SOP_NUMBER: 508.12-att-5
TITLE: Mental Health Comprehensive Audit Tool
REFERENCE_CODE: VG26-0001
DIVISION: Behavioral Health
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-06-28
WORD_COUNT: 16295
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/914078
URL: https://gps.press/sop-data/508.12-att-5/
SUMMARY:
This audit tool is used to evaluate mental health program compliance across multiple areas including staffing credentials, privileging files, clinical supervision, and training programs. The tool applies to all GDC facilities with mental health units and assesses whether core mental health staff (psychologists, psychiatrists, APRNs, nurses, counselors, technicians, and behavior specialists) meet required credentialing, licensing, and supervisory standards. Auditors use a scoring system (full compliance, partial compliance, non-compliance) to measure facility adherence to mental health operational standards.
KEY_TOPICS: mental health audit, credentialing files, privileging files, clinical supervision, staff certification, mental health licensing, APRN supervision, psychologist consultation, mental health nurses, behavior specialists, clinical competency, audit scoring, facility compliance
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 5
6/28/22
**Mental Health Comprehensive Audit Tool**
**I.** **ADMINISTRATION**
**A.** **Staffing Patterns**
**1.** **Credentialing Files (508.04)**
Review the credentialing file for core employees, to include GDC and contract employees (mental health
unit manager, clinical director, psychologists, psychiatrists, APRNs, mental health nurses, counselors,
mental health technicians, behavior specialists, activity therapists).
|Staff
Names
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
|
|
|
|
||||
|
|||||
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. The employee has a credentialing file.
Screen 2. All required credentialing documents are present and current, e.g., license, degree, board certificate, DEA
certificate, CPR card (Basic Life Support health care provider from American Heart Association or Red Cross
only), current CE verification consistent with licensure, current annual psychopharmacological training for
APRNs, verification of peer review for upper-level providers, and vitae/state application as appropriate.
Screen 3. If tele-psychiatry/psychology is provided, there is evidence (via initial evaluations, progress notes, or transfer
evaluations) of the provider being on-site once within the past 6 months.
Screen 4. A protocol which is signed by the APRN and supervising psychiatrist is present.
Screen 5. There is documentation in the credentialing file that APRN records were reviewed by a psychiatrist quarterly.
Auditor’s Signature/Title: ______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 1 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**2.** **Privileging Files (508.04)**
Review the privileging files for current mental health counselors, technicians, and behavior specialists.
|Staff
Names
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
|
|
|
|
||||
|
|||||
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scoreable Items = 30 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scoreable Items = 30 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scoreable Items = 30 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scoreable Items = 30 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scoreable Items = 30 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. This counselor/technician or behavior specialist has a privileging form.
Screen 2. The privileging form is completed annually, is current for counselors/technician or behavior specialists, and is
signed by an upper level provider.
Screen 3. The staff member is privileged to perform only those clinical functions for which they are credentialed.
Auditor’s Signature/Title: ______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 2 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**B.** **Training Programs (508.07 / 508.08)**
**1.** **Clinical Supervision/Consultation (508.07)**
Review the consultation files for mental health nurses and activity therapists, and the supervision files for
unlicensed counselors/technicians and behavior specialists.
|Staff
Names
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
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|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|
|
|
|
|
||||
|
|||||
|**FC =**|**FC =**|**PC =**|**PC =**|**NC=**|**NC=**|**NC=**|**Scorable Items = 70 - #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 70 - #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 70 - #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 70 - #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 70 - #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is a supervision file for an unlicensed counselor/technician, behavior specialist, or a consultation file
for an activity therapist or mental health nurse.
Screen 2. There is documentation that the unlicensed counselor/technician received clinical supervision at least three
(3) hours per month from a psychologist, that the activity therapist received one (1) hour per month of
consultation from a psychologist/designee, or that the mental health nurse received consultation at least
one (1) hour per month from a psychiatrist or APRN (if conducting a mental health-related group, the
mental health nurse also receives consultation from a psychologist) _._
Screen 3. The supervision/consultation form documents the date plus beginning and end times for each session.
Screen 4. The supervision/consultation form documents relevant clinical issues and names (with ID numbers) of
offenders/cases discussed.
Screen 5. The supervision form documents the unlicensed counselor’s clinical strengths and limitations _/_ areas for
development.
Screen 6. There is a current semi-annual report for clinical supervision on the unlicensed counselor/technician and
behavioral specialist.
Screen 7. There is documentation that the activity therapist, unlicensed counselor/technician, or mental health nurse
attended at least four (4) of the last six (6) monthly case conferences.
Auditor’s Signature/Title: ___________________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 3 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
|B. Training Programs (508.08) 2. Group Case Conference|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**|**Screen**|**Screen**|**Screen**|**FC**|**PC**
|**PC**
|**NC**|**NA**|**NR**|
|1. A file is maintained by the clinical director that documents monthly one
hour case conferences for mental health staff.|1. A file is maintained by the clinical director that documents monthly one
hour case conferences for mental health staff.|1. A file is maintained by the clinical director that documents monthly one
hour case conferences for mental health staff.|1. A file is maintained by the clinical director that documents monthly one
hour case conferences for mental health staff.||
|
||||
|2. There is documentation that the case conference was led by
a psychologist/psychiatrist/APRN.|2. There is documentation that the case conference was led by
a psychologist/psychiatrist/APRN.|2. There is documentation that the case conference was led by
a psychologist/psychiatrist/APRN.|2. There is documentation that the case conference was led by
a psychologist/psychiatrist/APRN.||
|
||||
|3. There is documentation of monthly attendance by counselors
(licensed and unlicensed)/technicians, behavior specialists,
activity therapists, mental health nurses and multifunctional
correctional officer (MFCO).|3. There is documentation of monthly attendance by counselors
(licensed and unlicensed)/technicians, behavior specialists,
activity therapists, mental health nurses and multifunctional
correctional officer (MFCO).|3. There is documentation of monthly attendance by counselors
(licensed and unlicensed)/technicians, behavior specialists,
activity therapists, mental health nurses and multifunctional
correctional officer (MFCO).|3. There is documentation of monthly attendance by counselors
(licensed and unlicensed)/technicians, behavior specialists,
activity therapists, mental health nurses and multifunctional
correctional officer (MFCO).||
|
||||
|4. There is documentation of the names and numbers of offenders/cases
discussed as well as relevant clinical issues.|4. There is documentation of the names and numbers of offenders/cases
discussed as well as relevant clinical issues.|4. There is documentation of the names and numbers of offenders/cases
discussed as well as relevant clinical issues.|4. There is documentation of the names and numbers of offenders/cases
discussed as well as relevant clinical issues.||
|
||||
|5. There is documentation of treatment team(s) and they are occurring
on a regular basis and are inter-disciplinary in composition.
|5. There is documentation of treatment team(s) and they are occurring
on a regular basis and are inter-disciplinary in composition.
|5. There is documentation of treatment team(s) and they are occurring
on a regular basis and are inter-disciplinary in composition.
|5. There is documentation of treatment team(s) and they are occurring
on a regular basis and are inter-disciplinary in composition.
||
|
||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 5 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 5 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 5 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**
|**Compliance Score**
**= %**
|**Compliance Score**
**= %**
|**Compliance Score**
**= %**
|
Auditor’s Signature/Title:______________________________________________________________
**3.** **In-Service Training (508.08)**
Review the training records of ten (10) MHCs/technicians, behavior specialists, MH nurses, ATs and MFCOs.
|Staff
Names
Screen
1.|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|**Staff**
**Names**
**Screen**
1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
|
|
|
|
||||
|
|||||
|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 50 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. There is documentation that the counselor/technician, behavior specialist, mental health nurse, activity therapist or
multifunctional correctional officer has completed the mandatory 3-day mental health training or is scheduled to attend an
upcoming session of the mandatory 3-day mental health training.
Screen 2. There is documentation that the counselor/technician, behavior specialist, mental health nurse, activity therapist or
multifunctional correctional officer has completed a minimum of two (2) hours of GDC/vendor-sponsored training (mental
health monthly in-service or annual) in ethics within the past year.
Screen 3. There is documentation that the counselor/technician, behavior specialist, mental health nurse, activity therapist or
multifunctional correctional officer has completed a minimum of two (2) hours of GDC/vendor-sponsored training (mental
health monthly in-service or annual) in suicide awareness within the past year.
Screen 4. There is documentation that the counselor/technician, behavior specialist, mental health nurse, activity therapist or
multifunctional correctional officer has completed at least two (2) hours of in-service training each month for at least four (4)
of the last six (6) months.
Screen 5. There is documentation that the multifunctional correctional officer has completed the initial correctional counselor training.
Auditor’s Signature/Title: __________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 4 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**C.** **Record Maintenance**
**1.** **Mental Health Clinical Files (Security, Confidentiality, and Organization) (508.09 / 508.10)**
|Screen|Col2|Col3|Col4|FC|PC|NC|NA|NR|
|---|---|---|---|---|---|---|---|---|
|1. Mental health records are maintained in a central, restricted
and secure location.|1. Mental health records are maintained in a central, restricted
and secure location.|1. Mental health records are maintained in a central, restricted
and secure location.|1. Mental health records are maintained in a central, restricted
and secure location.||||||
|2. There is an established system for checking out mental
health records which is monitored by a mental health staff
person (clerical when available) who is responsible for
checking out records and ensuring their return by the close
of business each day.|2. There is an established system for checking out mental
health records which is monitored by a mental health staff
person (clerical when available) who is responsible for
checking out records and ensuring their return by the close
of business each day.|2. There is an established system for checking out mental
health records which is monitored by a mental health staff
person (clerical when available) who is responsible for
checking out records and ensuring their return by the close
of business each day.|2. There is an established system for checking out mental
health records which is monitored by a mental health staff
person (clerical when available) who is responsible for
checking out records and ensuring their return by the close
of business each day.||||||
|3. Mental health records are released to third parties only after
the receipt of a valid Release of Information form signed by
the offender. (Check one mental health record. Section 5.)|3. Mental health records are released to third parties only after
the receipt of a valid Release of Information form signed by
the offender. (Check one mental health record. Section 5.)|3. Mental health records are released to third parties only after
the receipt of a valid Release of Information form signed by
the offender. (Check one mental health record. Section 5.)|3. Mental health records are released to third parties only after
the receipt of a valid Release of Information form signed by
the offender. (Check one mental health record. Section 5.)||||||
|4. A physical inventory (form M20-01-04) of all mental health
records is taking place at least monthly with the results
forwarded to the mental health unit manager.|4. A physical inventory (form M20-01-04) of all mental health
records is taking place at least monthly with the results
forwarded to the mental health unit manager.|4. A physical inventory (form M20-01-04) of all mental health
records is taking place at least monthly with the results
forwarded to the mental health unit manager.|4. A physical inventory (form M20-01-04) of all mental health
records is taking place at least monthly with the results
forwarded to the mental health unit manager.||||||
|5. Mental health providers review the limits of confidentiality
with offenders and place a signed copy of the Consent for
Mental Health Evaluation for Treatment Form in section 5
of the offender's mental health record. (review 10 files)|5. Mental health providers review the limits of confidentiality
with offenders and place a signed copy of the Consent for
Mental Health Evaluation for Treatment Form in section 5
of the offender's mental health record. (review 10 files)|5. Mental health providers review the limits of confidentiality
with offenders and place a signed copy of the Consent for
Mental Health Evaluation for Treatment Form in section 5
of the offender's mental health record. (review 10 files)|5. Mental health providers review the limits of confidentiality
with offenders and place a signed copy of the Consent for
Mental Health Evaluation for Treatment Form in section 5
of the offender's mental health record. (review 10 files)||||||
|6. Mental health records are organized into eight (8) sections
(nine (9) at the Integrated Treatment Facilities (ITFs) and
documents are filed in the appropriate sections. (review 10
files)
|6. Mental health records are organized into eight (8) sections
(nine (9) at the Integrated Treatment Facilities (ITFs) and
documents are filed in the appropriate sections. (review 10
files)
|6. Mental health records are organized into eight (8) sections
(nine (9) at the Integrated Treatment Facilities (ITFs) and
documents are filed in the appropriate sections. (review 10
files)
|6. Mental health records are organized into eight (8) sections
(nine (9) at the Integrated Treatment Facilities (ITFs) and
documents are filed in the appropriate sections. (review 10
files)
||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 5 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**C.** **Records Maintenance**
**2.** **Duty Officer Logbook (508.05)**
Review the records of ten (10) mental health offenders who have had an entry documented in the mental
health duty officer’s logbook within the past year.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
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|2.
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|3.
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|4.
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|5.
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|6.
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|7.
|
|
|
|
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|||||
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR=**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR=**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR=**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR=**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR=**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is a complete entry for every after-hour clinical call (date, time of call, location, action taken, etc.).
Screen 2. The offender(s) is/are identified by name, GDC number, mental health level and demographic information
and STG (if applicable or known).
Screen 3. There is a corresponding DAP note in the mental health record for all after hour clinical calls.
Screen 4. The corresponding DAP note includes all identifying data (date, time of call, action taken, persons
Notified, etc.)
Screen 5. The progress note provided a concise narrative of significant information.
Screen 6. The appropriate clinical action was taken _._
Screen 7. There is evidence (initial/signature) of a weekly review of the duty officer logbook by the mental health unit
manager/lead counselor.
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 6 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**D.** **Oversight Procedures**
**1.** **Scribe Reports**
Documents presented for the audit include (Scribe procedures to assure that the following reports can
be generated):
|Screen|Col2|Col3|Col4|FC|PC|Col7|NC|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. The mental health caseload summary.|1. The mental health caseload summary.|1. The mental health caseload summary.|1. The mental health caseload summary.||
|
|
|||
|2. The mental health caseload by counselor/technician.|2. The mental health caseload by counselor/technician.|2. The mental health caseload by counselor/technician.|2. The mental health caseload by counselor/technician.||
|
|
|||
|3. The offender by diagnosis list and level of care.|3. The offender by diagnosis list and level of care.|3. The offender by diagnosis list and level of care.|3. The offender by diagnosis list and level of care.||
|
|
|||
|4. The psychiatrists’/APRN’s schedules.|4. The psychiatrists’/APRN’s schedules.|4. The psychiatrists’/APRN’s schedules.|4. The psychiatrists’/APRN’s schedules.||
|
|
|||
|5. The psychologists’ schedules.|5. The psychologists’ schedules.|5. The psychologists’ schedules.|5. The psychologists’ schedules.||
|
|
|||
|6. The Scribe mental health level is consistent with the most recent
treatment pla~~ns.~~|6. The Scribe mental health level is consistent with the most recent
treatment pla~~ns.~~|6. The Scribe mental health level is consistent with the most recent
treatment pla~~ns.~~|6. The Scribe mental health level is consistent with the most recent
treatment pla~~ns.~~||
|
|
|||
|7. There is a suicide precautions (SP) profile list generated from Scribe.
|7. There is a suicide precautions (SP) profile list generated from Scribe.
|7. There is a suicide precautions (SP) profile list generated from Scribe.
|7. There is a suicide precautions (SP) profile list generated from Scribe.
||
|
|
|||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 7 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 7 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 7 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 7 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**D. Oversight Procedures (508.19)**
**2.** **Logs**
Review each log to assure the required elements are present and the state approved log is utilized.
Referral Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Record Request Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Parole and Evaluation Log
|Screen
1. Each required element is present on the state-approved log form.|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**
1. Each required element is present on the state-approved log form.
|**Screen**
1. Each required element is present on the state-approved log form.
|**Screen**
1. Each required element is present on the state-approved log form.
|**Screen**
1. Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Restrictive Housing Log
|Screen
1. Each required element is present on the state-approved log form.|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1- #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1- #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1- #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1- #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Sexual Allegation Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 8 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**2.** **Logs (continued)**
Involuntary Medication Hearing Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Discharge Log (Re-Entry)
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Crisis Stabilization Unit Log
|Screen
1. Each required element is present on the state–approved log form.|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Acute Care Unit Log
|Screen
1. Each required element is present on the state-approved log form.|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|**Screen**
1.Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Diagnostic Referral Log
|Screen
1. Each required element is present on the state–approved log form.|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|**Screen**
1. Each required element is present on the state–approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Observation Cell Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Each required element is present on the state–approved log form.
|1. Each required element is present on the state–approved log form.
|1. Each required element is present on the state–approved log form.
|1. Each required element is present on the state–approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 9 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**2.** **Logs (continued)**
SP Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Each required element is present on the state -approved log form.|1. Each required element is present on the state -approved log form.|1. Each required element is present on the state -approved log form.|1. Each required element is present on the state -approved log form.|||||||
|2. The re is one log for Suicide Precautions.
|2. The re is one log for Suicide Precautions.
|2. The re is one log for Suicide Precautions.
|2. The re is one log for Suicide Precautions.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 2 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 2 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 2 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 2 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Activity Therapy Group Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Each required element is present on the state -approved log form.
|1. Each required element is present on the state -approved log form.
|1. Each required element is present on the state -approved log form.
|1. Each required element is present on the state -approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Transfer Log
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|1. Each required element is present on the state-approved log form.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items =1 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance**
**Score = %**|**Compliance**
**Score = %**|**Compliance**
**Score = %**|
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 10 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**II.** **IDENTIFICATION**
**A.** **Identifying Severely Mentally Ill (SMI)**
**1.** **Evaluations**
**a.** **Diagnostics (508.15)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.|||||||||||||||
|7.
|
|
|
|
|
||||
|
|||||
|**FC =**
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA//**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. A mental health reception screen is completed on all offenders on the day of their arrival into the diagnostic
facility.
Screen 2. The mental health reception screen has been reviewed and signed by an upper-level provider.
Screen 3. The original mental health reception screen is filed in section 5 of the offender’s medical record and a copy in the
section 4 of the mental health chart.
Screen 4. Offenders are referred for an initial psychiatric _/_ psychological evaluation, within the time period specified by SOP.
(Emergency - 24 hours; routine - 14 days) _._
Screen 5. A release of information form is completed, signed and in place (section 3) to obtain previous treatment records.
Screen 6. A mental health evaluation for services form was completed within 1 - 5 business days of incarceration and
reviewed/signed by an upper-level provider (if the evaluator is unlicensed).
Screen 7. A mental health reception screen was completed at the receiving facility within 24 hours of transfer. If the offender
is already on the mental health caseload, a transfer evaluation was completed by the upper-level provider within
the time period specified by SOP (Emergency – 24 hours; routine 7 days).
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 11 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**b.** **Initial Psychiatric/Psychological Evaluations**
Pull ten (10) charts of offenders who had an Initial Psychiatric/Psychological Evaluation performed at the
present facility. (508.24) Five charts will be reviewed by a psychologist and five charts will be reviewed
by a psychiatrist.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|
**Psychiatric**
|**Psychological**|**Psychological**|**Psychological**|**Psychological**|**Psychological**|**Psychological**|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||
|
|
|
|
|
|
|7.
|||||||||**N/A**|**N/A**|**N/A**|**N/A**|**N/A**|**N/A**|
|8.
|||||||||||||||
|9.
|||||||||||||||
|10.
|||||||||
|
|
|
|
|
|
|11.
|
|
|
|
|
||||**N/A**|**N/A**|**N/A**|**N/A**|**N/A**|**N/A**|
|**FC =**
|**FC =**
|**PC =**|**PC =**|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 55 / 45 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 / 45 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 / 45 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 / 45 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 / 45 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is documentation indicating whether the initial psychiatric/psychological evaluation was conducted on-site
or by tele-mental health.
Screen 2. The initial psychiatric/psychological evaluation includes the referral information and chief complaint.
Screen 3. The initial psychiatric/psychological evaluation includes the current medication regimen and medication history.
Screen 4. The initial psychiatric/psychological evaluation includes relevant mental health history.
Screen 5. The initial psychiatric/psychological evaluation includes a history of substance use and treatment.
Screen 6. The initial psychiatric/psychological evaluation includes a relevant medical history.
Screen 7. The initial psychiatric evaluation identifies drug allergies.
Screen 8. The initial psychiatric/psychological evaluation includes a mental status examination.
Screen 9. The initial psychiatric/psychological evaluation includes diagnosis(es) or diagnostic impression using DSM-5
criteria and nomenclature. Include substance use diagnoses (if applicable).
Screen 10. The information contained in the initial psychiatric/psychological evaluation provides the DSM-5
criteria for the diagnosis or diagnostic impression.
Screen 11. The initial psychiatric evaluation includes page 3 (if pages 1 & 2 are completed by psychology and/or there is a
referral for medication).
Auditor’s Signature/Title: ______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 12 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**c.** **Sexual Allegation Evaluations and Referrals (508.22)**
Use the log for sexual allegation referrals and evaluations. Identify ten (10) offenders and review records.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
||||||||||||||
|6.
||||||||||||||
|7.
||||||||||||||
|8.
||||||||||||||
|9.
||||||||||||||
|10.
||||||||||||||
|11.
|
|
|
|
||||||||||
|**FC =**
|**PC =**
|**PC =**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 110 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 110 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 110 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 110 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 110 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is a signed consent form for the evaluation.
Screen 2. There is evidence that an upper level provider has reviewed the sexual allegation evaluation packet.
Screen 3. The evaluating counselor has received training and is privileged to perform the evaluation.
Screen 4. The sexual allegation evaluation was completed within 24 hours (or next business day).
Screen 5. The evaluation includes a comprehensive mental status exam.
Screen 6. The evaluation adequately assesses for emotional trauma.
Screen 7. The evaluation is clinically focused and is not involved with the security investigation and/or truth or falsehood
of the allegation.
Screen 8. If clinically indicated, the offender was referred for treatment or further evaluation.
Screen 9. If referred for treatment or further evaluation, a copy of the completed mental health referral form (M35-01-01) is present in the
sexual allegation log packet.
Screen 10. If referred for treatment or further evaluation, there is documentation in the mental health/medical file that this has occurred.
Screen 11. If referred for abuse/trauma treatment, the offender's treatment plan and progress notes confirm treatment for abuse/trauma.
Auditor’s Signature/Title: _______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 13 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**d.** **Restrictive Housing (508.20) 48 Hour Screen**
Pull records of ten (10) mental health offenders who have been placed in restrictive housing.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||
||||||||||
|**FC =**
|**FC =**
|
**PC**
**=**
|
**PC**
**=**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. A mental health screen/evaluation was performed within 2 working days of the mental health offender’s
placement in Restrictive Housing.
Screen 2. There was an individualized, substantive clinical assessment of contra-indication to restrictive housing _._
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 14 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**e.** **Disciplinary Report Evaluations (508.18)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|
|---|---|---|---|---|---|---|---|
|1.
||
|
||
|
||
|2.
||
|
||
|
||
|3.
||
|
||
|
||
|4.
||
|
||
|
||
|5.
|
|
|
||
|
||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 25 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Scorable Items = 25 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Scorable Items = 25 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is documentation that the evaluator reviewed documents/records, interviewed the offender,
and performed a Mental Status Exam (MSE).
Screen 2. The evaluator’s impressions are consistent with the results of the evaluation.
Screen 3. The evaluator’s conclusions and recommendations are consistent with the results of the evaluation,
including recommendations for alternative sanctions.
Screen 4. When alternative sanctions are recommended, they are specific and clinically appropriate.
Screen 5. There is documentation to reflect whether or not alternative sanctions were followed (via SCRIBE
or log documentation).
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 15 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**f.** **Parole Evaluations (508.15)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|
|---|---|---|---|---|---|---|---|
|1.
||||||||
|2.
||||||||
|3.
||||||||
|4.
|
|
|
|
|
|
||
|**FC =**|**PC =**|**NC =**|**Scorable Items = 20 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 20 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Scorable Items = 20 - #NA/N**
**Score = (FCX2) + (PCX1) =**
**R =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. Parole evaluations were completed within 30 days.
Screen 2. The evaluation adequately addresses issues of assets and limitations for release back to the community.
Screen 3. The evaluation includes appropriate recommendations should the offender be released on parole.
Screen 4. A psychologist has completed the recommendations section of the parole evaluation.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 16 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**2.** **Rounds / Restrictive Housing (508.19 and 508.20)**
Pull ten (10) charts of offenders who were referred for evaluation during the past year after being
identified with problems during restrictive housing rounds.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
||||||||||||||
|6.
|
|
|
|
||||
|
|||||
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 60 - #NA/**
**Score = (FCX2) + (PCX1)**
**=**
**NR =**|**Scorable Items = 60 - #NA/**
**Score = (FCX2) + (PCX1)**
**=**
**NR =**|**Scorable Items = 60 - #NA/**
**Score = (FCX2) + (PCX1)**
**=**
**NR =**|**Scorable Items = 60 - #NA/**
**Score = (FCX2) + (PCX1)**
**=**
**NR =**|**Scorable Items = 60 - #NA/**
**Score = (FCX2) + (PCX1)**
**=**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The Level I offender was referred using the referral form (M35-01-01) by a qualified mental health professional.
Screen 2. The mental health evaluation was completed in a timely manner. (between 24 hours - 5 business days)
Screen 3. A mental status evaluation (MSE) was completed.
Screen 4. If mental health problems were identified, there was documentation that appropriate treatment interventions were
made.
Screen 5. The referral findings are completed by an upper-level provider on the lower portion of the referral form (M35-0101).
Screen 6. Every 30 days in restrictive housing, there is documentation of follow-up by a mental health staff member (using
form M40-01-04) in the non-mental health offender’s medical chart (section 5).
Auditor’s Signature/Title: _______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 17 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**3.** **Referrals (508.19)**
**a.** **Routine/Self- Referrals**
Match the Referral Log with the mental health record and medical record for ten (10) offenders.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|**Type**
**Referral***
|||||||||||||||
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|||||||||||||||
|8.
|
|
|
|
|
||||
|
|||||
|**FC =**
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The Mental Health Referral Form (M35-01-01) is being used for all referrals except those from the Mental Health Reception
screen (information from a self-referral has been placed on a Mental Health Referral form)
Screen 2. A Mental Health Evaluation for Services (M31-01-01) and the Mental Status Evaluation (MSE) (M31-01-02) were completed.
Screen 3. The original of the Referral Form (M35-01-01) has been placed in section four (4) of the mental health record.
Screen 4. A copy of the Referral Form (M35-01-01) has been placed in section five (5) of the medical record.
Screen 5. The evaluation date in the Referral Log matches the evaluation date on the Referral Form (M35-01-01).
Screen 6. Non-emergency referrals have met with a qualified mental health professional within fourteen (14) days of receiving the referral.
Screen 7. The offender was appropriately placed on the mental health caseload and treatment was initiated per SOP _._
Screen 8. If the evaluation was done by tele-mental health, the documentation should be placed in the medical or mental health record.
***Type referral code:** Routine (R); Self (S)
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 18 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**b.** **Emergency Referrals (508.19)**
Match the Referral Log with the mental health records for ten (10) offenders.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|
|
|
|
|
||||
|
|||||
|**FC =**|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The Mental Health Referral Form (M35-01-01) is being used for all referrals except those from the Mental Health Reception
screen.
Screen 2. The Referral Form (M35-01-01) has been placed in section four (4) of the mental health record with a copy in section five (5)
of the medical record.
Screen 3. Emergency referrals have met with a qualified mental health professional within 24 hours of receiving the referral.
Screen 4. A Mental Health Evaluation for Services (M31-01-01) and the Mental Status Evaluation (MSE) (M31-01-02) were completed.
Screen 5. The offender was appropriately placed on the mental health caseload and treatment was initiated per Standard Operating
Procedures _._
Auditor’s Signature/Title: ______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 19 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**4.** **Classifying SMI**
**Appropriately Changing Levels of Care and Discontinuing Services (508.16)**
Review the records of five (5) mental health offenders whose level of care has been changed within the
past year and five (5) offenders who have been made Level I within the past year.
**Changing Levels of Care (Levels II – V)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|1.
||||||
|2.
|
|
||||
|**FC =**|**PC =**|**NC =**|**Scorable Items = 10 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Scorable Items = 10 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|
Screen 1. The appropriate level of care needed is being determined by an upper-level provider in collaboration with the
Treatment team when an offender has functioned well at their current level for at least 60 days.
Screen 2. There is a corresponding treatment team note in the mental health record justifying the decrease/increase in level
change by the treatment team, along with required signatures on the Treatment Plan and Diagnosis List.
Auditor’s Signature/Title: ________________________________________________________________
**Discontinuing Services**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|
|---|---|---|---|---|---|---|
|1.
|||||||
|2.
|
|
|||||
|**FC =**|**PC =**|**NC =**|**Scorable Items = 10 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Scorable Items = 10 - #NA/NR = Score**
**= (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. Offenders who have met treatment plan goals and have been stable without psychotropic medication for a
minimum of 60-days and were seen by a psychiatrist/APRN for follow-up within 60 days after medications were
discontinued, were appropriately discharged from the caseload.
Screen 2. An offender diagnosed with serious and persistent mental illness was taken off the caseload via treatment team only
when the psychiatrist/APRN or psychologist concluded and documented that the diagnosis of serious and persistent
mental illness was incorrect or no longer evident and completed a new Diagnosis List in collaboration with the
treatment team. Or, if not a serious and persistent mental illness, there is a discharge summary, treatment team
documentation, and documentation from an upper-level provider supporting the discharge.
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 20 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**III.** **TREATMENT**
**A.** **Direction of Treatment**
**1.** **Comprehensive Treatment Plans (508.21)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|||||||||||||||
|8.
|||||||||||||||
|9.
|
|
|
|
|
||||||||||
|**FC =**
|**FC =**
|
**PC =**|
**PC =**|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 90 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 90 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 90 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 90 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 90 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The Comprehensive Treatment Plan is current and was completed within the time frame (to include SLU reviews
Every 4 months and level 2 reviews every 6 months) required by Standard Operating Procedures.
Screen 2. The principal diagnosis and symptoms on the treatment plan match the principal diagnosis and symptoms on the
most current Diagnosis List.
Screen 3. The offender has reviewed and signed the Treatment Plan.
Screen 4 Presenting symptoms are listed as problems and are individualized, specific and appropriate.
Screen 5. The goal description is individualized, behavioral and appropriate.
Screen 6. Intervention strategies are individualized and appropriate to diagnosis and level of functioning.
Screen 7. For programs with activity therapy, the intervention strategies reflect therapeutic recreation.
Screen 8. Class of medication, if prescribed, is listed on the Treatment Plan as an intervention strategy with a specific goal
targeted toward a specific problem.
Screen 9. Strengths and weaknesses are listed in the Intervention section to further individualize the plan of treatment.
Auditor’s Signature/Title: _______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 21 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**B. Type of Treatment (508.21)**
**1.** **Non-Pharmacological Interventions**
**a.** **Group Treatment**
**(1)** **Therapy, Psycho-Education or Support Groups**
Pull charts of ten (10) offenders who are members of a therapy, psycho-education or support group and
match the attendance logs with the mental health records.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|**Type**
**Group***
1.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|2.
|||||||||||||||
|3
|||||||||||||||
|4.
|
|
|
|
|
||||
|
|||||
|**FC =**|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The number of groups conducted on a regular basis at this facility is commensurate with the scope
and size of its mental health program (i.e., minimum of one essential or maintenance group – e.g., Suicide
Precautions for all facilities without SLU services, minimum of one group per SLU, minimum of two groups per
SMHTU).
Screen 2. Roster and progress notes match.
Screen 3. Placement in the therapy or support group was determined by the Treatment Plan interventions and is
appropriate to diagnosis and/or problems.
Screen 4. Evidence of progress or lack of progress is reflected in the group progress notes.
*Type group code: Therapy (T); Psycho-Education (P); Support Group (S)
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 22 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**(2) Activity Therapy Groups (508.06)**
Pull charts of ten (10) offenders who are members of an activity therapy group and match the attendance
logs with the mental health records.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|||||||||||||||
|8.
|
|
|
|
|
||||
|
|||||
|**FC =**|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. An Activity Therapy Assessment (form M56-01-01) was completed within 30 days of the offender's placement
in the mental health program.
Screen 2. Upon transfer, the Activity Therapy Assessment was reviewed and signed by the offender and activity therapist.
Screen 3. The Activity Therapy Assessment identifies problems and/or needs regarding the offender's activities for the
individualized treatment plan.
Screen 4. The Activity Therapy Assessment form was filed in section four of the mental health record.
Screen 5. The Activity Therapy Assessment was reviewed annually.
Screen 6. Monthly Activity Therapy notes (M56-01-02) are documented on the approved group progress note form, which
is filed in section one of the mental health record.
Screen 7. The monthly Activity Therapy notes reflect the offender's progress toward established goals of the treatment plan.
Screen 8. Group roster and other group attendance data are maintained by the Activity Therapist, Mental Health Unit Manager, or
designee.
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 23 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**b. Group Data**
Review the scheduled Mental Health Groups. Review the number of offenders scheduled for the assigned
group. Count the number of offenders attending the group. Data will be recorded in the written report
but not scored.
|Group
Name|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|**Date**|
|
|
|
|
|
|**Time**||||||
|**# **Offenders
**Scheduled**||||||
|**# **Offenders
**Attending**
**Group**||||||
|**Percentage in**
**Attendance**
||||||
Screens 1-3 should reflect the number of groups. Screen 4 reflects the number of offenders.
|Screen
1. Number of groups for LII offenders.|#|
|---|---|
|**Screen**
1. Number of groups for LII offenders.||
|2. Number of groups for LIII/LIV offenders.||
|3. Number of activity therapy groups.||
|4. Number of groups for trauma-related symptoms.||
|5.Number of groups for suicide prevention (SP).||
|6. Number of offenders involved in offender incentive programming as a therapeutic
behavior management approach.|
|
|7. Number of group rooms available for conducting mental health groups.||
|8. For programs with community meetings, there is adequate seating and space.||
Screens should reflect a yes or no answer. Data will be recorded in the written report but not scored.
|Screen|Y|N|
|---|---|---|
|1. Is there an alternative sanctions program for DR's that includes tracking
recommended dispositions?|||
|2. Is there a list of alternative options available at this facility? If yes _____#|||
Auditor’s Signature/Title: _________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 24 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**c.** **MH Counseling (508.16)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
||||||||||||||
|6.
||||||||||||||
|7.
||||||||||||||
|8.
|
|
|
|
||||||
|
|
|
|
|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|** Scorable Items = 80 - #NA/**
** Score = (FCX2) + (PCX1) =**
**NR**
**=**|** Scorable Items = 80 - #NA/**
** Score = (FCX2) + (PCX1) =**
**NR**
**=**|** Scorable Items = 80 - #NA/**
** Score = (FCX2) + (PCX1) =**
**NR**
**=**|** Scorable Items = 80 - #NA/**
** Score = (FCX2) + (PCX1) =**
**NR**
**=**|** Scorable Items = 80 - #NA/**
** Score = (FCX2) + (PCX1) =**
**NR**
**=**|**Compliance Score = %**|**Compliance Score = %**|**Compliance Score = %**|
Screen 1. Frequency of progress notes is in compliance with Standard Operating Procedures.
Screen 2. Progress notes are signed, dated and affixed with the printed, typed or stamped name of the care provider.
Screen 3. Progress notes state if the problem/target symptoms are new, worse, unchanged, improved or eliminated.
Screen 4. Progress notes identify the problem and/or target symptoms from the treatment plan discussed during the session.
Screen 5. Progress note interventions are appropriate to the diagnosis **/** problems **/** target symptoms.
Screen 6. Progress note interventions are consistent with the comprehensive treatment plan interventions.
Screen 7. Progress notes present a clinical plan for future sessions.
Screen 8. Counseling sessions, including plans for intervention, reflect continuity of care.
Auditor’s Signature/Title: ______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 25 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**d.** **Restrictive Housing Services (508.20)**
Review the mental health records of ten (10) offenders who have been in restrictive housing. Auditors
will conduct rounds on offenders in restrictive housing. (If there are no mental health offenders in
restrictive housing, files of mental health offenders recently in restrictive housing will be reviewed for
compliance.)
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|
|
|
|
|
||||
|
|||||
|**FC =**|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The offender has recently been released from Observation Cell/ACU/CSU and was seen within 10 – 12 hours
(same day).
Screen 2. There is a weekly mental status evaluation and assessment (using 48-hour / Weekly restrictive housing rounds
(M40-01-03) made by a counselor. Quality documentation is evident (written text along with the checklist).
Screen 3. Counseling progress notes reflect continuation of treatment services at the frequency required by Standard
Operating Procedures while in restrictive housing _._
Screen 4. For offenders in restrictive housing over one month, out-of-cell therapeutic contacts are occurring in a
private/confidential space, on at least a monthly basis for Level II offenders and twice a month for Level III and
IV offenders.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 26 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**2. Type of Treatment: Pharmacological Interventions**
**a.** **Medication Non-Adherence (508.24/508.11)**
**(1)** **Statistics**
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Weekly listings of medication non-compliance are given to
the mental health staff.|1. Weekly listings of medication non-compliance are given to
the mental health staff.|1. Weekly listings of medication non-compliance are given to
the mental health staff.|1. Weekly listings of medication non-compliance are given to
the mental health staff.|||||||
|2. Non-compliance statistics have been presented at quarterly
CQI meetings.|2. Non-compliance statistics have been presented at quarterly
CQI meetings.|2. Non-compliance statistics have been presented at quarterly
CQI meetings.|2. Non-compliance statistics have been presented at quarterly
CQI meetings.|||||||
|3. If the percentage of non-adherence is greater than 20%, a
CQI study has been developed to address at least one of the
top three reasons for non-adherence.|3. If the percentage of non-adherence is greater than 20%, a
CQI study has been developed to address at least one of the
top three reasons for non-adherence.|3. If the percentage of non-adherence is greater than 20%, a
CQI study has been developed to address at least one of the
top three reasons for non-adherence.|3. If the percentage of non-adherence is greater than 20%, a
CQI study has been developed to address at least one of the
top three reasons for non-adherence.|||||||
|4. MARs are copied for psychiatry/tele-psychiatry clinics.
|4. MARs are copied for psychiatry/tele-psychiatry clinics.
|4. MARs are copied for psychiatry/tele-psychiatry clinics.
|4. MARs are copied for psychiatry/tele-psychiatry clinics.
|||||||
|**FC =**
|**PC =**|**NC =**|**Scorable Items = 4 - #NA/NR =**
**Score = (FCX2) + (PCX1) = **
|**Scorable Items = 4 - #NA/NR =**
**Score = (FCX2) + (PCX1) = **
|**Scorable Items = 4 - #NA/NR =**
**Score = (FCX2) + (PCX1) = **
|**Scorable Items = 4 - #NA/NR =**
**Score = (FCX2) + (PCX1) = **
|**Compliance Score**
**= % **|**Compliance Score**
**= % **|**Compliance Score**
**= % **|
**Auditor’s Signature/Title: ________________________________________________________________**
**(2)** **Non-Adherence Documentation (508.24)**
Locate ten (10) offender records of offenders who have been non-compliant.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|**1.**
|||||||||||||||
|**2.**
|||||||||||||||
|**3.**
|||||||||||||||
|**4.**
|
|
|
|
|
||||
|
|||||
|**FC =**
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 40 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
** = % **|**Compliance Score**
** = % **|**Compliance Score**
** = % **|
Screen 1. Documentation is present indicating the offender was counseled by the mental health nurse.
Screen 2. The offender is referred to the psychiatrist/APRN for issues, such as medication side effects or lack of
agreement with the medication plan.
Screen 3 Documentation is individualized and reflects the offender’s reasons for non-compliance.
Screen 4. Documentation addresses (identifies) “no-shows” versus refusals **.**
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 27 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**b.** **Quantitative Issues (508.24/508.09)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|||||||||||||||
|8.
|||||||||||||||
|9.
|||||||||||||||
|10.
|||||||||||||||
|11.
|||||||||||||||
|12.
|||||
||||||||||
|**FC =**
|**FC =**
|
**PC**
**=**
|
**PC**
**=**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 120 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 120 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 120 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 120 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 120 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The progress note indicates where the session took place (on-site, cell front, private office, remote (tele-psychiatry)
Screen 2. The medical record contains a psychiatric assessment or transfer summary.
Screen 3. The medical record contains an Informed Consent form for the current medication signed by offender and
prescriber within the past year.
Screen 4. For offenders on psychotropic medication, the psychiatrist has reviewed the Level IV offenders at
least every 30 days, the Level III offenders at least every 30 - 60 days or the Level II offenders at least
every 90 - 120 calendar days.
Screen 5. The psychiatric progress notes include the current diagnosis.
Screen 6. There is a psychiatric progress note for each order of psychotropic medication.
Screen 7. Progress notes are legible.
Screen 8. When a new medication is prescribed, there is a review of the offender’s adjustment to the
medication within 10 working days of its initiation.
Screen 9. The psychiatric progress notes include target symptoms for the medication prescribed.
Screen 10. The psychiatric progress notes include documentation of the effectiveness of the medications
prescribed and the presence or absence of side effects.
Screen 11. The psychiatric progress notes include laboratory results for tests related to the medication prescribed.
Screen 12. Progress notes explain reasons for change in diagnosis and/or medication.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 28 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**c.** **Qualitative Issues (508.24)**
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
||||||||||||||
|6.
||||||||||||||
|7.
|
|
|
|
||||
|
|||||
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 70 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 70 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. The type of psychotropic medication prescribed fits with the symptoms described in the treatment plan
and/or progress notes.
Screen 2. The Psychotropic medications prescribed are indicated for the current diagnosis or diagnoses or “off-label” use is
justified annually in the medical record.
Screen 3. The dosages of psychotropic medications are within the limits of normal psychiatric practice unless there
is documented justification for higher or lower dosages.
Screen 4. Appropriate time trials on prescribed psychotropic medications are allowed before changes are
made in dosage or medication.
Screen 5. Multiple psychotropic medications within the same class are used only when all appropriate single
medications have been adequately tried and/or the necessity of each medication is justified.
Screen 6. Combinations of medications with known adverse interactions are avoided.
Screen 7. The use of benzodiazepines is restricted to the treatment of well documented anxiety disorders
and emergencies.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 29 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**d.** **Laboratory Monitoring (508.24)**
**(1) Antipsychotic Medication**
Pull ten (10) charts of offenders with current prescriptions for antipsychotic medications.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|
|
|
|
|
||||||||||
|**FC =**
|**FC =**
|
**PC =**
|
**PC =**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 50 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 50 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 50 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 50 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 50 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. AIMs have been performed within the last six months.
Screen 2. The psychiatrist/APRN has reviewed or ordered FBS or HgbA1c at the time of initiation of the antipsychotic medication.
Screen 3. The psychiatrist/APRN has reviewed or ordered a lipid panel at the time of initiation of the antipsychotic medication.
Screen 4. The offender’s weight and waist circumference are documented within the past 6 months.
Screen 5. If offender has been on an antipsychotic medication prescribed over 1 year, items 1-2 have been done within the past year.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 30 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**(2)** **Tegretol**
Pull ten (10) charts of offenders with current prescriptions for Tegretol.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|
|
|
|
|
||||||||||
|**FC =**
|**FC =**
|
**PC =**|
**PC =**|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 60 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 60 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 60 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 60 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 60 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The initial work up indicates the psychiatrist has reviewed a recent CBC with Differential.
Screen 2. The initial work up indicates the psychiatrist has reviewed recent LFTs.
Screen 3. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent
pregnancy test.
Screen 4. After initiation of Tegretol, blood levels were done X2 within six months.
Screen 5. A Tegretol level has been done within the past six months.
Screen 6. The lab work in screens 1-2 has been repeated within the past six months.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 31 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**(3) Lithium**
Pull ten (10) charts of offenders with current prescriptions for Lithium.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||||||||||||
|3.
|||||||||||||||
|4.
|||||||||||||||
|5.
|||||||||||||||
|6.
|||||||||||||||
|7.
|||||||||||||||
|8.
|
|
|
|
|
||||||||||
|**FC =**
|**FC =**
|
**PC =**
|
**PC =**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The initial work up indicates the psychiatrist has reviewed a recent CBC.
Screen 2. The initial work up indicates the psychiatrist has reviewed a recent BUN, electrolytes and Creatinine.
Screen 3. The initial work up indicates the psychiatrist has reviewed a recent thyroid profile.
Screen 4. If the offender is over 45 years old or has a history of heart problems, the initial work up indicates
the psychiatrist has reviewed a recent EKG.
Screen 5. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent pregnancy test.
Screen 6. If the offender has been on Lithium for 1 year or longer, the procedures in screens 1-3 have been
done within the past six months.
Screen 7. If the Lithium dosage was changed, a level was done within 7 days after the change.
Screen 8. A Lithium level has been done within the past six months.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 32 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**(4)** **Valproic Acid**
Pull ten (10) charts of offenders with current prescriptions for Valproic acid.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||
|2.
||||||||||||||
|3.
||||||||||||||
|4.
||||||||||||||
|5.
|
|
|
|
||||
|
|||||
|**FC =**|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 50 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The initial work up indicates the psychiatrist has reviewed a recent CBC with Differential.
Screen 2. The initial work up indicates the psychiatrist has reviewed recent LFTs.
Screen 3. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent pregnancy test.
Screen 4. The lab work in screens 1-2 have been repeated in the last six months.
Screen 5. A Valproic Acid level has been done within the past 6 months and within 2 weeks of dosage change.
Auditor’s Signature/Title: ________________________________________________
**(5)** **Benzodiazepines**
Pull ten (10) charts of offenders with current prescriptions for benzodiazepines.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|||||
||||||||||
|**FC =**
|**FC =**
|
**PC**
**=**
|
**PC**
**=**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
** = %**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. If use has exceeded two weeks, there is a second psychiatric opinion concurring with the
continued use of benzodiazepines.
Screen 2. There is a psychiatric progress note indicating evaluation of drug abuse history.
Auditor’s Signature/Title: __________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 33 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**e.** **Medication Administration (508.24)**
Select ten (10) health records and corresponding MARs of mental health offenders receiving psychotropic
medications in the preceding 180 days.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|Col16|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
||||||||||||||||
|2.
||||||
||||||||||
|**FC =**
|**FC =**
|**FC =**
|**PC**
**=**
|**PC**
**=**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 20 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The MAR shows that medications were initiated on the day of the order (for medications that must be
started the same day), start day ordered or within 72 hours of the order being written. For stat meds, the same day.
(this is for formulary as well as non-formulary drugs)
Screen 2. There is a progress note completed by the psychiatrist/APRN or the nurse (if a verbal order is received) that
corresponds to each medication order.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 34 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**f.** **Heat Education (508.24)**
Pull ten (10) charts of offenders on psychotropic medications.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|
|
|
|
|
||||||||||
|**FC =**
|**FC =**
|
**PC =**
|
**PC =**
|**NC =**
|**NC =**
|**NC =**
|**Scorable Items = 10 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 10 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 10 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 10 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 10 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. The offender’s medical record contains documentation indicating heat counseling/education annually between
April 1st and September 30th.
Auditor’s Signature/Title: ________________________________________________________________
**g. Heat Monitoring**
|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1.There is a daily log for the supportive living units and
restrictive housing units to reflect the housing temperatures
from April 1st – September 30th.|1.There is a daily log for the supportive living units and
restrictive housing units to reflect the housing temperatures
from April 1st – September 30th.|1.There is a daily log for the supportive living units and
restrictive housing units to reflect the housing temperatures
from April 1st – September 30th.|1.There is a daily log for the supportive living units and
restrictive housing units to reflect the housing temperatures
from April 1st – September 30th.|||||||
|2.When housing temperature exceeds 85° F, the log reflects
adequate ice and fluids are provided in the housing unit.|2.When housing temperature exceeds 85° F, the log reflects
adequate ice and fluids are provided in the housing unit.|2.When housing temperature exceeds 85° F, the log reflects
adequate ice and fluids are provided in the housing unit.|2.When housing temperature exceeds 85° F, the log reflects
adequate ice and fluids are provided in the housing unit.|||||||
|3.When housing temperature exceeds 85° F, the log reflects fans
are used to increase air flow.|3.When housing temperature exceeds 85° F, the log reflects fans
are used to increase air flow.|3.When housing temperature exceeds 85° F, the log reflects fans
are used to increase air flow.|3.When housing temperature exceeds 85° F, the log reflects fans
are used to increase air flow.|||||||
|4. When housing temperature exceeds 85° F, the log reflects
additional showers are allowed.|4. When housing temperature exceeds 85° F, the log reflects
additional showers are allowed.|4. When housing temperature exceeds 85° F, the log reflects
additional showers are allowed.|4. When housing temperature exceeds 85° F, the log reflects
additional showers are allowed.|||||||
|5.There are fans in the non-air-conditioned supportive living
units and restrictive housing units.|5.There are fans in the non-air-conditioned supportive living
units and restrictive housing units.|5.There are fans in the non-air-conditioned supportive living
units and restrictive housing units.|5.There are fans in the non-air-conditioned supportive living
units and restrictive housing units.|||||||
|6. When log is not present, attempts to obtain the log have been
documented by the Mental Health Unit Manager/designee.
|6. When log is not present, attempts to obtain the log have been
documented by the Mental Health Unit Manager/designee.
|6. When log is not present, attempts to obtain the log have been
documented by the Mental Health Unit Manager/designee.
|6. When log is not present, attempts to obtain the log have been
documented by the Mental Health Unit Manager/designee.
|||||||
|**FC =**|**PC =**|**NC =**|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 6 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Auditor’s Signature/Title: _______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 35 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**3. Type of Treatment: Supportive Living Unit Services**
**a.** **Support Living Unit (SLU) Programming (508.16)**
Review Scribe schedules and treatment plans of supportive living unit offenders.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|||||||||||||||
|2.
|
|
|
|
|
||||
|
|||||
|**FC =**
|**FC =**
|**PC =**|**PC =**|**NC =**|**NC =**|**NC =**|**Scorable Items = 20 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 20 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 20 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 20 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 20 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. All therapeutic activities (groups such as psycho-educational, therapy, activity therapy; details;
education/vocational; chaplaincy activities/groups; recreation; etc.) on the offender’s schedule are also listed
in the intervention section in the treatment plan.
Screen 2. If living in an SLU, the offender is scheduled for at least four (4) hours of meaningful therapeutic programming
(See above) each day (4-5 days per week).
Auditor’s Signature/Title: ________________________________________________________________
**b.** **Community Meetings (508.16)**
|Screen|Col2|Col3|Col4|FC|PC|NC|NA|NR|
|---|---|---|---|---|---|---|---|---|
|
1. Community meetings are being held and documented
by a qualified mental health professional/designee in
each supportive living unit at least one (1) time a
week.|
1. Community meetings are being held and documented
by a qualified mental health professional/designee in
each supportive living unit at least one (1) time a
week.|
1. Community meetings are being held and documented
by a qualified mental health professional/designee in
each supportive living unit at least one (1) time a
week.|
1. Community meetings are being held and documented
by a qualified mental health professional/designee in
each supportive living unit at least one (1) time a
week.||||||
|2. At each supportive living unit correctional officer
(MFCO or other security staff) is available and
participating in each community meeting.|2. At each supportive living unit correctional officer
(MFCO or other security staff) is available and
participating in each community meeting.|2. At each supportive living unit correctional officer
(MFCO or other security staff) is available and
participating in each community meeting.|2. At each supportive living unit correctional officer
(MFCO or other security staff) is available and
participating in each community meeting.||||||
|
3. Community meetings focus on issues of community
living and mutual support as documented in a
community meeting log.
|
3. Community meetings focus on issues of community
living and mutual support as documented in a
community meeting log.
|
3. Community meetings focus on issues of community
living and mutual support as documented in a
community meeting log.
|
3. Community meetings focus on issues of community
living and mutual support as documented in a
community meeting log.
||||||
|**FC =**|**PC =**|**NC =**|**Scorable Items = 3 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 3 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 3 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 36 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**4.** **Type of Treatment: Stabilization Services**
**a.** **Acute Care Unit (508.30)**
Pull five (5) charts of offenders who were placed in the Acute Care Unit. Auditors will make rounds on offenders admitted
into the ACU.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|
|---|---|---|---|---|---|---|---|---|
|1.
|
|
|
|
||
|
||
|2.
|
|
|
|
||
|
||
|3.
|
|
|
|
||
|
||
|4.
|
|
|
|
||
|
||
|5.
|
|
|
|
||
|
||
|6.
|
|
|
|
||
|
||
|7.
|
|
|
|
||
|
||
|8.
|
|
|
|
||
|
||
|9.
|
|
|
|
||
|
||
|10.
|
|
|
|
||
|
||
|11.
|
|
|
|
||
|
||
|**FC =**|**PC =**|**NC =**|**NC =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. An Acute Care Unit admission evaluation has been completed by a psychiatrist/APRN/psychologist by the next working day after
placement in ACU.
Screen 2. Content of the mental health counselor admission progress note addressed psychological factors related to the
precipitating event, the offender’s state of mind (based on an MSE), and behavioral criteria for release from the ACU.
Screen 3. A daily progress note was completed by a psychiatrist/APRN/psychologist on each working day during placement in ACU
Screen 4. Daily progress notes including a mental status evaluation were completed by the Acute Care Unit counselor on
workdays, and included information regarding the offender’s progress/lack of progress.
Screen 5. Progress notes, including a mental status evaluation, were completed by the mental health nurse daily, including
weekends and holidays and contained information regarding the offender’s progress/lack of progress.
Screen 6. The Acute Care Unit treatment plan was individualized and established specific goals related to current issues.
Screen 7. Content of the mental health counselor’s discharge progress note addressed the offender’s state of mind and indicated
the discharge was done in concurrence with a psychiatrist/APRN/psychologist.
Screen 8. A Suicide Risk Assessment should be completed (if applicable) and if present, filed with the ACU packet in the medical file
(Section 5). A copy of the Suicide Risk Assessment should be in the mental health file (section 4).
Screen 9. A copy of the admission and discharge notes from the psychiatrist/APRN/psychologist, mental health nurse and mental health
counselor is present in section 1 of the mental health record.
Screen 10. Level 1 offenders are required to have a Mental Health Evaluation for Services (form M31-01-01) and an Initial
Psychiatric/Psychological Evaluation (form M60-01-06) completed prior to discharge.
Screen 11. Follow-up was done by a licensed mental health staff member within 48 hours (or 10 – 12 hrs. if placed in Restrictive Housing)
after discharge from the Acute Care Unit.
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 37 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**b. Stabilization Interventions/Crisis Stabilization Unit (508.31)**
Pull five (5) charts of offenders who were placed in the Crisis Stabilization Unit. Auditors will make rounds on offenders admitted into the
CSU.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|
|---|---|---|---|---|---|---|---|
|1.||||||||
|2.||||||||
|3.||||||||
|4.||||||||
|5.||||||||
|6.||||||||
|7.||||||||
|8.||||||||
|9.||||||||
|10.||||||||
|11.||||||||
|12.||||||||
|13.||||||||
|14.||||||||
|15.||||||||
|16.||||||||
|**FC =**|**PC =**|**NC =**|**NC =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Scorable Items = 80 - #NA/**
**Score = (FCX2) + (PCX1) =**
**NR =**|**Compliance Score**
**= %**|
Screen 1. An admission order was written by a psychiatrist within one hour of placement in the Crisis Stabilization Unit.
Screen 2. The admission order included the reason for admission, the diagnosis, vital signs, dietary orders, the nature, and frequency of
observation required.
Screen.3. Content of the mental health counselor admission progress note addressed psychological factors related to the precipitating event, the offender’s
mental status and behavioral criteria for release.
Screen 4. A Crisis Stabilization Unit admission evaluation (form M70-02-02) has been completed by a psychiatrist/APRN by the next working day after
placement into the CSU.
Screen 5. A mental health counselor note that addressed treatment issues was completed daily on workdays.
Screen 6. A Nursing Assessment was completed upon admission and included the reason for admission, vital signs, relevant history, and pertinent physical
and mental health observations.
Screen 7. A history and physical were completed within 24 hours of admission.
Screen 8. A nursing progress note, including a mental status evaluation, was completed during each shift.
Screen 9. A psychiatric note addressing treatment issues was completed daily (on workdays).
Screen 10. The Crisis Stabilization Unit treatment plan was individualized and established specific goals related to current issues.
Screen 11. A Suicide Risk Assessment should be completed (if applicable) and if present, filed with the CSU packet in the medical file.
Screen 12. A discharge summary is completed by the mental health counselor and was done in concurrence with a psychiatrist/APRN and/or psychologist
and was placed in section 5 of the medical record and section 1 of the mental health record. (The mental health record will have all the admission
and discharge notes only.)
Screen 13. A psychiatric discharge summary was completed, and content of the note addressed the offender’s mental status.
Screen 14. A copy of the admission and discharge notes from the psychiatrist/APRN, mental health nurse, and mental health counselor is present in section
1 of the mental health records.
Screen 15. Level 1 offenders are required to have an Initial Psychiatric/Psychological Evaluation completed prior to discharge.
Screen 16. Follow-up was done by a licensed mental health staff member within 48 hours (or 10 – 12 hours if placed in Restrictive Housing) after discharge from
the Crisis Stabilization Unit.
Auditor’s Signature/Title: _____________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 38 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**c. Suicide Precautions (508.29)**
Pull five (5) charts of offenders who were placed on suicide precautions with SP status.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
|---|---|---|---|---|---|---|---|---|---|
|1.
|
|
|
|
|
||
|
||
|2.
|
|
|
|
|
||
|
||
|3.
|
|
|
|
|
||
|
||
|4.
|
|
|
|
|
||
|
||
|5.
|
|
|
|
|
||
|
||
|6.
|
|
|
|
|
||
|
||
|7.
|
|
|
|
|
||
|
||
|8.
|
|
|
|
|
||
|
||
|9.|
|
|
|
|
||
|
||
|10.
|
|
|
|
|
||
|
||
|**FC =**
|**FC =**
|**PC =**|**NC =**|**NC =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. There is a Suicide Prevention Committee which is multi-disciplinary and meets on a monthly basis at this facility.
Screen 2. Placement on Suicide Precautions SP is clinically indicated, and offender was added to the mental health caseload.
Screen 3. Offenders placed on SP status have been given an SP profile in SCRIBE for their duration of the SP status.
Screen 4. If on SP status while in Observation/ACU/CSU, SP status is continued upon release from Observation/ACU/CSU
and continues until SP status is no longer warranted.
Screen 5. The Suicide Risk Assessment Instrument (SRAI) was completed, individualized, and signed on or before the first
working day after placement on suicide precautions.
Screen 6. There is an upper-level provider's original signature on page three of the Suicide Risk Assessment Instrument.
Screen 7. There is documentation that the offender (including those in restrictive housing) on SP and has received therapeutic
services at least two times per week.
Screen 8. There is documentation (in the progress note and treatment plan) targeting the reduction of suicide risk and/or selfinjurious behavior (SIB) while on SP status.
Screen 9. Provisions are made to supply the offender with a security garment, bedding and other items that will promote
offender safety in a way that is designed to prevent humiliation and degradation.
Screen 10. Discontinuation from SP status was clinically indicated and appropriately documented.
Auditor’s Signature/Title: ________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 39 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**d. Restraints (508.27)**
Pull five (5) charts of offenders who were placed in Restraints.
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
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|**FC =**
|**FC =**
|**PC =**|**NC =**|**NC =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Scorable Items = 55 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. A psychiatrist was contacted within one hour of placement in Restraints to obtain a Restraint Order.
Screen 2. The restraint order was recorded on each Restraint/Seclusion Order Form for no longer than 4 Hours and in
the medical record.
Screen 3. The provision of fluids, meals, toileting that is offered, and ROM is documented at least every two (2)
hours.
Screen 4. Observation of the offender was documented at least every 15 minutes.
Screen 5. Notification of the Warden is present for the first order and for subsequent 24-hour intervals of restraint.
Screen 6. Notification to the statewide mental health director is present if restraint was continued beyond 72 hours.
Screen 7. The original of the restraint package is with the Crisis Stabilization Unit paperwork in the medical record.
Screen 8. Progress notes indicate a psychiatrist evaluated the offender on the next working day.
Screen 9. Placement in restraints occurred after de-escalation (with specific efforts to de-escalate identified), was clinically
indicated and behavioral criteria for release were documented.
Screen 10. Mental status and behavioral information are recorded in the progress notes covering the restraint period.
Screen 11. There is evidence in the documentation that the offender was released from restraint when the behavioral
criteria for release were met.
Auditor’s Signature/Title: ________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 40 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**e. Involuntary Medication (508.26)**
Pull five (5) charts of offenders who were placed on Involuntary Medication. [1-8 completed by
psychiatry]
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
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|**FC =**
|**FC =**
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**PC =**|**NC =**|**NC =**|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Scorable Items = 80 - #NA/NR =**
**Score = (FCX2) + (PCX1) =**
|**Compliance Score**
** = %**|**Compliance Score**
** = %**|
Screen 1. The temporary involuntary medication order is for no longer than five days preceding the hearing.
Screen 2. Emergency medications administered were short acting injectables, not decanoates.
Screen 3. All MARs are marked to indicate that the offender is on involuntary medication.
Screen 4. Placement on involuntary medication was clinically indicated.
Screen 5. There is documentation that the treating psychiatrist talked with the offender about his/her assessment, reasons for the medication, risks and
benefits of the medicine and advantages and disadvantages of voluntary versus involuntary medication.
Screen 6. Medications ordered were within acceptable ranges per current practice or ranges outside the GDC formulary limits are justified.
Screen 7. A second psychiatric opinion of the need for medication is documented and in agreement with the treating psychiatrist.
Screen 8. There is evidence in documentation that there was substantial risk of harm to self or others at the time the
emergency medication was administered or there is a history through progress notes and/or community mental health records that indicate the
offender has a chronic psychiatric condition that results in deterioration of behavior that is life endangering and without medication the offender
could not improve their condition.
Screen 9. There is evidence that the mental health due process committee was composed of the deputy warden of care and treatment/designee, a non
treating mental health staff member, and a medical staff member who is not directly involved in treatment of the offender.
Screen 10. A mental health staff member represented the offender as an advocate in the hearing and adds documentation of treatment plans, crisis stabilization
notes and historical non-adherence in the hearing or the offender retained his/her own attorney.
Screen 11. The state advocate provides documentation supporting the necessity for a due process hearing.
Screen 12. There is evidence that the offender was notified of the hearing and was informed to the right to counsel.
Screen 13. The offender was given the opportunity to attend the hearing.
Screen 14. There is evidence that the offender was provided documentation of the results of the hearing within two working days following the hearing.
Screen 15. There has been a review and due process hearing every six months since the initiation of involuntary medication.
Screen 16. There is documentation that efforts were made to gain cooperation from the offender to take the medication voluntarily.
Auditor’s Signature/Title: _______________________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 41 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.
SOP 508.12
Attachment 5
6/28/22
**f. Observation Cell Unit (508.28)**
Review the files of offenders who remained in an observation cell. Auditors will make rounds on
offenders housed in the observation cell(s).
|Offender
ID#s
Screen|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|
|---|---|---|---|---|---|---|---|---|
|1.
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|**FC =**|**PC =**|**NC =**|**NC =**|**Scorable Items = 50- #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 50- #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Scorable Items = 50- #NA/NR**
**Score = (FCX2) + (PCX1) =**
**= **|**Compliance Score**
**= %**|**Compliance Score**
**= %**|
Screen 1. Offenders admitted were evaluated within 12 hours of placement by a qualified mental health professional.
Screen 2. There is an admission DAP note in the mental health record.
Screen 3. Admission was done in concurrence with a psychologist/psychiatrist/APRN.
Screen 4. There is daily documentation of efforts to obtain a CSU or ACU bed.
Screen 5. If placement exceeds 24 hours there is written justification on the Notification to Warden/Superintendent of
Subsequent 24-Hours of Observation in an Observation Cell (form M68-01-05) for each subsequent 24-hour period
in the observation cell and a copy of the form placed in section 8 of the mental health record
Screen 6. Form M68-01-05 is completed for each subsequent 24-hour period.
Screen 7. The warden/designee has reviewed and signed form M68-01-05.
Screen 8. There is a discharge DAP note in the mental health record.
Screen 9. The discharge DAP note reflects concurrence with a psychologist/psychiatrist/APRN.
Screen 10. The cell is suicide resistant (FC or NC only).
Auditor’s Signature/Title: _______________________________________________________________
********************************************************************************************************
FC = full (90% - 100%) compliance, PC = partial (70% - 89%) compliance, NC = non-compliance (less than 70%), NA = not applicable at this facility, NR =
not rated during this audit.
Scoring: FC = 2 PC = 1 NC = 0 NA and NR = are not scored
Form no. M26-01-05 Page 42 of 42
Retention Schedule: Completed forms shall be distributed to Central Office (original), Office of Audits & Compliance (copy), Facility Warden (copy), and MH
Unit Manager (copy) for five (5) years, and then destroyed.