FY 2018 Provider Record Review Crisis Stabilization Services Programmatic Review

Transcription

1 1 2 Offerings FY2018 Part I, Section III, Crisis Stabilization Unit s, Staffing Requirements pg. 55,and 168, Unit Certification Review Tool, Discription,8, d, pg.2 of 12 Administrative Section The Unit (CSU) meets all staffing requirements: a. Physician or staff member under Physician b. Full time Nursing Administrator is an RN c. RN present in facility at all times d. Staff to Individual ratio is based on acuity level e. Licensed or credentialed staff present to provide Individual, Group and Family Therapy Yes: The provider meets all staffing requirements required for the CSU. No: The provider is missing any one of the staff required for the CSU. Child and Adolescent: There is a minimum of (3) staff present within the C&A CSU including the charge nurse at all times. (If the charge nurse is an APRN, then he/she may not simultaneously serve as the accessible physician during the same shift.) Yes: The agency has (3) staff present within the C&A CSU including the charge nurse at all times and if the charge nurse is an APRN he/she is not serving as the accessible physician during the same shift. Based on DBHDD Provider Effective Date: January 1, 2018

2 No: The agency does not have (3) staff present within the C&A CSU including the charge nurse at all times and if the charge nurse is an APRN he/she is serving as the accessible physician during the same shift. 3 Unit Certification Review Tool, Discription,8, e, pg.2 of 12 Child and Adolescent: Staff to Individual ratio is no more than (4) Individuals to every (1) staff (including the staff charge nurse.) Yes: The staff to individual ratio is no more than (4) individuals to every (1) staff (including charge nurse.) No: The staff to individual ratio is more than (4) individuals to every (1) staff (including charge nurse.) 4 Rules and Regulations for Child and Adolescent Crisis Stabilization Units,, Chapter , 14,c, pg.12 Child and Adolescent: Staffing demonstrates the ratio of nursing staff to individual s increases on the basis of the clinical care needs of the individual, including required levels of observation for high risk individuals. Yes: Staffing demonstrates the ratio of nursing staff to individual s increases on the basis of the clinical care needs of the individual, including required levels of observation for high risk individuals. Based on DBHDD Provider Effective Date: January 1, 2018

3 No: Staffing changes does not demonstrate the ratio of nursing staff to individual s increases on the basis of the clinical care needs of the individual, including required levels of observation for high risk individuals. 5 6 Rules and Regulations for Units, Chapter Pharmacy s & Medication Management, e, x, pg. 287 Providers, 6 Medication, e, viii, pg.286 Provider adheres to their policy which define requirements and procedures for timely notification to prescribing professional regarding drug reactions, medication problems, medication errors and refusal of medications. Yes: Provider adheres to their policy/procedure. No: Provider does not adhere to their policy/procedure. There are protocols for handling of licit and illicit drugs brought into the service setting. This includes confiscating, reporting, documenting, educating, and appropriate discarding of the substances. The provider adheres to said protocols. Yes: Provider adheres to their protocols. No: Provider does not adhere to their protocols. Based on DBHDD Provider Effective Date: January 1, 2018

4 7 Providers,6, Medications, e, ix, pg. 286 Provider is adhering to their current policy and procedure for safe storage of medications. Yes: Provider adheres to their policy/procedure. No: Provider does not adhere to their policy/procedure Offerings Providers, 5, Infection Control, pg. 284 FY2018 Part I, Section III, Crisis Stabilization Unit s, Clinical Operations, 2, pg. 55 and pg.168 Providers, 6, Medications, e, xii, pg. 287 Provider adheres to their Infection Control Plan. Yes: Provider adheres to their Infection Control Plan. No: Provider does not adhere to their Infection Control Plan. Provider adheres to their Seclusion and Restraint procedures. Yes: Provider adheres to their procedure. No: Provider does not adhere to their procedure. Provider adheres to their procedures for monitoring of therapeutic blood levels, if required by the medication, such as Blood Glucose testing, Dilantin blood levels and Depakote blood levels; kidney or liver function tests. Yes: Provider adheres to their procedures. Based on DBHDD Provider Effective Date: January 1, 2018

5 No: Provider does not adhere to their procedures DBHDD Policy: Crisis Plans for Provision of Crisis s to Individuals who are Deaf, Deaf- Blind, and Hard of Hearing, Chapter Crisis Stabilization Unit s Accessibility pg. 55 and 168 NON- SCORED: Policies and procedures are present for adherence to Required Components of Crisis Plans for Provision of Crisis s to Individuals who are Deaf, Deaf-Blind, and Hard of Hearing. Yes: Crisis Plans contain required components for Provision of s to Individuals who are Deaf, Deaf-Blind, and Hard of Hearing. No: Crisis Plans does not contain required components for Provision of s to Individuals who are Deaf, Deaf-Blind, and Hard of Hearing. The agency has an identified Model or Curriculum for SU treatment on the CSU. Yes: The agency has an identified Model or Curriculum for SU treatment on the CSU and is reflective in programming and documentation within the record. No: The agency does not have an identified Model or Curriculum for SU treatment on the CSU and is not reflective in programming and documentation within the record. Based on DBHDD Provider Effective Date: January 1, 2018

6 13 Staff Training Unit Certification Review Tool, Discription,3, pg. 2 of 12 The agency has a physician who is either on site or available twenty-four (24) hours a day by telephone with 3.7-WM. Yes: The CSU has a Physician or Practitioner (PA, APRN-CNS, APRN-NP) on site or available 24 hours a day by phone. No: The CSU does not have Physician or Practitioner (PA, APRN- CNS, APRN-NP) on site or available 24 hours a day by phone. Policy Stats: CSU: Description, If the CSU physician(s) is/are not a psychiatrist there is one available for consultation. 14 Yes: The physician for the CSU is a psychiatrist or there is one available for consultation. No: The physician for the CSU is not a psychiatrist and there is not one available for consultation. Policy Stats: CSU: Description, Based on DBHDD Provider Effective Date: January 1, 2018 Does the agency have an Addictionologist on staff in the CSU or access to one for consultation? Yes: There is an Addictionologist on staff for the CSU or the agency has access to one for consultation.

7 Providers Part II, Sec.II,1, c, pg. 289 No: There is not an Addictionologist on staff for the CSU nor is there access to one for consultation. 16 Rules and Regulations for Child and Adolescent Crisis Stabilization Units, Chapter , description, 7, pg.11 Child and Adolescent: Does the C&A CSU provide services under the direction of a psychiatrist with training or experience in working with children and youth? Yes: The C&A CSU is under the direction of a psychiatrist with training or has experience in working with children and youth. No: The C&A CSU is not under the direction of a psychiatrist or a psychiatrist with training or experience working with children and youth. Score for Administrative Section: OVERALL SCORE: Based on DBHDD Provider Effective Date: January 1, 2018