SOP 508.12-att-3: Audit Process Outline for Mental Health Administration

SOP 508.12
Attachment 3

6/28/22

Audit Process Outline

I. Administration
A. Organizational Structure

1. Reporting Lines of Authority

- Review current organizational chart to assure each required element is present.
2. Duties

- Review current Performance Management forms to assure each required element is present.
B. Staffing Patterns

1. Staffing
a. Counselor/Offender Ratios (if applicable)

- Review current “MH Caseload by Counselor” report.

- Compare number of offenders assigned to each counselor as indicated on the current “MH
Caseload by Counselor” report to the staffing ratios on page 2 of the audit tool.

- Formula: (offender count) ÷ (offender ratio) = # of counselors needed.
b. Other MH Staff Ratios (if applicable)

Behavior Specialist:

- Review current “MH Caseload Summary” report.

- Determine the ratio by using the following formula. Formula: (offender count) ÷ (offender ratio)
= # of positions needed.
Psychiatrist/APRN:

- Review current “MH Caseload Summary” report.

- Determine the number of work hours needed at this facility by using the following formula.
Formula: (# of hours allotted) ÷ (offender ratio) = # of hours needed.
Psychologist:

- Review current “MH Caseload Summary” report.

- Determine the number of work hours needed at this facility by using the following formula.
Formula: (# of hours allotted) ÷ (offender ratio) = # of hours needed.
MH Nurses:

- Review current “MH Caseload Summary” report.

- Determine the ratio by using the following formula.
Formula: (offender count) ÷ (offender ratio) = # of nurses needed.
2. Credentialing/Privileging

- Review credentialing/privileging files on current employees to assure each required element is
present.
3. Contract Hours (if applicable)

- Review monthly GDC time sheets on all current MHM employees to assure each required
element is present.
4. Staff Meetings

- Review the minutes of weekly staff meetings for eight (8) weeks preceding the audit to assure
each required element is present.
5. On-Call

- Review current on-call roster for the mental health duty officer and duty psychiatrist to assure
each required element is present.
C. Training Programs

1. Weekly Supervision
2. Semi-annual Summary

- Review the clinical supervision file for all current unlicensed Mental Health Counselors,
Behavior Specialists, and MH Nurses to assure each required element is present. Also review the
clinical supervision file for all APRN’s.

Form no. M26-01-03 Page 1 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.

SOP 508.12
Attachment 3

6/28/22

3. Correctional Officer Training

- Review training records of all current Correctional Officers assigned to work the Supportive
Living Unit, Crisis Stabilization Unit, or Acute Care Unit to assure each required element is
present.
4. In-Service Training

- Review the training records of current MH Counselors and Behavior Specialist to assure each
required element is present.
D. Record Maintenance

1. Medical

- Identify medical files to be audited from the “Referral Log.”

- Files to be audited should be files on offenders who were placed on the caseload as a result of
in-house Referrals, Self-Referrals, and/or Segregation/Isolation Referrals.

- Review the medical files, section five, identified to assure each required element is present.
2. Institutional

- Identify institutional files to be audited from the “MH Caseload Summary” report.

- Review the institutional files identified to assure each required element is present.
3. MH Clinical File

- Identify MH Clinical Files to be audited from the “Referral Log.”

- Files to be audited should be files on offenders who were placed on the caseload as a result of
In-House Referrals, Self- Referrals, and/or Segregation/Isolation Referrals.

- Review the Clinical files identified to assure each required element is present.
E. Oversight Procedures

1. SCRIBE
a. SCRIBE Reports

- Review SCRIBE procedures to assure that the following reports can be generated.
b. SCRIBE consistency with Treatment Plans

- Identify Treatment Plans to be reviewed from the most recent “Treatment/Habilitation Plan
Tickler Report.”

- Compare MH Level on the Treatment/Habilitation Plan with SCRIBE MH Level of care.
2. Logs
a. Referral

- Review the “Referral Log” to assure each required element is present.
b. Records Request

- Review the “Records Request Log” to assure each required element is present.
c. Parole Evaluation

- Review the “Parole Evaluation Log” to assure each required element is present.
d. Isolation/Segregation Rounds

- Review the “Isolation/Segregation Rounds Log” to assure each required element is present.
e. Sexual Allegations

- Review the “Sexual Allegations Log” to assure each required element is present.
f. Involuntary Medication Hearing

- Review the “Involuntary Medication Hearing Log” to assure each required element is present.
g. Discharge

- Review the “Discharge Log” to assure each required element is present.
h. Crisis Stabilization Unit

- Review the “Crisis Stabilization Unit Log” to assure each required element is present.

Form no. M26-01-03 Page 2 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.

SOP 508.12
Attachment 3

6/28/22

i. Acute Care Unit

- Review the “Acute Care Unit Log” to assure each required element is present.
j. Due Process Hearing

- Review the “Due Process Hearing Log” to assure each required element is present.
3. Continuous Quality Improvement

- Review CQI minutes and CQI studies schedule for the year to assure compliance.

II. Identification
A. Identifying SMI

1. Evaluations
a. Diagnosis

- Review “Referral Logs” to identify diagnostic offenders in need of MH services.

- Review clinical and medical files to assure each element is present.
b. Initial Psychiatric/Psychological Evaluations

- Review “Referral Logs” to identify offenders who has received an Initial
Psychiatric/Psychological evaluation at the facility being audited.

- Review the clinical files to assure each element is present.
c. MH Services

- Review “Referral Logs” to identify offenders who is receiving MH Services as a result of a
Referral.

- Review the clinical files to assure each element is present.
d. Sexual Abuse

- Review the “Sexual Allegation Log” to identify offenders who was evaluated for alleged sexual
abuse.

- Review Sexual Allegation reports to assure each element is present.
e. Isolation/Segregation

(1) 30/90 day screens

- Review the daily isolation/segregation reports to identify offenders who have been in need of
30/90-day screens during the past six (6) months.

- Review clinical files to assure each element is present.
(2) 48 hour screens

- Review the daily isolation/segregation reports to identify offenders who have been placed in
isolation/segregation during the past six (6) months.

- Review clinical files to assure each element is present.
f. Parole

- Review the “Parole Log” to identify offenders who were evaluated as requested by the Parole
Board.

- Review files to assure each element is present.
g. Disciplinary

(1) Evaluations

- Review Scribe to identify offenders who has received disciplinary evaluations.

- Review clinical files to assure each element is present.
2. Rounds
a. SLU/CSU/ACU

- Review SLU/CSU/ACU and Isolation/Segregation Logs to assure each element is present.

Form no. M26-01-03 Page 3 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.

SOP 508.12
Attachment 3

6/28/22

b. Isolation/Segregation

- Review SCRIBE report to identify offenders who were referred for evaluation during the past
year after being identified with problems during isolation/segregation rounds.

- Review clinical files to assure each element is present.
3. Referrals
a. Routine Referrals

- Review SCRIBE report to identify offenders who were referred as a routine referral.

- Review clinical files to assure each element is present.
b. Self-Referrals

- Review SCRIBE report to identify offenders who were referred as a self-referral.

- Review clinical files to assure each element is present.
c. Emergency Referrals

- Review SCRIBE report to identify offenders who were referred as an emergency referral.

- Review clinical files to assure each element is present.
B. Diagnosing SMI

1. Consistency

- Randomly select ten (10) mental health clinical records.

- Review the records to assure each element on the audit tool is present.
2. Justification

- Randomly select ten (10) mental health clinical records.

- Review the records to assure each element on the audit tool is present.
C. Classifying SMI

1. Consistency

- Review the records of ten (10) Mental Health offenders.

- Review SCRIBE, SCRIBE and Utilization Reviews for consistency.
2. Appropriately Discontinuing Services

- Review the records of ten (10) mental health offenders who have been made Level I within the
past year to assure each element of the audit tool is present.
3. Appropriately Changing Levels of Care

- Review the records of ten (10) mental health offenders whose level of care has been changed
within the past year to assure each element of the audit tool is present.

III. Treatment
A. Direction of Treatment

1. Initial Treatment/Habilitation Plans

- Review “Treatment /Habilitation Plan Tickler File” to identify offenders. (In all facilities other
than Diagnostics, offenders can be identified on the “Referral Log.”)

- Review the clinical files to assure each element of the audit tool is present.
2. Comprehensive Treatment/Habilitation Plans

- Review “Treatment/Habilitation Plan Tickler File” to identify offenders.

- Review the clinical files to assure each element of the audit tool is present.
3. Comprehensive Treatment/Habilitation Plan Reviews

- Review “Treatment/Habilitation Plan Tickler File” to identify offenders.

- Review the clinical files to assure each element of the audit tool is present.
B. Type of Treatment

1. Non-Pharmacological Interventions
a. Group Treatment

Form no. M26-01-03 Page 4 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.

SOP 508.12
Attachment 3

6/28/22

(1) Therapy or Support Groups

- Pull charts of ten (10) offenders who are members of a therapy or support group and match the
attendance logs with the mental health records to assure each element of the audit tool is resent.
(2) Psycho-Educational Groups

- Pull charts of ten (10) offenders who are members of a Psycho-Educational group and match the
attendance logs with the mental health records to assure each element of the audit tool is present.
b. Individual Treatment

- Pull charts of ten (10) offenders who are receiving individual therapy/counseling and match the
attendance logs with the mental health records to assure each element of the audit tool is present.
c. MH Counseling

- Pull charts of ten (10) offenders who are receiving MH Counseling.

- Review the mental health records to assure each element of the audit tool is present.
d. Lockdown Services

- Review the mental health records of mental health offenders who have been locked down for at
least the past two (2) weeks to assure each element of the audit tool is present.
e. Therapeutic Progress

- Identify offenders who are not on medication.

- Review the mental health records to assure each element of the audit tool is present.
f. Interventions for Depression

- Review the “Diagnosis List” and identify offenders who are diagnosed with Depression.

- Review the mental health records to assure each element of the audit tool is present.
2. Pharmacological Interventions
a. Medication Non-Adherence

(1) Statistics

- Review medication Non-Adherence statistics to assure each element of the audit tool is present.
(2) Non-Adherence Documentation

- Identify ten (10) offenders who have been non-adherent with medication.

- Review the mental health records to assure each element of the audit tool is present.
b. Quantitative Issues

- Review medical records of ten (10) offenders who are on medication.

- Assure each element of the audit tool is present.
c. Qualitative Issues

- Review ten (10) files of offenders who are on medication.

- Assure each element of the audit tool is present.
d. Laboratory Follow-up

(1) Antipsychotic medications

- Pull ten (10) charts of offenders with current prescriptions for Antipsychotic medications.

- Assure each element of the audit tool is present.
(2) Tegretol

- Pull ten (10) charts of offenders with current prescriptions for Tegretol.

- Assure each element of the audit tool is present.
(3) Lithium

- Pull ten (10) charts of offenders with current prescriptions for Lithium.

- Assure each element of the audit tool is present.
(4) Valproic Acid

- Pull ten (10) charts of offenders with current prescriptions for Valproic Acid.

- Assure each element of the audit tool is present.

Form no. M26-01-03 Page 5 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.

SOP 508.12
Attachment 3

6/28/22

(5) Benzodiazepines

- Pull ten (10) charts of offenders with current prescriptions for Benzodiazepines.

- Assure each element of the audit tool is present.
e. Heat Education

- Interview MH Nurses, offenders and review files to assure each element of the audit tool is
present.
f. Heat Monitoring

- Interview offenders, review temperature logs, and view housing thermostats to assure each
element of the audit tool is present.
3. Out Patient Services
a. General Population Integration

- Ask the OA to pull TOPs report for mental health offenders.

- Review the number of mental health offenders in general population groups, education/vocation
trades, and on work details.

- Assure each element of the audit tool is present.
b. Group Roster and Treatment Plan Congruence

- Pull charts of ten (10) mental health offenders who are members of a therapy, support, and/or
psychoeducational group.

- Assure each element of the audit tool is present.
4. SLU Services
a. Support Living Unit Programming

- Review and confirm SLU offenders, SCRIBE schedules and treatment plans.

- Assure each element of the audit tool is present.
b. Community Meetings

- Assure each element of the audit tool is present.
5. Stabilization Services
a. Acute Care Unit

- Review the “Acute Care Unit Log” to identify ten (10) offenders who were placed in the Acute
Care Unit.

- Review files to assure each element of the audit tool is present.
b. Crisis Stabilization Unit

- Review the “Crisis Stabilization Unit Log” to identify ten (10) offenders who were placed in the
Crisis Stabilization Unit.

- Review files to assure each element of the audit tool is present.
d. Restraints

- Review the “Crisis Stabilization Unit Log” to identify ten (10) offenders who were placed in
restraints.

- Review files to assure each element of the audit tool is present.
e. Involuntary Medication

- Review the “Involuntary Medication Hearing Log” to identify offenders who were involuntary
medicated.

- Review files to assure each element of the audit tool is present.
f. Emergency Involuntary Medication

- Identify offenders who were administered emergency involuntary medications.

- Review files to assure each element of the audit tool is present.

Form no. M26-01-03 Page 6 of 6

Retention Schedule: This form shall be utilized in the mental health area until replaced or obsolete.