TREATMENT SITE VISIT EVALUATION PROTOCOL
Agency and Site Location:Date of Site Visit
Site Evaluator(s):
Agency Staff Present:
Section 1: Financial Data / Examples of Evidence Required / Standard Met / CA Notes
1. / A copy of the previous fiscal year’s annual audit consistent with OMB A-133 regulations and MDCH/BSAS audit guidelines issued in 1998 was submitted on time. (Due April 30) / The CMHSP will review these items prior to the site-visit.
Any items of concern will be discussed during site visit.
2. / The audit contained findings.
3. / The program received a management letter.
4. / If yes is indicated on either 3 or 4, the program has submitted satisfactory responses.
5. / For fixed unit rate contracts, cost documentation has been submitted on the supplemental cost information form that documents the program’s cost per unit of service.
6. / For Performance Based Contracts (e.g. Women’s Designated Specialty Services) program has complied with 15% or $10,000 deviation allowance per budget category, whichever is greater.
Section 2: REPORTS AND OTHER DOCUMENTATION / Examples of Evidence Required / Standard Met / CA Notes
7. / Scheduled reports and data entered into ProviderConnect have been received on time. / These items will be reviewed prior to the site-visit.
Any items of concern will be discussed during site visit.
8. / Current satisfaction data is being submitted to the CMHSP and number submitted are appropriate in relation to number of clients served by provider.
9. / Current Provider Application is on file with all relevant up-to-date attachments.
10. / Provider is licensed for all service categories provided under CMHSP funding. All entry level agencies are licensed for screening, assessment, referral and follow-up (SARF)
11. / Waiting list reports have been provided on a monthly or more frequent schedule through May 31, 2012.
12. / Plan of correction from previous site visit was submitted /accepted in timely manner (if applicable).
13. / Proof of current substance abuse service accreditation is on file.
14. / Current proof of Fidelity Bonding Insurance, professional Liability Insurance and General Insurance id on File and meets required levels.
Section 3: POLICIES/PROCEDURES
/ Examples of Evidence Required / Standard Met / CA Notes
15. / There are policies/procedures to meet the Limited English Proficiency (LEP) requirements. Materials promoting translation services are posted in visible location. / Agency policy
Material examples
16. / Provider has clinical protocols that are being used in planning and providing treatment to Covered Persons. / Clinical protocol/policy
17. / Provider has a written cultural competency plan is in place that:
· Identifies and assesses of the cultural needs of potential and active clients based on population served
· Identifies how access to services is facilitated for persons with diverse cultural backgrounds and LEP
· Identifies standards for the recruitment and hiring of culturally competent staff members
· Establishes a process to ensure that contractual providers comply with all applicable requirements concerning the provision of culturally competent services
· Establishes a process to asses annually its compliance with the its written cultural competence plan / Cult. Competency plan
18. / Recipients Rights: Policies and Procedures are in place and meet requirements as detailed in 42 CFR. / Policy/procedure
19. / Protected Health Information: Policies and Procedures are in place and meet HIPPA requirements. / Policy/procedure
Section 4: STAFF QUALIFICATIONS MDCH Protocol B.6.4.2 / Examples of Evidence Required / Standard Met / CA Notes
20. / Provider monitors staff maintenance of licensure and/or certifications, and timely completion of MCBAP development plans. / Procedure
Staff Credentialing form or alternative
21. / All staff who bill services under CMHSP funding meet required standards to provide services as defined in the Provider Qualifications Per Medicaid Services and HCPCS/CPT Codesas appropriate. / New hire forms
Credential Files
22. / Provider has policies and procedures to assess training needs and ensure that treatment staff receives appropriate, on-going training. / Agency policy
Staff development plans
23. / Provider has policies and procedures to ensure that all direct service treatment staff are culturally competent to provide planned services. / Agency policy
24. / There are current records of staff training and development on communicable disease for all staff with client contact. A minimum of Level 1 Training on file for each clinician. / Agency training records
25. / Processes are in place to ensure staff is qualified to perform their jobs, including those who are inexperienced in SUD services and who are not-licensed or certified. / Orientation records
Training records
26. / Performance monitoring/ staff evaluation conducted. / Policy/Evaluations
27. / There is verification that ensures provider is checking to see if their staff is excluded from participating in any state or federal programs (i.e. Medicaid) / LARA check
www.sam.gov or https://exclusions.oig.hhs.gov/
28. / Criminal background checks are completed for all new employees and periodically during employment. / Examples of CB Reports
Policy/Procedure
Section 5: QUALITY ASSURANCE AND EVALUATION / Examples of Evidence Required / CA Notes
29. / There is evidence that the provider addresses client complaints :
1. Takes specific action on individual cases as appropriate
2. Identifies and investigates sources of dissatisfaction
3. Identifies and outlines systematic action steps to follow up on findings / Examples/ Reports
30. / Provider has quality improvement plan that addresses practice guidelines for each service that include: adoption process, training, implementation, monitoring by supervisor, evaluation of documentation. MDCH CFR 438.236 / QI plan and relating policies/procedures.
Training records
Evaluation forms/process
31. / There is evidence that the agency is providing regular scheduled clinical supervision for appropriate staff. Clinical supervision should address such issues as; modalities of treatment, case reviews, crisis, and integrated care. / Clinical Supervision notes
32. / There is evidence that the agency reviews Admission/Discharge data on a regular bases and has development plans to improve deficient area such as employment, housing, completed treatment, and decrease in primary drug / Quality Improvement meeting minutes
Leadership meeting minutes
33. / There is evidence that the agency has implemented recommendations from CARF, MDCH or other accrediting/ monitoring agency / Latest CARF report
Latest report from MDCH or other monitoring agency.
Strategic plan/QI plan
Section VIII: Fetal Alcohol Spectrum Disorders
http://www.michigan.gov/documents/mdch/TX_Policy_11_FASD_295506_7.pdf / Examples of Evidence Required / Standard Met / CA Notes
34. / Please describe how FASD prevention efforts are provided within the treatment regimen for women of childbearing age who use alcohol. / Materials used
Discussion
35. / Please describe how the program screens the children of clients who use alcohol are screened for FASD and referred for further diagnostic services if appropriate. / Discussion
SECTION IX: Peer Recovery/Recovery Support Services (only for providers of this service)Treatment Technical Advisory #07
36. / Evidence that all recovery coaches meet the following minimum requirements:
· Peer in recovery
· HS diploma or equivalent, recommended
· Stable recovery / Policy/procedures
Discussion
37. / Training requirements: Evidence that recovery coaches have received the following training subjects as part of the new hire process: Fundamentals of addiction and recovery, personal safety, ethics, confidentiality, maintaining appropriate relationships (boundary setting), CPR/First Aid/Universal precautions (recommended), individualized treatment and recovery planning, role as a member of a recovery team, cultural competence, recipient rights, communicable disease (Level 1) / Staff training log
Orientation Procedures
38. / Evidence that appropriate continuing education in addiction and recovery supports is completed. / Staff training log
39. / Evidence that services provided by the recovery coach are based on the individual needs of the client and are documented in the treatment plan or a recovery plan. / Case file review
40. / Evidence that the clients receiving services are not able to meet recovery support needs through services from another eligible service or program, and meet at least one of the following:
· Client has a documented need in community living skills, health care, housing, employment/financial, education or another functional area in the person’s life,
· Client has a demonstrated history of recovery failure
· Client has a SUD involving a primary drug of choice that will require longer term involvement in treatment services to support recovery, or
· The chronicity and severity of the client’s disorder is such that ongoing support is needed to increase probability of recovery. / Case file review
Policies/Procedures for recipient selection
Section X: Discussion Items / CA Notes
Unmet Need: What services or community drug use patterns would you like to target that you have been unable to? In other words, if you were to expand or enhance services what would you want to do?
Assessment Tools/Procedures:
· What assessment tool is your agency using?
· When/how is assessment integrated into initial services?
Welcoming: What is your agency doing, or planning to do to ensure compliance with the Welcoming policy, Treatment Technical Advisory #05?
· Environment
· Staff competency
· Performance Indicators
Evidence-based Services:
· Which evidence-based treatment models are being used?
· How is fidelity measured?
· How determine appropriate model for a client at any given time?
Outcomes Tracked:
· Does the agency have a comprehensive evaluation plan for services?
· Does the agency track outcomes for clients served? What outcomes are tracked
· How is the information used to improve services?
· How are results shared?
MDCH priorities and expectations
· How is your agency working to reduce obesity, reduce infant mortality and reduce tobacco use?
· How is your agency Promoting the patient-centered medical home concept
· How is your agency Preventing and controlling disease by reducing the percentage of Michigan high school students who smoke cigarettes and Increasing the percentage of Michigan children 19 – 35 months of age who receive all recommended vaccines.
Trauma Informed Care:
· Does the Agency screen/assess for an individual’s history of experiencing violence/trauma?
· Does the Agency provide psychosocial education for individuals regarding symptoms of trauma?
· Are plans developed for every individual that specify trauma triggers?
· Have staff been trained in Trauma informed Care?
Dual Diagnosis Capable/Enhanced:
· Is there a formalized and documented coordination of mental health services (DDC)? Or Are most services integrated within existing program (DDE)?
· Is there a formal and standardized assessment for mental health disorders and documented in 50-69% (DDC) or are assessments for mental health disorders integrated with the assessment for substance use symptoms in at least 90% (DDE)
· Do treatment plans routinely address both disorders although substance use is addressed as primary (DDC) or do plans address both disorders equivalently and in specific detail (DDE).
· Are staff trained in common signs, symptoms, detection and triage for co-occurring disorders ( 80% or more of staff trained DDE)
Support:
· Are there any technical assistance needs that we could help you with?
· What do you think are the most important issues that we should focus on in the coming year?
· Any other thoughts you would like to share with us?