SOP 508.12-att-4: Audit Tool Scoring Guidelines

SOP 508.12
Attachment 4

6/28/22

# Audit Tool Scoring Guidelines

There are two Audit Tools used in the State. One is the Comprehensive Audit Tool and the other
is known as the Abbreviated Audit Tool. The Comprehensive Audit Tool is used for Self-Audits
and the Central Office audit. The following staff utilizes the Comprehensive Audit Tool:

- Designated State Auditors and

- Unit Managers. (Unit Managers often utilize designated facility staff)

MH Program Development Consultants use the Abbreviated Audit Tool for the Integrated
Treatment Facilities. The Abbreviated Audit Tool contains the most critical items from the
Comprehensive Audit Tool. It is used to rapidly assess the status of our MH programs.

These guidelines are to be used with the:

- State Audit Tool,

- Abbreviated Audit Tool, and

- Audit Tool Scoring Sheet(s).

Four (4) scoring examples are presented below. If you have any questions, please call Carole
Hodnett at 478-445-5855.

EXAMPLE (1):

|Screen|Col2|Col3|Col4|Col5|FC|PC|NC|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|
1. There is a current organizational chart showing reporting lines of authority.
|
1. There is a current organizational chart showing reporting lines of authority.
|
1. There is a current organizational chart showing reporting lines of authority.
|
1. There is a current organizational chart showing reporting lines of authority.
|
1. There is a current organizational chart showing reporting lines of authority.
|
X |
|
|
|
|
|
2. The organizational chart has positions and names of at least core MH/MR staff.
|
2. The organizational chart has positions and names of at least core MH/MR staff.
|
2. The organizational chart has positions and names of at least core MH/MR staff.
|
2. The organizational chart has positions and names of at least core MH/MR staff.
|
2. The organizational chart has positions and names of at least core MH/MR staff.
|
|
X |
|
|
|
||
FC =1|
PC =1|
NC =0|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|
Scorable Items = 2 -#NA/NR =2
Score = (FC x2) + (PC x1) =2 + 1 = 3|

1. Indicate the answer to each screen with a full compliance (FC), partial compliance (PC),
non-compliance (NC), non-applicable (NA), or not rated (NR).
2. Count the number of full compliance (FC), partial compliance (PC), and non-compliance
(NC). Indicate the number of each compliance in the appropriate box.
3. Subtract the number of not-applicable (NA) and not rated (NR) from the number of
screens. This will give you the number of Scorable Items .
4. Multiply the number of full compliant (FC) screens times two (2) and multiply the
number of partial compliance (PC) screens times one (1). Add the full compliance
number to the partial compliance number to get the Score.

Form no. M26.01.04 Page 1 of 3

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

SOP 508.12
Attachment 4

6/28/22

EXAMPLE (2):

|Inmate
ID#s
-------->
Screen
/
/|354657|999867|574635|132435|675564|887799|354212|Col9|908789|576899|433552|
|---|---|---|---|---|---|---|---|---|---|---|---|
|
1.|
FC|
FC|
FC|
PC|
NC|
NC|
NA|
NA|
NR|
FC|
PC|
|
2.|
FC|
FC|
PC|
PC|
PC|
FC|
NA|
NA|
NR|
FC|
FC|
|
3.|
FC|
FC|
FC|
FC|
PC|
PC|
NA|
NA|
NR|
PC|
NC|
|


|


|


|


|
FC =13|
PC =8|
NC =3
|
NC =3
|
Scorable Items = 30 - #NA/NR =30-
6=24
Score = (FC x2) + (PC x1) = 26 + 8=34|
Scorable Items = 30 - #NA/NR =30-
6=24
Score = (FC x2) + (PC x1) = 26 + 8=34|
Scorable Items = 30 - #NA/NR =30-
6=24
Score = (FC x2) + (PC x1) = 26 + 8=34|
Scorable Items = 30 - #NA/NR =30-
6=24
Score = (FC x2) + (PC x1) = 26 + 8=34|

1. Write the inmate ID numbers in the blocks indicated.
2. Next to each screen, indicate if the screen was in full compliance (FC), partial compliance
(PC), non-compliant (NC), not rated (NR), or not applicable (NA).
3. Count the number of full compliance (FC), partial compliance (PC), and non-compliance
(NC). Indicate the number of each compliance in the appropriate box(s).
4. Subtract the number of not-applicable (NA) and not rated (NR) from the number of
screens. This will give you the number of Scorable Items .
5. Multiply the number of full compliant (FC) screens times two (2) and Multiply the
number of partial compliance (PC) screens times one (1). Add the full compliance number
to the partial compliance number to get the score .

Once the Audit tool has been completed, transfer the scores to the Audit Tool Scoring Sheet.

Form no. M26.01.04 Page 2 of 3

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

SOP 508.12
Attachment 4

6/28/22

EXAMPLE (3):

|Domains|Items Reviewed|Full Compliance|Partial Compliance|Non-Compliance|
|---|---|---|---|---|
|
EXAMPLES ONE AND TWO


|
EXAMPLES ONE AND TWO


|
EXAMPLES ONE AND TWO


|
EXAMPLES ONE AND TWO


|
EXAMPLES ONE AND TWO


|
|
Example One|
2 |
2 |
1 |
0 |
|
Example Two|
24|
26|
8 |
3 |
|
Sub-Total|
26|
28|
9 |
3 |

1. Under Items Reviewed, indicate the number of scorable items for each section scored.
2. Indicate the number of full compliance items scored for each section.
3. Indicate the number of partial compliance items scored for each section.
4. The sub- total indicates the total number of items for each section.

EXAMPLE (4):

COMPLIANCE SUMMARY

|Domains|Items Reviewed|Full Compliance|Partial Compliance|Col5|Non-Compliance|
|---|---|---|---|---|---|
|
Sub Total|
26|
28|
9|
9|
3|
|
Overall|
26|
28(54%)|
9(35%)|
9(35%)|
3(11%)|
|
|
|
Total Compliance
|
Total Compliance
|
89%||

1. Record the sub-totals from each area on the scoring sheet.
2. Add each column to get the Overall score. (On the Scoring Tool there are three domains).
Divide the total number of partial compliances by the number of Items reviewed to get
partial compliance percentage.
3. Divide the total number of non-compliance by the number of Items Reviewed to get noncompliance percentage.
4. To get the Total Compliance percentage, add the full and particle compliance
percentage.

Form no. M26.01.04 Page 3 of 3

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