SOP 508.12-att-6: Comprehensive Audit Tool Scoring Sheet

Division:
Mental Health Administration
Effective Date:
June 28, 2022
Reference Code:
VG26-0001
Topic Area:
508 Policy-MH Administration/Staff/Certification
PowerDMS:
View on PowerDMS
Length:
1,015 words

Summary

This is an audit scoring form (M26-01-06) used to evaluate mental health program compliance across three main domains: Administration, Identification of Seriously Mentally Ill (SMI) inmates, and Treatment. The form tracks compliance levels (Full, Partial, or Non-Compliance) across multiple categories including staffing, training, record maintenance, clinical evaluations, and treatment services. Audit results are maintained by the facility mental health area, Central Office Audits and Compliance, and the Office of Health Services for five years.

Key Topics

  • mental health audit
  • compliance scoring
  • SMI identification
  • treatment evaluation
  • credentialing
  • privileging
  • clinical training
  • psychiatric evaluation
  • medication management
  • non-pharmacological interventions
  • isolation segregation log
  • crisis stabilization
  • activity therapy
  • audit tool
  • facility audit
  • mental health documentation
  • clinical supervision
  • intake evaluation

Full Text

Comprehensive Audit Tool Scoring Sheet

Facility:

Date:

COMPLIANCE SUMMARY

SOP 508.12
Attachment 6

6/28/22

|Domains
Administration
Identification
Treatment|%|Items Reviewed|Full Compliance|Partial
Compliance|Non-Compliance|
|---|---|---|---|---|---|
|_Domains_
Administration
Identification
Treatment||||||
|_Domains_
Administration
Identification
Treatment||||||
|_Domains_
Administration
Identification
Treatment||||||
|Overall||||||

Scoring Formula: (FCX2) + (PCX1)(Scorable Items) X (2) = Compliance Score

Compliance Scores

I. Administration

|Staffing Patterns Page 1 – 2|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Credentialing Files||||||
|Privileging Files
||||||
|Subtotal||||||

|Training Programs Page 3-4|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Clinical
Consultation/
Supervision||||||
|Group Case
Conference||||||
|In-Service Training
||||||
|Subtotal||||||

Form no. M26-01-06 Page 1 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

SOP 508.12
Attachment 6

6/28/22

|Record Maintenance Page 5-6|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|MH/MR
Clinical/Medical Files||||||
|Duty Officer Logbook
||||||
|Subtotal||||||

|Oversight Procedures Page 7 – 10|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial Compliance_|_Non-Compliance_|
|Scribe Reports||||||
|Referral Log||||||
|Record Request Log||||||
|Parole Log||||||
|Isolation/
Segregation Log||||||
|Sexual Allegation Log||||||
|Involuntary Medication
Hearing Log||||||
|Discharge Log||||||
|Crisis Stabilization Log||||||
|Acute Care Unit Log||||||
|Diagnostic Referral Log||||||
|Observation Cell Log||||||
|Isolation/Segregation
(Tier) Log||||||
|Suicide Precautions Log
(SP)||||||
|Activity Therapy Group
Log||||||
|Subtotal||||||

Form no. M26-01-06 Page 2 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

II. Identification

|Identifying SMI - Evaluations Page 11 – 16|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Diagnostics||||||
|Initial Psychiatric/
Psychological*||||||
|Sexual Allegations||||||
|Isolation/Segregation||||||
|Disciplinary Evaluations||||||
|Parole
||||||
|Subtotal||||||

*Initial Psychiatric/Psychological

SOP 508.12
Attachment 6

6/28/22

|Psychiatric|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|Psychological
||||||
|Subtotal||||||

|Identifying SMI - Rounds Page 17|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Isolation/
Segregation
||||||
|Subtotal||||||

|Identifying SMI - Referrals Page 18-19|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Routine/Self
Referral||||||
|Emergency Referrals
||||||
|Subtotal||||||

Form no. M26-01-06 Page 3 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

|Classifying SMI Page 20|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Appropriately
Changing Levels of
Care/Discontinuing
Services*
||||||
|Subtotal||||||

*Classifying SMI

|Changing Levels of
Care|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|Discontinuing
Services
||||||
|Subtotal||||||

III. Treatment

SOP 508.12
Attachment 6

6/28/22

|Direction of Treatment Page 21|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Comprehensive
Treatment/
Habilitation Plans
||||||
|Subtotal||||||

|Type of Treatment – Non-Pharmacological Interventions Page 22 – 26
Domains % Items Reviewed Full Compliance Partial Non-Compliance
Compliance
Groups|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|Type of Treatment – Non-Pharmacological Interventions Page 22 – 26
_Domains_
_% _
_Items Reviewed_
_Full Compliance_
_Partial_
_Compliance_
_Non-Compliance_
Groups




|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Type of Treatment – Non-Pharmacological Interventions Page 22 – 26
_Domains_
_% _
_Items Reviewed_
_Full Compliance_
_Partial_
_Compliance_
_Non-Compliance_
Groups




||||||
|Activity Therapy
Groups||||||
|Counseling||||||
|Lockdown Services
||||||
|Subtotal||||||

Form no. M26-01-06 Page 4 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

|Type of Treatment – Pharmacological Interventions Page 27 – 35|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|Med. Non-
Adherence *||||||
|Quantitative Issues||||||
|Qualitative Issues||||||
|Lab. Follow-Up*||||||
|Medication
Administration||||||
|Heat Education||||||
|Heat Monitoring
||||||
|Subtotal||||||

*Medication Non-Adherence

|Statistics|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|Documentation
||||||
|Subtotal||||||

*Laboratory Follow-Up

SOP 508.12
Attachment 6

6/28/22

|Antipsychotic
Medications|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|Tegretol||||||
|Lithium||||||
|Valproic Acid||||||
|Benzodiazepines
||||||
|Subtotal||||||

Form no. M26-01-06 Page 5 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

|Type of Treatment – Supportive Living Unit Services Page 36|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|SLU Programming||||||
|Community
Meetings
||||||
|Subtotal||||||

|Type of Treatment – Stabilization Services Page 37- 43|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|_Domains_|_% _|_Items_
_Reviewed_|_Full Compliance_|_Partial_
_Compliance_|_Non-Compliance_|
|ACU||||||
|CSU||||||
|Suicide Precautions *||||||
|Restraints||||||
|Involuntary
Medication||||||
|Observation Cell
||||||
|Subtotal||||||

*Suicide Precautions

SOP 508.12
Attachment 6

6/28/22

|SP1|Col2|Col3|Col4|Col5|Col6|
|---|---|---|---|---|---|
|SP2
||||||
|Subtotal||||||

Form no. M26-01-06 Page 6 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

Compliance
I. Administration

|Domains|%|Items
Reviewed|Full Compliance|Partial
Compliance|Non-Compliance|
|---|---|---|---|---|---|
|Staffing Patterns||||||
|Training Programs||||||
|Record Maintenance||||||
|Oversight Procedures||||||
|Subtotal ||||||

II. Identification

|Domains|%|Items
Reviewed|Full Compliance|Partial
Compliance|Non-Compliance|
|---|---|---|---|---|---|
|Evaluations||||||
|Rounds||||||
|Referrals||||||
|Classifying SMI||||||
|Subtotal ||||||

III. Treatment

SOP 508.12
Attachment 6

6/28/22

|Domains|%|Items
Reviewed|Full Compliance|Partial
Compliance|Non-Compliance|
|---|---|---|---|---|---|
|Treatment Plans||||||
|Non-Pharmacological
Interventions||||||
|Pharmacological
Interventions||||||
|Supportive Living Unit
Services||||||
|Stabilization Services||||||
|
Subtotal ||||||

Form no. M26-01-06 Page 7 of 7

Retention Schedule: Upon completion, this form shall be maintained in the applicable facility (mental health area), Audits and
Compliance (Central Office), and the Office of Health Services (mental health area) for five (5) years, and then destroyed.

Attachments (6)

  1. Documents Needed to Facilitate a Comprehensive Audit (702 words)
  2. Audit Process Outline for Mental Health Administration (2,358 words)
  3. Audit Tool Scoring Guidelines (945 words)
  4. Mental Health Comprehensive Audit Tool (16,295 words)
  5. Comprehensive Audit Tool Scoring Sheet (1,015 words)
  6. Integrated Treatment Facility (ITF) Comprehensive Audit Tool (12,243 words)
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