Date of Review Reason for Review: Inspection of Care Action Plan Follow-up (Focus of Follow-up: ) Beneficiary Record ID: Beneficiary Age: Custody: DCFS DYS Provider Name: Acute RTC PRTF Date of Admission: Reviewer/Credentials: 1. Is there documentation of a PCP referral, for beneficiaries under age 21, for 211.000 inpatient psychiatric services made prior to the provision of services or 213.000 there is a retroactive PCP referral covering the service and received no 213.100 more than 45 calendar days after the date of the service (or the date of Medicaid authorization)? PCP NA, if any of the following: 1) Beneficiary is 21 years of age or older; 2) Admission was an emergency admission; 3) Admission was a non-emergency admission and less than 45 days since date of admission. CON 2. Is there a PCP referral renewal prior to the expiration of previous referral or every six months (whichever is first)? NA, if any of the following: 1) Beneficiary is 21 years of age or older; 2) Admission is less than 6 months 3. Is there is a written Certificate of Need (CON) in the beneficiary record that states the individual is or was in need of inpatient psychiatric services for emergency admissions and non-emergency admissions? 4. Is there a written Certificate of Need made at the time of admission for acute admissions and prior to admission for non-emergency admissions? 213.300 215.100 215.500 215.100 ADMISSION EVALUATIO 5. Were the parents/legal guardians informed and given a copy of restraints and seclusion policy upon beneficiary s admission to the facility? 6. Is there documentation of a Social Evaluation conducted by professional staff? 221.702 Adopted in compliance with Ark. Code Ann. 25-15-204 Page 1 of 6
7. Is there documentation of a Social Evaluation conducted within 60 hours of admission by professional staff? 8. Is there documentation of a Psychiatric Evaluation conducted by professional staff? 9. Is there documentation of a Psychiatric Evaluation conducted within 60 hours of admission by professional staff? 10. Is there documentation of a Medical Evaluation conducted by a physician? 11. Is there documentation of a Medical Evaluation conducted by a physician within 60 hours of admission? 12. Does the Medical Evaluation include symptoms, complaints and complications indicating the need for admission? 13. Does the Medical Evaluation include a medical history? Medical Evaluation 14. Does the Medical Evaluation include a summary of present medical findings? 15. Does the Medical Evaluation include a diagnosis? 16. Does the Medical Evaluation include a mental and physical functional capacity of the beneficiary? 17. Does the Medical Evaluation include a prognosis? PLAN OF CARE 18. Is there is an Individual Plan of Care developed by the facility-based team (physician and MHP)? 19. Is the Individual Plan of Care completed no later than 14 days after the admission? 20. Is the Individual Plan of Care developed in consultation with the recipient and his or her parent(s), legal guardian(s), or others in whose care he or she will be released after discharge? 215.220 Adopted in compliance with Ark. Code Ann. 25-15-204 Page 2 of 6
21. Does the Plan of Care include diagnoses? 22. Does the Plan of Care include symptoms, complaints and complications indicating the need for admission? 23. Does the Plan of Care state treatment objectives? Plan of Care Review 24. Does the Plan of Care state any orders for medications, diet, treatments, restorative and rehabilitative services or special procedures recommended for the health and safety of the recipient? 25. Does the Plan of Care contain an integrated program of therapies, social services, activities and experiences designed to meet the treatment objectives? 26. Does the Plan of Care include discharge plans and, at an appropriate time, post-discharge plans, and also include the coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care in the recipient s family, school and community upon discharge? 27. Is the Individual Plan of Care designed to improve the recipient s condition to the extent that inpatient psychiatric services will no longer be necessary and to achieve the recipient s discharge from inpatient status at the earliest possible time? 28. Is the Individual Plan of Care based on a diagnostic evaluation that includes examination of the medial, social, psychological, behavioral and developmental aspects of the recipient s situation and reflects the need for inpatient psychiatric services? Dates of Plan of Care Reviews reviewed: list all reviewed 29. Is the Plan of Care reviewed by the facility based team every 30 calendar days? 30. Does the plan of care review determine whether services being provided are or were required on an inpatient basis? 31. Does the plan of care review recommend changes in the plan as indicated by the recipient s overall adjustment as an inpatient? 218.300 215.220 218.300 218.300 Adopted in compliance with Ark. Code Ann. 25-15-204 Page 3 of 6
32. Was there documentation that the attending physician reviews the prescribed medications at least every 30 days? 456.610 (b) (1) Has there been any use of restraints or seclusion for this beneficiary? Please list dates and times: informational only SECLUSION AND RESTRAINT 33. Was there a physician order specific to the acute incident requiring the use of restraints or seclusion and no standing/prn order? 34. Was the intervention conducted within the time limitations for the beneficiary s specific age? 221.702 221.704 35. Was the date and time that the order was obtained documented? 36. Were the start and stop times of the emergency safety intervention documented? 37. If there was harm or injury to the beneficiary as a result of the intervention, was medical treatment immediate? 221.710 38. Was there a face-to-face assessment within one hour of initiation of the intervention? 39. The restraint or seclusion intervention was not used as a means of coercion, discipline, convenience or retaliation? 40. Was the parent/guardian notified of the intervention within 24 hours after the occurrence? 221.702 221.707 Adopted in compliance with Ark. Code Ann. 25-15-204 Page 4 of 6
41. Is there documentation of a face to face post intervention debriefing within 24 hours after the use of restraint or seclusion with staff involved and beneficiary? 221.709 42. Is there documentation of a post intervention debriefing within 24 hours after the use of restraint or seclusion with all staff involved including appropriate supervisory and administrative staff? 43. Was the documentation of the intervention completed by the end of the staff s shift? 44. Was the purpose of therapeutic leave days clearly documented in the beneficiary s record? 221.709 Therapeutic Leave Documentation 45. Did the therapeutic leave evaluation documentation provide support to the plan of care objectives and goals? 46. Was there documentation of staff contact with beneficiary and person(s) responsible for the beneficiary for therapeutic leave in excess of 72 consecutive hours? 47. Were there progress notes that provide statements that track the beneficiary s actions and reactions and clearly reveal the beneficiary s achievements or regressions while on therapeutic leave? 48. Did records document the specific service provided? 204.100 49. Did records document the date and actual time the services were provided 204.100 (Time frames may not overlap between services. All services must be outside the time frame of other services)? 50. Did records document the relationship of the services to the treatment 204.100 regimen described in the plan of care? 51. Did records document updates describing the patient s progress? 204.100 52. Were records legible and concise? 204.100 53. Did records document reflect the name and title of the person providing 204.100 the service as being at the appropriate professional level? Adopted in compliance with Ark. Code Ann. 25-15-204 Page 5 of 6
Medical Necessity 54. Are inpatient services medically necessary for this beneficiary based upon documentation in the clinical record of the beneficiary s severity of illness (i.e., diagnosis, current condition, symptoms, response to treatment, etc.)? 142.100 212.000 215.100 215.321 221.610 *215.500 Acute Only Adopted in compliance with Ark. Code Ann. 25-15-204 Page 6 of 6