sample record review. WAC 388-877B-0280
8 Does the agency have a policy regarding transportation of individuals to medical appointments or individual outings?
Evidence: P&P transportation internal and Medicaid
#DIV/0!
Possible ScoreGeneral Contract Requirements - Score
Possible ScoreAchieved Percent
Possible ScoreAchieved PercentBilling / Financial Requirements
Billing and Financial - ScorePossible ScoreAchieved Percent
Substance Abuse Block Grant Requirements - Score
Substance Abuse Block Grant Fund RequirementsAchieved Percent
PPW Requirements
Youth Residential Requirements
Youth Residential - Score
1 Does the agency have specific criteria for therapeutic and rule violation discharges? Evidence: P&P discharge2 Is the agency providing the opportunity for the individual’s clinical individual and group services to be
provided by someone of the same gender?Evidence: P&P treatment/programming
3 Is the agency currently licensed with the Department of Early Learning? Evidence: Cuurent license status4 Does the PPW program staffing include a licensed nurse? Evidence: Staffing level in P&P. Sample shift staffing.
#DIV/0!
Withdrawal Management Requirements1 Does the agency ensure the program is open for admission and service availability 24 hours per day, 365
days per year?Evidence: P&P
2 Does the agency ensure pregnant women unable to access treatment due to lack of capacity and in need of withdrawal management are referred to CUP program within 24 hours of request?
Evidence: P&P
3 Does the agency maintain protocols for MAT patients in need of withdrawal management from other substances?
Evidence: P&P
4 Does the agency ensure access to on-site crisis stabilization, including mental health screening, assessment, intervention, and referral to respond to any immediate or on-going crisis?
Evidence: P&P
Adult Withdrawal Management Requirements - ScorePossible ScoreAchieved Percent #DIV/0!
1 Does the agency accept admissions for all eligible individuals authorized from a Behavioral Health Organization unless there are specific documented reasons relative to health, welfare, or safety of individuals?
Evidence: P&P admission
2 Did the agency provide each individual with necessary personal items: i.e. soap, toothpaste, and sanitary items from the funds provided by the BHO and included in the daily bed rate?
Evidence: P&P
3 Does the agency provide access to services for MAT substitution individuals? Evidence: P&P for coordination or guest dosing. Business arrangement with local facility.
4 Does the agency ensure there are no policies/procedures denying treatment services to any individual solely on the basis that the individual is taking prescribed medications?
Evidence: P&P regarding admission and continuity of medical care or prescriptions.
5 Does the agency ensure treatment services are not denied solely on the basis of the individual’s drug of choice?
Evidence: Admission criteria specifically the excluded section.
6 Does the agency accept involuntarily committed individuals by a court pursuant to RCW 70.96A, provided that the individual is deemed to be medically appropriate for the level of care provided?
Evidence: Admission criteria specifically the excluded section.
7 Does the agency have a policy to discharge an individual and notify the assessment agency/referral in writing of such termination if the individual is absent from the facility for more than 24 hours?
Evidence: P&P Discharge
#DIV/0!
#REF!#REF!#REF!
Total Achieved ScoreTotal Possible ScoreAchieved Percent
Achieved Percent
Adult Residential Requirements
Adult Residential - ScorePossible ScoreAchieved Percent
PPW - ScorePossible Score
Individual Individual Individual Individual Individual Individual Individual Individual Individual Individual
Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender
Evidence Age Age Age Age Age Age Age Age Age Age
Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status
D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason
Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis
Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility
1GAIN SS, Assessment documentation #DIV/0! #DIV/0!
2Assessment and ISP review
3Assessment, ISP review, Referral documentation
#DIV/0! #DIV/0!
4Are ASAM Criteria requirements for admission, continued stay, and discharge criteria documented? Assessment, ISP
review, D/C summary
5Assessment documentation packet.
6
Is enrollee voice evident in the individual service plan (ISP)? ISP review. Use of quotes, individual signature with signature statement (i.e. "this ISP represents my goals and included my voice").
7Were services sensitive and responsive to the individual and family's age, gender, language, culture, ethnicity, and sexual orientation?
ISP and chart notes.
8
Did the agency provide appropriate referrals / transfer agreements with local service providers once services were completed? (youth and family in a youth program)
Review assessment to identify needs and review the referral documentation.
9
Did the agency coordinate services and provide discharge planning within the first week of residential treatment with the referring outpatient agency to exchange assessment, admission, treatment progress, and continuing care information? If an outpatient provider was not established, did the agency coordinate a referral back to one within the individual’s home community in the first few weeks?
Review discharge: ROI, evidence of records exchanged.
10
Did the agency include referrals to other services such as housing, transportation, medical, mental health, schools, juvenile corrections operations, community mobilizations groups, vocational services, Division of Children and Family Services, BHO, other resources or services in the discharge plan to meet the needs of the individual?
Review admission documentation for those who had these needs identified during the assessment/admission. Review Assessment, ISP, and progress notes.
11
Record review of discharge plan. Ensure that all needs were included in the discharge plan.
0 0 0 0 0 0 0 0 0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Comprehensive SUD Residential Review File Review
Total Averages
General Contract Requirements
General Contract Requirements - Subsection Score 0
Is there a GAIN-SS with quadrant placement?
For individuals identified as co-occurring, is there documentation that the individual has been referred for the appropriate services?
Is notification of enrollee rights documented?
Did the agency providing discharge planning services to include, at a minimum, coordination of services to financially eligible individuals who are in need of medical services?
Did the agency provide individual service planning that sought to identify and treat individuals with co-occurring disorders?
Possible Score 0Achieved Percent #DIV/0!
Substance Abuse Block Grant Fund Requirements
1
ISP and progress note review against the criteria #DIV/0! #DIV/0!
0 0 0 0 0 0 0 0 0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1Review of the assessment #DIV/0! #DIV/0!
2
GAIN SS, Assessment documentation, and clinical documentation #DIV/0! #DIV/0!
3
ISP and clinical/progress note documentation
#DIV/0! #DIV/0!
4Review of clinical record and data report- codes
#DIV/0! #DIV/0!
5Record review- Discharge planning and ISP review
#DIV/0! #DIV/0!
6
Record review. Check minimum standard for a clinical shift note.
#DIV/0! #DIV/0!
0 0 0 0 0 0 0 0 0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
1
Review clinical record and ISP.
#DIV/0! #DIV/0!
0 0 0 0 0 0 0 0 0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Withdrawal Management
1Agency ensures withdrawal management service coordination with other agencies. ROI. Coordination
/case management notes.
#DIV/0! #DIV/0!
2 Agency ensures an assessment is requested if patient has been admitted 2 or more times in the same quarter.
ROI. Care coordination.
#DIV/0! #DIV/0!
3
Did the agency provide screening, referral, and support services to family members? Review of screening tool/document, referral doc, and documentation of family sessions.
4Agency shall ensure each patient receives counseling regarding the patient’s substance use disorder, utilizing counseling techniques to motivate acceptance of a referral into treatment. Assessments provided to those able to participate. Documentation maintained in file.
Review of chart notes.#DIV/0! #DIV/0!
5 Agency provides minimum 1 hour of substance abuse education 5 days per week. Documentation is maintained in patient file.
Review of chart notes.#DIV/0! #DIV/0!
Withdrawal Management - subsection score 0 0 0 0 0 0 0 0 0 0 0Possible Score 0
Achieved Percent #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
0Possible Score 0
Substance Abuse Block Grant - Subsection Score
Achieved Percent #DIV/0!Youth Residential
0Possible Score 0
Achieved Percent
Did the agency provide an assessment of the family and encourage their participation in treatment services?
Did the agency meet contract requirements to provide a minimum of one (1) charting note for each individual, for each day, evening, and night shift to assure individual whereabouts and safety?
Did the agency provide discharge planning and post treatment placement assistance to youth and family with managed referrals back to their home community?
Did the agency provide ancillary treatment services to family members that are relevant to the individual’s recovery while in residence and during the designated continuing care period?
Did the agency provide availability of daily individual counseling for youth as needed clinically to ensure progress and success in treatment?
Where clinically indicated, did the agency facilitate a referral for mental health services, which may have included a psychiatric evaluation for purposes of assessment, individual service planning, behavior intervention, and/or discharge planning?
Total Points Achieved #REF!Total Points Possible #REF!
Youth Residential - subsection score 00
Achieved Percent #DIV/0!
PPW - subsection score
#DIV/0!
Possible Score
Was the client provided individualized treatment modalities that focus on sustaining long-term recovery for themselves and there child(ren)? (i.e parenting support and education, college readiness, job skills and employment readiness, medication and medical emergency management, etc.)
PPW
Achieved Percent #REF!Notes
Did the assessment include mother’s age, living arrangements and family support data for post-partum women?
Review Period
Reviewer
Provider
Client ID
ScorePossible Points
Percentage Comments
The clinical record contains a vocational assessment including work history, skills, training, education, and
personal career goals.0 #DIV/0!
The clinical record specifically addresses how employment will affect the income and benefits the
consumer is receiving because of their disability. If any ofthese pose barriers, the choices and resolutions are
discussed.
0 #DIV/0!
The clinician sssists the individual to create an individualized job and career plan focused on their
strengths and skills. 0 #DIV/0!
There is documentation that the clinician is assisting the consumer in finding employment opportunities that are
consistent with the consumer’s skills, goals, and interests.0 #DIV/0!
The agency documents any outreach, job coaching, and support at the worksite, when requested by the individual
or their employer. 0 #DIV/0!
The agency provides information regarding the requirements of ADA at the individual’s request.
SBHO Review Tool: Supported Employment
Review Period
Reviewer
Provider
Client ID
ScorePossible Points
Percentage Comments
The intake includes sufficient clinical information to justify the provisional diagnosis using diagnostic and
statistical manual (DSM) criteria.0 #DIV/0!
The intake includes a recommendation of a course of treatment. If the consumer is in need of non-RSN
services, appopriate referrals are made. 0 #DIV/0!
The intake includes input from people who provide active support to the individual, if the individual so
requests, or if the individual is under thirteen years of age.
0 #DIV/0!
There is an identification of risk of harm to self and others, including suicide/homicide;
0 #DIV/0!
Assigned Level (Not Authorized for Servces) is appropriate for client’s diagnosis, symptomatology, and service needs and adheres to the guidelines in
the current SBHO's Levels of Care.
0 #DIV/0!
Comments:
SBHO Review Tool: Zero Prat/Consumers Not Authorized for Care
Actual Points Possible Points Comments
Is the resident involved in activities at the facility? 0 0 #DIV/0!
There is evidence of coordination between the outpatient provider and the facility. 0 0 #DIV/0!
Client voice is incorporated into his or her care at the facility. 0 0 #DIV/0!
There is evidence that efforts are being made to help the resident learn independent living skills in order to eventually move to a lower level of care. 0 0 #DIV/0!
The treatment plan includes a goal addresing the residential treatment needs, interventions, and outcomes.
0 0 #DIV/0!
The individual has a current crisis plan. 0 0 #DIV/0!
Is there a current PARS for the consumer? 0 0 #DIV/0!
Do the consumer’s clinical presentation demonstrate a need for this residential level of care?
0 0 #DIV/0!
The individual has a history or recent episode of failing to live independently in the community due to his/her psychiatric illness.
0 0 #DIV/0!
The individual is currently enrolled in outpatient services or is in the process of being authorized and assigned to outpatient services. 0 0 #DIV/0!
Resident Care/Treatment
Treatment Planning
Authorization
SBHO Residential Review:
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Subcontractual Delegation and Assessment Plan 9.04 Page 1 of 6
Policy Name: SUBCONTRACTUAL DELEGATION AND ASSESSMENT Policy Number: 9.04
Reference: DSHS Contract, Subcontractual Delegation, 42 CFR 438.206, 230
Effective Date: 7/2005
Revision Date(s): 6/2016
Reviewed Date: 6/2016; 7/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Form: HIPAA Business Associates Addendum• Plan: Quality Management Plan• Policy: Corrective Action Plan• Tool: Delegation and Assessment Tool
PURPOSE
The Salish Behavioral Health Organization (SBHO) enters into contracts with qualified network providers and monitors for compliance. The SBHO oversees and is accountable for all the functions performed by the subcontractor performing the SBHO required Pre-Paid Inpatient Health Plan (PIHP) functions on an ongoing basis.
DEFINITIONS
Subcontractor delegation means an entity authorized to act as representative for another; a deputy or an agent. In this policy, it refers to an entity or organization that is contractually responsible for conducting the SBHO Pre-Paid Inpatient (PIHP) functions.
PROCEDURE
The SBHO maintains a subcontractual delegation relationship for the operation of the SBHO:
• Authorization and Utilization Management functions, including costumer servicefunctions, authorization determinations for all SBHO services (that requireauthorization), conducting the service denial notifications and appeal process on
Salish BHO Policies and Procedures
Subcontractual Delegation and Assessment Plan 9.04 Page 2 of 6
behalf of the SBHO, and entering prior authorization inpatient information into Provider 1.
• Certain clinical functions are included in our subcontracts with network providers thatmay be considered subdelegations.
SBHO Authorization and Utilization Management Subcontractor delegated Responsibilities The delegated subcontractor must meet all the requirements as identified in the standards requirements (listed below), and in addition the following:
1. The SBHO contracts with an independent utilization management organization toconduct the inpatient, outpatient, residential, and intake assessment authorizationdeterminations.
2. The delegated subcontractor has the responsibility of proving authorizationdeterminations and the service denial notifications, including Notice of AdverseBenefit Determination letters to Medicaid individuals when an adverse action occurs.The contractor must also provide the Appeals Review, on behalf of the SBHO, uponrequest.
3. The delegated subcontractor must maintain URAC and/or NCQA accreditation, statelicensure, and comply with all federal and Washington State regulations.
4. The delegated subcontractor must maintain adequate number of staff to ensurecompliance with contact including utilization care managers, clinical staff withexpertise, and a Board Certified Medical Director to meet the contracted federal andstate authorization timeframes set before the SBHO as a PIHP.
5. The delegated subcontractor must use the SBHO medical necessity definition, Levelof Care standards, state developed Community Psychiatric Inpatient authorizationforms and procedures, ASAM Criteria, and adhere to the SBHO UtilizationManagement Plan.
6. The delegated subcontractor will participate, upon request, in the SBHO UtilizationManagement or Quality Improvement Committees.
7. The delegated subcontractor will supply requested reports, data or informationneeded by the SBHO to assure and maintain compliance with all federal and statereporting requirements and standards. The required reports include, but are notlimited to:
a. Monthly authorization reports, including number of authorizations (Medicaidand non-Medicaid), type of authorization (outpatient, inpatient, residential, orintake), type of level, start and expiration date, number of denials, requestedand conducted Appeals, and other authorization information as requested.
b. Monthly report of flagged high user of crisis services and high risk individuals(per SBHO definitions).
Salish BHO Policies and Procedures
Subcontractual Delegation and Assessment Plan 9.04 Page 3 of 6
c. Quarterly trend report.d. Other reports for review by the Utilization Management Committee or as
requested by the SBHO.
8. The SBHO requires a formalized delegation agreement that is part of the contractwith the utilization management organization.
9. The SBHO will conduct the first delegation audit and review as soon as mutuallyagreed upon date (between the SBHO and the organization) can be established.
10. The SBHO monitors contractor compliance through the standard processes listedbelow, in addition the SBHO uses the feedback provided from:
• Feedback from the annual Department’s External Quality ReviewOrganization (EQRO) BHO reviews. The EQRO monitors the regional IScompliance with regulations, functions, capacity, an overall performance. TheSBHO will use the EQRO findings, in conjunction with the applicable IS itemson the SBHO Subcontractors Delegation and Assessment Tool, to monitordelegated PIHP functions.
Standard Requirements for PIHP Delegated Functions 1. Before any new subcontracting delegation decision is finalized, the SBHO will
evaluate the prospective subcontractor’s ability to perform the activities to be delegated. This is done in the following areas:
• organizational capacity• clinical/staffing capacity• quality improvement processes• HIPAA and Medicaid compliance• (IT only) data security requirements• (ASO, only) authorization for services and utilization management
2. The standards requirements are as follows:
Organizational Capacity Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:
• Maintain licensing by the state as necessary• Maintain written policies and procedures covering its adherence to contract
and relevant regulations• Have an adequate data system and staffing to participate in required data
reporting; e.g., data on service authorizations, inpatient certifications,evaluation of MIS system, provision of data for SBHO quality managementneeds, and ongoing management data to monitor performance of delegatedduties
• Maintenance of an internal quality management/quality improvement processand documentation of minutes for SBHO review
Salish BHO Policies and Procedures
Subcontractual Delegation and Assessment Plan 9.04 Page 4 of 6
• Demonstration of a management team that is responsive to feedback fromSBHO (and its Ombuds and Quality Review Team), allied providers, andservice recipients
• Training and supervision with staff that reflect SBHO’s mission and goals aswell as adherence with contract and regulations
• Ongoing support for client rights, from provision of information on client rightsto responsive action when feedback suggests there may be problems in thisarea
Clinical/Staffing Capacity Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:
• The availability of qualified staff to assume delegated functions; this includesmental health professionals with clinical expertise in treating children andadults, a sufficient number of mental health specialists, and chemicaldependency professionals.
• Care management staff must show an understanding of State Access to Careguidelines, and familiarity with current best practices and promising practices.
• Hiring for clinical staff includes verification of licensure or certification,background checks, review of any loss of licensure or felony convictions, andreference checks.
• Competence in implementing delegated functions, as seen in concurrent andretrospective reviews of service authorizations, provider decisions regardingongoing care, care coordination with allied providers, supervisory feedback tostaff, and response to grievances.
• Effective use of training so that staff understand relevant clinical proceduresand expected practice (e.g., use of Access to Care standards to determineeligibility for services).
• Openness to SBHO feedback on delegated functions and capacity to makechanges in practice when requested.
• Availability of a physician to provide reviews to any inpatient denials and toprovide second opinions when requested.
• Documentation of decision making associated with inpatient certification.• Effective medical records practices.• Timely communication with SBHO regarding delegated decisions.• Participation in any training and feedback from SBHO regarding delegated
functions.
Quality Improvement Processes Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:
Salish BHO Policies and Procedures
Subcontractual Delegation and Assessment Plan 9.04 Page 5 of 6
• Implement and document a quality management/quality improvement process.
• Participates in SBHO’s policies and procedures for grievances and fair hearings; they provide relevant information to enrollees at entry to services and participate actively in the resolution of enrollee grievances.
• Contractors are given feedback on quality issues by SBHO’s Quality Review Team. Contractors respond appropriately and in a timely way to QRT recommendations for improvement.
HIPAA & Medicaid Compliance Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:
• Contractors comply with HIPAA standards and 42 CFR Part 2 • Signed HIPAA Business Associates Agreement with SBHO • Demonstrates effective medical records practices • Update system to meet new regulations
Standard Subcontract Delegation Requirements 1. The SBHO requires a formalized delegation agreement, which is part of the contract,
with any organization or entity that provides subcontract delegated SBHO PIHP functions.
2. The contract, including the delegation agreement, between SBHO and the delegated
subcontractor, will: • Specify the activities and reports responsibilities designated to the
subcontractor; and • Provide for revoking delegation or imposing other sanctions if the
subcontractor’s performance is inadequate. 3. All delegated subcontractors will comply with the SBHO Compliance Plan and
monitoring activities. 4. Sign the SBHO HIPAA Business Associates Addendum.
Standard Subcontractor Delegation Monitoring, Audits and Review
1. SBHO monitors current subcontractor’s delegated performance on an ongoing basis and subjects them to formal routine reviews through contract monitoring and clinical service review, as well as ongoing concurrent reviews.
2. Before any new subcontractor delegating decision is finalized, the SBHO will
evaluate the prospective subcontractor’s ability to perform the activities to be delegated.
Salish BHO Policies and Procedures
Subcontractual Delegation and Assessment Plan 9.04 Page 6 of 6
3. The SBHO uses the SBHO Subcontractor Delegation and Assessment Tool to conduct pre-evaluation and routine subcontractor delegation performance reviews.
4. The SBHO administrator, or his designee, will direct these monitoring activities. 5. Formal reports are shared with quality management committee, and with the SBHO
Executive and Advisory Boards. 6. If the SBHO identifies deficiencies or areas for improvement, SBHO takes corrective
action. The delegated subcontractor will respond to specified areas of non-compliance with a Corrective Action Plan (CAP). Any required CAP shall be submitted to SBHO no later than 30 days after the receipt of the audit results for approval. See the SBHO Corrective Action policy.
7. The subcontracts, including the Agreement, have provisions for terminating the
contractual relationship.
SBHO Data Security Checklist
ITEM SCORE COMMENTS
Data Security Requirements – Agency
1 IS/ IT Disaster Recovery Plan, present and meets requirements of contact. Examples of evidence- Disaster Plan checklist
2 Electronic data protected by transporting data within contractor’s internal network or
encrypting any data in transit outside the contractor’s internal network. This includes transit over public internet.
3 Data stored on local workstations hard disks have restricted access to authorized users by requiring unique user IDs and hardened passwords.
4
Data stored on network servers and made available through shared folders have restricted access to authorized users through access control lists which will grant access only after authorized user has authenticated to the network using a unique user ID and hardened password. Data on disks mounted to such servers must be located in an area which is accessible only to authorized personnel and access controlled with use of a key, card key, combination lock or comparable mechanism.
5
Paper documents protected by storing records in a secured area only accessible to authorized personal. Such records must be stored in a locked container to which only authorized persons have access. Data stored on optical disks will not be transported out of a secured area and must be kept in secure storage.
6
Access to State data will be controlled by DSHS staff who will issue authentication credentials. Contractor will notify DSHS staff immediately whenever an authorized user in possession of such credentials is terminated or otherwise leaves the employ of the contractor or the authorized user no longer requires access to perform work for the contractor.
ITEM
SCORE
COMMENTS
7
Storage of data on portable media or devices is given special protection, if being transported outside of an secure area, by: (check all that apply) __ Encrypting the data and devices to 128 bits __ Controlling access to devices with a password or stronger authentication
methods, forced password changes every 90 days __ Manually locking devices whenever they are left unattended and setting devices to
lock automatically after a period of inactivity (maximum period is 20 minutes) __ Physically protect portable devices an media by: keeping them in locked storage when not in use, using check-in procedures, and frequent inventories
8
Transporting portable devices: Devices and media with DSHS data must be under the physical control of agency staff with authorization to access data.
9
Portable devices: DSHS data shall not be stored on portable devices or media unless specifically authorized. Portable devices include Handhelds/PDAs, Ultra mobile PCs, Flash memory devices, portable hard disks, and laptop/ notebook computers (if transported outside of secure area).
10
DSHS data may be stored on portable media as part of a contractor’s existing documented backup processes for business continuity or disaster recovery purposes. If backup media retired while still containing DSHS information such media will be destroyed.
11
DSHS data may be stored on non-portable media as part of a contractor’s existing documented backup processes for business continuity or disaster recovery purposes. If backup media retired while still containing DSHS information such media will be destroyed.
12 DSHS data is segregated or otherwise distinguishable from non-DSHS data. This includes procedures for storage of data on media, in a logical container, within a shared database, and paper documents.
13
Disposal of media stored on server or workstation hard disks or on removable media: - using a wipe utility - degaussing - physical destruction
ITEM
SCORE
COMMENTS
14 Disposal of paper documents with sensitive or confidential information - recycling through a contracting firm - onsite shredding, pulping, or incineration
15 Disposal of optical discs: -incineration, shredding, defacing readable surface with a coarse abrasive
16 Disposal of magnetic tape: - degaussing, incinerating, or crosscut shredding
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Items of Delegation 9.04c Page 1 of 4
Salish Behavioral Health Organization Items of Delegation Activity Delegated To Relevant Policies and Comments
Assign Levels of Care and request authorization for services.
Contracted Providers 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan 11.01Access to Services, Timely
Authorization and re-authorization for inpatient, outpatient treatment services, and residential services
ASO Contractor- CommCare 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan 12.01 DSHS InPt Instructions
Assessments of consumers prior to determination of appropriateness of inpatient, outpatient, or residential services
Contracted Providers 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan
Adverse Determinations (Denials)
ASO Contractor- CommCare 6.03 Appeal Process 6.05 NOA Requirements 7.01 Auth for OP Services 7.03 LOC 7.06 UM Plan 12.03 Voluntary InPt Denials
EPSDT – Initial intake review and Level of Service assignment
Request made by Contracted Provider, CMHS
Review by SBHO Contractor Child Mental Health Specialist
7.03 LOC 11.08 EPSDT Coordination
EPSDT – Coordination of Individual Service Teams
Contracted Providers Oversight by SBHO Children’s
Services Manager
2.17 Special Pop- Coordination of Care for Children 11.08 EPSDT Coordination
Care Management: • Assessment and Re-
Assessment s• Collaboration in
authorizations requiredfor extension, dischargeand transfer needs
ASO Contractor- CommCare 7.03 LOC 11.01Access to Services, Timely 11.11 Housing Services 11.19 Primary & Hospital Coordination of Care 11.20 Special Healthcare Needs- Quality & Appropriateness 11.21 Special Healthcare Needs- Direct Care
Inpatient, Outpatient, and Residential Services
Contracted Providers 2.08 Rehab & Integrated Care 2.11 Enrollee Rights 2.12 Consent for Treatment 2.13 Second opinion 2.16 Special Needs Accommodation Process
Salish BHO Policies and Procedures
Items of Delegation 9.04c Page 2 of 4
Activity Delegated To Relevant Policies and Comments 2.21 Recovery & Resiliency 3.02 Culturally Competent Services 3.03 Culturally Competent Service Structure 7.03 LOC 11.02 Access to Services Prior to Intake 11.03 Service Modalities- Outpatient 11.04 Service Modalities- Crisis 11.05 ISP 12.01DSHS InPt Instructions 12.06 Admission & DC Coordination from InPt care
Appeals ASO Contractor- CommCare, Medical Director
6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.03 Appeal Process 12.03 Voluntary InPt Denials
Fair Hearings DBHR/ DSHS 6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.04 Fair Hearing
Communication with consumers - Provide Member Handbook
SBHO 2.06 Comprehensive Info Plan 2.07 General Info Req 2.07a SBHO Handbook
Communication with members – negative action
ASO Contractor- CommCare 7.01a SBHO Auth. Ltr 7.01c SBHO Ltr of Ineligibility 6.03a CommCare Appeal Acknowledgement Ltr 6.05a&b NOA Ltr, templates
Telephonic communication with consumers re: NOD/NOA
ASO Contractor- CommCare 6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.03a CommCare Appeal Acknowledgement Ltr 6.05a&b NOA Ltr, templates 12.03 Voluntary InPt Denials
Communication with consumers and providers
QRT Contractor 9.01 Monitoring Sufficiency 9.02 Monitoring Contractors 9.08 QRT
Staff credentialing and licensure including MHP and MH Specialist
Contracted Providers 3.03 Culturally Competent Service Structure 3.03a Specialists Directory 3.03b Bilingual Directory 3.03c EBP Directory 3.07 Provider Staff Qualifications 3.08 Credentialing & Recredentialing
Monitoring a LRA or a Conditional Release.
Contracted Psychiatric Provider and Contracted
Providers
9.07 Standard Chart Reviews 9.07a Intake & Reauth Standard Tool 9.07e Crisis Chart Review Tool
Salish BHO Policies and Procedures
Items of Delegation 9.04c Page 3 of 4
Activity Delegated To Relevant Policies and Comments Ombuds Services BRIDGES Ombuds
Contractor 6.01Complaint, Grievance, Appeal & fair Hearing Req 13.02 Ombuds Services
Maintenance of Profiler Regional EMR hardware and network
KMHS – IT 4.01 Loading of State Enrollment Data 4.02 Data Transfer to the Department 4.03 IS Processing procedures 4.04 IS Encounter Submission 4.05 Data Error Resolution 4.06 Acceptance of Late MIS Data 4.07 Data System Backup & Recoverability SBHO Subcontract
Crisis Hotlines Contracted Providers (subcontracted to Crisis Clinic of the Peninsulas)
11.01 Access to Services, Timely 11.04 Service Modalities- Crisis 11.06 Crisis Prevention Plan
After hours customer services – authorizations
ASO Contractor- CommCare 7.01 Auth for OP Services 7.06 UM Plan
Special Population Consult
Contracted Provider 2.17 Special Populations- Coordination of Care for Children 2.18 Special Populations- Coordination of Care for Older Adults 2.19 Special Populations- Coordination of Care for Disabled 2.20 Special Populations- Coordination of Care for Minorities 3.01Availability of Services 3.02 Culturally Competent Services 3.03 Culturally Competent Service Structure 3.03a Specialists Directory 3.03b Bilingual Directory 3.03c EBP Directory
Salish BHO Policies and Procedures
Items of Delegation 9.04c Page 4 of 4
Activity Delegated To Relevant Policies and Comments Interpreter Services SBHO Language Line for
Contracted Providers use 2.14 Interpreter Services 2.15 Consumer Rights in Braille
Coordination of Care Contracted Providers 2.17 Special Populations- Coordination of Care for Children 2.18 Special Populations- Coordination of Care for Older Adults 2.19 Special Populations- Coordination of Care for persons with Disabilities 2.20 Special Populations- Coordination of Care for Ethnic Minorities 2.21Recovery & Resiliency 11.08 EPSDT Coordination 11.17 Notification of Primary MH Care Provider Termination 11.20 Special Healthcare Needs- Coordination of Care 11.21 Special Healthcare Needs- Direct Care 11.22 Special Healthcare Needs- Quality & Appropriateness 14.01 Working Agreements
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Periodic Reviews of the E&T Facilitites 9.05 Page 1 of 2
Policy Name: PERIODIC REVIEWS OF THE E&T FACILITIES Policy Number: 9.05
Reference: 42 CFR 438.202, 206, 207; WAC 388-865-0284, -0229; DSHS contract
Effective Date: 8/2007
Revision Date(s): 6/2016
Reviewed Date: 6/2016; 7/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors
PURPOSE
The Salish Behavioral Health Organization (SBHO) shall ensure periodic reviews of the evaluation and treatment service facilities consistent with contract requirements and state and federal regulations.
DEFINITIONS
An Evaluation and Treatment (E&T) facility is certified by the Department and provides (involuntary and voluntary) inpatient evaluation and treatment services for more than twenty-four (24) hours within a general facility.
PROCEDURE
1. The SBHO shall conduct periodic reviews of the evaluation and treatmentfacilities that are currently certified and licensed by the Department.
• Ensure all services provided must be covered under a current Departmentissued certification.
Salish BHO Policies and Procedures
Periodic Reviews of the E&T Facilitites 9.05 Page 2 of 2
• Ensure all services provided must be covered under a current Department Of Health issued license.
2. The SBHO shall review the facilities policies and procedures.
• Ensure all current facility policies and procedures are written in accordance and are consistent with the SBHO policies and procedures.
• Ensure all current facility policies and procedures are implemented accordingly. The E&T may be asked to demonstrate/ provide evidence of how a policy is implemented.
• Efforts will be made to accompany the Department during the annual certification review.
3. Through the period review process if the SBHO believed that a facility was not in compliance with an applicable statute, rule and regulation, the SBHO will notify the proper authorities (certification/ licensing entity).
MONITORING
1. This policy is a mandate by Washington Administrative Code (WAC) regulation. This policy is monitored through periodic reviews of the evaluation and treatment facilities, in addition to:
• Annual SBHO Provider and Subcontractor Administrative Review • Annual Provider Crisis Chart Review • Quarterly Provider Performance Reports • Grievance Tracking Reports
2. If a provider performs below expected standards during any of the reviews listed
above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Periodic Review of Residential Programs 9.06 Page 1 of 2
Policy Name: PERIODIC REVIEW OF RESIDENTIAL PROGRAMS Policy Number: 9.06
Reference: DSHS contract
Effective Date: 8/2009
Revision Date(s): 6/2016
Reviewed Date: 6/2016; 7/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors
PURPOSE
The Salish Behavioral Health Organization (SBHO) shall ensure periodic reviews of the mental health residential facilities consistent with contract requirements and state and federal regulations.
PROCEDURE
1. The SBHO shall conduct periodic reviews of SBHO contracted residentialtreatment facilities located within the region that are currently certified by theDepartment of Social and Health Services (DSHS) and licensed by theDepartment of Health (DOH).
2. The SBHO will conduct annual reviews of the residential facility and clinicalcharts. The review tool will be revised, as needed, to incorporate a more focusedreview, programmatic changes and/ or current compliance concerns.
3. If the SBHO becomes aware that a facility is not in compliance with an applicablestatue, rule and regulation, the SBHO will notify the proper authorities(certification/ licensing entity).
Salish BHO Policies and Procedures
Periodic Review of Residential Programs 9.06 Page 2 of 2
MONITORING
1. This policy is monitored through: • Annual chart review of consumers receiving treatment at a mental health
residential facility • Grievance Tracking Reports
2. If a provider performs below expected standards during any of the reviews listed
above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Standard Chart Reveiws 9.07 Page 1 of 2
Policy Number: 9.07 Policy Name: STANDARD CHART REVIEWS
Reference: DSHS Contract
Effective Date: 8/2004
Revision Date(s): 6/2016
Reviewed Date: 6/2016; 7/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans• Tool: Standard Chart Review Tool• Tool: Crisis Chart Review Tool
PURPOSE
The purpose of the Salish Behavioral Health Organization (SBHO) chart review process is to monitor compliance with Washington Administrative Codes (WAC) and contract requirements as well as to give feedback to providers on quality of service delivery.
PROCEDURE
1. The SBHO staff will review 500 clinical records each fiscal year.
2. Information collected from the reviews will be reported to each provider.
3. In general, providers will be asked to develop a corrective action plan for chartreview items that average below 90 percent unless the review sample size is toosmall to require such action. However, there may be times when the sample sizeis small but the deficiencies found during the review warrant a corrective action. Itis understood that some deficiencies in charts cannot be fixed and this is to benoted by the provider as part of the corrective action.
Salish BHO Policies and Procedures
Standard Chart Reveiws 9.07 Page 2 of 2
MONITORING
1. This policy is a mandate by contract and statute. This policy will be monitored through use of SBHO:
• Annual Provider Reviews • Quality Management Plan activities, such as reviewing targeted issues for
trends and recommendations. • Review of previous provider corrective action plans, including provider
profiles related to performance on targeted indicators.
2. If a provider performs below expected standards during the quarterly review listed above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Quality Review Team 9.08 Page 1 of 5
Policy Name: QUALITY REVIEW TEAM (QRT) Policy Number: 9.08
Reference: WAC 388-865-0282; DSHS Contract
Effective Date: 7/2005
Revision Date(s): 2/2013; 7/2016
Reviewed Date: 12/2014; 7/2016
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Corrective Action Plans
PURPOSE
The Salish Behavioral Health Organization (SBHO) assures that a Quality Review Team (QRT) is established and maintained, and does so as a committee of the Advisory Board with administrative support provided by the SBHO.
Further, the QRT functions are separate and discrete from those of the Ombuds person. In further accordance with WAC 388-865-0282 and the contract established with the Department (August 17, 2001), the SBHO established policies and procedures which outline the size, appointment, removal and tenure, and decision making process of the QRT.
PROCEDURE
Independent Execution of Duties and Membership
It is the policy of the SBHO to assure the independent execution of the QRT duties, and affirm that no measures or actions will be taken which might threaten, intimidate or otherwise diminish the QRT independent function, so long as the QRT acts in a legal manner and conforms to the requirements of the SBHO/ DSHS contracts.
1. Appointment and Size: The QRT and its chair are appointed by the chairpersonof the Advisory Board, with appointments approved by the SBHO Advisory
Salish BHO Policies and Procedures
Quality Review Team 9.08 Page 2 of 5
Board. At least two members from the Advisory Board, as well as additional members from consumer and advocacy groups in the region shall be appointed and the committee shall total at least five and no more than ten people.
2. Representation: The QRT shall have membership representative of the
demographics of the region.
3. Tenure and Removal: Appointments to the QRT shall be for a period of two years. Membership shall terminate upon resignation or removal from the Advisory Board. Members may be appointed for additional terms.
Purpose and Responsibility It is the policy of the QRT to monitor and evaluate the efficiency, effectiveness and benefits of services for people with mental illness within the region.
1. The purpose of the SBHO QRT is to: a. Assist the SBHO in its quality assurance process. b. Provide a check and balance system to ensure that targeted individuals
receive appropriate levels of quality care. c. Collect information and make recommendations which will assist
consumers to have their needs met and their welfare protected. d. Visit, assess and evaluate SBHO services and the services of SBHO
subcontractors regarding: • The system for quality of care. • The degree to which services are consumer focused/directed. • The extent of development of alternatives to hospitalization, cross
system coordination and range of treatment options.
2. It is the responsibility of the SBHO QRT, with administrative support to:
a. Meet regularly to conduct QRT business, no less than quarterly. b. Record the agenda, minutes, plans, and conclusions of its meetings. c. Visit and review service provision sites. d. Collect such information as is necessary to make recommendations that
will assist consumers to have their needs met and welfare protected. e. Report recommendations to the SBHO.
Salish BHO Policies and Procedures
Quality Review Team 9.08 Page 3 of 5
f. Maintain client confidentiality. g. Involve representatives of under served groups in developing
recommendations that affect such groups. h. Undertake such other review as is deemed appropriate to fulfill its
purposes. i. Participate in Advisory Board meetings no less than quarterly.
3. The QRT has the authority to:
a. Evaluate the Contractor’s relationships and cross system activities
including but not limited to schools, state and local hospitals, jails and shelters.
b. Enter and monitor any state or community psychiatric hospital or ward
providing psychiatric care coordination with the Contractor or the Department to resolve systemic issues provided reasonable time notice and confidentiality concerns are met.
c. Monitor the SBHO and its subcontractors Quality Management Plan
implementation. State Training It is the policy of the QRT that its members attend state sponsored training, as available, in accordance with WACs and DSHS /SBHO contracts.
1. Upon SBHO receipt of notice of training events no less than four weeks in advance of training from the Department, the SBHO staff will notify all QRT membership of the training availability.
2. QRT membership, with the assistance of SBHO support staff, will arrange to
attend trainings. 3. QRT membership attending trainings will be reimbursed at the usual and
customary rate for SBHO staff per Kitsap County Policies and Procedures for their travel and expenses (lodging and meals).
Information Collection It is the policy of the SBHO QRT to address mental health service delivery system issues and service delivery issues in order to support the SBHO and QRT purposes and fulfill its responsibilities.
1. The SBHO QRT will collect information regarding system and policy issues by:
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Quality Review Team 9.08 Page 4 of 5
a. Holding open forums in each catchment area to which the public is invited and asked to provide input regarding local services, focusing on addressing system issues and information.
b. Reviewing information including SBHO prepared semi-annual or quarterly
reports; SBHO site visit monitoring reports; or other policies, plans or materials as is deemed necessary to fulfill its function.
2. The SBHO QRT will collect information regarding service delivery issues by:
a. Welcoming input from interested consumers, service providers, the SBHO,
Ombuds staff and the Department regarding problems of access to services and/or quality of care improvement
b. Reviewing data submitted by providers to the SBHO; c. Making independent annual site visits to providers in which:
• Providers identify processes and practices of service delivery. • Interviews regarding QRT areas of interest or concern are held. • Information helpful to the QRT purpose and responsibilities is
collected.
d. Reviewing information compiled by the SBHO staff during site reviews including Corrective Action Plans.
Recommendations It is the policy of the QRT to fulfill its reportorial responsibilities in a timely manner. The QRT will:
1. Prepare and present written reports, as requested, to the SBHO Executive Board.
2. Prepare and present to the Advisory Board reports of its findings as made. 3. Prepare and present to the SBHO written report of information and findings
relative to materials review within 30 days of said review and as follows:
a. Review findings will be maintained in general confidentiality until they have been submitted to the SBHO and response generated.
b. The SBHO will have thirty (30) days within which to prepare and deliver its
written response.
4. Prepare and present to the SBHO and Advisory Board a written report of provider site visit information and findings as follows:
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Quality Review Team 9.08 Page 5 of 5
a. Information and findings will be maintained in general confidentiality until
they have been submitted to the provider and a response generated; b. Providers will have thirty (30) days within which to prepare and deliver a
written response and/or will follow policies and procedures governing Compliance, Monitoring and Non-Compliance including the fulfillment of Corrective Action Plans as identified in the SBHO Policies and Procedures, which ever is more restrictive.
5. The Chair of the QRT will be responsible for collecting, assessing and reviewing
the information, from which the report is compiled with assistance from the membership, and will compile and deliver legible reports within identified time periods; or may, upon agreement from the membership and the SBHO, delegate such duties to a member of the QRT. Assistance may be afforded by the SBHO.
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QRT Onsite Review Activities 9.08a Page 1 of 2
SBHO Quality Review Team (QRT) Reviews
Pre, On-Site, and Post Review Activities
Pre-Review Activities
1. Available Consumer Satisfaction Surveys -Study of current and past year
2. Available SBHO Ancillary Provider Surveys- Study of current and past year
3. Ombuds reports- shares trends and areas of concern
4. SBHO staff reports-a. summarizes agency strengths and current challengesb. agency performance reports documenting numbers of consumers, by age
groups, minority status, and service hoursc. distributes the most recent agency financial audits submitted to PRSN
5. QRT members- share information about agency services identified from theirindividual advocacy and family/ consumer reports.
6. QRT discuss, identify, and prioritize the providers from the “Optional AncillaryProviders” list.
7. QRT, Ombuds, and SBHO staff set preferred dates for on-site visit.
8. SBHO staff-a. Notifies agency, schedules staff interviews and Clubhouse lunchb. Invites designated Ancillary Providers (from “Standardized” and “Optional” lists),
and schedules interviews with agency Directors or their designated contactc. Reserves a QRT confidential Caucus locationd. Schedules room and meal accommodations for QRT
9. Local QRT member- contacts local NAMI to schedule Family and Consumer Forum
On-Site Activities
1. Family and Consumer Forum
2. Ancillary Provider Interviews
3. Agency Visit and Program/ Services Staff Interviews (includes Entrance Interview)
4. Lunch with consumers at Clubhouse
5. Caucus, Planning for Exit Interview
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QRT Onsite Review Activities 9.08a Page 2 of 2
Post On-Site Report and Recommendations
1. QRT Chair drafts review report, sends report to QRT members for review and comment
2. SBHO staff sends final draft to agency Director for response within 30 days 3. QRT considers agency Director’s comments and prepares a final report. 4. QRT members present the final report to SBHO Advisory Board with copies to
Executive Board, SBHO staff, Ombuds, Network Providers, and the Department. Report is approved and made public information.
(Rev. 8/2016)
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Provider-Subcontractor Non-compliance Penalties 9.09 Page 1 of 2
Policy Name: PROVIDER AND SUBCONTRACTOR NON-COMPLIANCE PENALTIES Policy Number: 9.09
Reference: DSHS and Provider Contract
Effective Date: 8/2004
Revision Date(s): 2/2013; 7/2016
Reviewed Date: 12/2014; 7/2016, 7/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Policy: Correction Action Plan• Policy: Monitoring of Contractors
PURPOSE
It is the policy of the Salish Behavioral Health Organization (SBHO) to promote its mission through assurance of subcontract compliance and to consider the imposition of penalties on providers for noncompliance in accordance with state laws and regulations.
PROCEDURE
1. In the event that a provider or subcontractor fails to provide the SBHO withrequested data, reports, statistics, schedules, or information; or files fraudulentreports; or fails to meet contractual terms, the SBHO may:• Provide a written notice to the provider identifying the area(s) of non-
compliance and specifying redress.• Identify, as appropriate, the specific amount of time within which the provider
may correct the area(s) without penalty.• In the event that the provider does not correct the area(s) within the specified
amount of time, institute any or all of the following actions, under the SBHOcontract with the provider:a. Withholding payment.
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Provider-Subcontractor Non-compliance Penalties 9.09 Page 2 of 2
b. Financial penalties.c. File a request with the Department to consider suspension, revocation,
limitation, or restriction of licensure or certification.• This includes filing a report with the Medicaid Fraud and Control
Unit.d. File a request with the Department to consider refusal to grant licensure or
certification.e. Other SBHO action under chapter 71.24 RCW.
2. The SBHO may deny partial or full funding to providers based solely on findingsof substantial noncompliance with the terms of the provider’s contract.
MONITORING
1. The SBHO will complete an array of monitoring activities for each of itscontracting entities every calendar quarter. Such monitoring activities shall beused to determine current contractor performance and their ability to meetcontractual obligations prior to the close of the contract period. Areas in which acontractor’s performance is substantively lower than expected shall require thesubmission of corrective action plans on the part of the contractor.
2. The SBHO will review and/or conduct on-site monitoring reviews of providercompliance regularly in accordance with the SBHO monitoring schedule, but mayconduct a review outside of that schedule as the SBHO considers appropriate foroversight purposes. The site review will consider any or all areas of contractcompliance.
3. The SBHO may, prior to the date of the monitoring activity report, inform theprovider of any substantial noncompliance, either in the specific or theaggregate, which places the provider at risk of punitive action as noted in (1)above. Any such notification, if verbal, will be followed by a written memorandumgenerated within 36 hours of the verbal notification but which will not replace themonitoring report.
4. The monitoring report will report areas of compliance and those of non-compliance as well as suggestions which may be of assistance to the provider tosupport the SBHO mission.
5. In the event of areas of non-compliance, the report will request a CorrectiveAction Plan (CAP), generated by the provider in response to the report, for eachitem of provider non-compliance. Reference SBHO Corrective Action Plan.
6. The SBHO may deny partial or full funding to contractors and/ or subcontractorsbased solely on findings of substantial noncompliance as outlined within theterms of the contract.
SALISH BHO
PROVIDER MONITORING POLICIES AND PROCEDURES
Corrective Action Plans 9.10 Page 1 of 3
Policy Name: CORRECTIVE ACTION PLANS Policy Number: 9.10
Reference: DSHS and Provider Contract
Effective Date: 7/2005
Revision Date(s): 6/2016
Reviewed Date: 6/2016; 6/2017
Approved by: SBHO Executive Board
CROSS REFERENCES
• Plan: Quality Management Plan• Policy: Provider and Subcontractor Non-Compliance Penalties
PURPOSE
The Salish Behavioral Health Organization (SBHO) monitors contracted agencies according to the monitoring policy. The SBHO shall require contracted providers to develop corrective action plans when a provider is found to not be in compliance with the contract or when other monitored functions and services are found to be deficient.
PROCEDURE
1. Reasons the SBHO may request a Corrective Action Plan (CAP) include, but arenot limited to the following:
• The provider is found to be out of compliance with contract or working agreementrequirements.
• Provider performance is below the standard as outlined in the SBHO QualityManagement Plan
• A trend of sub-standard performance has been identified.
• A problem exists that negatively impacts individuals receiving services.
• The provider has failed to perform any of the contractually required behavioralhealth services.
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Corrective Action Plans 9.10 Page 2 of 3
• The provider has failed to develop, produce, and/or deliver to the SBHO anyrequested statements, reports, data, data corrections, accountings, claims,and/or documentation.
• The provider has failed to implement corrective action required by the SBHOwithin prescribed time frames.
2. Corrective action plans developed by the provider must be submitted for approvalto the SBHO within 30 calendar days of notification.
3. Corrective action plans may require modification of any policies or procedures bythe provider relating to the fulfillment of its contractual obligations.
4. The SBHO may extend or reduce the time allowed for corrective action dependingupon the nature of the situation.
5. Corrective action plans are reviewed by the SBHO, which determines if they areacceptable.
6. The Corrective Action Plan will include:• Date of the Plan• Identified item of non-compliance• Any specified actions specifically required by the SBHO• Any dates specified by the SBHO by which the provider must be compliant• Specific action(s) the provider proposes to bring the item into compliance• Specific goal(s) and/or outcome(s) the provider’s action addresses• Date by which the action(s) will be completed• Date by which the goal(s) and/or outcome(s) will be attained• Proposed documentation evidencing completion of the action(s) and• Attainment of the goal(s)/outcome(s)
7. Performance in the identified area is monitored by the SBHO to determine if thecorrective action plan has been successfully implemented. If compliance and/orperformance continues to be insufficient, the SBHO may:• Require a revised corrective action plan• Offer technical assistance to the provider• Reject the plan• Require the provider to obtain outside technical assistance• Following the corrective action steps included the subcontract, withhold
payments and /or invoke financial penalties8. The SBHO may inform the provider of any substantial noncompliance, which
places the provider at risk of punitive action. Any such notification, if verbal, will befollowed by a written memorandum generated within 36 hours of the verbalnotification.
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Corrective Action Plans 9.10 Page 3 of 3
MONITORING
This policy is a mandated by contract and statute.
1. This policy is monitored through use of SBHO:
• Annual SBHO Provider and Subcontractor Administrative Review
• Quality Management Plan activities, such as review targeted issues fortrends and recommendations
• Annual Provider Chart Reviews
• Review of previous Provider Corrective Action Plans related to policy,including provider profiles related to performance on targeted indicators
2. If a contractor or subcontractor consistently performs below expected standardsduring a contract period, the SBHO has the option of imposing punitive action and/or financial penalties as outlined in the contract.