SOP_NUMBER: 508.12-att-2
TITLE: Documents Needed to Facilitate a Comprehensive Audit
REFERENCE_CODE: VG26-0001
DIVISION: Mental Health Administration
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-06-28
WORD_COUNT: 702
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429697
URL: https://gps.press/sop-data/508.12-att-2/

SUMMARY:
This attachment is a checklist of documents that GDC mental health departments must compile and provide during comprehensive audits. It specifies what documents are needed (such as credentialing files, training records, logs, and clinical files), the timeframe for which they should cover, and which facilities must provide them. The list ensures auditors can review staffing credentials, treatment planning, medication management, and quality improvement activities across all GDC facilities.

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

ATTACHMENTS:
  2. Documents Needed to Facilitate a Comprehensive Audit
     URL: https://gps.press/sop-data/508.12-att-2/
  3. Audit Process Outline for Mental Health Administration
     URL: https://gps.press/sop-data/508.12-att-3/
  4. Audit Tool Scoring Guidelines
     URL: https://gps.press/sop-data/508.12-att-4/
  5. Mental Health Comprehensive Audit Tool
     URL: https://gps.press/sop-data/508.12-att-5/
  6. Comprehensive Audit Tool Scoring Sheet
     URL: https://gps.press/sop-data/508.12-att-6/
  7. Integrated Treatment Facility (ITF) Comprehensive Audit Tool
     URL: https://gps.press/sop-data/508.12-att-7/

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FULL TEXT:
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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|
|<br> <br>Credentialing Files|Current Mental Health Counselors, Behavior<br>Specialist, Activity Therapist, Mental Health<br>Nurses, Secretaries/Clerks, Licensed Master’s<br>Clinicians, Psychiatrist, Psychologist, CNS, Unit<br>Director|<br> <br>All Facilities|
|<br>Privileging Files|Current Mental Health Counselors and Behavior<br>Specialists|<br>All Facilities|
|Minutes of Mental Health Staff<br>Meetings|<br>Since last audit to present time|<br>All Facilities|
|On-call roster for the Mental Health<br>Duty Officer|<br>Current|<br>All Facilities|
|On-call Logbook|Current|All Facilities|
|<br>Consultation/Supervision Files|Current Mental Health Counselors, Behavior<br>Specialists, Mental Health Nurses, Activity<br>Therapist|<br>All Facilities|
|<br>Training Records|Current Correctional Officers assigned to work<br>Supportive Living Units, Crisis Stabilization<br>Units and/or Acute Care Units|All Facilities with Supportive<br>Living Units, Crisis Stabilization<br>Units and/or Acute Care Units|
|Training Records to include:<br>       Mental Health Training<br>       Ethics Training and<br>       In-Service Training|Current Mental Health Counselors and Behavior<br>Specialist|<br> <br>All Facilities|
|Mental Health Caseload Summary|Current|All Facilities|
|Mental Health Caseload Summary by<br>Counselor|<br>Current|<br>All Facilities|
|Mental Health Offenders by Diagnosis<br>and Level of Care|<br>Current|<br>All Facilities|
|Psychiatrists and Clinical Nurse<br>Specialists Schedules|Eight (8) weeks preceding the audit|<br>All Facilities|
|<br>Psychologist Schedules|Eight (8) weeks preceding the audit|<br>All Facilities|
|Treatment/Habilitation Plan Tickler<br>Report|Current and the month preceding the audit|<br>All Facilities|
|Daily Lock-Down<br>(Isolation/Segregation) Report|Current and the month preceding the audit|<br>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|
|<br>        Crisis Stabilization|<br>Since last audit to present time|Facilities with Crisis Stabilization<br>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<br>|
|Observation Cell<br>|Since last audit to present time|Facilities with 2~~nd~~ Tier Cells|
|1~~st~~ Tier Isolation/Segregation<br>         Cell|<br>Since last audit to present time|<br>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<br>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<br>Health Records)|<br>Since last audit to present time|<br>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<br>name who have been non-adherent<br>with medication|<br>Current and month preceding the audit|<br> <br>All Facilities|
|Sexual Allegation Reports|Since last audit to present time|All Facilities|
|Parole Evaluations|Since last audit to present time|All Facilities|
|<br>Certificate of Approval|<br>Current|All Facilities with observation or<br>ACU/CSU cells|
|Monthly Report|Current|All Facilities|
|Self-Audit|Current|All Facilities|
|CQI Studies and Schedule|For past calendar year|All Facilities|
|<br>Copies of entries made by Mental<br>Health Staff in SLU/CSU/ACU log|<br>Twelve weeks preceding the audit|All Facilities with Supportive<br>Living Units, Crisis Stabilization<br>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<br>medications from the pharmacist:<br>      Antipsychotic Medication<br>      Tricyclic Antidepressants<br>      Tegretol<br>      Lithium<br>      Valproic Acid<br>      Benzodiazepines|<br> <br> <br> <br> <br> <br> <br>Current|<br> <br> <br> <br> <br> <br> <br>All Facilities|
|Medical files of offenders on the<br>following medications:<br>      Antipsychotic Medication<br>      Tricyclic Antidepressants<br>      Tegretol<br>      Lithium<br>      Valproic Acid<br>      Benzodiazepines|<br> <br> <br> <br> <br> <br> <br>Current|<br> <br> <br> <br> <br> <br> <br>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.