chapter 9 provider monitoring policies

SALISH BHO

PROVIDER MONITORING POLICIES AND PROCEDURES

Monitoring Contractor andSubcontractor Sufficiency 9.01 of 2

Policy Name: MONITORING CONTRACTOR AND SUBCONTRACTOR SUFFICIENCY Policy Number: 9.01

Reference: 42 CFR 438.206; 42 CFR 438.207; DSHS Contract

Effective Date: 8/2004

Revision Date(s): 12/2011; 4/2016

Reviewed Date: 4/2016; 6/2017

Approved by: SBHO Executive Board

CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors• Policy: Provider and Subcontractor Administrative Review• Policy: Subcontractual Delegation and Assessment Plan

PURPOSE

The Salish Behavioral Health Organization (SBHO) will monitor provider network and subcontractor sufficiency and provide reports to the state.

PROCEDURE

1. SBHO providers will complete a report detailing current staffing.a. Report will be updated as per contract.b. Report will detail number of network staff and areas of specialty employed by

each network provider. Specialties include:• Credentials, such as psychiatrists, MHPs, MSWs, CDPs, etc.• Age, such as child and geriatric• Minority• Disability and hearing impaired• Evidence Based Practice training, and• Bilingual skills

Salish BHO Policies and Procedures

Monitoring Contractor andSubcontractor Sufficiency 9.01 of 2

2. SBHO subdelegated contractors will provide evidence of how previous fiscal year activities outlined in the contracts were met during the regularly scheduled Administrative Reviews.

3. SBHO staff will monitor contractor reports and delegation agreements through the

following activities: a. Conduct a GEOACESS mapping, with significant alternations to population

and/or public transportation routes, to ensure adequate capacity for the expected enrollment in our service area in accordance with state standards for access to care travel times, as required.

b. SBHO will monitor the report for losses or additions of individuals with

particular specialties. c. The SBHO will work with network providers to ensure continued access to

specialists. d. If a network provider loses internal access to a particular specialist, the SBHO

will work with the provider to: • Encourage the hiring of replacement staff or train existing staff to meet

qualifications • Maintain access via referrals for outside-agency contracts or

arrangements with other network providers e. The SBHO will conduct regularly scheduled formal reviews of contractors and

subcontractors with Subdelegation Agreements, using the SBHO Subcontractual Delegation and Assessment Plan.

MONITORING

1. Policy Monitoring. The SBHO will conduct resource management of network sufficiently through:

• Grievance Reports and system tracking of concerns and grievances to assess if there is a pattern that suggests inadequacy in network sufficiency or gaps in service capability. The reports will be reviewed by SBHO staff and the Quality Improvement Committee.

• Regularly scheduled SBHO Provider and Subcontractor Administrative Review

• Monthly Provider Chart Reviews • Reference existing GEOACESS maps to analyze gaps in meeting state

standards. 2. If a provider performs below expected standards during any of the reviews listed

above a Corrective Action will be required for SBHO approval.

SALISH BHO


Monitoring of Contractors 9.02 Page 1 of 2

Policy Name: MONITORING OF CONTRACTORS Policy Number: 9.02

Reference: 42 CFR 438.206, 207; WAC 388-865-0268; DSHS Contract


Revision Date(s): 2/2013; 4/2016; 6/2017



CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Provider and Subcontractor Administrative Review

PURPOSE

The Salish Behavioral Health Organization (SBHO) shall monitor contracted providers for compliance with contract requirements and state and federal regulations.

PROCEDURE

1. The SBHO monitors contractor compliance and performance by a variety of means

• Contractor licensing and certification is monitored during the routine SBHOadministrative reviews.

• Statistical monitoring is performed quarterly in the SBHO performance reports.• Contractor performance is compared to statewide standards on specific performance

measures.• Timely access to services is monitored through MIS data reports.• A random sample of clinical files is reviewed annually, at a minimum totaling 500

charts in a year.• A standardized clinical chart review is utilized, as well as targeted/ focused chart

reviews such as Practice Guidelines and zero PRATs.• Files are reviewed for data accuracy against the SBHO database.

Peninsula RSN Policies and Procedures

Monitoring of Contractors 9.02 Page 2 of 2

• Grievance reports are compiled quarterly and monitored for patterns of grievances that bears investigation by SBHO staff and the Quality Improvement Committee.

• SBHO monitors and oversees the agency semi-annual revenue and expense reports submitted to the SBHO.

• SBHO conducts annual delegation agreement/plan reviews.

2. The SBHO conducts regularly scheduled SBHO provider and subcontractor administrative reviews, targeting areas of trend and corrective action from previous reviews. The SBHO will:

• Deliver to the provider copies of the format of the review at the time of review, or earlier.

• Report the results of the review in writing to the provider, including areas needing improvement or other acts of non-compliance, within 30 calendar days of the completion of the review.

• Identify required redress or repair and the time limits, and the form or format or other evidence that the provider is required to submit in order to be considered compliant.

• Report to the provider the possibility of punitive response as may result from failure to comply.

MONITORING

1. This policy is a mandate by contract and statute. This policy is monitored through use of SBHO:

• Regularly scheduled SBHO Provider and Subcontractor Administrative/ Subdelegated Review

• Annual Provider Chart Reviews • Grievance Tracking Reports • Biennial Provider Quality Review Team review • Quality Management Plan activities, such as review targeted issues for trends and

recommendations. • Review of previous provider corrective action plans related to the Age and Cultural

Competence policy, including provider profiles related to performance on targeted indicators.

2. If a provider performs below expected standards during any of the reviews listed above a

Corrective Action will be required for SBHO approval. Reference 9.11 SBHO Corrective Action Plan Policy.


Monitoring Table 9.02a Page 1 of 2

SBHO MONITORING TABLE FY 2017-18 Activities

Monitoring Activity SBHO Contractor Due Date

Date Activity

Completed

SBHO Provider Admin. Review True Star Annual

SBHO Provider Admin. Review KRC Annual

Grievance Tracking Reports analysis and network grievances submitted to Department SBHO July 30

SBHO Gaps Analysis SBHO

SBHO Provider Admin. Review WEOS Annual

Provider R & E Reports September

Clinical chart reviews: Network Annual

SBHO Subcontractor Admin. Review Ombuds Annual

Provider Performance Reports – (previous FY Totals) October

SBHO Provider Admin. Review BOH Annual

1st QRT On-Site Provider Review Fall

Grievance Tracking Reports analysis and network grievances submitted to Department SBHO October 31

SBHO Provider Admin. Review Cascadia Annual

Provider Performance Reports- 1st Qtr of current FY December

SBHO Provider Admin. Review Cedar Grove Annual

SBHO Provider Admin. Review OPG Annual

SBHO Provider Admin. Review KMHS Annual

Grievance Tracking Reports analysis and network grievances submitted to Department SBHO January 31

Provider R&E Reports February

SBHO Provider Admin. Review PBH Annual


Monitoring Table 9.02a Page 2 of 2

SBHO Provider Admin. Review Spec. Srvcs. II Annual

SBHO Provider Admin. Review Spec. Srvcs. III Annual

Provider Performance Reports- 2nd Qtr of current FY March

2nd QRT On-Site Provider Review Spring

SBHO Provider Admin. Review WSTC Annual

Grievance Tracking Reports analysis and network grievances submitted to Department SBHO April 30

SBHO Provider Admin. Review Agape Annual

SBHO Provider Admin. Review DBH Annual

Provider Performance Reports-3rd Qtr of current FY June

Grievance Tracking Reports analysis and network grievances submitted to Department SBHO July 30

Provider Performance Reports- 4th Qtr of current FY and Yearly Totals September

QUIC Review Provider QM Plans and QA Reports Annual

SBHO Fiscal Review of each Provider Agency Annual

SBHO Subdelegated Admin. Review: ASO ASO Biennial

SBHO Subdelegated Admin. Review: KMHS IS IS Biennial

SBHO Review of E&Ts AIU & YIU Annual

SBHO Review of Residential Programs KMHS & PBH Annual

Provider Performance Reports- 4th Qtr of current FY and Yearly Totals September

SALISH BHO


Provider – Subcontractor Administrative Review 9.03 Page 1 of 2

Policy Name: SBHO PROVIDER AND SUBCONTRACTOR ADMINISTRATIVE REVIEW Policy Number: 9.03

Reference: 42 CFR 438.230; WAC 388-865-0264, -0268


Revision Date(s): 2/2013



CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Monitoring of Contractors• Policy: Standard Chart Reviews

PURPOSE

It is the policy of the Salish Behavioral Health Organization (SBHO) to establish a standardized process for network provider and subcontractor administrative reviews. This administrative review is in addition to the existing monthly SBHO chart reviews, Quality Review Team (QRT) on-site, and other monitoring activities.

PROCEDURE

1. The SBHO Administrative Reviews will:a. Monitor the PIHP and state contracted delegated administrative activities,

as well as agency administrative activities.There is a focus to ensure recent changes to state laws (WACs and RCWs),contracts, and federal regulations are implemented.

b. Conduct routine administrative reviews of network providersc. Use measurement standards consistent with industry standards (i.e.

Corrective Action benchmarks).2. For identified area of deficiencies or areas of improvement, a final report and

corrective action plans will be required within 30 days.


Provider and Subcontractor Administrative Review 9.03 Page 2 of 2

MONITORING

1. This policy is a mandated by contract or statute. This policy will be monitored through use of SBHO:

• Routine SBHO Provider and Subcontractor Administrative/ Subdelegated Review

• Review of previous provider corrective action plans related to policy, including provider profiles related to performance on targeted indicators.

2. If a provider performs below expected standards, a corrective action will be

required for SBHO approval. Reference SBHO Corrective Action Plan policy.

SBHO Administrative Review - Chart

Items

ReviewID

Reviewer

Agency

Date of Review

1. Evidence of agency purchasing

services if not able to provide

medically necessary behavioral health

services.

2. Ensure MH Intake packet or SUD

assessment process includes current

version of outpatient rights.

3. Medicaid only - Evidence of client

notified of primary clinician

terminated/no longer employed at

agency) within 15 days of separation.

4. Evidence in chart how advanced

directive information was made

available/distributed/tracked.

5. Evidence that request for second

opinion appointments occur within 30

days,when requested.

6. Evidence of choice or change of

provider is effected when requested.

7. Review process for agency securing

"restricted access" or unauthorized

access clinical charts.

8. Clients have access and right to

review clinical file and be told cost for

copying.

9. Review ROI and ROI process in client

file; request a staff member to describe

agency process.

10. Review charts for evidence of PIPs

and new program development

SBHO Administrative Review -

HIPAA/42 CFR

ReviewID. Please input the first 3 of

Agency Name and year of review (eg.

CAS2017, WES2017).

Reviewer

Agency

Date of Review

1. Provide policies and procedures that

show the agency aligns with federal regs

and SBHO policies.

2. Demonstrate that a HIPAA log exists and

that it is up-to-date.

3. Provide documentation and describe

process which demonstrates how Breach

vs Violation is determined.

4. Review agency ROI(s) for adherence to

HIPAA (and 42 CFR Part 2, if SUD).

6. Provide agency policy which identifies

permitted uses and disclosures of client

records or client information.

5. Provide information regarding methods

which would be used for any breach

notification.

7. Provide agency policies which clearly

define and identify authorized disclosures.

8. Ensure agency has a policy which

reflects that only necessary minimum

information will be disclosed.

9. Revew policy and procedure that

demonstrates the patient's right to access

their records.

10. Review policy and procedure that

demonstrates a patient's right to amend

their record.

11. Review policy and procedure that

demonstrates the patient's right to receive

an accounting of disclosures regarding

their records.

12. Provide policy and procedure which

demonstrates the patient's right to restrict

access to their records.

13. Provide policy and procedure which

demonstrates patient's right to recieve

agency's notice of privacy practices.

14. Provide visual verification that interview

rooms are secure and private.

15. Provide visual verification that the front

reception area has reminders that there is

limited or no privacy in that area.

16. Provide visual verification that

computer screen and monitors are

maintained as secure, including the use of

privacy settings.

17. Provide visual verfication of secure and

privacy log-in access, including password

management and that staff can report

clear understanding of need and use of

this practice.

18. Review agency risk assessment and

discuss with administration to ensure it is

up-to-date and has identified high,

medium, and low risks.

19. Review agency log to ensure provision

of effective risk training (this can be part of

Compliance training).

20. Observe files to ensure patient content

is in locked container - either locked files

and/or locked shred bin.

21. Observe office doors are locked or

office does not have patient content

available to unauthorized persons.


Information Systems

Review_ID. Please input value with first

3 of Agency Name and Year of

Review. (e.g. PEN2016, AGA2017)

Agency

Reviewer Date of Review

1. Provide evidence that the provider's

Disaster Plan is up to date.

2. Provide evidence that a copy of

provider's Disaster Plan is stored off-site.

3. Demonstrate Disaster Plan has been

tested.

4. Provide evidence that the provider's

Disaster Plan contains agency's mission

or scope.

5. Provide evidence that that there is

an appointed disaster recovery team.

6. Provide evidence that provider's

Disaster Plan has provisions for back-up

of key personnel.


Disaster Plan includes identification of

emergency procedures.


Disaster Plan contains procedures for

allowing effective communication.

20. Data on disks mounted to servers are

located in area accessible only to

authorized personnel, access by key, card

key, combination lock or comparable.

21. Paper documents stored in secured

area only accessible to authorized

persons, storedd in locked container.

22. Evidence that data stored on optical

disks will not be transported out of secured

area and must be kept in secure storage.

23. Evidence that access to State data

controlled by DSHS staff who issue

authentication credentials. Notice to DSHS

immediately when staff leaves employ or

no longer needs access.

24. Data storage on portable

media/devices transported outside

secured area - encrypt data and devices

to 128 bits.



secured area - access control with

password or stronger authentication.



secured area - manual locking devices

whenever left unattended; auto lock after

< 20 minutes.



secured area - physical protect portable

devices/media - kept in locked storage,

using check-in, frequent inventories.


Disaster Plan contains visibly listed

emergency telephone numbers.


Disaster Plan contains application

inventory, e.g. Office software.


Disaster Plan contains prioritization for

business recovery.


Disaster Plan contains hardware and

software vendor list.


Disaster Recovery Plan contains

confirmation of updated system and

operations documentation


Disaster Plan contains process for

frequent backup of systems and data.


Disaster Plan contains offsite storage of

system and data backup files.



designated recovery options that may

include use of a hot or cold site.



evidence that disaster recovery tests

have been performed.

28. Evidence that devices/media with

DSHS data must be in physical control of

authorized agency staff.

29. Evidence that DSHS data not stored on

any portable devices or media unless

specifically authorized.

30. Evidence that DSHS data may be

stored on portable media as part of

contractor's existing documnted bakc

process for business continuity/disaster

31. Evidence that DSHS data may be

stored on non-portable media as part of

contractor's existing documented bakup

processes for business continutity or

disaster recovery. If backup media retired

while containing DSHS information media

will be destroyed.

32. Evidence that DSHS data is

segregated/distinguishable from non-DSHS

data. Includes procedures for data

storage on media, in logical container,

within shared database, and paper

documents.

33. Evidence that media stored on server

or workstation hard disks or removable

media is disposed using wipe utiltiy,

degaussing, and/or physical destruction.

34. Evidence that paper documents with

sensitive or confential information is

disposed by recycling through a

contracting firm or onsite shredding,

pubping or incineration.

35. Evidence that optical discs are

disposed by incineration, shredding, or

defacing readable surface with a coarse

abrasive.

36. Evidence that magnetic tape is

disposed by degaussing, incinerating,

orcrosscut shredding.

18. Data stored on local stations hard

disks have restricted access to

authorized users, requiring unique user

IDs and hardened passwords.

19. Data stored have restricted access

using control lists using unique user ID

and hardened password.

37. Provider sends timely certifications that

attest, based on best knowledge,

information and belief, to the accuracy,

completeness and truthfulness of the

information and/or data.

Personnel

Agency Name

SBHO Staff Reviewer

1. Ensure number of qualified agency personnel, age

appropriate, sufficent number, and access/travel standards.

Measure - Review caseload numbers, availability to specialists,

and travel standards.

2. Verify primary source verification for education and

credentials (state slicensure can substitute primary source

documents). Measure - Reandom review of 10% of personnel

files of recently hired staff for primary source verification check.

(See Personnel checklist).

3. Random sample review of agency employee files for training

and evaluation plans. Measure - Random review of 10% of

recently hired staff (See Personnel checklist).

4. Signed statements are maintained on file acknowledging

understanding and agreement to abide by HIPAA

requirements. Measure - Random review of 10% of recently

hired staff (see Personnel checklist).

5. Agency staff have received annual HIPAA training. New staff

receive training within 30 days of start date. Measure - Random

review of 10% of recently hired staff (see Personnel checklist).

6. Verify Medicaid fraud and abuse training. Measure - Random

review of 10% of recently hired staff (see Personnel checklist).

7. Verify Safety and Violence Prevention training occurs

annually. Measure - Random review of 10% of recently hired

staff DMHPs (see Personnel checklist).

Review ID: AGA2017

BEA2017

8. DMHPs only: Evidence of deputized date for recently hired

(previous 12 months) DMHPs. Measure - 100% review of all

recently hired DMHPs (see Personnel checklist).

10. Random sample of Exit Interviews from recently departed

staff (within the past 12 months). Measure - Random review Exit

Interviews for trends.

11. Verify Agency provides Cultural Diversity training twice a

year to staff. Measure - Random review of 10% of recently hired

staff (see Personnel Records Checklist).

9. Verify no Physician Incentive Plan(s). Measure - Random

Review


Personnel Records Checklist

ReviewID. Please input value with first 3 of Agency Name and

Year of Review. (e.g. PEN2016, AGA2017)

Agency Staff Name

Date of Review

Agency

Staff Name

Position

Medicaid Fraud and Abuse Training

HIPPA training within first 30 days of hire

Signed HIPPA statement

WSP or other background check

Board Certification, state licesnure, or agency affiliated

School training certificate/Specialists Training log

Current Training Plan

Current Evaluation Plan

Attended annual safety and violence prevention training

SUD - Blood Born Pathogen Training

Evidence of date deputized

SUD - TB Test on file

SUD - Control of disease

Cultural Diverstiy Training provided twice a year

Evidence that personnel file contain signed attestation to abide

by Code of Conduct


Program Integrity

Reviewer

Agency

2. Demonstrate policy and procedures

that providers follow for reports of

allegations of Medicaid Fraud or Abuse

from agency/staff in the past 12 months in

log.

3. Review policy and procedure, as well as

observe evidence that ensure Federal

Exclusion website searches are conducted

upon hire, continue every month following

(inclucing view ongoing files which can be

paper or electronic).

4. Ensure monthly Federal Exclusion

attestations are submitted in a timely

manner.

5. Evidence provided that provider has

maintained a current list of management

staff that includes name, DOB, and SS

number.

6. Provider has mechanism that if an

employee or subcontractor is found to

have a conviction or sanction or found to

be under investigation for criminal offense

related to healthcare are to be removed

from direct responsibility for, or

involvement with the Salish BHO/PIHP

funded services.

22. Provide evidence that provider is in

compliance with non-discrimination policies

(such as Title IV or the Civil Rights Act of 1964,

Age Discrimination Act of 1965, Rehabilitation

Act of 1973, Title II and II of American with

Disabilities Act) and DSHS Administrative

policies.

23. Agency has been responsive to SBHO

CAP requests - e.g. Admin Rev, chart

reviews, UMC, Fiscal audit, QUIC.

24. Provide evidence of policy which

ensures enrollee is notified of changes in

state law related to direct services.

25. Agency is able demonstrate how they

identify/confirm payer at time of service.

26. Provide evidence that agency

policies, procedures, and form

demonstrate an effort to ensure sliding fee

scale payments.

27. Provide evidence that policy and

procedure regarding all non-Medicaid

individuals seeking services are assisted

with accessing Medicaid to determine if

they qualify for that program.

1. Provide evidence that provider has

current Medicaid Fraud Abuse (MFA) Plan.

Comply with SBHO Medicaid Fraud and

Abuse Plan. Measure - Review agency

plan for updates, such as SBHO

Compliance Committee participation, risk

assessment, method of reviewing

subcontractors.

Review ID: AGA2017

14. Observe and verify accurate method

of exclusion check.

7. Provide evidence of provider's

Compliance Committee meetings and

available trainings to staff. Measure -

Review of agency Compliance

Committee meeting notes and training

logs.

15. Ensure agency administration is familiar

with CLAS (HHS website) expectations.

8. Review of agency cultural diversity

goals and how the goals are assessed.

9. Provide evidence of provider's

participation in SBHO Compliance

Committee.

10. Provide evidence of Compliance

training, e.g. listed in training log. Training

must occur at least annually.

11. Provide evidence of Agency Code of

Conduct. Ensure content adhere's to

SBHO Code of Conduct content.

12. Ensure agency has an identifed

Compliance Officer.

13. Provide evidence that provider has

adequate retention policy, in line with

SBHO policy and contract.

16. Provide evidence that ensures staff is

aware of types of disasters/emergencies

and what agency protocols are in the

event of such.

17. Ensure emergency exit routes are

posted.

28. Medicaid clients only: Provide

evidence of policy that client receives

notification (within 15 days) that primary

clinician is no longer working there, e.g.

terminated.

29. Medicaid client only: Ensure there is

policy procedure that allows agency

clinician to advocate for Medicaid clients

so that they are not denied, limited, or

discontinued medically necessary

behavioral health services.

30. Demonstrate agency has effective

Critical Incident Policy.

31. Review Critical Incident Log for

adequate content and process.

32. Ensure there is a designated person(s)

to process/log all critical incidents.

33. Review smoking Policy - in light with

WAC 388-877-0420(16) 388-877-020(12).

34. Identify all, if any, civil monetary

penalties and assessments of vendors,

providers, or subcontractors.

35. Review provider safety policy and

ensure it includes adequate safety, e.g.

Marty Smith safety outreach protocols.

36. After review of broad spectrum of policies

and procedures - clear evidence is present off

current practice/acronyms and review dates in

policies.

37. Medicaid clients - Review Policy to

ensure second opinions occur within 30

days, when requested. Non-Medicaid - as

resources available.

38. Provide evidence that policy and

procedure ensures client choice and

change of providers is done, when

requested.

18. Provider is able to demonstrate

agency alternative communication

methods for persons with visual or hearing

impairment or limitation.

19. Provider is able to

demonstrate/describe plan to evacuate

all persons, including person with mobility

impairment and children if child care

offered.

20. Provide evidence of policy to ensure

emergency phone access when power

outage and/or phone service is out.

21. Overall review of policies and

procedures shows compliance with all

applicable state and federal laws.


policy/procedure includes securing

"restricted access" of clinical charts.

40. Provide evidence of provider policy

regarding client right to have access and

review their clinical file.

41. Review ROI Policy to ensure

appropriate procedure how disclosure is

processed.

42. Provide evidence of policy reflecting

compliance with SBHO Seclusion and

Restraint policy; Also evidence in incident

reports.

SBHO Administrative Review - Quality

Assurance

Review ID. Please input as first 3

of Agency Name and Year (eg.

KIT2017, OLY2017)

Reviewer

Agency

Date of Review

1. Provide evidence of an

existing Quality Management

Plan.

2. Provide evidence that the

provider is actively

implementing their Quality

Managaement Plan.

3. Ensure evidence that

provider participates in the

SBHO Quality Improvement

Committee.

4. Provide evidence that

services are offered/provided

to improve the treatment of

consumers regarding the

quality of intake evaluations.


services are offered/provided

to improve treatment of

consumers regarding

effectiveness of prescription

medications.

6. Review of policy/procedure

which reflects - training plans,

who funds trainings, required

trainings, and frequency.

14. Provide evidence of agency

policy/procedure which reflects the

enrollee's rights during the grievance

process.


policy showing what is applicable

content in written notices involved in

the grievance process.


policy which reflects that record

retention of grievances is 10 years.


policy/procedure which outlines the

appeal process and timelines.


policy/procedure which outlines

requirements and process of Adverse

Benefit Determinations.

19. Provide evidence of adequate

policy/procedure regarding rights and

process for administrative hearings.

7. Provide agency

policy/procedure which

reflects adequate clinical

supervision (at least annually.

8. Provide policy/procedure

which reflects credential

requirments and prohibits staff

from providing clinical services

if not adequately credentialed.

9. Demonstrate that the

agency collects, maintains,

and uses information to correct

deficiencies and improve

services, including sentinel

events.


agency has and uses a clear

definition of grievance which

aligns with the WAC grievance

definition.

11. Provide clearly written

policy showing enrollee rights

which align with WAC enrollee

rights.


clients are informed of Ombuds

services, including contact

information given to client.

13. Provide evidence of

agency policy/procedure

which reflects who and when a

grievance may be filed with

agency or SBHO.

20. Provide evidence of accurate and

substantive policy/procedure which

outlines process for grievance

reporting. Include who, what, when,

where.

21. Provide evidence of ongoing data

collection by the agency. Data is

actively used to discern objective

measures aimed at examining clinical

services.

22. Provide evidence that the agency

has valid method to identify areas

warranting improvement.

23. Provide evidence of that agency is

implementing plans to improve areas

identified as warranting improvement.


culture includes consumer choice and

participation in Quality Management.

25. Provide evidence that family and

other natural supports identified by

enrollee are a part of the enrollee's

evaluation and treatment process.

Walk-throughSBHO Administrative Review -

ReviewID.

Reviewer

Agency

Date of Review

1. Evidence of brochures/flyer in

reception/main lobby, treatment

rooms, satellite sites.

2. Evidence of Point to your Language

sign in lobby/reception.

3. Evidence of Posted Advanced

Directives in reception/lobby -

brochure.

4. Evidence of posted enrollee rights in

all prevalent languages in public

areas.

5. Evidence of SBHO Member

handbook or agency comparable

information sheet explaining all

benefits for enrollee.

6. Evidence of DSHS Benefits Booklet

available in conspicuous areas of

agency.

7. Agency staff can explain process

when an individual requests to review

their own medical record.

8. Confirm by observing - agency has

all necessary licnses, cerfications

and/or permits as required by law.

9. Observe Medicaid Fraud Control

Unit Hotline Reporting Flyer in common

Staff area.

10. In ET - Observe posted client rights.

11. In ET - Observe HIPAA privacy

practices - private interview rooms,

privacy screens, locked files/doors.

12. In ET - Observe Ombuds

brochures/flyers in client areas.

13. In ET - Observe inpatient policy

regarding security and safety.

14. Observe agency call logs which

contains date and type of call (e.g.

grievance, information,requesting

services) and date of attempted

resolution.

15. Evidence of log for use of

interpreters.

16. Observe layout to determine ADA

accessibility; consider ADA checklist

completed by agency.

17. www.ada.gov/racheck.pdf - Ensure

ADA assessment is done.

FY 2017 BRIDGES Ombuds Program

SBHO Administrative Review Tool Date:

Conducted by: Scoring range: 1-absent, 2-partially developed, 3-evidence of full compliance

# ITEM SCORE COMMENTS

1. Administrative Services

a Ombuds program Information is made available Measure- Review marketing/informational materials.

b Comply with SBHO Fraud and Abuse Plan Measure– Review staff training to identify and report possible fraud/abuse.

c Provide evidence of Code of Conduct. Ensure elements adhere to SBHO Code of Conduct content.

d Identify all, if any, civil monetary penalties and assessments of vendors, subcontractors.

e Advanced Directives written information is provided and available (42 CFR 438.6.i.3, SBHO Rights) Measure- Review written information

f Programs comply with all applicable state and federal laws. Measure – Audit contract compliance and review policies and procedures.

g ADA self-assessment of building completed Measure- ADA self- assessment tool completed

h Programs submit required SBHO reports in a timely manner. Measure- Submission of monthly program activity, quarterly concerns and bi-

annual Exhibit N reports 2. General Services

a Maintain confidentiality. Measure- Review Ombuds case records, documentation, and verify ROIs

b Direct concerns through formal and informal channels for grievances Measure- Review staff training records. Review records for compliance with

SBHO Grievance policy. Protocol for addressing client dissatisfaction with Ombuds services.

c Remain accessible to consumers, including a toll free phone number. Measure- Verify toll free number and accessible

FY 2017 # ITEM SCORE COMMENTS

d Receive and investigate concerns at the request of an individual. Measure- Review call log, ROI process, and investigation process

e Assist in conflict resolution to resolve concerns and grievances at the lowest/ most local level. Measure- Ombuds Manual for Investigation and Resolution P&P, review

informal grievance process

f Assist and advocate for clients and family members in voicing concerns/ grievances with the provider, SBHO, or DSHS (DBHR). Measure- Review case notes

g Responds to issues of concerns in a timely manner; close cases in a timely manner. Measure- Review logs for response times, Exhibit N for closed cases status.

h Tracks data and trends regarding dignity and respect issues Measure- Review data collections and tracking trends

i Review agency cultural diversity goals and how the goals are assessed. Is agency administration familiar with CLAS (HHS website) expectations.

j Actively outreaches to consumers and family members to inform them of services and provide assistance with issues of dissatisfaction. Measure- Review outreach activities, how services are publicized

k Coordinates and collaborates with allied system advocacy and Ombuds services to improve the effectiveness of advocacy and to reduce duplication of efforts for shared clients (WAC) Measure- Review case examples

l Refer matters to mediation, when possible and appropriate. Measure- Review case record that was referred to mediation services.

3. Quality Assurance Activities

a

Participate on the SBHO Quality Improvement Committee, Quality Review Team activities, and monthly SBHO Advisory Board meetings. Make recommendations to improve the quality of services provided through the network, based on investigation and reporting trends. Measure- Review participation in QUIC and QRT

b

Program improvements. Efforts to target and improve BRIDGES program services or areas needing improvement. Able to demonstrate steps to address issue(s). Measure- Review staff meeting notes or other documentation

FY 2017

# ITEM SCORE COMMENTS

4. Enrollee Rights

a Posted general enrollee rights in all prevalent languages. Measure- Has rights available in prevalent languages.

b Ombuds is aware of client rights regarding a second opinion. Measure- Staff interview

c Ombuds is aware of a client’s rights regarding choice and change of providers. Measure- Staff interview

5. Utilization and Resource Management a Demonstrate understanding of authorization requirements and process.

Measure- Staff interview

b Demonstrate knowledge of appeal process for clients when services have been denied or reduced. Measure- Staff interview.

6. Personnel a Ensure number of qualified staff to provide age and culturally appropriate

services. Measure - Review monthly activity reports for program.

b Ombuds staff have not been employed by a service provider two years previous to hire, unless with SBHO notification or DSHS approval Measure – Personnel records.

c Review of agency employee files for supervision, training, and/or evaluation plans Measure- Review all personnel files for evidence of training (state

sponsored Peer Support or BHC, ect) documents, evaluation plans, and supervision logs.

d Review of Exit Interviews from recently departed staff (within the past 12 months) Measure- Review Exit Interviews if applicable.

e Signed statements are maintained on file acknowledging understanding and agreement to abide by HIPAA requirements. Measure – Review all personnel files, HIPAA training

f Staff interviews (see staff interview questions) Measure- Conduct Staff interview(s)

FY 2017

Staff Interview Questions

Staff interviewed: ________________________________________________

1. True or False. An individual can request a Fair Hearing, prior to exhausting the local Grievance process.

2. Do you know how to access Interpreters/ Hearing Impaired services, if they were needed for a

client requesting your services?

3. True or False. A client with special health care needs shall have unencumbered access to a MHP.

4. If a client or family member requested a second opinion, what are the next steps?

a. For an intake assessment b. Regarding diagnosis or treatment strategy

5. If a client requested a change of providers, what are the guidelines (timeframes) listed on the

SBHO Client Rights form?

6. Are you aware of your roles, responsibilities, and communication channels when you are concerned of agency or staff Medicaid Fraud and Abuse?

7. Please give an example of when you had the opportunity to advocate for a client so that they

were not denied, limited, or discontinued medically necessary behavioral health services? 8. Please explain the Ombuds role in the appeal process for a client whose behavioral health

services have been denied or reduced.

9. From your perspective, what are the top three behavioral health service delivery issues most commonly addressed through the Ombuds program?

10. Please provide the SBHO feedback about how our office could assist in the quality improvement of services provided through the Ombuds program?

11. What is the approximate time between when records are requested by a provider (Profiler) and

when records are received?

# Scoring Source Monitoring Process

Manual – Pg. 11EMR, Intake Assessment,

Client Info

WAC 388‐877A‐0130

Salish Behavioral Health Organziation WISe Review Tool

Assess/Engagement

Criteria

1WISe Manual Sec. 3, Pg.

10

2 WAC 388‐877A‐0130

Met, Not Met, N/A

Met, Not Met, N/A

6WISe Manual Assessing

Phase, Pg. 16

3

4WISe Manual Sec. 2 &3,

Pg 8, 10


8

Met, Not Met, N/A

Met, Not Met, N/A

Met, Not Met, N/A

Met, Not Met, N/A

There is a CANS screen documenting eligibility for WISe services by someone certified in performing CANS screens and assessments and completed within 10 days of the request, documenting eligibility.

An intake assessment is available in the record and was completed by a mental health professional.

There is documentation that the individual met Access to Care Standards.

A full CANS assessment was completed within 30 days of the WISe screen (enrollment into WISe)

A full CANS Assessment was completed every 90 days after the initial Full CANS Assessment.

A Family Narrative has been completed

EMR, OP Reviews

EMR, OP Reviews, Client Info.

EMR, Client Info, BHAS reporting &/or WISe

reviewsEMR, Client Info, WISE

reviewsEMR, WISe team

reviews, Supervisor review


WISe Manual Sec. 4, Pgs. WAC 388‐877A‐0135

Y/N Family Vision Statement Y/N Team Mission Statement Y/N Useful Strengths (CANS) Y/N Additional Strengths (Team) Y/N Background Needs (CANS) Y/N Targeted Needs (CANS) Y/N Needs Statements (Team) Y/N Anticipated Outcomes (CANS) Y/N Targeted Outcome Statements (Team) Y/N Strategies and Interventions (Team) Y/N Useful Strengths Activities (Team) Y/N Action Steps for Team Members (Team) Y/N Strengths to Build (CANS) Y/N Strengths Building Activities (Team)

7WISe Manual Sec. 4, PG.

3, 8

Met, Not Met, N/A

Met, Not Met, N/A

Met, Not Met, N/A

Cross System Care Plan (CSCP)/Individual Service Plan (ISP)

Safety/Crisis Plan was completed and a copy was given to the youth and family

The Cross System Plan includes the following:

Criteria

11

EMR, WISe review, CSCP, Scanned documentsEMR, CFT, ISP, Note review, WISE review

EMR, CFT Notes, ISP and Scanned Documents; WISe Clinical Team

Review

EMR, Incidental Notes, WISe review

There is evidence of family and youth voice in the Cross System Planning. Are there signatures and evidence a dopy of the CSCP and all revisions were given to family? Quotes? Verbiage for the youth and family? The Cross System Plan incorporates the Individual Service Plan (ISP) or there is a separate ISP in the chart. It was competed with 30 days after the first routine appointment.

8

9WISe Manual Sec. 4, Pgs. 8, 55; WAC 388‐877A‐

0350 5 (B) & (vi)

10WISe Manual Sec. 2 & 4, Pg. 8, 21‐22; WAC 388‐

Met, Not Met, N/A

WAC 388 877A 0350 5(A)EMR, Incidental Notes,

WISe reviewA complete list of participants and their contact information is included in Cross Systems Planning and is documented. Met, Not Met, N/A


WISe Manual Sec. 2, Pg. 8,

WAC 388‐877‐0620

Y/N Evaluates progress towards meeting needs and the effectiveness of indicated strategies.

Y/N The CFT adjusts strategies to meet changes in the needs and outcomes, creating the most effective mix of services and supports.

Y/N The CFT evaluates whether there is progress towards the designated outcomes. The team adjusts the outcomes to guide next steps.

Y/N The CFT adds members and strives to create a mix of formal, informal and natural supports. Y/N The CFT acknowledges successes and adds to strengths as they are identified.


14, 36


7


8, 17, 19

13WISe Manual Sec. 2 & 4,

Pg. 8, 17, 19

16

17WISe Manual Sec. 4 & Appendix C, Pg. 17, 42

18WISe Manual Appendix C

& H, Pg. 42‐45, 55 Met, Not Met, N/A

21 WAC 388‐877‐0640

Met, Not Met, N/A

Met, Not Met, N/A

Met, Not Met, N/A

19WISe Manual Sec. 4 & Appendix C, Pg. 22, 23,

44

20WISe Manual Sec. 2 &3,

Pg. 3, 5, 13,

Met, Not Met, N/A

Met, Not Met, N/A

There is documentation of transition planning within the CFT meetings to address successful transition away from formal supports as informal supports are in place and providing needed support. Evidence is found in CFT meeting notes, CSCP and Crisis plan.

Services are provided in the location preferred by the youth and/or family. Evidence of this will be demonstrated in regular participation and meeting notes.

Child and Family Teams (CFTs)

The chart includes all necessary releases of information

CFT notes include a list of attendees. (Attendees are those invited as preferred by the youth and family and as indicated on the CANS assessment and intake assessment as relevant to the youth and family.

CFTs are facilitated by a WISe trained Care Coordinator, who typically facilitates and coordinates services and supports.

Notes document that the family and youth were offered the support of a Peer Certified Youth and/or Family Partner.

Documentation that CFT meeting notes were shared with all members of the CFT within a week of each meeting.

CFTs include the youth, parents/caregivers, relevant family members, and natural and community supports as identified in # 10 or address why they were not present.

CFT notes indicate CFTs occurred at least every 30 days

Criteria

EMR, CFT Meeting Minutes, WISe reviews,

Incidental Documentation

Met, Not Met, N/A

The CFT: (Evidence should be found in updated Cross System Care Plan and meeting notes)

Met, Not Met, N/A

Met, Not Met, N/A

Met, Not Met, N/A

Date:

Reviewer:

Provider:

Client Name:

Client ID:

Adult or Child:

Diagnosis:

Systems Present or Involved:

Comments(Improvements Discussed, themes, Strengths in care, Notable

Outcomes, etc .)

Coordination of Care:

Appropriate involvment of Natural Supports?

Appropriate Coordination of Systems?

Strengths and Recovery:

Strengths noted and incorporated in treatment?

Treatment team includes voice of Client/parents/caregiver?

Treatment Effectiveness

Treatment approach is appropriate and reflects clincially sound methods?

Utilization

Client assignment consistent with Level of Care guidelines?

Service Intensity appropriate for needs of client?

SBHO Resource Management Review of Care

Comments:

Review Period

Reviewer

Provider

Client ID

Date of Service

Documentation includes source of referral/identity of caller. 0 #DIV/0!

Documentation includes nature of the crisis. 0 #DIV/0!

Documentation includes the outcome including, basis for decision to not respond in person, follow-up contacts made,

referrals made.0 #DIV/0!

If the consumer has an Advance Directive, it is followed as nearly as possible considering the circumstances.

0 #DIV/0!

Did follow-up services recommended by the crisis worker/DMHP occur as evidenced by documentation?

0 #DIV/0!

The outcome of the intervention/crisis response is clearly documented.

0 #DIV/0!

Evidence of collaboration with consumer and others identified by the consumer as needed.

0 #DIV/0!

Is there appropriate referral/coordination with other systems/settings?

0 #DIV/0!

There is a written plan delineating how to resolve the crisis if the client was not hospitalized. N//A if person was

hospitalized.0 #DIV/0!

Were safety needs and risk factors adequately addressed? 0 #DIV/0!

Were services provided in the least restrictive setting? 0 #DIV/0!

Clinical Record (All Face to Face Reviews)

SBHO Review Tool: Crisis Services

Documentation for Phone Call Only Crisis Contacts

Children only: If NOT detained: o Documentation that a minor’s parent (if child age 13-17) was informed of the right

to request a court review of the decision not to detain.0 #DIV/0!

Was the person detained or hospitalized voluntarily, or was an LRA revoked?

#DIV/0!

Is the presence of a mental disorder adequately justified? 0 #DIV/0!

Is the cause for detention/hospitalization adequately identified?

0 #DIV/0!

Less restrictive alternatives were adequately investigated and documented.

0 #DIV/0!

Contact with the liaison or hospital treatment team occurs within three working days of an enrolled consumer’s

admission to the hospital. Contact must include a provisional placement plan for the enrollee to return to the community that can be implemented when the enrollee is

determined to be ready for discharge.

0 #DIV/0!

There was a non crisis contact within 7 days of discharge and there was an effort to ensure a medication appointment

within 30 days of discharge. 0 #DIV/0!

Were services between hospitalizations adequate to the person's needs?

0 #DIV/0!

Did the person have a follow-up medication management appointment?

0 #DIV/0!

The person has a crisis plan (2 if yes, 0 if person meets SBHO criteria for crisis plan requirements but does not have

one. Otherwise, N/A)0 #DIV/0!

N/A if not present. If present, does the crisis plan describe interventions that include resources of 1) the individual (such as coping skills), 2) natural supports (i.e. friends

family,neighbors), and 3) institutional/systems (i.e. calling crisis clinic) as appropriate?

0 #DIV/0!

If the client has a crisis plan, is there evidence it was utilized?

0 #DIV/0!

Additional Questions (High Utilizer Reviews Only)

Inpatient Justification and Follow-up (Inpatient Reviews Only)

Have intensive community based treatment modalities been fully exhausted?(i.e. wraparound, PACT)

0 #DIV/0!

Comments:

Date of Review

Reviewer

Provider

Client ID

Admit Date

Actual ScorePossible

ScorePercentage Comments

The consumer received a medical evaluation within 24 hours of admit (licensed physician, ARNP, PA-

C). WAC 388-865-0541 (2)0 #DIV/0! Progress Notes/H&P

There is a psychosocial evaluation by a MHP WAC 388-865-0541 (2)

0 #DIV/0! Progress Notes/H&P

There is an initial treatment plan WAC 388-865-0541 (2)

0 #DIV/0!

For inpatient treatment plan you have to go to the drop down menu at the bottom where it says Cost Ctr. Loc. Click on inpt KMHS,

then cklick on profile of treatment plan

There is an admission diagnosis and information that the diagnosis was based upon. WAC 388-865-

0541 (2)0 #DIV/0! Progress Notes/H&P

Authorization from a physician was obtained within 1 hour of initiating seclusion or restraint. WAC 388-

865-0545 (1)0 #DIV/0!

This is documented on the seclusion and restraint forms which are scanned into the

file. They will be in attachments.

The consumer was informed of the reasons for use of seclusion or restraint and the specific behaviors which must be exhibited in order to gain release from these procedures. WAC 388-865-0545 (2)

0 #DIV/0! same as above

There is documentation of staff observation of the consumer at least every fifteen minutes and

observation recorded in the consumer's clinical record. WAC 388-865-0545 (3)


If the use of restraint or seclusion exceeds twenty-four hours, a licensed physician assessed the

consumer and write a new order if the intervention will be continued. This procedure is repeated again

for each twenty-four hour period that restraint or seclusion is used. WAC 388-865-0545 (4)


All assessments and justification for the use of seclusion or restraint are documented in the

consumer's medical record. WAC 388-865-0545 (5)0 #DIV/0! same as above

SBHO E&T Chart Review Tool

E&T Admission and Intake

Adult Seclusion and Restraint (complete only if there was an episode of seclusion or restraint)

Authorization from a physician was obtained within 1 hour of initiating seclusion or restraint. WAC 388-

865-0546 (1)0 #DIV/0! same as above

The child was not restrained or secluded for a period in excess of two hours without having been

evaluated by a mental health professional. The child was directly observed every fifteen minutes and the

observation recorded in the consumer's clinical record. WAC 388-865-0546 (2)


If the restraint or seclusion exceeded twenty-four hours, the consumer was examined by a licensed

physician. The facts determined by his or her examination and any resultant decision to continue restraint or seclusion over twenty-four hours was

recorded in the consumer's clinical record over the signature of the authorizing physician. This

procedure must be repeated for each subsequent twenty-four hour period of restraint or seclusion.

WAC 388-865-0546 (3)


There is evidence the plan was developed collaboratively with the consumer (consider if client

is voluntary/involuntary). 388-865-0547 (2)0 #DIV/0!

There is a discharge plan including plan for follow-up where appropriate. 388-865-0547 (4)

0 #DIV/0! Attachment

There is documentation of the course of treatment. 388-865-0547 (5)

0 #DIV/0!

Progress Notes (Contains Med Provider and Group Notes); Reports: Inpatient MHP

Daily Note, YIU/AIU Shift Note Report, YIU/AIU Inpatient Nursing Daily Note

Involuntary Consumers: There is documentation of daily contact with a MHP for the purpose of

observation, evaluation, release from involuntary commitment to accept voluntary treatment, and discharge from the facility to accept voluntary

treatment upon referral. 388-865-0547 (6)

0 #DIV/0!

Inpatient MHP Daily Note (called "IMHP") or for weekends the nursing note in the

regular progress note report has an MHP note at the end.

Children: Seclusion and Restraint (complete only if there was an episode of seclusion or restraint)

E&T Documentation and Treatment Planning

Med Rights: (a) The prescriber attempted to obtain informed consent for medications. 388-865-0570 (1)

0 #DIV/0! In dr's prog note or attached form.

(b) The consumer was asked if he or she wishes to decline treatment during the twenty-four hour period prior to any court proceeding wherein the consumer has the right to attend and is related to his or her continued treatment. 388-865-0570 (1)

0 #DIV/0! Attachment "24HR"

(c) Of the reasons why any anti-psychotic medication is administered over the consumer's objection or lack of consent. 388-865-0570 (1)

0 #DIV/0! Proress Notes/Med Provider

If the physician administered anti-psychotic medications over a consumer's objections or lack of consent all of the following were present: A second opinion is documented OR, an emergency existed requiring the involuntary medication (likelihood or

hard to self/others, AND no alternative to anti-psychotic medications). 388-865-0570 (2)

0 #DIV/0! Proress Notes/Med Provider

Is there documentation that a Children's MH Specialist evaluated the child within 24 hours of

admit? WAC 388-865-0575 (3)0 #DIV/0! MHP progress note in reports

If child was voluntarily admitted without parent consent, the parent is notified within 24 hours of

admit. WAC 388-865-0575 (8)0 #DIV/0! Same as above

The child was evaluated by the facility, including the need for CD treatment, need for restricting the right to communicate with parents. WAC 388-865-0575

(10)

0 #DIV/0! Progress Notes/H&P

The child was advised of their rights in accordance with RCW 71.34. WAC 388-865-0575 (10)

0 #DIV/0! Attachment

Information concerning treatment of the child was only disclosed only in accordance with RCW

71.34.340 WAC 388-865-0575 (16)0 #DIV/0! Attachment

Consumer Rights and Medication Rights

Children: Special Considerations

Comments:

Review Period

Reviewer

Provider

Client ID

Date of Service

ScorePossible Points

Percentage Comments

The intake includes the presenting problems as described by the individual and others providing

support to the individual, with consent if age13 or older (under age 12 with agency discretion).

0 #DIV/0!

There is sufficient information to demonstrate medical necessity.

0 #VALUE!

The intake includes sufficient clinical information to justify the provisional diagnosis using diagnostic and

statistical manual (DSM) criteria.0 #VALUE!

The intake includes a recommendation of a course of treatment.

0 #DIV/0!

The intake includes input from people who provide active support to the individual, if the individual so

requests, or if the individual is under thirteen years of age.

0 #DIV/0!

The intake is culturally and age relevant. 0 #VALUE!

Children only: The intake contains a devlopmental history.

0 #DIV/0!

The intake includes the current physical health status, including any medications the individual is taking.

0 #DIV/0!

If the individual does not have a PCP, they are referred to one. If there is a PCP, the name is

documented. 0 #VALUE!

The intake documents history of substance abuse (including tobacco) or problem gambling and

treatment.0 #DIV/0!

The intake documents any previously accessed inpatient or outpatient services and/or medications to

treat a mental health condition.0 #DIV/0!

The intake indicates whether they are under the supervision of the department of corrections.

0 #VALUE!

SBHO Review Tool: Intake

Intake Report

There is an identification of risk of harm to self and others, including suicide/homicide and referral to crisis

services if appropriate. 0 #VALUE!

The plan was initiated with at least one goal identified by the individual, or their parent or other legal representative if applicable, at the first session

following the intake evaluation.

0 #DIV/0! First goal may be in prog note instead.

The full plan must was developed within thirty days from the first session following the intake evaluation.

0 #DIV/0!

Date of Request for Services

Date of Intake

Days Between Request and Intake 0

Date of First Routine service

Days Between Request and First Routine Service 0

The first service occurred within 28 days.

If routine service did not occur within 28 days there is adequate documentation explaining why (0, 2, or n/a).

0 #DIV/0!

If the client did not receive a first routine appointment within 28 days, engagement efforts were adequate

and appropriate to the Consumer0 #DIV/0!

A specialist consultation was completed when required:

1. Ethnic Minorities: In all cases. 2. Children: In all cases.

3. Geriatric: When clinically indicated. 4. Developmental Disability: In all cases.

Treatment Plan Report/DLA-20 Report

Progress Notes Report

If the current PRAT is an initial one completed upon client enrollment, rate this item. Assigned

Level is appropriate for client’s diagnosis, GAF/CGAS score (intakes prior to 10/1/15), symptomatology, and

service needs and adheres to the guidelines in the current PRSN's Levels of Care.

0 #VALUE!

Evidence that facilitation of EPSDT services occurred for all children (0-21) adhering to the periodicity schedule, while brokering with multiple system providers to meet the identified needs of the

child/family.

0 #DIV/0!

Documentation exists that demonstrates communication with referral source (EPSDT medical

provider), specifically written notice provided that includes at minimum: date of intake, diagnosis and

level of care assignment.

0 #VALUE!

Written notification to child’s medical provider (for children referred without EPSDT) requesting that documentation be provided that a Healthy Child

screening has been completed or that one will occur. NA if client does not have a PCP.

0 #VALUE!

If no medical care provider is identified by enrollee, then a copy of EPSDT rights contained in the MHD

benefits booklet is provided as well as assistance with selection/accessing of medical provider. NA if client

has PCP.

0 #VALUE!

Develop an Individual Service Team (IST) including identified formal systems and natural supports for

children authorized for Level II services and involved in two or more service systems (cross-system

involved.)

0 #VALUE!

There is a cross-system Individual Service Plan (ISP) which addresses overall needs of both the child and family across life domains for cross-system Level II

clients.

0 #VALUE!

Either the individual service plan or a separate plan specifically addresses the conditions of the LRA order

and plan for transition to voluntary treatment. 0 #VALUE!

Consumer has signed LRA rights. 0 #VALUE!

PRAT Report

EPSDT (Complete this section if client is under age 21)

Community Support (LRA) Scores (Only Consumers on LRAs)

If the consumer is on a 90-day or a 180-day LRA, the consumer has been evaluated monthly by an MHP

with regard to release from or continuation of an involuntary treatment order.

0 #VALUE!

If the consumer is on an LRA they receive receives psychiatric medication services at least once ever

seven days for the first 14 days following discharge from the inpatient facility, unless the attending

physician determines another schedule is more appropriate and documents this in the record and at least once every 30 days after that (unless otherwise

changed by the prescriber).

0 #DIV/0!

Other Comments:

Review Period

Reviewer

Review Type: Bipolar/Schizophrenia

Provider

Client ID

Diagnosis(es)


Percentage Comments

If the client has a MH diagnosis in addition to Bipolar Disorder is there evidence that condition is being

addressed or treated (e.g. goal on tx plan, involved in COD tx, etc.) Not applicable if client has no MH

diagnoses other than bipolar disorder.

0 #DIV/0!

Is the client being prescribed a mood stabilizer medication, either by the MH agency prescriber or by

his or her primary care provider?0 #DIV/0!

If in crisis, have risk factors for suicide been evaluated?

0 #DIV/0!

If warranted, is the importance of maintaining regular sleep/wake cycles and consistent patterns of

daily activities in preventing relapse of mania reflected as a goal on the treatment plan based on

documentation in the chart?

0 #DIV/0!

If the client has a crisis plan, are the identified early markers of manic episodes on the plan and are

possible interventions listed?0 #DIV/0!

SBHO Review: Practice Guidelines

Bipolar Practice Guidelines (Bipolar Only)

If the client has a MH diagnosis in addition to schizophrenia is there evidence that condition is being addressed or treated (e.g. goal on tx plan,

involved in COD tx, etc.) Not applicable if client has no MH diagnoses other than schizophrenia.

0 #DIV/0!

Is the client being prescribed an antipsychotic medication, either by the MH agency prescriber or by

his or her primary care provider?0 #DIV/0!

IF the client has disengaged or missed two or more consecutive appointments in the previous six months, has the client been called or has an outreach attempt been made to where the client resides? (Enter n/a if

not applicable)

0 #DIV/0!

Is the client receiving or been offered at least one of the following psychosocial treatments (as evidenced

by notes from clinician, prescriber, or other care providers?): Family intervention, supported

employment, ACT, social skills training, CBT, stress management training.

0 #DIV/0!

If in Crisis: Have risk factors for suicide been evaluated?

0 #DIV/0!

If in Crisis: Have risk factors for behavior dangerous to others been evaluated?

0 #DIV/0!

Comments:

Schizophrenia Practice Guidelines (Schizophrenia Only)

Review Period

Reviewer

Provider

Client ID


Percentage Comments

Treatment plan goals based on the intake assessment and diagnosis (or based on an updated assessment of

consumer). 0 #DIV/0! N/A if no treatment plan

The treatment plan was reviewed every 180 days. 0 #DIV/0! N/A if no treatment plan

The 180 day review includes a narrative justification for continued treatment at the level of care requested.

0 #DIV/0! N/A if no treatment plan

Demonstrates the individual's participation in the development of the individual service plan using

quotes from the individual. 0 = No evidence, 1 = Quotes in review only, 2 = Quotes in treatment plan

problem statement or goal.

0 #DIV/0! N/A if no treatment plan

Includes treatment goals that are measurable. 0 #DIV/0! N/A if no treatment plan

Identifies medically necessary interventions, mutually agreed upon by the individual and provider, for this

treatment episode.0 #DIV/0! N/A if no treatment plan

The person has a crisis plan (2 if yes, 0 if person meets PRSN criteria for crisis plan requirements but does not have one. Otherwise, N/A if not required)

0 #DIV/0!

Adult: Any of these in last 2 years: Inpatient stay, suicide attempt, violent act; Or, ITA eval in last 6 months; Or, current S/I or H/I; Or in

residential services; Or assigned clinician/assessor believed it is necessary.

Child: Same as above or child's living situation is at risk.

N/A if not present. If present, does the crisis plan describe interventions that include resources of 1) the individual (such as coping skills), 2) natural supports

(i.e. friends family, neighbors), and 3) institutional/systems (i.e. calling crisis clinic) as

appropriate?

0 #VALUE!

The plan addresses the overall identified needs of the individual, including those that best met by another service delivery system, such as education, primary

medical care, child welfare, drug and alcohol, developmental disabilities, aging and adult services,

corrections and juvenile justice as appropriate.

#DIV/0!

Coordination for those with complex medical needs is tracked through the treatment plan and progress

notes. 0 #VALUE!

N/A if no treatment plan (no longer a 1x year requirement for all consumers. Instead focuses on those with complex medical

needs).

Treatment Plan Report/DLA-20 Report (Review after reading intake)

SBHO Review Tool: Reauth

If a service occurs, the service is an intervention on the treatment plan.

0 #DIV/0!

Notes identify treatment goal being addressed, and this goal is reflective of treatment plan.

0 #VALUE!

The notes document the consumer's response to treatment and their progress toward the goals on the

treatment plan. 0 #VALUE!

The consumer is receiving other services listed in WAC 388-877A-0100 (2) and is therefore not "meds

only".0 #DIV/0! MEDICAL SERVICES

The individual or if applicable, their parent/guardian provided informed consent for new medications.

0 #VALUE! MEDICAL SERVICES

The clinical/medical record contains both the name and purpose of the medication prescribed, and clinical support for any change in medication and/or dosage.


The medical provider assessed the individual for side effects of prescribed medications and interactions

between medications. 0 #VALUE! MEDICAL SERVICES

The medications prescribed have been reviewed by the prescriber at least every 3 months.


Progress Notes Report

If the current PRAT is for a continuing/renewed benefit, rate this item. Assigned level is appropriate for client's diagnosis, GAF/CGAS score (for review periods before 10/1/15), symptomatology, and service. Criteria used to determine re-authorization of an existing benefit adheres to guidelines in current PRSN Levels of Care. Continuation of service at assigned level is justified by documentation in chart of the client's clinical presentation as described in the treatment notes.

0 #VALUE!

The frequency of service and type of service utilized is the best fit for this client, given the

documented description of their clinical presentation in the treatment notes, and in the intake if it was

completed within the previous year.

0 #VALUE!Note: Can be used to indicate under/over

utilization, even when the PRAT is adequate.

Evidence that facilitation of EPSDT services occurred for all children (0-21) adhering to the periodicity schedule, while brokering with multiple system providers to meet the identified needs of the

child/family.

0 #DIV/0!

Documentation exists that demonstrates communication with referral source (EPSDT medical

provider), specifically written notice provided that includes at minimum: date of intake, diagnosis and

level of care assignment.

0 #VALUE!

Written notification to child’s medical provider (for children referred without EPSDT) requesting that documentation be provided that a Healthy Child

screening has been completed or that one will occur. NA if client does not have a PCP.

0 #VALUE!

If no medical care provider is identified by enrollee, then a copy of EPSDT rights contained in the MHD

benefits booklet is provided as well as assistance with selection/accessing of medical provider. NA if client

has PCP.

0 #VALUE!

Develop an Individual Service Team (IST) including identified formal systems and natural supports for

children authorized for Level II services and involved in two or more service systems (cross-system involved.)

0 #VALUE!

There is a cross-system Individual Service Plan (ISP) which addresses overall needs of both the child and family across life domains for cross-system Level II

clients.

0 #VALUE!

Either the individual service plan or a separate plan specifically addresses the conditions of the LRA order

and plan for transition to voluntary treatment. 0 #VALUE!

Consumer has signed LRA rights. 0 #VALUE!

If the consumer is on a 90-day or a 180-day LRA, the consumer has been evaluated monthly by an MHP withregard to release from or continuation of an involuntary

treatment order.

0 #VALUE!

EPSDT (Complete this section if client is under age 21)

PRAT Report

Community Support (LRA) Scores (Only Consumers on LRAs)

If the consumer is on an LRA they receive receives psychiatric medication services at least once ever

seven days for the first 14 days following discharge from the inpatient facility, unless the attending physician determines another schedule is more

appropriate and documents this in the record and at least once every 30 days after that (unless otherwise

changed by the prescriber).

0 #DIV/0!

Comments:

Facility Name and Type (RTF/BH)

Reviewer

Provider

Client ID

Review Date

Date of Admission to Facility

Actual PointsPossible Points

Percentage Comments

Is the resident involved in activities at the facility? #DIV/0!

There is evidence of coordination between the outpatient provider and the facility. #DIV/0!

Client voice is incorporated into his or her care at the facility. #DIV/0!

There is evidence that efforts are being made to help the resident learn independent living skills in order to eventually move to a lower level of care. #DIV/0!

The treatment plan includes a goal addresing the residential treatment needs, interventions, and

outcomes. #DIV/0!

The individual has a current crisis plan. #DIV/0!

Is there a current PARS for the consumer? #DIV/0!

Do the consumer’s clinical presentation demonstrate a need for this residential level of

care? #DIV/0!

SBHO Residential Review

Resident Care/Treatment

The individual has a history or recent episode of failing to live independently in the community due

to his/her psychiatric illness. #DIV/0!

The individual is currently enrolled in outpatient services or is in the process of being authorized

and assigned to outpatient services. #DIV/0!

#NAME?

Comments:

1 SBHO 1/23/17

Salish BHO, SUD Clinical Review Tool

Agency/Provider name

Clinician name and credential

Clinical chart identifier Chart is active or closed Active Closed (Date): Review date

SBHO clinical reviewer SUD Assessment Review

Requirements for SUD assessments are referenced in WAC 388-877-0610, and, WAC 388-877B, Medicaid contract, BHSC Contract Item

# Requirement In File

Yes/No/NA Comments

1 Date of request for SUD assessment

2 Face to face assessment has been completed within 14 calendar days of the individual’s request.

3 Reason for assessment is documented.

4 Alcohol & other drug, and tobacco use history is documented.

5 • Type of substance6 • Route of administration7 • Amount, frequency, and duration of use

8 Individual’s PCP is documented.

9 History of self-harm is documented.

10 A history of problem pathological gambling (PPG) is documented.

11 Record of prior treatment history is documented.

2 SBHO 1/23/17

12 DOC supervision is documented.

13 GAIN-SS completed at time of assessment and is included in determining medical necessity.

14

HIV brief risk intervention is documented.

15

DSM-5 diagnosis is documented with appropriate supporting evidence.

16

Individual ASAM dimensions document applicable information, risk ratings, and recommended levels of care. Medical necessity has been determined and documented.

17

Recommended ASAM level of care and duration of treatment are documented.

18

Individual has been informed of assessment results (individual’s signature is verification).

19

Assessment is co-authenticated by CDP if assessment is completed by CDPT.

20

Supporting documentation has been reviewed (court documents, police report, BAC results, etc…).

21

Urinalysis done if required, results documented.

Comments (Link comments to specific item # above):

3 SBHO 1/23/17

Individual Service Plan (ISP) Review

Requirements for Individual Service Plans (ISP’s) are referenced in WAC 388-877-0620, and, WAC 388-877B

Item #

Requirement

In File Yes/No/NA

Comments

1

An ISP has been created and signed by the individual before treatment services are received (Outpatient).

2

An ISP has been created and signed by the individual within five days of admission (Intensive Inpatient).

3

Patient’s name is documented on all ISP’s.

4

ISP’s are strength based. The Individual’s strengths have been identified and included in the development if the ISP.

5

ISP’s indicate the ASAM dimension and current level of care specific to the individual’s needs.

6

ISP’s include a problem statement specific to the individual’s identified needs.

7

ISP’s include a goal statement indicating the desired outcome of the ISP.

8

ISP’s include objectives, with assigned dates or conditions, addressing accomplishment of the goal.

9

ISP’s are updated to reflect changes in the individual’s treatment needs, and achievement of goals and/or objectives.

10

ISP’s address referral to PCP for coordination of complex medical needs if applicable.

11

ISP goals and objectives are Specific, Measureable, Attainable, Realistic, and Time sensitive (SMART).

12

The individual’s voice is reflected (quoted) in the ISP. The individual’s participation is documented.

13

ISP’s have been reviewed and signed by the individual.

4 SBHO 1/23/17

14

ISP’s document the name, credential, and signature of the CDP/CDPT who worked with the individual to create it.

15

ISP’s have been co-authenticated by a CDP if it was developed by a CDPT.

16

The chart documents mutual agreement of the ISP and that the individual received a copy.


5 SBHO 1/23/17

Clinical Record Content and Documentation Review

Requirements for Clinical Record Documentation are referenced in WAC 388-877-0640, and, WAC 388-877B Item

#

Requirement In File

Yes/No/NA

Comments

1 The clinical record documents the date and time of the individual’s first contact with the agency.

List date and time:

2

The clinical record documents the date and time of the individual’s assessment.

List date and time:

3

The clinical record documents the date and time of the individual’s admission to treatment.

List date and time:

4

The clinical record documents the date and time when the individual began receiving services.

List date and time:

5

The clinical record documents the date and time of the individual’s discharge from treatment services.

List date and time:

6

The clinical record documents the individual has been informed of HIPAA.

7

The clinical record documents the individual has been informed of confidentiality requirements under 42 CFR Part 2.

8

The clinical record documents demographic information specific to the individual.

9

The clinical record documents the individual is under civil or criminal order for Mental Health or Substance Use Disorder treatment.

10

The clinical record documents a court order exempting the individual from reporting requirements.

11

The clinical record documents the individual has signed a consent to treatment if not court ordered.

12

The clinical record documents the individual has signed a counselor disclosure form IAW RCW 18.19.060, and WAC 246-811-090.

13

The clinical record documents the individual has received a copy of their individual patient rights.

14

The clinical record documents the individual is aware of agency grievance procedures.

6 SBHO 1/23/17

15

The clinical record documents the individual has received a copy of treatment rules and responsibilities.

16

The clinical record contains medication records for the individual if applicable.

17

The clinical record contains laboratory and/or urinalysis reports if applicable.

18

The clinical record contains properly completed Releases of Information (ROI’s), IAW 42 CFR Part 2 signed and dated by the individual for the release of confidential information.

19

The clinical record documents the individual has had a TB test or screen.

20

The clinical record documents individual counseling sessions as required by WAC 388-877B. Requirements vary with level of care (LOC).

21

The clinical record documents the individual began receiving services within 28 days of request. If not, the reason is documented.

22

Progress notes indicate coordination with other service delivery systems if applicable. (Mental Health, PPW services, etc…)

23

Progress notes document referral to PCP, and coordination of care with PCP if the individual has complex medical needs.

24

Individual service plan reviews are completed per WAC 388-877B requirement based on the level of care the individual is receiving.

25

The clinical record documents ISP’s are updated/modified to reflect progress (or lack of), adjustments, or completion of the ISP.

26

The clinical record contains copies of status reports to courts, DOC, DOL, DSHS, etc… Reports are signed and dated by agency CDP/CDPT.

27

ASAM level of care (LOC) and continuing stay requirements are documented.

7 SBHO 1/23/17

28

Justification for level of care (LOC) change is documented when transferring an individual from one LOC within the same agency at the same location.

29

The clinical record documents progress notes that include date, time, duration, participant name, summary of the session, and the name of the CDP/CDPT who provided it.

30

The clinical record documents that staff met with individual at time of discharge, unless individual left without notice, to;

31

Determine care recommendations and finalize a continuing care plan.

32

Assist the individual in making contact with necessary agencies or services.

33

Provide and document the individual was provided a copy of the plan.

34

The clinical record documents that a discharge summary was completed within seven days of the individual’s discharge date.

35

All clinical record content and documentation requirements completed by a CDPT are co-authenticated by a CDP.


8 SBHO 1/23/17

______________________________________________________________________________ _______________________________ Signature of Salish BHO Reviewer Date

# Item Score Notes / Comments

1 Is a criminal background check and an excluded provider check through the Office of Inspector General (OIG) conducted for all agency staff members?

Evidence: P & P, sample checks. Once demonstrated, review every other year (or next contract cycle).

2 Are background checks conducted for all agency volunteers, board members, and interns? Evidence: P & P, sample checks. Once demonstrated, review every other year.3 Is a background check conducted for all subcontractors? Evidence: P & P, sample checks. Once demonstrated, review every other year.4 Does the agency ensure employees are trained in: The skills each employee needs to effectively perform the

functions included in their job description and the population in which they directly serve;Safety and violence prevention per RCW 49.19.030;Personnel training consistent with WAC 388-877-0500(6);HIPAA compliance and confidentiality of records and Enrollee information;Utilizing natural supports, building on Individual strengths, and recovery and resiliency;Suicidal risk identification and intervention;Basic Life Support (CPR and first aid) and prevention and control of communicable disease, including HIV/AIDS, blood borne pathogens and tuberculosis (TB);Psychotropic medications (if applicable).

Evidence: Job description review, P&P new employee orientation and staff training, training sign-in sheet, personnel record sample. Once demonstrated, review every other year.

5 Does the agency provide training in treatment methods that address individual age, gender, language, literacy, culture, ethnicity and sexual orientation?

Evidence: P&P, staff training, Sample training

6 Does the agency have established referral relationships with the assessment entities, outpatient individual providers, vocational or employment services, and courts which specify aftercare expectations and services including procedure for involvement of referents in treatment activities?

Evidence: P&P care coordination and ISP. Sample chart review.

7 Does the agency have internal policies and practices to measure and improve the quality of services? Quality Plan elements list

Evidence: P&P quality improvement. QM plan. Sample of initiative. Once demonstrated, review every other year.

8 Does the agency have internal policies and practices to accept and make necessary adjustments to continue treatment for any clinically appropriate individual taking opiate substitution medication?

Evidence: P&P. Once demonstrated, review every other year.

9 Does the agency have policy and provide training for staff to implement person-centered techniques, such as motivational interviewing, to assist the individual in completing recommended level of care?

Evidence: P&P AMAs & Staff Training. Once demonstrated, review every other year.

10 Does the agency have policy and procedure for notifying the responsibile BHO and any other required agencies of critical incidents including serious injury requiring medical attention, alleged sexual abuse, serious physical assaults between individuals, alleged abuse of a youth by a staff member, or other instances of suspected individual abuse in accordance with state law?

Evidence: P&P Incident reporting and CPS/APS reporting

11 Does the agency allow individuals to leave the facility for the purposes of obtaining medical treatment not available at the center, conducting personal business, visiting with family members or significant others, and for other reasons that may be beneficial to the individuals treatment program?

Evidence: P&P temporary pass

12 Does the agency have specific criteria for therapeutic and rule violation discharges? Evidence: P&P Discharges

Instructions: Please score each item in the Contract Review based on a Three (3) point rating: "0" = Not in Compliance; "1" = Partially in Compliance; "3" = Fully in Compliance. Select N/A if not applicable.Name of BHO conducting Review:

City / State / Zip:Home BHO of Residential Facility:Primary Contact Name:Dates of Review:

Residential Facility Name: Address:

Comprehensive SUD Residential Review: Contract Review

All Contracts

Name of Reviewer:

13 Is the agency in compliance with contract requirements relating to maintenance of records? Evidence: P&P records maintenance. Site review. Once demonstrated, review every other year.

14 Is the agency following requirements related to the permitted and required uses or disclosures of protected health information?

Evidence : P&P, Review HIPPA tracking sheet of releases

#DIV/0!

1 Does the agency make continuing education services available to staff? Evidence: P&P and personnel record review2 Has the agency ensured that information on the priority populations was publicized? Evidence: P&P and sample of methods of publication (brochures, website, community

presentation, etc.)3 Did the agency ensure that the following order of priority was followed for admission to treatment: (a)

Pregnant injecting drug users; (b) Pregnant substance users; (c) Injecting drug users; (d) Parenting women?

Evidence: Admission P&P

#DIV/0!

1 Were all potential Medicaid-eligible individuals screened for Medicaid eligibility? This is only applicable for direct admits. Evidence: P&Ps admission and financial eligibility. Sample of records.

2 Are potential Medicaid-eligible persons referred to the Health Care Navigators to apply for medical coverage?

Evidence: P&Ps admission and financial eligibility. Once demonstrated, review every other year.

3 Once enrolled in the program are all individuals screened for financial eligibility no less than once each month?


4 Does the agency have policies and procedures on income eligibility for DBHR, Medicaid, and third party insurance individuals?


5 Is the agency charging any fees to Medicaid-eligible individuals (with the exception of ADIS)? Evidence: P&P. Once demonstrated, review every other year.

#DIV/0!

1 Do CDPs who are working with youth have 10 hours of their 40 CEU’s specific to youth? Evidence: Personnel record review. Review annually.2 Does the agency meet “supervised care” requirements for program site and in public places? Evidence: Site review and P&Ps

3 For level II programs, is the agency providing specialized treatment groups addressing co-existing mental health concerns that may complicate substance use disorder treatment? (hours for these groups may be a part or in addition to the 20 hours required in WAC)

Evidence: Program schedule. Review annually

4 Does the agency provide recreational, leisure, and free time that are appropriate to the ages, abilities, and individual interests of the individual? (Minimum of 7 hours/weekly of supervised recreational activity)?

Evidence: Programming description

5 Is the agency following contract requirements regarding individual age for admission and exceptions for youth under age 13 and for 18, 19, or 20 year old admissions?

Evidence: P&P admission/intake. Chart review. Again, the regional BHO could use its population as a proxy. WAC 388-877B-0280

6 Does the agency ensure compliance with contract restrictions on nicotine products? Evidence: P&P admission paperwork describing compliance with nicotine products.7 Does the agency meet the contract requirements for required number of hours and content for treatment

modality?Evidence: Data report- level to hours. Sample record review. WAC 388-877B-0280

8 Does the agency have a policy regarding transportation of individuals to medical appointments or individual outings?

Evidence: P&P transportation internal and Medicaid

#DIV/0!

Possible ScoreGeneral Contract Requirements - Score

Possible ScoreAchieved Percent

Possible ScoreAchieved PercentBilling / Financial Requirements

Billing and Financial - ScorePossible ScoreAchieved Percent

Substance Abuse Block Grant Requirements - Score

Substance Abuse Block Grant Fund RequirementsAchieved Percent

PPW Requirements

Youth Residential Requirements

Youth Residential - Score

1 Does the agency have specific criteria for therapeutic and rule violation discharges? Evidence: P&P discharge2 Is the agency providing the opportunity for the individual’s clinical individual and group services to be

provided by someone of the same gender?Evidence: P&P treatment/programming

3 Is the agency currently licensed with the Department of Early Learning? Evidence: Cuurent license status4 Does the PPW program staffing include a licensed nurse? Evidence: Staffing level in P&P. Sample shift staffing.

#DIV/0!

Withdrawal Management Requirements1 Does the agency ensure the program is open for admission and service availability 24 hours per day, 365

days per year?Evidence: P&P

2 Does the agency ensure pregnant women unable to access treatment due to lack of capacity and in need of withdrawal management are referred to CUP program within 24 hours of request?

Evidence: P&P

3 Does the agency maintain protocols for MAT patients in need of withdrawal management from other substances?

Evidence: P&P

4 Does the agency ensure access to on-site crisis stabilization, including mental health screening, assessment, intervention, and referral to respond to any immediate or on-going crisis?

Evidence: P&P

Adult Withdrawal Management Requirements - ScorePossible ScoreAchieved Percent #DIV/0!

1 Does the agency accept admissions for all eligible individuals authorized from a Behavioral Health Organization unless there are specific documented reasons relative to health, welfare, or safety of individuals?

Evidence: P&P admission

2 Did the agency provide each individual with necessary personal items: i.e. soap, toothpaste, and sanitary items from the funds provided by the BHO and included in the daily bed rate?

Evidence: P&P

3 Does the agency provide access to services for MAT substitution individuals? Evidence: P&P for coordination or guest dosing. Business arrangement with local facility.

4 Does the agency ensure there are no policies/procedures denying treatment services to any individual solely on the basis that the individual is taking prescribed medications?

Evidence: P&P regarding admission and continuity of medical care or prescriptions.

5 Does the agency ensure treatment services are not denied solely on the basis of the individual’s drug of choice?

Evidence: Admission criteria specifically the excluded section.

6 Does the agency accept involuntarily committed individuals by a court pursuant to RCW 70.96A, provided that the individual is deemed to be medically appropriate for the level of care provided?

Evidence: Admission criteria specifically the excluded section.

7 Does the agency have a policy to discharge an individual and notify the assessment agency/referral in writing of such termination if the individual is absent from the facility for more than 24 hours?

Evidence: P&P Discharge

#DIV/0!

#REF!#REF!#REF!

Total Achieved ScoreTotal Possible ScoreAchieved Percent

Achieved Percent

Adult Residential Requirements

Adult Residential - ScorePossible ScoreAchieved Percent

PPW - ScorePossible Score

Individual Individual Individual Individual Individual Individual Individual Individual Individual Individual

Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender

Evidence Age Age Age Age Age Age Age Age Age Age

Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status Chart Status

D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason D/C Reason

Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis

Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility Eligibility

1GAIN SS, Assessment documentation #DIV/0! #DIV/0!

2Assessment and ISP review

3Assessment, ISP review, Referral documentation

#DIV/0! #DIV/0!

4Are ASAM Criteria requirements for admission, continued stay, and discharge criteria documented? Assessment, ISP

review, D/C summary

5Assessment documentation packet.

6

Is enrollee voice evident in the individual service plan (ISP)? ISP review. Use of quotes, individual signature with signature statement (i.e. "this ISP represents my goals and included my voice").

7Were services sensitive and responsive to the individual and family's age, gender, language, culture, ethnicity, and sexual orientation?

ISP and chart notes.

8

Did the agency provide appropriate referrals / transfer agreements with local service providers once services were completed? (youth and family in a youth program)

Review assessment to identify needs and review the referral documentation.

9

Did the agency coordinate services and provide discharge planning within the first week of residential treatment with the referring outpatient agency to exchange assessment, admission, treatment progress, and continuing care information? If an outpatient provider was not established, did the agency coordinate a referral back to one within the individual’s home community in the first few weeks?

Review discharge: ROI, evidence of records exchanged.

10

Did the agency include referrals to other services such as housing, transportation, medical, mental health, schools, juvenile corrections operations, community mobilizations groups, vocational services, Division of Children and Family Services, BHO, other resources or services in the discharge plan to meet the needs of the individual?

Review admission documentation for those who had these needs identified during the assessment/admission. Review Assessment, ISP, and progress notes.

11

Record review of discharge plan. Ensure that all needs were included in the discharge plan.

0 0 0 0 0 0 0 0 0 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Comprehensive SUD Residential Review File Review

Total Averages

General Contract Requirements

General Contract Requirements - Subsection Score 0

Is there a GAIN-SS with quadrant placement?

For individuals identified as co-occurring, is there documentation that the individual has been referred for the appropriate services?

Is notification of enrollee rights documented?

Did the agency providing discharge planning services to include, at a minimum, coordination of services to financially eligible individuals who are in need of medical services?

Did the agency provide individual service planning that sought to identify and treat individuals with co-occurring disorders?

Possible Score 0Achieved Percent #DIV/0!

Substance Abuse Block Grant Fund Requirements

1

ISP and progress note review against the criteria #DIV/0! #DIV/0!

0 0 0 0 0 0 0 0 0 0


1Review of the assessment #DIV/0! #DIV/0!

2

GAIN SS, Assessment documentation, and clinical documentation #DIV/0! #DIV/0!

3

ISP and clinical/progress note documentation

#DIV/0! #DIV/0!

4Review of clinical record and data report- codes

#DIV/0! #DIV/0!

5Record review- Discharge planning and ISP review

#DIV/0! #DIV/0!

6

Record review. Check minimum standard for a clinical shift note.

#DIV/0! #DIV/0!

0 0 0 0 0 0 0 0 0 0


1

Review clinical record and ISP.

#DIV/0! #DIV/0!

0 0 0 0 0 0 0 0 0 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Withdrawal Management

1Agency ensures withdrawal management service coordination with other agencies. ROI. Coordination

/case management notes.

#DIV/0! #DIV/0!

2 Agency ensures an assessment is requested if patient has been admitted 2 or more times in the same quarter.

ROI. Care coordination.

#DIV/0! #DIV/0!

3

Did the agency provide screening, referral, and support services to family members? Review of screening tool/document, referral doc, and documentation of family sessions.

4Agency shall ensure each patient receives counseling regarding the patient’s substance use disorder, utilizing counseling techniques to motivate acceptance of a referral into treatment. Assessments provided to those able to participate. Documentation maintained in file.

Review of chart notes.#DIV/0! #DIV/0!

5 Agency provides minimum 1 hour of substance abuse education 5 days per week. Documentation is maintained in patient file.

Review of chart notes.#DIV/0! #DIV/0!

Withdrawal Management - subsection score 0 0 0 0 0 0 0 0 0 0 0Possible Score 0

Achieved Percent #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

0Possible Score 0

Substance Abuse Block Grant - Subsection Score

Achieved Percent #DIV/0!Youth Residential

0Possible Score 0

Achieved Percent

Did the agency provide an assessment of the family and encourage their participation in treatment services?

Did the agency meet contract requirements to provide a minimum of one (1) charting note for each individual, for each day, evening, and night shift to assure individual whereabouts and safety?

Did the agency provide discharge planning and post treatment placement assistance to youth and family with managed referrals back to their home community?

Did the agency provide ancillary treatment services to family members that are relevant to the individual’s recovery while in residence and during the designated continuing care period?

Did the agency provide availability of daily individual counseling for youth as needed clinically to ensure progress and success in treatment?

Where clinically indicated, did the agency facilitate a referral for mental health services, which may have included a psychiatric evaluation for purposes of assessment, individual service planning, behavior intervention, and/or discharge planning?

Total Points Achieved #REF!Total Points Possible #REF!

Youth Residential - subsection score 00

Achieved Percent #DIV/0!

PPW - subsection score

#DIV/0!

Possible Score

Was the client provided individualized treatment modalities that focus on sustaining long-term recovery for themselves and there child(ren)? (i.e parenting support and education, college readiness, job skills and employment readiness, medication and medical emergency management, etc.)

PPW

Achieved Percent #REF!Notes

Did the assessment include mother’s age, living arrangements and family support data for post-partum women?

Review Period

Reviewer

Provider

Client ID


Percentage Comments

The clinical record contains a vocational assessment including work history, skills, training, education, and

personal career goals.0 #DIV/0!

The clinical record specifically addresses how employment will affect the income and benefits the

consumer is receiving because of their disability. If any ofthese pose barriers, the choices and resolutions are

discussed.

0 #DIV/0!

The clinician sssists the individual to create an individualized job and career plan focused on their

strengths and skills. 0 #DIV/0!

There is documentation that the clinician is assisting the consumer in finding employment opportunities that are

consistent with the consumer’s skills, goals, and interests.0 #DIV/0!

The agency documents any outreach, job coaching, and support at the worksite, when requested by the individual

or their employer. 0 #DIV/0!

The agency provides information regarding the requirements of ADA at the individual’s request.

SBHO Review Tool: Supported Employment

Review Period

Reviewer

Provider

Client ID


Percentage Comments

The intake includes sufficient clinical information to justify the provisional diagnosis using diagnostic and

statistical manual (DSM) criteria.0 #DIV/0!

The intake includes a recommendation of a course of treatment. If the consumer is in need of non-RSN

services, appopriate referrals are made. 0 #DIV/0!

The intake includes input from people who provide active support to the individual, if the individual so

requests, or if the individual is under thirteen years of age.

0 #DIV/0!

There is an identification of risk of harm to self and others, including suicide/homicide;

0 #DIV/0!

Assigned Level (Not Authorized for Servces) is appropriate for client’s diagnosis, symptomatology, and service needs and adheres to the guidelines in

the current SBHO's Levels of Care.

0 #DIV/0!

Comments:

SBHO Review Tool: Zero Prat/Consumers Not Authorized for Care

Actual Points Possible Points Comments

Is the resident involved in activities at the facility? 0 0 #DIV/0!

There is evidence of coordination between the outpatient provider and the facility. 0 0 #DIV/0!

Client voice is incorporated into his or her care at the facility. 0 0 #DIV/0!

There is evidence that efforts are being made to help the resident learn independent living skills in order to eventually move to a lower level of care. 0 0 #DIV/0!

The treatment plan includes a goal addresing the residential treatment needs, interventions, and outcomes.

0 0 #DIV/0!

The individual has a current crisis plan. 0 0 #DIV/0!

Is there a current PARS for the consumer? 0 0 #DIV/0!

Do the consumer’s clinical presentation demonstrate a need for this residential level of care?

0 0 #DIV/0!

The individual has a history or recent episode of failing to live independently in the community due to his/her psychiatric illness.

0 0 #DIV/0!

The individual is currently enrolled in outpatient services or is in the process of being authorized and assigned to outpatient services. 0 0 #DIV/0!

Resident Care/Treatment

Treatment Planning

Authorization

SBHO Residential Review:

SALISH BHO


Subcontractual Delegation and Assessment Plan 9.04 Page 1 of 6

Policy Name: SUBCONTRACTUAL DELEGATION AND ASSESSMENT Policy Number: 9.04

Reference: DSHS Contract, Subcontractual Delegation, 42 CFR 438.206, 230





CROSS REFERENCES

• Form: HIPAA Business Associates Addendum• Plan: Quality Management Plan• Policy: Corrective Action Plan• Tool: Delegation and Assessment Tool

PURPOSE

The Salish Behavioral Health Organization (SBHO) enters into contracts with qualified network providers and monitors for compliance. The SBHO oversees and is accountable for all the functions performed by the subcontractor performing the SBHO required Pre-Paid Inpatient Health Plan (PIHP) functions on an ongoing basis.

DEFINITIONS

Subcontractor delegation means an entity authorized to act as representative for another; a deputy or an agent. In this policy, it refers to an entity or organization that is contractually responsible for conducting the SBHO Pre-Paid Inpatient (PIHP) functions.

PROCEDURE

The SBHO maintains a subcontractual delegation relationship for the operation of the SBHO:

• Authorization and Utilization Management functions, including costumer servicefunctions, authorization determinations for all SBHO services (that requireauthorization), conducting the service denial notifications and appeal process on



behalf of the SBHO, and entering prior authorization inpatient information into Provider 1.

• Certain clinical functions are included in our subcontracts with network providers thatmay be considered subdelegations.

SBHO Authorization and Utilization Management Subcontractor delegated Responsibilities The delegated subcontractor must meet all the requirements as identified in the standards requirements (listed below), and in addition the following:

1. The SBHO contracts with an independent utilization management organization toconduct the inpatient, outpatient, residential, and intake assessment authorizationdeterminations.

2. The delegated subcontractor has the responsibility of proving authorizationdeterminations and the service denial notifications, including Notice of AdverseBenefit Determination letters to Medicaid individuals when an adverse action occurs.The contractor must also provide the Appeals Review, on behalf of the SBHO, uponrequest.

3. The delegated subcontractor must maintain URAC and/or NCQA accreditation, statelicensure, and comply with all federal and Washington State regulations.

4. The delegated subcontractor must maintain adequate number of staff to ensurecompliance with contact including utilization care managers, clinical staff withexpertise, and a Board Certified Medical Director to meet the contracted federal andstate authorization timeframes set before the SBHO as a PIHP.

5. The delegated subcontractor must use the SBHO medical necessity definition, Levelof Care standards, state developed Community Psychiatric Inpatient authorizationforms and procedures, ASAM Criteria, and adhere to the SBHO UtilizationManagement Plan.

6. The delegated subcontractor will participate, upon request, in the SBHO UtilizationManagement or Quality Improvement Committees.

7. The delegated subcontractor will supply requested reports, data or informationneeded by the SBHO to assure and maintain compliance with all federal and statereporting requirements and standards. The required reports include, but are notlimited to:

a. Monthly authorization reports, including number of authorizations (Medicaidand non-Medicaid), type of authorization (outpatient, inpatient, residential, orintake), type of level, start and expiration date, number of denials, requestedand conducted Appeals, and other authorization information as requested.

b. Monthly report of flagged high user of crisis services and high risk individuals(per SBHO definitions).



c. Quarterly trend report.d. Other reports for review by the Utilization Management Committee or as

requested by the SBHO.

8. The SBHO requires a formalized delegation agreement that is part of the contractwith the utilization management organization.

9. The SBHO will conduct the first delegation audit and review as soon as mutuallyagreed upon date (between the SBHO and the organization) can be established.

10. The SBHO monitors contractor compliance through the standard processes listedbelow, in addition the SBHO uses the feedback provided from:

• Feedback from the annual Department’s External Quality ReviewOrganization (EQRO) BHO reviews. The EQRO monitors the regional IScompliance with regulations, functions, capacity, an overall performance. TheSBHO will use the EQRO findings, in conjunction with the applicable IS itemson the SBHO Subcontractors Delegation and Assessment Tool, to monitordelegated PIHP functions.

Standard Requirements for PIHP Delegated Functions 1. Before any new subcontracting delegation decision is finalized, the SBHO will

evaluate the prospective subcontractor’s ability to perform the activities to be delegated. This is done in the following areas:

• organizational capacity• clinical/staffing capacity• quality improvement processes• HIPAA and Medicaid compliance• (IT only) data security requirements• (ASO, only) authorization for services and utilization management

2. The standards requirements are as follows:

Organizational Capacity Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:

• Maintain licensing by the state as necessary• Maintain written policies and procedures covering its adherence to contract

and relevant regulations• Have an adequate data system and staffing to participate in required data

reporting; e.g., data on service authorizations, inpatient certifications,evaluation of MIS system, provision of data for SBHO quality managementneeds, and ongoing management data to monitor performance of delegatedduties

• Maintenance of an internal quality management/quality improvement processand documentation of minutes for SBHO review



• Demonstration of a management team that is responsive to feedback fromSBHO (and its Ombuds and Quality Review Team), allied providers, andservice recipients

• Training and supervision with staff that reflect SBHO’s mission and goals aswell as adherence with contract and regulations

• Ongoing support for client rights, from provision of information on client rightsto responsive action when feedback suggests there may be problems in thisarea

Clinical/Staffing Capacity Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:

• The availability of qualified staff to assume delegated functions; this includesmental health professionals with clinical expertise in treating children andadults, a sufficient number of mental health specialists, and chemicaldependency professionals.

• Care management staff must show an understanding of State Access to Careguidelines, and familiarity with current best practices and promising practices.

• Hiring for clinical staff includes verification of licensure or certification,background checks, review of any loss of licensure or felony convictions, andreference checks.

• Competence in implementing delegated functions, as seen in concurrent andretrospective reviews of service authorizations, provider decisions regardingongoing care, care coordination with allied providers, supervisory feedback tostaff, and response to grievances.

• Effective use of training so that staff understand relevant clinical proceduresand expected practice (e.g., use of Access to Care standards to determineeligibility for services).

• Openness to SBHO feedback on delegated functions and capacity to makechanges in practice when requested.

• Availability of a physician to provide reviews to any inpatient denials and toprovide second opinions when requested.

• Documentation of decision making associated with inpatient certification.• Effective medical records practices.• Timely communication with SBHO regarding delegated decisions.• Participation in any training and feedback from SBHO regarding delegated

functions.

Quality Improvement Processes Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:



• Implement and document a quality management/quality improvement process.

• Participates in SBHO’s policies and procedures for grievances and fair hearings; they provide relevant information to enrollees at entry to services and participate actively in the resolution of enrollee grievances.

• Contractors are given feedback on quality issues by SBHO’s Quality Review Team. Contractors respond appropriately and in a timely way to QRT recommendations for improvement.

HIPAA & Medicaid Compliance Each prospective contractor or subcontractor must demonstrate the following, as the item applies to the delegated functions:

• Contractors comply with HIPAA standards and 42 CFR Part 2 • Signed HIPAA Business Associates Agreement with SBHO • Demonstrates effective medical records practices • Update system to meet new regulations

Standard Subcontract Delegation Requirements 1. The SBHO requires a formalized delegation agreement, which is part of the contract,

with any organization or entity that provides subcontract delegated SBHO PIHP functions.

2. The contract, including the delegation agreement, between SBHO and the delegated

subcontractor, will: • Specify the activities and reports responsibilities designated to the

subcontractor; and • Provide for revoking delegation or imposing other sanctions if the

subcontractor’s performance is inadequate. 3. All delegated subcontractors will comply with the SBHO Compliance Plan and

monitoring activities. 4. Sign the SBHO HIPAA Business Associates Addendum.

Standard Subcontractor Delegation Monitoring, Audits and Review

1. SBHO monitors current subcontractor’s delegated performance on an ongoing basis and subjects them to formal routine reviews through contract monitoring and clinical service review, as well as ongoing concurrent reviews.

2. Before any new subcontractor delegating decision is finalized, the SBHO will

evaluate the prospective subcontractor’s ability to perform the activities to be delegated.



3. The SBHO uses the SBHO Subcontractor Delegation and Assessment Tool to conduct pre-evaluation and routine subcontractor delegation performance reviews.

4. The SBHO administrator, or his designee, will direct these monitoring activities. 5. Formal reports are shared with quality management committee, and with the SBHO

Executive and Advisory Boards. 6. If the SBHO identifies deficiencies or areas for improvement, SBHO takes corrective

action. The delegated subcontractor will respond to specified areas of non-compliance with a Corrective Action Plan (CAP). Any required CAP shall be submitted to SBHO no later than 30 days after the receipt of the audit results for approval. See the SBHO Corrective Action policy.

7. The subcontracts, including the Agreement, have provisions for terminating the

contractual relationship.

SBHO Data Security Checklist

ITEM SCORE COMMENTS

Data Security Requirements – Agency

1 IS/ IT Disaster Recovery Plan, present and meets requirements of contact. Examples of evidence- Disaster Plan checklist

2 Electronic data protected by transporting data within contractor’s internal network or

encrypting any data in transit outside the contractor’s internal network. This includes transit over public internet.

3 Data stored on local workstations hard disks have restricted access to authorized users by requiring unique user IDs and hardened passwords.

4

Data stored on network servers and made available through shared folders have restricted access to authorized users through access control lists which will grant access only after authorized user has authenticated to the network using a unique user ID and hardened password. Data on disks mounted to such servers must be located in an area which is accessible only to authorized personnel and access controlled with use of a key, card key, combination lock or comparable mechanism.

5

Paper documents protected by storing records in a secured area only accessible to authorized personal. Such records must be stored in a locked container to which only authorized persons have access. Data stored on optical disks will not be transported out of a secured area and must be kept in secure storage.

6

Access to State data will be controlled by DSHS staff who will issue authentication credentials. Contractor will notify DSHS staff immediately whenever an authorized user in possession of such credentials is terminated or otherwise leaves the employ of the contractor or the authorized user no longer requires access to perform work for the contractor.

ITEM

SCORE

COMMENTS

7

Storage of data on portable media or devices is given special protection, if being transported outside of an secure area, by: (check all that apply) __ Encrypting the data and devices to 128 bits __ Controlling access to devices with a password or stronger authentication

methods, forced password changes every 90 days __ Manually locking devices whenever they are left unattended and setting devices to

lock automatically after a period of inactivity (maximum period is 20 minutes) __ Physically protect portable devices an media by: keeping them in locked storage when not in use, using check-in procedures, and frequent inventories

8

Transporting portable devices: Devices and media with DSHS data must be under the physical control of agency staff with authorization to access data.

9

Portable devices: DSHS data shall not be stored on portable devices or media unless specifically authorized. Portable devices include Handhelds/PDAs, Ultra mobile PCs, Flash memory devices, portable hard disks, and laptop/ notebook computers (if transported outside of secure area).

10

DSHS data may be stored on portable media as part of a contractor’s existing documented backup processes for business continuity or disaster recovery purposes. If backup media retired while still containing DSHS information such media will be destroyed.

11

DSHS data may be stored on non-portable media as part of a contractor’s existing documented backup processes for business continuity or disaster recovery purposes. If backup media retired while still containing DSHS information such media will be destroyed.

12 DSHS data is segregated or otherwise distinguishable from non-DSHS data. This includes procedures for storage of data on media, in a logical container, within a shared database, and paper documents.

13

Disposal of media stored on server or workstation hard disks or on removable media: - using a wipe utility - degaussing - physical destruction

ITEM

SCORE

COMMENTS

14 Disposal of paper documents with sensitive or confidential information - recycling through a contracting firm - onsite shredding, pulping, or incineration

15 Disposal of optical discs: -incineration, shredding, defacing readable surface with a coarse abrasive

16 Disposal of magnetic tape: - degaussing, incinerating, or crosscut shredding

SALISH BHO


Items of Delegation 9.04c Page 1 of 4

Salish Behavioral Health Organization Items of Delegation Activity Delegated To Relevant Policies and Comments

Assign Levels of Care and request authorization for services.

Contracted Providers 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan 11.01Access to Services, Timely

Authorization and re-authorization for inpatient, outpatient treatment services, and residential services

ASO Contractor- CommCare 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan 12.01 DSHS InPt Instructions

Assessments of consumers prior to determination of appropriateness of inpatient, outpatient, or residential services

Contracted Providers 7.01 Auth for OP Services 7.03 LOC 7.04 Intake Eval & Eval Services 7.05 PRAT 7.06 UM Plan

Adverse Determinations (Denials)

ASO Contractor- CommCare 6.03 Appeal Process 6.05 NOA Requirements 7.01 Auth for OP Services 7.03 LOC 7.06 UM Plan 12.03 Voluntary InPt Denials

EPSDT – Initial intake review and Level of Service assignment

Request made by Contracted Provider, CMHS

Review by SBHO Contractor Child Mental Health Specialist

7.03 LOC 11.08 EPSDT Coordination

EPSDT – Coordination of Individual Service Teams

Contracted Providers Oversight by SBHO Children’s

Services Manager

2.17 Special Pop- Coordination of Care for Children 11.08 EPSDT Coordination

Care Management: • Assessment and Re-

Assessment s• Collaboration in

authorizations requiredfor extension, dischargeand transfer needs

ASO Contractor- CommCare 7.03 LOC 11.01Access to Services, Timely 11.11 Housing Services 11.19 Primary & Hospital Coordination of Care 11.20 Special Healthcare Needs- Quality & Appropriateness 11.21 Special Healthcare Needs- Direct Care

Inpatient, Outpatient, and Residential Services

Contracted Providers 2.08 Rehab & Integrated Care 2.11 Enrollee Rights 2.12 Consent for Treatment 2.13 Second opinion 2.16 Special Needs Accommodation Process



Activity Delegated To Relevant Policies and Comments 2.21 Recovery & Resiliency 3.02 Culturally Competent Services 3.03 Culturally Competent Service Structure 7.03 LOC 11.02 Access to Services Prior to Intake 11.03 Service Modalities- Outpatient 11.04 Service Modalities- Crisis 11.05 ISP 12.01DSHS InPt Instructions 12.06 Admission & DC Coordination from InPt care

Appeals ASO Contractor- CommCare, Medical Director

6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.03 Appeal Process 12.03 Voluntary InPt Denials

Fair Hearings DBHR/ DSHS 6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.04 Fair Hearing

Communication with consumers - Provide Member Handbook

SBHO 2.06 Comprehensive Info Plan 2.07 General Info Req 2.07a SBHO Handbook

Communication with members – negative action

ASO Contractor- CommCare 7.01a SBHO Auth. Ltr 7.01c SBHO Ltr of Ineligibility 6.03a CommCare Appeal Acknowledgement Ltr 6.05a&b NOA Ltr, templates

Telephonic communication with consumers re: NOD/NOA

ASO Contractor- CommCare 6.01Complaint, grievance, Appeal, & Fair Hearing Req 6.03a CommCare Appeal Acknowledgement Ltr 6.05a&b NOA Ltr, templates 12.03 Voluntary InPt Denials

Communication with consumers and providers

QRT Contractor 9.01 Monitoring Sufficiency 9.02 Monitoring Contractors 9.08 QRT

Staff credentialing and licensure including MHP and MH Specialist

Contracted Providers 3.03 Culturally Competent Service Structure 3.03a Specialists Directory 3.03b Bilingual Directory 3.03c EBP Directory 3.07 Provider Staff Qualifications 3.08 Credentialing & Recredentialing

Monitoring a LRA or a Conditional Release.

Contracted Psychiatric Provider and Contracted

Providers

9.07 Standard Chart Reviews 9.07a Intake & Reauth Standard Tool 9.07e Crisis Chart Review Tool



Activity Delegated To Relevant Policies and Comments Ombuds Services BRIDGES Ombuds

Contractor 6.01Complaint, Grievance, Appeal & fair Hearing Req 13.02 Ombuds Services

Maintenance of Profiler Regional EMR hardware and network

KMHS – IT 4.01 Loading of State Enrollment Data 4.02 Data Transfer to the Department 4.03 IS Processing procedures 4.04 IS Encounter Submission 4.05 Data Error Resolution 4.06 Acceptance of Late MIS Data 4.07 Data System Backup & Recoverability SBHO Subcontract

Crisis Hotlines Contracted Providers (subcontracted to Crisis Clinic of the Peninsulas)

11.01 Access to Services, Timely 11.04 Service Modalities- Crisis 11.06 Crisis Prevention Plan

After hours customer services – authorizations

ASO Contractor- CommCare 7.01 Auth for OP Services 7.06 UM Plan

Special Population Consult

Contracted Provider 2.17 Special Populations- Coordination of Care for Children 2.18 Special Populations- Coordination of Care for Older Adults 2.19 Special Populations- Coordination of Care for Disabled 2.20 Special Populations- Coordination of Care for Minorities 3.01Availability of Services 3.02 Culturally Competent Services 3.03 Culturally Competent Service Structure 3.03a Specialists Directory 3.03b Bilingual Directory 3.03c EBP Directory



Activity Delegated To Relevant Policies and Comments Interpreter Services SBHO Language Line for

Contracted Providers use 2.14 Interpreter Services 2.15 Consumer Rights in Braille

Coordination of Care Contracted Providers 2.17 Special Populations- Coordination of Care for Children 2.18 Special Populations- Coordination of Care for Older Adults 2.19 Special Populations- Coordination of Care for persons with Disabilities 2.20 Special Populations- Coordination of Care for Ethnic Minorities 2.21Recovery & Resiliency 11.08 EPSDT Coordination 11.17 Notification of Primary MH Care Provider Termination 11.20 Special Healthcare Needs- Coordination of Care 11.21 Special Healthcare Needs- Direct Care 11.22 Special Healthcare Needs- Quality & Appropriateness 14.01 Working Agreements

SALISH BHO


Periodic Reviews of the E&T Facilitites 9.05 Page 1 of 2

Policy Name: PERIODIC REVIEWS OF THE E&T FACILITIES Policy Number: 9.05

Reference: 42 CFR 438.202, 206, 207; WAC 388-865-0284, -0229; DSHS contract





CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors

PURPOSE

The Salish Behavioral Health Organization (SBHO) shall ensure periodic reviews of the evaluation and treatment service facilities consistent with contract requirements and state and federal regulations.

DEFINITIONS

An Evaluation and Treatment (E&T) facility is certified by the Department and provides (involuntary and voluntary) inpatient evaluation and treatment services for more than twenty-four (24) hours within a general facility.

PROCEDURE

1. The SBHO shall conduct periodic reviews of the evaluation and treatmentfacilities that are currently certified and licensed by the Department.

• Ensure all services provided must be covered under a current Departmentissued certification.


Periodic Reviews of the E&T Facilitites 9.05 Page 2 of 2

• Ensure all services provided must be covered under a current Department Of Health issued license.

2. The SBHO shall review the facilities policies and procedures.

• Ensure all current facility policies and procedures are written in accordance and are consistent with the SBHO policies and procedures.

• Ensure all current facility policies and procedures are implemented accordingly. The E&T may be asked to demonstrate/ provide evidence of how a policy is implemented.

• Efforts will be made to accompany the Department during the annual certification review.

3. Through the period review process if the SBHO believed that a facility was not in compliance with an applicable statute, rule and regulation, the SBHO will notify the proper authorities (certification/ licensing entity).

MONITORING

1. This policy is a mandate by Washington Administrative Code (WAC) regulation. This policy is monitored through periodic reviews of the evaluation and treatment facilities, in addition to:

• Annual SBHO Provider and Subcontractor Administrative Review • Annual Provider Crisis Chart Review • Quarterly Provider Performance Reports • Grievance Tracking Reports

2. If a provider performs below expected standards during any of the reviews listed

above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.

SALISH BHO


Periodic Review of Residential Programs 9.06 Page 1 of 2

Policy Name: PERIODIC REVIEW OF RESIDENTIAL PROGRAMS Policy Number: 9.06

Reference: DSHS contract





CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans• Policy: Monitoring of Contractors

PURPOSE

The Salish Behavioral Health Organization (SBHO) shall ensure periodic reviews of the mental health residential facilities consistent with contract requirements and state and federal regulations.

PROCEDURE

1. The SBHO shall conduct periodic reviews of SBHO contracted residentialtreatment facilities located within the region that are currently certified by theDepartment of Social and Health Services (DSHS) and licensed by theDepartment of Health (DOH).

2. The SBHO will conduct annual reviews of the residential facility and clinicalcharts. The review tool will be revised, as needed, to incorporate a more focusedreview, programmatic changes and/ or current compliance concerns.

3. If the SBHO becomes aware that a facility is not in compliance with an applicablestatue, rule and regulation, the SBHO will notify the proper authorities(certification/ licensing entity).


Periodic Review of Residential Programs 9.06 Page 2 of 2

MONITORING

1. This policy is monitored through: • Annual chart review of consumers receiving treatment at a mental health

residential facility • Grievance Tracking Reports

2. If a provider performs below expected standards during any of the reviews listed

above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.

SALISH BHO


Standard Chart Reveiws 9.07 Page 1 of 2

Policy Number: 9.07 Policy Name: STANDARD CHART REVIEWS

Reference: DSHS Contract





CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans• Tool: Standard Chart Review Tool• Tool: Crisis Chart Review Tool

PURPOSE

The purpose of the Salish Behavioral Health Organization (SBHO) chart review process is to monitor compliance with Washington Administrative Codes (WAC) and contract requirements as well as to give feedback to providers on quality of service delivery.

PROCEDURE

1. The SBHO staff will review 500 clinical records each fiscal year.

2. Information collected from the reviews will be reported to each provider.

3. In general, providers will be asked to develop a corrective action plan for chartreview items that average below 90 percent unless the review sample size is toosmall to require such action. However, there may be times when the sample sizeis small but the deficiencies found during the review warrant a corrective action. Itis understood that some deficiencies in charts cannot be fixed and this is to benoted by the provider as part of the corrective action.


Standard Chart Reveiws 9.07 Page 2 of 2

MONITORING

1. This policy is a mandate by contract and statute. This policy will be monitored through use of SBHO:

• Annual Provider Reviews • Quality Management Plan activities, such as reviewing targeted issues for

trends and recommendations. • Review of previous provider corrective action plans, including provider

profiles related to performance on targeted indicators.

2. If a provider performs below expected standards during the quarterly review listed above a Corrective Action will be required for SBHO approval. Reference SBHO Corrective Action Plan Policy.

SALISH BHO


Quality Review Team 9.08 Page 1 of 5

Policy Name: QUALITY REVIEW TEAM (QRT) Policy Number: 9.08

Reference: WAC 388-865-0282; DSHS Contract


Revision Date(s): 2/2013; 7/2016



CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Corrective Action Plans

PURPOSE

The Salish Behavioral Health Organization (SBHO) assures that a Quality Review Team (QRT) is established and maintained, and does so as a committee of the Advisory Board with administrative support provided by the SBHO.

Further, the QRT functions are separate and discrete from those of the Ombuds person. In further accordance with WAC 388-865-0282 and the contract established with the Department (August 17, 2001), the SBHO established policies and procedures which outline the size, appointment, removal and tenure, and decision making process of the QRT.

PROCEDURE

Independent Execution of Duties and Membership

It is the policy of the SBHO to assure the independent execution of the QRT duties, and affirm that no measures or actions will be taken which might threaten, intimidate or otherwise diminish the QRT independent function, so long as the QRT acts in a legal manner and conforms to the requirements of the SBHO/ DSHS contracts.

1. Appointment and Size: The QRT and its chair are appointed by the chairpersonof the Advisory Board, with appointments approved by the SBHO Advisory



Board. At least two members from the Advisory Board, as well as additional members from consumer and advocacy groups in the region shall be appointed and the committee shall total at least five and no more than ten people.

2. Representation: The QRT shall have membership representative of the

demographics of the region.

3. Tenure and Removal: Appointments to the QRT shall be for a period of two years. Membership shall terminate upon resignation or removal from the Advisory Board. Members may be appointed for additional terms.

Purpose and Responsibility It is the policy of the QRT to monitor and evaluate the efficiency, effectiveness and benefits of services for people with mental illness within the region.

1. The purpose of the SBHO QRT is to: a. Assist the SBHO in its quality assurance process. b. Provide a check and balance system to ensure that targeted individuals

receive appropriate levels of quality care. c. Collect information and make recommendations which will assist

consumers to have their needs met and their welfare protected. d. Visit, assess and evaluate SBHO services and the services of SBHO

subcontractors regarding: • The system for quality of care. • The degree to which services are consumer focused/directed. • The extent of development of alternatives to hospitalization, cross

system coordination and range of treatment options.

2. It is the responsibility of the SBHO QRT, with administrative support to:

a. Meet regularly to conduct QRT business, no less than quarterly. b. Record the agenda, minutes, plans, and conclusions of its meetings. c. Visit and review service provision sites. d. Collect such information as is necessary to make recommendations that

will assist consumers to have their needs met and welfare protected. e. Report recommendations to the SBHO.



f. Maintain client confidentiality. g. Involve representatives of under served groups in developing

recommendations that affect such groups. h. Undertake such other review as is deemed appropriate to fulfill its

purposes. i. Participate in Advisory Board meetings no less than quarterly.

3. The QRT has the authority to:

a. Evaluate the Contractor’s relationships and cross system activities

including but not limited to schools, state and local hospitals, jails and shelters.

b. Enter and monitor any state or community psychiatric hospital or ward

providing psychiatric care coordination with the Contractor or the Department to resolve systemic issues provided reasonable time notice and confidentiality concerns are met.

c. Monitor the SBHO and its subcontractors Quality Management Plan

implementation. State Training It is the policy of the QRT that its members attend state sponsored training, as available, in accordance with WACs and DSHS /SBHO contracts.

1. Upon SBHO receipt of notice of training events no less than four weeks in advance of training from the Department, the SBHO staff will notify all QRT membership of the training availability.

2. QRT membership, with the assistance of SBHO support staff, will arrange to

attend trainings. 3. QRT membership attending trainings will be reimbursed at the usual and

customary rate for SBHO staff per Kitsap County Policies and Procedures for their travel and expenses (lodging and meals).

Information Collection It is the policy of the SBHO QRT to address mental health service delivery system issues and service delivery issues in order to support the SBHO and QRT purposes and fulfill its responsibilities.

1. The SBHO QRT will collect information regarding system and policy issues by:



a. Holding open forums in each catchment area to which the public is invited and asked to provide input regarding local services, focusing on addressing system issues and information.

b. Reviewing information including SBHO prepared semi-annual or quarterly

reports; SBHO site visit monitoring reports; or other policies, plans or materials as is deemed necessary to fulfill its function.

2. The SBHO QRT will collect information regarding service delivery issues by:

a. Welcoming input from interested consumers, service providers, the SBHO,

Ombuds staff and the Department regarding problems of access to services and/or quality of care improvement

b. Reviewing data submitted by providers to the SBHO; c. Making independent annual site visits to providers in which:

• Providers identify processes and practices of service delivery. • Interviews regarding QRT areas of interest or concern are held. • Information helpful to the QRT purpose and responsibilities is

collected.

d. Reviewing information compiled by the SBHO staff during site reviews including Corrective Action Plans.

Recommendations It is the policy of the QRT to fulfill its reportorial responsibilities in a timely manner. The QRT will:

1. Prepare and present written reports, as requested, to the SBHO Executive Board.

2. Prepare and present to the Advisory Board reports of its findings as made. 3. Prepare and present to the SBHO written report of information and findings

relative to materials review within 30 days of said review and as follows:

a. Review findings will be maintained in general confidentiality until they have been submitted to the SBHO and response generated.

b. The SBHO will have thirty (30) days within which to prepare and deliver its

written response.

4. Prepare and present to the SBHO and Advisory Board a written report of provider site visit information and findings as follows:



a. Information and findings will be maintained in general confidentiality until

they have been submitted to the provider and a response generated; b. Providers will have thirty (30) days within which to prepare and deliver a

written response and/or will follow policies and procedures governing Compliance, Monitoring and Non-Compliance including the fulfillment of Corrective Action Plans as identified in the SBHO Policies and Procedures, which ever is more restrictive.

5. The Chair of the QRT will be responsible for collecting, assessing and reviewing

the information, from which the report is compiled with assistance from the membership, and will compile and deliver legible reports within identified time periods; or may, upon agreement from the membership and the SBHO, delegate such duties to a member of the QRT. Assistance may be afforded by the SBHO.

Salish Behavioral Health Organization Policies and Procedures

QRT Onsite Review Activities 9.08a Page 1 of 2

SBHO Quality Review Team (QRT) Reviews

Pre, On-Site, and Post Review Activities

Pre-Review Activities

1. Available Consumer Satisfaction Surveys -Study of current and past year

2. Available SBHO Ancillary Provider Surveys- Study of current and past year

3. Ombuds reports- shares trends and areas of concern

4. SBHO staff reports-a. summarizes agency strengths and current challengesb. agency performance reports documenting numbers of consumers, by age

groups, minority status, and service hoursc. distributes the most recent agency financial audits submitted to PRSN

5. QRT members- share information about agency services identified from theirindividual advocacy and family/ consumer reports.

6. QRT discuss, identify, and prioritize the providers from the “Optional AncillaryProviders” list.

7. QRT, Ombuds, and SBHO staff set preferred dates for on-site visit.

8. SBHO staff-a. Notifies agency, schedules staff interviews and Clubhouse lunchb. Invites designated Ancillary Providers (from “Standardized” and “Optional” lists),

and schedules interviews with agency Directors or their designated contactc. Reserves a QRT confidential Caucus locationd. Schedules room and meal accommodations for QRT

9. Local QRT member- contacts local NAMI to schedule Family and Consumer Forum

On-Site Activities

1. Family and Consumer Forum

2. Ancillary Provider Interviews

3. Agency Visit and Program/ Services Staff Interviews (includes Entrance Interview)

4. Lunch with consumers at Clubhouse

5. Caucus, Planning for Exit Interview

Salish Behavioral Health Organization Policies and Procedures

QRT Onsite Review Activities 9.08a Page 2 of 2

Post On-Site Report and Recommendations

1. QRT Chair drafts review report, sends report to QRT members for review and comment

2. SBHO staff sends final draft to agency Director for response within 30 days 3. QRT considers agency Director’s comments and prepares a final report. 4. QRT members present the final report to SBHO Advisory Board with copies to

Executive Board, SBHO staff, Ombuds, Network Providers, and the Department. Report is approved and made public information.

(Rev. 8/2016)

SALISH BHO


Provider-Subcontractor Non-compliance Penalties 9.09 Page 1 of 2

Policy Name: PROVIDER AND SUBCONTRACTOR NON-COMPLIANCE PENALTIES Policy Number: 9.09

Reference: DSHS and Provider Contract


Revision Date(s): 2/2013; 7/2016

Reviewed Date: 12/2014; 7/2016, 7/2017


CROSS REFERENCES

• Policy: Correction Action Plan• Policy: Monitoring of Contractors

PURPOSE

It is the policy of the Salish Behavioral Health Organization (SBHO) to promote its mission through assurance of subcontract compliance and to consider the imposition of penalties on providers for noncompliance in accordance with state laws and regulations.

PROCEDURE

1. In the event that a provider or subcontractor fails to provide the SBHO withrequested data, reports, statistics, schedules, or information; or files fraudulentreports; or fails to meet contractual terms, the SBHO may:• Provide a written notice to the provider identifying the area(s) of non-

compliance and specifying redress.• Identify, as appropriate, the specific amount of time within which the provider

may correct the area(s) without penalty.• In the event that the provider does not correct the area(s) within the specified

amount of time, institute any or all of the following actions, under the SBHOcontract with the provider:a. Withholding payment.


Provider-Subcontractor Non-compliance Penalties 9.09 Page 2 of 2

b. Financial penalties.c. File a request with the Department to consider suspension, revocation,

limitation, or restriction of licensure or certification.• This includes filing a report with the Medicaid Fraud and Control

Unit.d. File a request with the Department to consider refusal to grant licensure or

certification.e. Other SBHO action under chapter 71.24 RCW.

2. The SBHO may deny partial or full funding to providers based solely on findingsof substantial noncompliance with the terms of the provider’s contract.

MONITORING

1. The SBHO will complete an array of monitoring activities for each of itscontracting entities every calendar quarter. Such monitoring activities shall beused to determine current contractor performance and their ability to meetcontractual obligations prior to the close of the contract period. Areas in which acontractor’s performance is substantively lower than expected shall require thesubmission of corrective action plans on the part of the contractor.

2. The SBHO will review and/or conduct on-site monitoring reviews of providercompliance regularly in accordance with the SBHO monitoring schedule, but mayconduct a review outside of that schedule as the SBHO considers appropriate foroversight purposes. The site review will consider any or all areas of contractcompliance.

3. The SBHO may, prior to the date of the monitoring activity report, inform theprovider of any substantial noncompliance, either in the specific or theaggregate, which places the provider at risk of punitive action as noted in (1)above. Any such notification, if verbal, will be followed by a written memorandumgenerated within 36 hours of the verbal notification but which will not replace themonitoring report.

4. The monitoring report will report areas of compliance and those of non-compliance as well as suggestions which may be of assistance to the provider tosupport the SBHO mission.

5. In the event of areas of non-compliance, the report will request a CorrectiveAction Plan (CAP), generated by the provider in response to the report, for eachitem of provider non-compliance. Reference SBHO Corrective Action Plan.

6. The SBHO may deny partial or full funding to contractors and/ or subcontractorsbased solely on findings of substantial noncompliance as outlined within theterms of the contract.

SALISH BHO


Corrective Action Plans 9.10 Page 1 of 3

Policy Name: CORRECTIVE ACTION PLANS Policy Number: 9.10

Reference: DSHS and Provider Contract





CROSS REFERENCES

• Plan: Quality Management Plan• Policy: Provider and Subcontractor Non-Compliance Penalties

PURPOSE

The Salish Behavioral Health Organization (SBHO) monitors contracted agencies according to the monitoring policy. The SBHO shall require contracted providers to develop corrective action plans when a provider is found to not be in compliance with the contract or when other monitored functions and services are found to be deficient.

PROCEDURE

1. Reasons the SBHO may request a Corrective Action Plan (CAP) include, but arenot limited to the following:

• The provider is found to be out of compliance with contract or working agreementrequirements.

• Provider performance is below the standard as outlined in the SBHO QualityManagement Plan

• A trend of sub-standard performance has been identified.

• A problem exists that negatively impacts individuals receiving services.

• The provider has failed to perform any of the contractually required behavioralhealth services.



• The provider has failed to develop, produce, and/or deliver to the SBHO anyrequested statements, reports, data, data corrections, accountings, claims,and/or documentation.

• The provider has failed to implement corrective action required by the SBHOwithin prescribed time frames.

2. Corrective action plans developed by the provider must be submitted for approvalto the SBHO within 30 calendar days of notification.

3. Corrective action plans may require modification of any policies or procedures bythe provider relating to the fulfillment of its contractual obligations.

4. The SBHO may extend or reduce the time allowed for corrective action dependingupon the nature of the situation.

5. Corrective action plans are reviewed by the SBHO, which determines if they areacceptable.

6. The Corrective Action Plan will include:• Date of the Plan• Identified item of non-compliance• Any specified actions specifically required by the SBHO• Any dates specified by the SBHO by which the provider must be compliant• Specific action(s) the provider proposes to bring the item into compliance• Specific goal(s) and/or outcome(s) the provider’s action addresses• Date by which the action(s) will be completed• Date by which the goal(s) and/or outcome(s) will be attained• Proposed documentation evidencing completion of the action(s) and• Attainment of the goal(s)/outcome(s)

7. Performance in the identified area is monitored by the SBHO to determine if thecorrective action plan has been successfully implemented. If compliance and/orperformance continues to be insufficient, the SBHO may:• Require a revised corrective action plan• Offer technical assistance to the provider• Reject the plan• Require the provider to obtain outside technical assistance• Following the corrective action steps included the subcontract, withhold

payments and /or invoke financial penalties8. The SBHO may inform the provider of any substantial noncompliance, which

places the provider at risk of punitive action. Any such notification, if verbal, will befollowed by a written memorandum generated within 36 hours of the verbalnotification.



MONITORING

This policy is a mandated by contract and statute.

1. This policy is monitored through use of SBHO:

• Annual SBHO Provider and Subcontractor Administrative Review

• Quality Management Plan activities, such as review targeted issues fortrends and recommendations

• Annual Provider Chart Reviews

• Review of previous Provider Corrective Action Plans related to policy,including provider profiles related to performance on targeted indicators

2. If a contractor or subcontractor consistently performs below expected standardsduring a contract period, the SBHO has the option of imposing punitive action and/or financial penalties as outlined in the contract.