SOP_NUMBER: 508.12-att-4
TITLE: Audit Tool Scoring Guidelines
REFERENCE_CODE: VG26-0001
DIVISION: Mental Health Administration
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-06-28
WORD_COUNT: 945
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429708
URL: https://gps.press/sop-data/508.12-att-4/

SUMMARY:
This document provides instructions for scoring mental health program audits using two audit tools: the Comprehensive Audit Tool (used for self-audits and central office audits) and the Abbreviated Audit Tool (used for rapid assessments of integrated treatment facilities). It explains how to rate audit items as fully compliant, partially compliant, non-compliant, not applicable, or not rated, and demonstrates how to calculate compliance scores and percentages through four detailed examples.

KEY_TOPICS: audit tool, scoring guidelines, comprehensive audit tool, abbreviated audit tool, compliance rating, full compliance, partial compliance, non-compliance, audit scoring, mental health program audit, facility audit, scorable items, compliance percentage, audit example

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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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|
|---|---|---|---|---|---|---|---|---|---|
|<br>1.  There is a current organizational chart showing reporting lines of authority.  <br>|<br>1.  There is a current organizational chart showing reporting lines of authority.  <br>|<br>1.  There is a current organizational chart showing reporting lines of authority.  <br>|<br>1.  There is a current organizational chart showing reporting lines of authority.  <br>|<br>1.  There is a current organizational chart showing reporting lines of authority.  <br>|<br>**X **|<br>|<br>|<br>|<br>|
|<br>2.  The organizational chart has positions and names of at least core MH/MR staff.  <br>|<br>2.  The organizational chart has positions and names of at least core MH/MR staff.  <br>|<br>2.  The organizational chart has positions and names of at least core MH/MR staff.  <br>|<br>2.  The organizational chart has positions and names of at least core MH/MR staff.  <br>|<br>2.  The organizational chart has positions and names of at least core MH/MR staff.  <br>|<br>|<br>**X **|<br>|<br>|<br>|
||<br>**FC =1**|<br>**PC =1**|<br>**NC =0**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**Score = (FC x2) + (PC x1) =2 + 1 = 3**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**Score = (FC x2) + (PC x1) =2 + 1 = 3**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**Score = (FC x2) + (PC x1) =2 + 1 = 3**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**Score = (FC x2) + (PC x1) =2 + 1 = 3**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**Score = (FC x2) + (PC x1) =2 + 1 = 3**|<br>**Scorable Items = 2 -#NA/NR =2** <br>**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<br>ID#s<br>--------><br>Screen<br>/<br>/|354657|999867|574635|132435|675564|887799|354212|Col9|908789|576899|433552|
|---|---|---|---|---|---|---|---|---|---|---|---|
|<br>1.|<br>**FC**|<br>**FC**|<br>**FC**|<br>**PC**|<br>**NC**|<br>**NC**|<br>**NA**|<br>**NA**|<br>**NR**|<br>**FC**|<br>**PC**|
|<br>2.|<br>**FC**|<br>**FC**|<br>**PC**|<br>**PC**|<br>**PC**|<br>**FC**|<br>**NA**|<br>**NA**|<br>**NR**|<br>**FC**|<br>**FC**|
|<br>3.|<br>**FC**|<br>**FC**|<br>**FC**|<br>**FC**|<br>**PC**|<br>**PC**|<br>**NA**|<br>**NA**|<br>**NR**|<br>**PC**|<br>**NC**|
|<br> <br> <br>|<br> <br> <br>|<br> <br> <br>|<br> <br> <br>|<br>**FC =13**|<br>**PC =8**|<br>**NC =3** <br>|<br>**NC =3** <br>|<br>**Scorable Items = 30 - #NA/NR =30-** <br>**6=24** <br>**Score = (FC x2) + (PC x1) = 26 + 8=34**|<br>**Scorable Items = 30 - #NA/NR =30-** <br>**6=24** <br>**Score = (FC x2) + (PC x1) = 26 + 8=34**|<br>**Scorable Items = 30 - #NA/NR =30-** <br>**6=24** <br>**Score = (FC x2) + (PC x1) = 26 + 8=34**|<br>**Scorable Items = 30 - #NA/NR =30-** <br>**6=24** <br>**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|
|---|---|---|---|---|
|<br>**EXAMPLES ONE AND TWO** <br> <br> <br>|<br>**EXAMPLES ONE AND TWO** <br> <br> <br>|<br>**EXAMPLES ONE AND TWO** <br> <br> <br>|<br>**EXAMPLES ONE AND TWO** <br> <br> <br>|<br>**EXAMPLES ONE AND TWO** <br> <br> <br>|
|<br>**Example One**|<br>**2 **|<br>**2 **|<br>**1 **|<br>**0 **|
|<br>**Example Two**|<br>**24**|<br>**26**|<br>**8 **|<br>**3 **|
|<br>**Sub-Total**|<br>**26**|<br>**28**|<br>**9 **|<br>**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|
|---|---|---|---|---|---|
|<br>**Sub Total**|<br>26|<br>28|<br>9|<br>9|<br>3|
|<br>**Overall**|<br>26|<br>28(54%)|<br>9(35%)|<br>9(35%)|<br>3(11%)|
|<br>|<br>|<br>**Total Compliance**  <br>|<br>**Total Compliance**  <br>|<br>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.