SOP 508.12-att-2: Documents Needed to Facilitate a Comprehensive Audit
Summary
Key Topics
- mental health audit
- documentation requirements
- credentialing files
- privileging files
- training records
- mental health staff meetings
- psychiatric schedules
- treatment plans
- medication logs
- isolation records
- clinical files
- quality improvement
- mental health caseload
- offender diagnosis
- activity therapy
- parole evaluations
Full Text
SOP 508.12
Attachment 2
6/28/22
|Documents Needed to Facilitate a Comprehensive Audit|Col2|Col3|
|---|---|---|
|Needed Documents|Time Frame|Applicable Facilities|
|Organizational Chart|Current|All Facilities|
|
Credentialing Files|Current Mental Health Counselors, Behavior
Specialist, Activity Therapist, Mental Health
Nurses, Secretaries/Clerks, Licensed Master’s
Clinicians, Psychiatrist, Psychologist, CNS, Unit
Director|
All Facilities|
|
Privileging Files|Current Mental Health Counselors and Behavior
Specialists|
All Facilities|
|Minutes of Mental Health Staff
Meetings|
Since last audit to present time|
All Facilities|
|On-call roster for the Mental Health
Duty Officer|
Current|
All Facilities|
|On-call Logbook|Current|All Facilities|
|
Consultation/Supervision Files|Current Mental Health Counselors, Behavior
Specialists, Mental Health Nurses, Activity
Therapist|
All Facilities|
|
Training Records|Current Correctional Officers assigned to work
Supportive Living Units, Crisis Stabilization
Units and/or Acute Care Units|All Facilities with Supportive
Living Units, Crisis Stabilization
Units and/or Acute Care Units|
|Training Records to include:
Mental Health Training
Ethics Training and
In-Service Training|Current Mental Health Counselors and Behavior
Specialist|
All Facilities|
|Mental Health Caseload Summary|Current|All Facilities|
|Mental Health Caseload Summary by
Counselor|
Current|
All Facilities|
|Mental Health Offenders by Diagnosis
and Level of Care|
Current|
All Facilities|
|Psychiatrists and Clinical Nurse
Specialists Schedules|Eight (8) weeks preceding the audit|
All Facilities|
|
Psychologist Schedules|Eight (8) weeks preceding the audit|
All Facilities|
|Treatment/Habilitation Plan Tickler
Report|Current and the month preceding the audit|
All Facilities|
|Daily Lock-Down
(Isolation/Segregation) Report|Current and the month preceding the audit|
All Facilities|
|Logs:|||
|Referrals|Since last audit to present time|All Facilities|
|Records Request|Since last audit to present time|All Facilities|
|Parole|Since last audit to present time|All Facilities|
|Isolation/Segregation Rounds|Since last audit to present time|All Facilities|
|Sexual Allegation|Since last audit to present time|All Facilities|
|Involuntary Medication Hearings|Since last audit to present time|Level III/IV/V Facilities|
|Discharge|Since last audit to present time|All Facilities|
|Transfer|Since last audit to present time|All Facilities|
|
Crisis Stabilization|
Since last audit to present time|Facilities with Crisis Stabilization
Units|
|Acute Care|Since last audit to present time|Facilities with Acute Care Units|
|Diagnostic Referral|Since last audit to present time|Diagnostic Facilities and PDC’s
|
|Observation Cell
|Since last audit to present time|Facilities with 2~~nd~~ Tier Cells|
|1~~st~~ Tier Isolation/Segregation
Cell|
Since last audit to present time|
All Facilities|
Form no. M26-01-02 Page 1 of 2
Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.
SOP 508.12
Attachment 2
6/28/22
|Documents needed to Facilitate a Comprehensive Audit
Page Two|Col2|Col3|
|---|---|---|
|Needed Documents|Time Frame|Applicable Facilities|
|SP2 Log|Since last audit to present time|All Facilities|
|SP1 Log|Since last audit to present time|All Facilities|
|Activity Therapy Group Log|Since last audit to present time|Level III and above Facilities|
|Physical Inventory Log (Mental
Health Records)|
Since last audit to present time|
All Facilities|
|CQI Studies Schedule|Current|All Facilities|
|CQI Meeting Minutes|Since last audit to present time|All Facilities|
|Group Rosters|Current|All Facilities|
|Group printout(s)|Current|All Facilities|
|Group Attendance Logs|Current|All Facilities|
|List of Mental Health Offenders by
name who have been non-adherent
with medication|
Current and month preceding the audit|
All Facilities|
|Sexual Allegation Reports|Since last audit to present time|All Facilities|
|Parole Evaluations|Since last audit to present time|All Facilities|
|
Certificate of Approval|
Current|All Facilities with observation or
ACU/CSU cells|
|Monthly Report|Current|All Facilities|
|Self-Audit|Current|All Facilities|
|CQI Studies and Schedule|For past calendar year|All Facilities|
|
Copies of entries made by Mental
Health Staff in SLU/CSU/ACU log|
Twelve weeks preceding the audit|All Facilities with Supportive
Living Units, Crisis Stabilization
Units, and/or Acute Care Units|
|Re-Entry Forms|Since last audit to present time|All Facilities|
|Non-Adherence Status|Since last audit to present time|All Facilities|
|List of offenders on the following
medications from the pharmacist:
Antipsychotic Medication
Tricyclic Antidepressants
Tegretol
Lithium
Valproic Acid
Benzodiazepines|
Current|
All Facilities|
|Medical files of offenders on the
following medications:
Antipsychotic Medication
Tricyclic Antidepressants
Tegretol
Lithium
Valproic Acid
Benzodiazepines|
Current|
All Facilities|
Individual Clinical and Medical files will be requested at the time of the audit. Other
documentation (not listed above) is subject to be requested for review.
Form no. M26-01-02 Page 2 of 2
Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.