Central Ohio Mental Health Center

CENTRAL OHIO MENTAL HEALTH CENTER Administrative Procedure

Subject: Quality Assurance and Improvement ODADAS Certified Programs

Section: 11.05.01.01.01

Effective Date: 10/16/2009

Approved by: ______Mark Travis, Executive Director

PURPOSE: Central Ohio Mental Health Center practices quality assurance and improvement in accordance with ODADAS Rule # 3793:2-1-04 and establishes the following administrative procedures as the minimum requirements in order to be certified or licensed by ODADAS to provide chemical dependency services.

PROCEDURE:

I. The Executive Director hereby assigns the Chief Compliance Officer (CCO) the responsibility to develop, implement, and coordinate the Center’s Quality Assurance and Improvement Plan, including risk management activities, for programs providing chemical dependency services according the ODADAS standards for Quality Assurance and Improvement. The Executive Director, with the assistance of the CCO, shall update the plan at least annually and submit it to the Center’s Board of Director’s for approval.

II. The Center’s written Quality Assurance and Improvement Plan shall include procedures and criteria for conducting: A. Completeness of Clinical Records Review conducted at least quarterly. B. Peer Review, meaning the evaluation of the clinical pertinence and appropriateness of services delivered. Peer review shall be conducted by staff that is qualified to provide the same alcohol and drug addiction services under review. Peer review shall occur at least quarterly and shall determine the following: 1) Assessments were thorough, complete, and timely 2) Treatment plan problems, goals, and objectives were based on the results of the assessment. 3) Services were related to the treatment plan goals and objectives 4) Documentation accurately reflects the services that were provided. C. Adherence to ODADAS Level of Care protocols for admission to, continued stay, and discharge criteria. Review activities will be complete as part of the peer review process. D. Waiting List Management Review conducted quarterly 1) Review activities will include: identification of pregnant women, intravenous drug users, non-emergency status clients, and clients with medical or psychiatric emergencies; maintaining contact with clients; evaluation of adherence with policy and procedures for removing clients from the waiting list and procedures for notifying referral sources of the client’s waiting list status.

4/21/2018 Page 1 of 3 041806001166620569abda9445c9eb35.doc 2) If there is no waiting list, the quarterly report will document that there was no waiting list. E. Client Satisfaction Surveys conducted on an annual basis 1) All clients receiving AoD services will be offered the opportunity to participate in the Client Satisfaction Survey. Prior to a planned discharge, each client will be asked to complete a client satisfaction survey. Annually, a client satisfaction survey will be distributed to all clients participating in the AoD program at that time to provide feedback on services provided by the Center. 2) To ensure anonymity in survey participation, data collection, analysis, and report findings, the client will place the completed Client Satisfaction Survey in a sealed envelope (provided) and return it to the site receptionist or may mail the completed survey to Central Ohio Mental Health Center, 250 South Henry Street, Delaware, OH 43015. 3) The Client Satisfaction Survey will include, at a minimum, the following measures: a) Accessibility (timeliness of appointments) b) Appropriateness (responsiveness to client needs) c) Cultural competency (of staff providing services) d) Overall Satisfaction 4) Completed surveys will be collected by the Quality Specialist, data analyzed and summary results reported in the Center’s Quality Assurance and Improvement Report. F. Referral Source Satisfaction Surveys conducted on an annual basis. 1) Annually, The Center will identify those agencies and individuals that make referrals to the Center for AoD services. Each identified agency or individual will be mailed a Satisfaction Survey with a return addressed stamped envelope to return completed surveys. 2) The Referral Source Satisfaction Survey will include, at a minimum, the following measures: a) Access (ease of referral) b) Program Information (general information about the program) c) Client information (feedback about client) d) Overall Satisfaction 3) Completed surveys will be collected by the Quality Specialist, data analyzed and summary results reported in the Center’s Quality Assurance and Improvement Report. G. Safety and Risk Management Activities, including but not limited to, the following: 1) Safeguarding against potential hazardous working conditions for staff, clients, and visitors to the program through the completion of Monthly Facility Safety Checklist and all schedule safety drills and inspections. 2) Review all reported Major and Unusual Incidents, including, but not limited to MUI reports (death or injury to a client or staff, sexual/physical abuse of a client by a staff, or significant disruption of service) being appropriately made to ODADAS and the DMMH&RSB within 72 hours of discovery and, appropriateness of follow-up services, evaluation of trends or patterns, and any recommended improvements. 3) Review of the Center’s financial reports monthly to monitor and address any significant financial loss to the program.

4/21/2018 Page 2 of 3 041806001166620569abda9445c9eb35.doc 4) Safety and risk management activities will be summarized and results reported in the Center’s Quality Assurance and Improvement report that is reviewed and approved by the Center’s Board of Directors. H. A conflict of interest statement assuring that any service provider cannot review his/her own client records for quality assurance and improvement activities

III. The CCO is responsible for maintaining documentation of the Center quality assurance, risk management, and quality improvement activities undertaken as part of the Quality Assurance and Improvement Plan for ODADAS certified programs.

IV. At least quarterly, the CCO is responsible for preparing a summary report of the Center quality assurance, risk management, and quality improvement activities for review by the Center’s Quality Assurance Committee and submission by the Executive Director to the Center’s Board of Director’s. The CCO will be responsible for monitoring and implementation of any corrective action(s) requested by the Board or Director’s in response to the Center’s Quality Assurance and Improvement Report.

Revised: 10/16/2009, 04/21/2005 Reviewed: 11/05/2007 Approved: 11/20/2003

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