SOP_NUMBER: 508.12-att-6
TITLE: Comprehensive Audit Tool Scoring Sheet
REFERENCE_CODE: VG26-0001
DIVISION: Mental Health Administration
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-06-28
WORD_COUNT: 1015
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/429712
URL: https://gps.press/sop-data/508.12-att-6/
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
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/
========================================================================
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.