PREPARING FOR A TRIENNIAL PROGRAM OVERSIGHT AND

COMPLIANCE REVIEW

PRESENTED BY:ANDREA KUHLEN, ASSISTANT DIRECTOR

ISABEL CHAVEZ, BEHAVIORAL HEALTH MANAGER

Imperial CountyImperial CountyBehavioral Health ServicesBehavioral Health Services

Learning ObjectivesLearning Objectives

o Are able to organize and plan for a successful audit.

o Are able to ensure compliance through an ongoing monitoring system.

o Are able to develop a process for collecting and updating back up documentation to support responses to Protocol questions.

o Are able to identify a process that assures all areas of DHCS Protocol are in compliance.

Pre-Audit YearsPre-Audit Years

1. Attend the DHCS Protocol Review Identify changes to the ProtocolIdentify changes in state and federal laws and regulation and /or terms of DHCS contract with the MHP.

Pre-Audit YearsPre-Audit Years

2. Advise the clinical programs and access staff of the changes, as applicable.

Revise policies, procedures and forms as needed

Establish new policies, procedures and forms as needed.

Remind staff to continue with established processes or update processes as a result of MHP changes (i.e. new committees, change in responsibilities, etc.).

Pre-Audit YearsPre-Audit Years

3. Advise Quality Management staff of the changes.

4. Assign staff responsibility for sections of the protocol (i.e., Access, Authorization, etc.) according to job duties & responsibilities.

Pre-Audit YearsPre-Audit Years

5. Quality Management provides technical assistance to clinical programs and access staff to implement changes.

6. Based on assigned section(s), monitor compliance to ensure processes continue (i.e., logging, reports, test calls, etc.).

Pre-Audit YearsPre-Audit Years

7. Monitor compliance. Routinely complete reports (i.e. monthly, quarterly,

biannually) and present to QM staff. If opportunity for improvement is identified, presents

reports to QI Committee at least quarterly If not, schedules for QI Committee at least annually

as required Work closely with clinical/access staff on issues

that need immediate attention.

Pre-Audit YearPre-Audit Year

8. Annually update documents used as back up to Protocol questions: QI Work Plan Implementation Plan Informing Materials Training Plan

Audit Year Audit Year

Audit YearAudit Year

1. Attend DHCS Protocol Training.

2. Complete 2-8 above for pre-audit years.

3. Updates protocol folder tab to reflect correct numbering and section, if changed.

Audit YearAudit Year

4. Updates cover letter to reflect changes, if any.

Cover letter identifies: Protocol question Supporting documentation that was submitted for the previous audit Applicable laws or regulations

Audit Year – Cover Letter Audit Year – Cover Letter

Audit YearAudit Year

5. Folder content: Cover letter Back-up documents

Logs Reports Policies & procedures Other documents

Audit Year –Folder ContentAudit Year –Folder Content

Audit YearAudit Year

6. Four months prior to review, issue folder for each question to assigned QM staff. Staff reviews folder:

Ensure applicable regulations are cited. Replaces reports, logs and documents with

the current version. Adds any additional documentation that

supports compliance. Highlights and tabs pertinent sections of the

document(s) that directly answers protocol question.

Audit Year –Highlights, TabsAudit Year –Highlights, Tabs

Audit YearAudit Year

7. Weekly Quality Management staff meeting

Staff present completed folders. If approved, updates cover letter as

necessary. Provides completed folder to QM clerical

staff.

Audit YearAudit Year

8. Final Steps

QM clerical staff updates cover letter and prepares a second set for DHCS, i.e.,

MHP = red folder DHCS = blue folder QM manager reviews content of the folders to

ensure contents are the exactly the same and in the same order.

Folders are placed in hanging folders in plastic storage boxes in the order of the protocol

Labels boxes: MHP and DHCS.

Audit YearAudit Year

Audit Year-Attestation Audit Year-Attestation

1. Completes 2-8 above for Audit Year Only one box Labels box: Attestation

Audit Week Audit Week

Boxes delivered to review room. Subject matter expert presents response to

Protocol question and answers reviewer’s question. For example:

Patients’ Rights – Beneficiary Protection PAU Supervisor – Authorization Privacy Officer – Program Integrity

Audit WeekAudit Week

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