SOP 508.12-att-7: Integrated Treatment Facility (ITF) Comprehensive Audit Tool

Division:: Mental Health Administration
Effective Date:: June 28, 2022
Reference Code:: VG26-0001
Topic Area:: 508 Policy - Mental Health Administration/Staff/Certification
PowerDMS:: View on PowerDMS
Length:: 12,243 words

Summary

This audit tool is used to assess compliance with mental health staffing requirements, credentialing, and training standards at Georgia's Integrated Treatment Facilities. The tool evaluates whether mental health staff (counselors, nurses, psychiatrists, APRNs, and psychologists) have complete credentialing files, current privileging forms, appropriate clinical supervision and consultation, and required in-service training. Auditors use a scoring system based on full compliance, partial compliance, and non-compliance to measure facility adherence to mental health administration policies.

Key Topics

mental health credentialing
staffing credentials
privileging files
clinical supervision
mental health nurses
counselors
psychiatrists
APRN
in-service training
compliance audit
facility audit
credentialing files
clinical consultation
unlicensed counselors
treatment facility standards

Full Text

SOP 508.12
Attachment 7

6/28/22
Page 1 of 36

# Integrated Treatment Facility (ITF) Comprehensive Audit Tool

I. Administration:

A. Staffing Patterns:

1. Credentialing Files (SOP 508.04)
Review the credentialing file for core employees, to include GDC and contract employees (MH
Unit Manager, Clinical Director, Counselors, MH Technicians, MH Nurses, Psychiatrists,
APRN’s, and Psychologists).

|Staff
Names

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|FC =|PC =|PC =|PC =|NC =|NC =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. The employee has a credentialing file. [VI.A.1. & VI.B.3]
Screen 2. All required credentialing documents are present and current, e.g., license, degree, board
certificate, DEA certificate, addiction certification, CPR card, verification of peer review for upper level
providers, and vitae/state application as appropriate.
Screen 3. A protocol, which is signed by the APRN and supervising psychiatrist, is present.

Auditor’s Signature/Title: __________________________________________________________

******************
FC = full (90%-100%) compliance, PC = partial (50% - 89%) compliance, NC = non-compliance (less than 50%),
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 M26-01-07

Retention Schedule: Upon completion, this form shall be maintained for 5 years or two successive audits, whichever is longer.
With the Original: Central Office; Copy: Office of Investigations; Facility Warden; MH Unit Manager

SOP 508.12
Attachment 7

6/28/22
Page 2 of 36

2. Privileging Files (SOP 508.04)

Review the privileging files for current Counselors.

|Staff
Names

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|FC =|PC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. This Mental Health Counselor/Technician has a privileging form. [VI.A.1. & VI.B.3]
Screen 2. The Privileging form is complete and current for Counselors. [VI.B.I]
Screen 3. The staff member is privileged to perform only those clinical functions for which he/she is
credentialed. [VI.B.1].

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 3 of 36

B. Training Programs (SOP 508.07)

1. Clinical Supervision/Consultation

Review the supervision/consultation files for Mental Health nurses and unlicensed counselors.

|Staff
Names

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|4.|4.||||||||||||||
|5.|5.||||||||||||||
|6.|6.||||||||||||||
|7.|7.||||||||||||||
|8.|8.||||||||||||||
|FC =|PC =|PC =|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) =|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. There is a supervision/consultation file for each unlicensed counselor and MH Nurse.
Screen 2. There is documentation that the unlicensed Counselor received clinical supervision at least three (3) hours per
month from a psychologist or approved LPC Supervision _or that the MH Nurse received Consultation at least_
_one (1) hour per month from a psychiatrist or APRN._
Screen 3. There is documentation that the MH/MR Nurse who facilitated a treatment group received consultation at
least one (1) hour per month from a psychologist.
Screen 4. The Supervision/Consultation form documents the date plus beginning and end times for each session.
Screen 5. The Supervision/consultation form documents relevant clinical issues and names (with ID numbers) of
detainees/cases discussed.
Screen 6. The Supervision form documents the unlicensed counselor’s clinical strengths and limitations _/ areas_ for
development.
Screen 7. A current, _complete, individualized_ semi-annual evaluation report is included in the unlicensed counselor’s
file.
Screen 8. There is documentation in the credentialing file that _APRN_ records were reviewed by a psychiatrist within the
past three (3) months.

Auditor’s Signature/Title: _________________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 4 of 36

2. In-Service Training (508.08)

Review the training records of ten (10) Mental Health Counselors. Central Office staff will
assign training site for Integrated Treatment Facility staff.

|Staff
Names

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/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. There is documentation that the counselor has completed the mandatory MH training, or he/she is
scheduled to attend an upcoming session of the mandatory MH Training. [D.3.b.]
Screen 2. There is documentation that the counselor has completed the annual two (2) hour block of instruction in
ethics. [C.1 & 1.b.]
Screen 3. There is documentation that the counselor has completed at least two (2) hours of in-service training each
month for the past four (4) months [C.1.] (Excused absence must be documented. This will be sick or annual leave,
training, crisis intervention, etc.).
Screen 4. Have all staff been trained on Motivational Interviewing.
Screen.5. Have all staff been trained on Co-Occurring Disorders.
Screen 6. Have all staff been trained on Stages of Change.

Auditor’s Signature/Title: _________________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 5 of 36

3. Correctional Officer Training (Mental Health Training)

Review the training records of all correctional officers, check the personnel file to ensure all
have attended Basic Mental Health Training.

1 [st] Shift Officers

|Staff
Names

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|
|---|---|---|---|---|---|---|---|---|---|---|
|1.|||||||||||

2 [nd] Shift Officers

|Staff
Names

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|
|---|---|---|---|---|---|---|---|---|---|---|
|1.|||||||||||

Screen 1. There is documentation that the correctional officer has completed the mandatory Mental Health training or that
the officer is scheduled to attend an upcoming session of the mandatory Mental Health training.

Auditor’s Signature/Title: _________________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 6 of 36

C. Record Maintenance (SOPs 508.09/508.10)

Medical Records (Security, Confidentiality & Organization) (Part 1)

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Medical records are maintained in a central and secure location.
[B.1.]|1. Medical records are maintained in a central and secure location.
[B.1.]|1. Medical records are maintained in a central and secure location.
[B.1.]|1. Medical records are maintained in a central and secure location.
[B.1.]|||||||
|2. Medical records are released to third parties only after the receipt
of a valid Release of Information form signed by the offender. (Check
one medical record. Section 5.) [D.1.]

|2. Medical records are released to third parties only after the receipt
of a valid Release of Information form signed by the offender. (Check
one medical record. Section 5.) [D.1.]

|2. Medical records are released to third parties only after the receipt
of a valid Release of Information form signed by the offender. (Check
one medical record. Section 5.) [D.1.]

|2. Medical records are released to third parties only after the receipt
of a valid Release of Information form signed by the offender. (Check
one medical record. Section 5.) [D.1.]

|||||||
|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 = %|

Auditor’s Signature/Title: _________________________________________________________________

Medical Records (Part 2) (SOP 508.09)

|Offender
ID#s

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.
|
|
|
|
||||||||||
|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. Primary care providers review the limits of confidentiality with offender and place a signed copy of the
Consent Mental Health Evaluation for Treatment Form in section 5 of the offender’s medical record.
Screen 2. All MH documents are filed under the MH tab in the medical file.

Auditor’s Signature/Title: _________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 7 of 36

D. Oversight Procedures
1. SCRIBE (SOP 508.01)
a. SCRIBE Reports

Review Scribe procedures to assure that the following reports can be generated:

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. The Mental Health Caseload Summary. [ C.8.1.c.1.]|1. The Mental Health Caseload Summary. [ C.8.1.c.1.]|1. The Mental Health Caseload Summary. [ C.8.1.c.1.]|1. The Mental Health Caseload Summary. [ C.8.1.c.1.]|||||||
|2. The Mental Health Caseload by Counselor. [C.8.a.(2).]|2. The Mental Health Caseload by Counselor. [C.8.a.(2).]|2. The Mental Health Caseload by Counselor. [C.8.a.(2).]|2. The Mental Health Caseload by Counselor. [C.8.a.(2).]|||||||
|3. The Offender by Diagnosis List and Level of Care. [C.8.1.(3).]|3. The Offender by Diagnosis List and Level of Care. [C.8.1.(3).]|3. The Offender by Diagnosis List and Level of Care. [C.8.1.(3).]|3. The Offender by Diagnosis List and Level of Care. [C.8.1.(3).]|||||||
|4. The Psychiatrist’ Schedules. [C.8.1.(4).]|4. The Psychiatrist’ Schedules. [C.8.1.(4).]|4. The Psychiatrist’ Schedules. [C.8.1.(4).]|4. The Psychiatrist’ Schedules. [C.8.1.(4).]|||||||
|5. The Psychologist’ Schedules. [C.8.a.(4).]|5. The Psychologist’ Schedules. [C.8.a.(4).]|5. The Psychologist’ Schedules. [C.8.a.(4).]|5. The Psychologist’ Schedules. [C.8.a.(4).]|||||||
|6. Is there a list of anticipated participant graduates.|6. Is there a list of anticipated participant graduates.|6. Is there a list of anticipated participant graduates.|6. Is there a list of anticipated participant graduates.|||||||
|7. Is there a City/County report generated on an ongoing basis and
distributed.

|7. Is there a City/County report generated on an ongoing basis and
distributed.

|7. Is there a City/County report generated on an ongoing basis and
distributed.

|7. Is there a City/County report generated on an ongoing basis and
distributed.

|||||||
|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) =|Scorable Items = 7 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 8 of 36

LOGS (SOP 508.19)

b. Sexual Allegation Log

Review the Sexual Allegation Log to assure each required element is present.

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. The log contains the date the Mental Health Unit Manager was notified
of the allegation.|1. The log contains the date the Mental Health Unit Manager was notified
of the allegation.|1. The log contains the date the Mental Health Unit Manager was notified
of the allegation.|1. The log contains the date the Mental Health Unit Manager was notified
of the allegation.|||||||
|2. The log contains the date the special counselor was notified of the
allegation.|2. The log contains the date the special counselor was notified of the
allegation.|2. The log contains the date the special counselor was notified of the
allegation.|2. The log contains the date the special counselor was notified of the
allegation.|||||||
|3. The log contains the name of the alleged victim’s special counselor.|3. The log contains the name of the alleged victim’s special counselor.|3. The log contains the name of the alleged victim’s special counselor.|3. The log contains the name of the alleged victim’s special counselor.|||||||
|4. The log contains the name of the alleged victim’s facility.|4. The log contains the name of the alleged victim’s facility.|4. The log contains the name of the alleged victim’s facility.|4. The log contains the name of the alleged victim’s facility.|||||||
|5. The log contains the name and ID# of the alleged victim.

|5. The log contains the name and ID# of the alleged victim.

|5. The log contains the name and ID# of the alleged victim.

|5. The log contains the name and ID# of the alleged victim.

|||||||
|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) =|Scorable Items = 5 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

c. Discharge Log

Review the Discharge Log to assure each required element is present.

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. The log contains the offender’s name and ID#.|1. The log contains the offender’s name and ID#.|1. The log contains the offender’s name and ID#.|1. The log contains the offender’s name and ID#.|||||||
|2. The log contains the date of release.|2. The log contains the date of release.|2. The log contains the date of release.|2. The log contains the date of release.|||||||
|3. The log contains the type of release.|3. The log contains the type of release.|3. The log contains the type of release.|3. The log contains the type of release.|||||||
|4. The log contains the name of the probation or parole office to which the
offender was released (if applicable).|4. The log contains the name of the probation or parole office to which the
offender was released (if applicable).|4. The log contains the name of the probation or parole office to which the
offender was released (if applicable).|4. The log contains the name of the probation or parole office to which the
offender was released (if applicable).|||||||
|5. The log contains the date form M01-0020-01 was sent to the probation
or parole office (if applicable).|5. The log contains the date form M01-0020-01 was sent to the probation
or parole office (if applicable).|5. The log contains the date form M01-0020-01 was sent to the probation
or parole office (if applicable).|5. The log contains the date form M01-0020-01 was sent to the probation
or parole office (if applicable).|||||||
|6. The log contains the primary diagnosis carried by the offender at the
time of release.|6. The log contains the primary diagnosis carried by the offender at the
time of release.|6. The log contains the primary diagnosis carried by the offender at the
time of release.|6. The log contains the primary diagnosis carried by the offender at the
time of release.|||||||
|7. The log contains the name and dosage of medications the offender was
provided upon release.|7. The log contains the name and dosage of medications the offender was
provided upon release.|7. The log contains the name and dosage of medications the offender was
provided upon release.|7. The log contains the name and dosage of medications the offender was
provided upon release.|||||||
|8. The log contains the referral status of the offender (voluntary or 1013)
(If applicable)|8. The log contains the referral status of the offender (voluntary or 1013)
(If applicable)|8. The log contains the referral status of the offender (voluntary or 1013)
(If applicable)|8. The log contains the referral status of the offender (voluntary or 1013)
(If applicable)|||||||
|9. The log contains the date and time of the inmate’s first follow-up
appointment after release.|9. The log contains the date and time of the inmate’s first follow-up
appointment after release.|9. The log contains the date and time of the inmate’s first follow-up
appointment after release.|9. The log contains the date and time of the inmate’s first follow-up
appointment after release.|||||||
|10. Has the REPAC been faxed to the Chief/MH Probation Officer 30 days
prior to release?

|10. Has the REPAC been faxed to the Chief/MH Probation Officer 30 days
prior to release?

|10. Has the REPAC been faxed to the Chief/MH Probation Officer 30 days
prior to release?

|10. Has the REPAC been faxed to the Chief/MH Probation Officer 30 days
prior to release?

|||||||
|FC =|PC =|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) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 9 of 36

d. Diagnostic Referral Log

Review the Diagnostic Referral Log to assure each required element is present.

Auditor’s Signature/Title: _________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 10 of 36

e. Duty Officer Logbook (SOP 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|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|4.|4.||||||||||||||
|5.
|5.
|
|
|
|
||||||||||
|FC =|PC =|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. There is a complete entry for every clinical call. (Date, time of call, action taken, etc.) [F.1]
Screen 2. There Is a corresponding DAP note in the MH record for all after hours clinical calls. [F.1.d]
Screen 3. The corresponding DAP note includes all identifying data (date, time of call, action taken, persons notified,
etc.) [F.10]
Screen 4. The progress note provided a concise narrative of significant information. [VI.F.10]
Screen 5. The appropriate clinical action was taken.

Auditor’s Signature/Title: _________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 11 of 36

E. Continuous Quality Improvement

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Quality of psychotropic mediation prescription was reviewed quarterly.|1. Quality of psychotropic mediation prescription was reviewed quarterly.|1. Quality of psychotropic mediation prescription was reviewed quarterly.|1. Quality of psychotropic mediation prescription was reviewed quarterly.|||||||
|2. Psychotropic medication non-adherence was reviewed six months.|2. Psychotropic medication non-adherence was reviewed six months.|2. Psychotropic medication non-adherence was reviewed six months.|2. Psychotropic medication non-adherence was reviewed six months.|||||||
|3. Treatment plans were reviewed quarterly.|3. Treatment plans were reviewed quarterly.|3. Treatment plans were reviewed quarterly.|3. Treatment plans were reviewed quarterly.|||||||
|4. The 4 Quadrants of Care were reviewed quarterly.|4. The 4 Quadrants of Care were reviewed quarterly.|4. The 4 Quadrants of Care were reviewed quarterly.|4. The 4 Quadrants of Care were reviewed quarterly.|||||||
|5. The MFCO weekly documentation was reviewed quarterly.|5. The MFCO weekly documentation was reviewed quarterly.|5. The MFCO weekly documentation was reviewed quarterly.|5. The MFCO weekly documentation was reviewed quarterly.|||||||
|6. There is a schedule of Continuous Quality Improvement (CQI) studies for
the year.|6. There is a schedule of Continuous Quality Improvement (CQI) studies for
the year.|6. There is a schedule of Continuous Quality Improvement (CQI) studies for
the year.|6. There is a schedule of Continuous Quality Improvement (CQI) studies for
the year.|||||||
|7. There is evidence of quarterly meetings.|7. There is evidence of quarterly meetings.|7. There is evidence of quarterly meetings.|7. There is evidence of quarterly meetings.|||||||
|8. Minutes and data are sent to Central Office Quarterly.|8. Minutes and data are sent to Central Office Quarterly.|8. Minutes and data are sent to Central Office Quarterly.|8. Minutes and data are sent to Central Office Quarterly.|||||||
|9. The staff has been creative and designed additional studies

|9. The staff has been creative and designed additional studies

|9. The staff has been creative and designed additional studies

|9. The staff has been creative and designed additional studies

|||||||
|FC =|PC =|NC =|Scorable Items = 9 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 9 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 9 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 9 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 12 of 36

II. IDENTIFICATION
A. Identifying SMI
1. Evaluations
a. Diagnostics (508.36)

|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/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. A Reception Screen is completed on all offenders on the day of their arrival into the system. [VI.A.2.]
Screen 2. A Health Screening Form (P-24-001-01) is completed on all offenders on the day of their arrival into the
system. [VI.A.2.]
Screen 3. Offenders on psychotropic medications are referred for an initial psychiatric _/psychological_ evaluation,
_within the time period specified by standard Operating procedures._ ( _Emergency – 24 hours; routine – 14_
_days)._
Screen 4. A release of information is in place (section 5 of the medical record) to obtain previous treatment records.
[VI.A.5.b.]
Screen 5. A mental health evaluation was completed within 7 days of their arrival into the system. [VI.A.6.]
Screen 6. An Addiction Severity Index was completed within 7 days of their arrival into the system.

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 13 of 36

b. Mental Health Services

Screen 1. A psychologist has reviewed and signed all evaluations performed by unlicensed Mental Health personnel.
Screen 2. The Mental Health Evaluations for Services (Form M31-01-01) has been completed for each offender.

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 14 of 36

c. Initial Psychiatric/Psychological Evaluations
(508.24)

Pull ten (10) charts of offenders who had an Initial Psychiatric/Psychological Evaluation
performed at the present facility. 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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|Psychiatric|Psychiatric|Psychiatric|Psychiatric|Psychiatric|Psychiatric|Psychiatric|Psychiatric|Psychological|Psychological|Psychological|Psychological|Psychological|Psychological|
|1.||||||||||||||
|2.||||||||||||||
|3.||||||||||||||
|4.||||||||||||||
|5.||||||||||||||
|6.||||||||||||||
|7.||||||||||||||
|8.||||||||||||||
|9.||||||||||||||
|10.
|
|
|
|
||||||||||
|FC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 100 - #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. [VI.A.1.b]
Screen 3. The Initial Psychiatric/Psychological Evaluation includes relevant mental health history. [VI.A.1.c]
Screen 4. The Initial Psychiatric/Psychological Evaluation includes a history of substance use and treatment.
[VI.A.1.d]
Screen 5. The Initial Psychiatric/Psychological Evaluation includes a medication history.
Screen 6. The Initial Psychiatric Evaluation identifies drug allergies.
Screen 7. The Initial Psychiatric/Psychological Evaluation includes the current medication regimen. [VI.A.1.f.
Screen 8. The Initial Psychiatric/Psychological Evaluation includes a mental status examination. [VI.A.1.e]
Screen 9. The Initial Psychiatric/Psychological Evaluation includes a diagnosis or diagnostic impression using
DSM criteria and nomenclature. [VI.A.2]
Screen 10. The information contained in the Initial Psychiatric/Psychological Evaluation provides the DSM
criteria for the diagnosis or diagnostic impression. [VI.3.h]

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 15 of 36

d. Sexual Allegations (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.
|
|
|
|
||||||||||
|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. There is a signed Consent Form for the evaluation. [VI.A.2]
Screen 2. The evaluating Counselor has received training and is privileged to perform the evaluation. [VI.D]
Screen 3. The Sexual Allegation Evaluation was completed within 24 hours. [VI.B.4]
Screen 4. The Evaluation includes a mental status exam and assesses for emotional trauma. [VI.B.3]
Screen 5. The Evaluation is clinically focused and is not involved with the security investigation and/or truth or
falsehood of the allegation. [VI.A.3]
Screen 6. If clinically indicated, the offender was referred for treatment or further evaluation. [VIB.5.]
Screen 7. If referred for treatment or further evaluation, a copy of the completed MH Referral Form (M35-01-01) is present

in the Sexual Allegation Log packet.
Screen 8. If referred for treatment or further evaluation, there is documentation in the Mental Health file that this has
occurred.
Screen 9. If referred for abuse/trauma treatment, the offender's treatment plan and progress notes confirm treatment for
abuse/trauma.

Auditor’s Signature/Title: _______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 16 of 36

e. Disciplinary Report (508.18)
(1) Evaluations

|Offender
ID#s

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.||||||||||||||
|3.
|
|
|
|
||||||||||
|FC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 30- #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30- #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30- #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30- #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30- #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. When alternative sanctions are recommended, they are specific and clinically appropriate.
Screen 2. There is documentation to reflect whether or not alternative sanctions were followed.
Screen 3. There is documentation that a Learning Experience was utilized (when applicable) instead of a disciplinary
report.

Auditor’s Signature/Title: _______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 17 of 36

(2) Documentation

Locate ten (10) records of offenders who have been non-compliant and/or a behavior problem

|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/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. Is there documentation in SCRIBE for each Disciplinary Report / Learning Experience.
Screen 2. Does the Monthly Summary Report reflect each Disciplinary Report / Learning Experience?
Screen 3. Was the Probation Officer/Chief notified of the offenders’ Disciplinary Report / Learning Experience.
Screen 4. Is there a SCRIBE note entered by the Probation Officer/Chief concerning the Disciplinary Report / Learning
Experiences and does the conversation summarize the issues.
Screen 5. Is there documentation showing progressive disciplinary procedures for each infraction.

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 18 of 36

f. Isolation/Segregation

48 Hour Screen

Pull records of ten (10) Mental Health offenders who have been placed in
isolation/segregation. (508.20)

Screen 1. A MH screen/evaluation was performed within 2 working days of the MH offender’s
placement in isolation/segregation. [VI.A.2]
Screen 2. There was a substantive clinical assessment of contra-indication to lockdown _._

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 19 of 36

III. TREATMENT
A. Direction of Treatment (508.21)

1. Comprehensive Treatment/Habilitation Plans

|Offender
ID#s 
Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|4.|4.||||||||||||||
|5.|5.||||||||||||||
|6.|6.||||||||||||||
|7.

|7.

|
|
|
|
||||||||||
|FC =|PC =|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. The Comprehensive Treatment Plan is current and was completed within the time frame required by
Standard Operating Procedures. [C.]
Screen 2. The psychology supervisor has reviewed and signed the Treatment Plan.
Screen 3. The offender has reviewed and signed the Treatment Plan.
Screen 4. Problems are individualized, specific and appropriate. [VI.A.4.a]
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. Class of medication, if prescribed, is listed on the Treatment Plan as an intervention strategy with a
specific goal targeted toward a specific problem.

Auditor’s Signature/Title: _______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 20 of 36

2. Comprehensive Treatment/Habilitation Plan Reviews (508.21)

Screen 1. The treatment/habilitation plan has been reviewed as required by SOP and is current.
Screen 2. The two main sections of the comprehensive treatment/habilitation plan review are complete: psychiatric
diagnosis and summary of progress and changes in discharge criteria.

Auditor’s Signature/Title: _______________________________________________________________

3. Diagnosing SMI
Consistency

Randomly select ten (10) Mental Health clinical records (508.21)

|Offender
ID#s

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|
|
|
|
||||||||||
|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 Diagnosis on the Mental Health Diagnosis List and on the Treatment/Habilitation Plan is the same.

Auditor’s Signature/Title: _______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 21 of 36

B. Type of Treatment
1. Non-Pharmacological Interventions
a. Mental Health Counseling Documentation (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.||||||||||||||
|9.||||||||||||||
|10.||||||||||||||
|11.||||||||||||||
|12.
|
|
|
|
||||||||||
|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. Progress notes are signed, dated, and affixed with the printed, typed, or stamped name of the care
provider.
Screen 2. Progress notes state if the problem/target symptoms are new, worse, unchanged, improved or
eliminated since the previous session.
Screen 3. Progress notes identify the problem and/or target symptoms for the session.
Screen 4. Progress notes discuss the problem, intervention, observations, etc.
Screen 5. Progress notes present a plan of intervention in terms of the problem/target symptoms.
Screen 6. Frequency of progress notes is in compliance with Standard Operating Procedures.
Screen 7. Progress note interventions are appropriate to the diagnosis and problems.
Screen 8. Progress note interventions are consistent with the Comprehensive Treatment/Habilitation Plan
interventions.
Screen 9. Counseling sessions, including plan for intervention, reflect continuity of care.
Screen 10. There is a minimum of two progress notes each month.
Screen 11. There is a monthly summary note each month.
Screen 12. There is proof (fax confirmation/ probation officer), that the monthly summary was faxed to the referring
Chief Probation Officer.

Auditor’s Signature/Title: __________________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 22 of 36

b. Multifunctional Officer Documentation

Look in Scribe to ensure weekly notes are being made on all offenders.

|Offender
ID#s

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.||||||||||||||
|3.||||||||||||||
|4.
|
|
|
|
||||||||||
|FC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. Is there a weekly note in Scribe by the Multifunctional Officer?
Screen 2. Does the weekly note adequately reflect the probationer’s behavior?
Screen 3. Do the notes reflect communication with the probation office?
Screen 4. Is there documentation that the Probation Officer visited or attended a conference call with the
probationer prior to release?

Auditor’s Signature/Title: __________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 23 of 36

c. Quadrants of Care

Locate ten (10) records of offenders

|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/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. Is the “4 Quadrants Model” used for all offenders?
Screen 2. Does the Counselor utilize the “4 Quadrants Model” in the group selection process?
Screen 3. Is there documentation in the file supporting the “4 Quadrants Model.”
Screen 4. Is there documentation showing that the participant’s mental health, substance abuse, and criminogenic
factors were utilized in determining his/her Quadrant assignment?
Screen 5. Are severe Substance Abuse/severe Mental Health offenders being placed in the
appropriate groups?

Auditor’s Signature/Title: __________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 24 of 36

d. Group Treatment (508.16)
(1) Therapy or Support Groups

Pull charts of ten (10) offenders who are members of a therapy or support group and match
the attendance logs with the MH records.

|Offender
ID#s
Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.||||||||||||||
|3
|
|
|
|
||||||||||
|FC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. Roster and progress notes match.
Screen 2. Placement in the therapy or support group was determined by the Treatment Plan interventions and
is appropriate to diagnosis and/or problems.
Screen 3. Evidence of progress or lack of progress is reflected in the group progress notes.

Auditor’s Signature/Title: ________________________________________________________________

(2) Psycho-Educational Groups

Pull charts of ten (10) offenders who are members of a psycho-education group and match the
attendance logs with the MH records.

|Offender
ID#s
Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3
|3
|
|
|
|
||||||||||
|FC =|PC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 30 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 25 of 36

(3) 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 MH records.

|Offender
ID#s 
Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|Col16|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||||
|2.||||||||||||||||
|3.||||||||||||||||
|4.||||||||||||||||
|5.||||||||||||||||
|6.||||||||||||||||
|7.
|
|
|
|
||||||||||||
|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. An Activity Therapy Assessment (form M56-01-01) was completed within 30 days of the offender's
placement in the ITF. [508.06 B.]
Screen 2. The Activity Therapy Assessment identifies problems and/or needs regarding the offender's activities and
individualized treatment plan. [VI.E.1]
Screen 3. The Activity Therapy Assessment form was filed in section four of the Mental Health record. [VI.E.3]
Screen 4. The Activity Therapy Assessment was reviewed annually. [VI.E.3]
Screen 5. Monthly Activity Therapy notes are documented on the approved Activity Therapy group progress note
form, which is filed in section one of the mental health record. (M56-01-02)
Screen 6. The monthly Activity Therapy notes reflect the offender's progress toward established goals of the
Treatment Plan. [VI.E.2]
Screen 7. Group roster and other group attendance data are maintained by the Mental Health Unit Manager.
[VI.E.3]

Auditor’s Signature/Title: _________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 26 of 36

e. Community Meetings (508.44)

|Screen|Col2|Col3|Col4|FC|PC|NC|Col8|NA|NR|
|---|---|---|---|---|---|---|---|---|---|
|1. Community meetings are being held in each ITF dorm
on a daily basis.|1. Community meetings are being held in each ITF dorm
on a daily basis.|1. Community meetings are being held in each ITF dorm
on a daily basis.|1. Community meetings are being held in each ITF dorm
on a daily basis.|||||||
|2. A Multifunctional Correctional Officer is participating in
each community meeting.|2. A Multifunctional Correctional Officer is participating in
each community meeting.|2. A Multifunctional Correctional Officer is participating in
each community meeting.|2. A Multifunctional Correctional Officer is participating in
each community meeting.|||||||
|3. Community meetings focus on issues of community
living and mutual support.

|3. Community meetings focus on issues of community
living and mutual support.

|3. Community meetings focus on issues of community
living and mutual support.

|3. Community meetings focus on issues of community
living and mutual support.

|||||||
|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) =|Scorable Items = 3 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 27 of 36

2. Pharmacological Interventions
a. Medication Non-Adherence (508.24/508.11)

|(1) Statistics|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
|---|---|---|---|---|---|---|---|---|---|
|Screen|Screen|Screen|Screen|FC|PC|NC|NC|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.
[508.24 C.6.]

|4. MARs are copied for psychiatry/tele-psychiatry
clinics.
[508.24 C.6.]

|4. MARs are copied for psychiatry/tele-psychiatry
clinics.
[508.24 C.6.]

|4. MARs are copied for psychiatry/tele-psychiatry
clinics.
[508.24 C.6.]

|||||||
|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) 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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.||||||||||||||
|3.||||||||||||||
|4.
|
|
|
|
||||||||||
|FC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. Documentation is present indicating the offender was counseled by the Mental Health
nurse or was referred to psychiatry. [C.5.]
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. [507.04.33]
Screen 3 Documentation is individualized and reflects offender’s reasons for non-compliance. [507.04.33 VI. D]
Screen 4. Documentation addresses (identifies) “no-shows” versus refusals .

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 28 of 36

b. Quantitative 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.||||||||||||||
|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. The medical record contains a psychiatric evaluation. [508.09 VI.E.1. g]
Screen 2. The medical record contains a signed Informed Consent Form for the current medication signed by offender and
prescriber within the past year. [A.9]
Screen 3. The psychiatrist has reviewed the offender every 120 calendar days. [B.1]
Screen 4. The psychiatric progress notes include the current diagnosis. [B.2.f]
Screen 5. There is a psychiatric progress note for each order of psychotropic medication. [A.8]
Screen 6. Progress notes are legible.
Screen 7. 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. [VI.B.1]
Screen 8. The psychiatric progress notes include target symptoms for the medication prescribed [VI.A.1.f]
Screen 9. The psychiatric progress notes include documentation of the effectiveness of the medications prescribed
and the presence or absence of side effects. [VI.B.2.a]
Screen 10. The psychiatric progress notes include laboratory results for tests related to the medication
prescribed. [VI.B.2.c and VI.E]
Screen 11. Progress notes explain reasons for change in diagnosis and/or medication. [VI.B.2]

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 29 of 36

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/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. The type of psychotropic medication prescribed fits with the symptoms described in the treatment
plan and/or progress notes. [VI.C.1]
Screen 2. The Psychotropic medications prescribed are indicated for the current diagnosis or diagnoses or “offlabel” 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. [VI.E.3]

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 30 of 36

d. Laboratory Monitoring (508.24)
(1) New Generation Antipsychotic (NGA) Medication

Pull ten (10) charts of offenders with current prescriptions for new generation antipsychotic
medications.

|Offender
ID#s
Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|Col12|Col13|Col14|Col15|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|4.|4.||||||||||||||
|FC =|PC =|PC =|PC =|NC =|NC =|NC =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 40 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|Compliance
Score = %|

Screen 1. The psychiatrist/APRN has reviewed or ordered FBS or HgbA1c at the time of initiation of NGA.
Screen 2 The psychiatrist/APRN has reviewed or ordered a lipid panel at the time of initiation of NGA.
Screen 3. The offender’s weight and waist circumference are documented within the past 6 months.
Screen 4. AIMs have been performed within the last six months. [E.1.b.2]
Screen 5. If offender has been on an NGA over 1 year, items 1-2 have been done within the past year.

Auditor’s Signature/Title: ________________________________________________________________

(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.|1.||||||||||||||
|2.|2.||||||||||||||
|3.|3.||||||||||||||
|4.|4.||||||||||||||
|5.|5.||||||||||||||
|6.|6.||||||||||||||
|FC =|PC =|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. [VI.E.4.a (1)]
Screen 2. The initial work up indicates the psychiatrist has reviewed recent LFTs. [VI.E.4.a (3)]
Screen 3. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent
pregnancy test. [VI.E.3.a (5)]
Screen 4. After initiation of Tegretol, blood levels were done X2 within six months. [VI.E.4.c]
Screen 5. Blood levels have been done within the past six months. [VI.E.4.c]
Screen 6. The lab work in screens 1-2 has been repeated within the past six months.

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 31 of 36

(4) 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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.||||||||||||||
|3.||||||||||||||
|4.||||||||||||||
|5.||||||||||||||
|6.||||||||||||||
|7.||||||||||||||
|8.
|
|
|
|
||||||||||
|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. [VI.E.3.a (1)]
Screen 2. The initial work up indicates the psychiatrist has reviewed a recent BUN, electrolytes, and Cr.
[VI.E.3.a (2)]
Screen 3. The initial work up indicates the psychiatrist has reviewed a recent thyroid profile. [VI.E.3.a (4)]
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. [VI.E.3/a (6)]
Screen 5. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent pregnancy test.
[VI.E.3.a (5)]
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. [VI.E.3.b (1)]
Screen 7. If the Lithium dosage was changed, a level was done within 7 days after the change. [VI.E.3]
Screen 8. A lithium level has been done within the past six months. [VI.E.3]

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 32 of 36

(5) 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/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. The initial work up indicates the psychiatrist has reviewed a recent CBC with Differential. [VI.E.5.a
(1)]
Screen 2. The initial work up indicates the psychiatrist has reviewed recent LFTs. [VI.E.4.a (3)]
Screen 3. If the offender is female, the initial work up indicates the psychiatrist has reviewed a recent
pregnancy test. [VI.E.3.a (5)]
Screen 4. The lab work in screens 1-2 have been repeated in the last six months. [VI.E.5.b]
Screen 5. Blood levels have been done within the past 6 months and within 2 weeks of dosage change.

Auditor’s Signature/Title: ________________________________________________________________

(6) 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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.
|
|||
||||||||||
|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. [VI.E.6.a (5)]
Screen 2. There is a psychiatric progress note indicating evaluation of drug abuse history. [VI.E.6.a (4)]

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 33 of 36

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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.||||||||||||||
|2.
|
|
|
|
||||||||||
|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. [508.24]

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 34 of 36

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|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|1.
|
|
|
|
||||||||||
|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. [508.24 F.3.] (Section 5, medical file)

Auditor’s Signature/Title: ________________________________________________________________

|g. Heat Monitoring (508.24)|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|
|---|---|---|---|---|---|---|---|---|
|Screen|Screen|Screen|Screen|FC|PC|NC|NA|NR|
|1. There is a daily log for the Supportive Living Units and
lockdown units to reflect the housing temperatures from
April 1st – September 30th. [F.3.]|1. There is a daily log for the Supportive Living Units and
lockdown units to reflect the housing temperatures from
April 1st – September 30th. [F.3.]|1. There is a daily log for the Supportive Living Units and
lockdown units to reflect the housing temperatures from
April 1st – September 30th. [F.3.]|1. There is a daily log for the Supportive Living Units and
lockdown units to reflect the housing temperatures from
April 1st – September 30th. [F.3.]||||||
|2. When housing temperature exceeds 90° F, the log reflects
adequate ice and fluids are provided in the housing unit.
[F.3.]|2. When housing temperature exceeds 90° F, the log reflects
adequate ice and fluids are provided in the housing unit.
[F.3.]|2. When housing temperature exceeds 90° F, the log reflects
adequate ice and fluids are provided in the housing unit.
[F.3.]|2. When housing temperature exceeds 90° F, the log reflects
adequate ice and fluids are provided in the housing unit.
[F.3.]||||||
|3. When housing temperature exceeds 90° F, the log reflects
fans are used to increase air flow. [F.3.]|3. When housing temperature exceeds 90° F, the log reflects
fans are used to increase air flow. [F.3.]|3. When housing temperature exceeds 90° F, the log reflects
fans are used to increase air flow. [F.3.]|3. When housing temperature exceeds 90° F, the log reflects
fans are used to increase air flow. [F.3.]||||||
|4. When housing temperature exceeds 90° F, the log reflects
additional showers are allowed. [F.3.]|4. When housing temperature exceeds 90° F, the log reflects
additional showers are allowed. [F.3.]|4. When housing temperature exceeds 90° F, the log reflects
additional showers are allowed. [F.3.]|4. When housing temperature exceeds 90° F, the log reflects
additional showers are allowed. [F.3.]||||||
|5. There are an adequate number of fans in the Supportive
Living Unit and lockdown units.

|5. There are an adequate number of fans in the Supportive
Living Unit and lockdown units.

|5. There are an adequate number of fans in the Supportive
Living Unit and lockdown units.

|5. There are an adequate number of fans in the Supportive
Living Unit and lockdown units.

||||||
|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 = %|

Auditor’s Signature/Title: ________________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 35 of 36

3. Stabilization Services
a. Observation Cell Unit (508.28)

Review the files of offenders who remained in an observation cell over 24 hours.

|Offender
ID#s

Screen

|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|
|---|---|---|---|---|---|---|---|---|---|
|1.|1.|||||||||
|2.|2.|||||||||
|3.|3.|||||||||
|4.|4.|||||||||
|5.|5.|||||||||
|6.|6.|||||||||
|7.|7.|||||||||
|8.|8.|||||||||
|9.|9.|||||||||
|10.
|10.
|

|

|
|
|||||
|FC =|PC =|PC =|NC =|NC =|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =
|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =
|Scorable Items = 100 - #NA/NR =
Score = (FCX2) + (PCX1) =
|Compliance
Score = %|Compliance
Score = %|

Screen 1. Offenders admitted was evaluated within 12 hours of placement by a Qualified Mental Health Provider. [C.5.h.]
Screen 2. There is an admission DAP note in the medical record.
Screen 3. Admission was done in concurrence with a psychiatrist and/or psychologist. [05.]
Screen 4. Date of last placement in an observation cell was not within a 7-day time frame. [C.5.i.]
Screen 5. If the inmate was admitted twice in a seven (7) day period, then he/she was sent to a CSU, ACU or Correct
Care [C.5.i.]
Screen 6. If placement exceeds 24 hours there is written justification on form M68-01-05 for the length of stay in the
observation cell. [VI.C.5.g.]
Screen 7. If over 24 hours a copy of form M68-01-05 is in section five of the medical record.
Screen 8. The Warden/designee has reviewed and signed form M68-01-05. [C.5.g.]
Screen 9. There is a discharge DAP note in the medical record. [VI.C.5.e]
Screen 10. The discharge DAP note reflects concurrence with a psychiatrist and/or psychologist. [VI.C.5.e]

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

SOP 508.12
Attachment 7

6/28/22
Page 36 of 36

b. 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.|1.|||||||||
|2.|2.|||||||||
|3.|3.|||||||||
|4.|4.|||||||||
|5.|5.|||||||||
|6.|6.|||||||||
|7.

|7.

|

|

|||||||
|FC =|PC =|PC =|NC =|NC =|Scorable Items = 35 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 35 - #NA/NR =
Score = (FCX2) + (PCX1) =|Scorable Items = 35 - #NA/NR =
Score = (FCX2) + (PCX1) =|Compliance
Score = %|Compliance
Score = %|

Screen 1. Placement on Suicide Precautions SP is clinically indicated.
Screen 2. The Suicide Risk Assessment Instrument (SRAI) was completed, individualized, and signed on or
before the first working day after placement on suicide precautions.
Screen 3. There is an upper-level provider's original signature on page three of the Suicide Risk Assessment
Instrument.
Screen 4 There is documentation that the offender on SP has received therapeutic services at least two
times per week.
Screen 5. The offender is receiving treatment specific to reduction of suicide risk or SIB.
Screen 6. There is documentation that the offender in CSU had daily contact with a MH nurse.
Screen 7. Discontinuation from SP status was clinically indicated and appropriately documented.

Auditor’s Signature/Title: ______________________________________________________________

Form M26-01-07

Attachments (6)

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

Machine-readable: JSON Plain Text