SOP 508.12: Mental Health Audits and Evaluations of Mental Health Services

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|
|Policy Number: 508.12|Effective Date: 6/28/2022|Page Number: 1 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

Central Office Mental Health Services, under the direction of the Office of Health
Services, will maintain the responsibility for auditing or evaluating mental health
care delivery and/or services in Georgia Department of Corrections (GDC) facilities.
This procedure is applicable to all GDC facilities with a mental health mission.

II. Authority:

A. Ga. Comp. R. & Regs. R. 125-1-2-.10;

B. NCCHC Correctional Mental Health Care Standards and Guidelines for

Delivering Services, 2014;

C. NCCHC Standards for Health Services in Juvenile Detention and Confinement

Facilities, 2011; and

D. ACA Standards: 5-ACI-6D-02 (Mandatory) and 4-ALDF-7D-09.

III. Definitions:

None.

IV. Statement of Policy and Applicable Procedures:

A. Central office mental health services will establish a schedule to ensure the

periodic audit and/or evaluation of mental health care delivery and services.
Findings and recommendations will be furnished in writing both to facility
Wardens/Superintendents and other divisional managers as appropriate.

B. Audits and evaluations of mental health care delivery and services will be

conducted using the Attachments to this SOP and incorporate the following:

1. GDC mental health standard operating procedures (SOPs);

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|
|Policy Number: 508.12|Effective Date: 6/28/2022|Page Number: 2 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

2. National Commission on Correctional Health Care, Correctional Mental

Health Care Standards and Guidelines for Delivering Services, and where
applicable, National Commission on Correctional Health Care, Standards for
Health Services in Juvenile Detention and Confinement Facilities;

3. American Correctional Association Standards, operational standards designed

to enhance correctional practices;

4. At applicable facilities, monitoring service and delivery requirements and

performance standards as stated and required in the contract for the delivery
of comprehensive health services;

5. Monitoring compliance with contemporary mental health practices in the

community.

C. The GDC statewide mental health director will determine the frequency of

facility audits.

1. The central office audit team will review each mental health program at

mental health facilities at least every year using either the Mental Health
Comprehensive Audit Tool (M26-01-05) and Comprehensive Audit Tool
Scoring Sheet (M26-01-06) or the Integrated Treatment Facility
Comprehensive Audit Tool (M26-01-07) developed by the statewide mental
health director/designee.

2. Each mental health program will perform one self-audit within six (6) months

of the Comprehensive Audit, using either the Mental Health Comprehensive
Audit Tool (M26-01-05) or the Integrated Treatment Facility Comprehensive
Audit Tool (M26-01-07).

3. Each mental health program will respond to any audit deficiencies (score of

70% or less and/or identified areas of concern) by submitting a Mental Health

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|
|Policy Number: 508.12|Effective Date: 6/28/2022|Page Number: 3 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

Program Audit Corrective Action Plan (M26-01-01) to the statewide mental
health director/designee within one month of:

a. Receiving a mental health audit report from central office; and

b. Completing a self-audit.

D. The Audit Team will be multi-disciplinary, consisting of core members and, as

needed, trained/experienced substitutes/assistants. Large audits will require the
use of additional discipline-specific staff members. Core members include the
following:

1. GDC chief psychologist;

2. Statewide mental health director’s designee(s);

3. Mental health program consultant/program consultant supervisor;

4. Psychologist;

5. Psychiatrist;

6. Mental health nurse;

7. Activity therapist (when applicable); and

8. Mental health vendor representative(s) (as needed).

E. Mental health professionals may be asked to assist with the audit workload

and/or to provide an opportunity for professional development. Participants
outside of the core audit team must:

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|Policy Name: Mental Health Audits and Evaluation~~s ~~of Mental Health Services|
|Policy Number: 508.12|Effective Date: 6/28/2022|Page Number: 4 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

1. Be approved by the statewide mental health director or the GDC chief

psychologist; and

2. Have clinical/administrative experience in a mental health correctional

facility that utilizes GDC SOPs.

V. Attachments:

Attachment 1: Mental Health Program Audit Corrective Action Plan (M26-01-01)
Attachment 2: Documents Needed to Facilitate a Comprehensive Audit (M26-01-02)
Attachment 3: Audit Process Outline (M26-01-03)
Attachment 4: Audit Tool Scoring Guidelines (M26-01-04)
Attachment 5: Mental Health Comprehensive Audit Tool (M26-01-05)
Attachment 6: Comprehensive Audit Tool Scoring Sheet (M26-01-06)
Attachment 7: Integrated Treatment Facility Comprehensive Audit Tool (M26-01-07)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1, 5, 6, and 7 shall be maintained in the mental health
area of the applicable facility, central office Audits and Compliance, and the Office
of Health Services (mental health area) for five (5) years and then destroyed. The
Mental Health Unit Manager shall also maintain a copy of Attachments 5 and 7.
Attachments 2, 3, and 4 shall be utilized in the mental health area until replaced or
obsolete.