MAGELLAN HEALTH SERVICES ORGANIZATION SITE - SITE REVIEW PACKET Behavioral Health Intervention Services (BHIS) ONLY

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1 MAGELLAN HEALTH SERVICES ORGANIZATION SITE - SITE REVIEW PACKET 2011 Behavioral Health Intervention Services (BHIS) ONLY Proprietary: Magellan Health Services policies apply to all subsidiaries,including Magellan Behavioral Health v Page 1

2 MAGELLAN HEALTH SERVICES ORGANIZATION SITE REVIEW PREPARATION GUIDE Please have documentation listed below available for the MHS reviewer on the day of your review. DOCUMENTS WE NEED COPIES OF The MHS Site Reviewer will need copies of the following documents during the review: 1. If organization is accredited: Evidence of one of the following accreditation, inclusive of all sites to be contracted with Magellan. Must also evidence any corrective action in process:. a) TJC: The Joint Commission accreditation, OR b) HFAP: Healthcare Facilities Accreditation Program, OR c) CARF: Commission on Accreditation of Rehabilitation Facilities, OR d) COA: Council On Accreditation, OR e) AAAHC: Accreditation Association for Ambulatory Healthcare. 2. State Licensure/Certification (all that apply) DOCUMENTS TO SEE AND REVIEW The MHS Site Reviewer will need to review the following documents during the review: 1. Organizational chart 2. Clinical documentation which outlines program content and structure 3. Referral source procedures and supporting documents, including both incoming and outgoing referrals 4. Quality Management Program documents, include description, plan, minutes, studies, satisfaction surveys etc. 5. Policies, procedures for reporting critical incidents; logs of reporting 6. Policies, procedures for member/patients rights; rights statement, evidence of distribution of same. 7. Complaint policy, procedures, tracking logs 8. Policy,procedure regarding Advanced Directives (if applicable) 9. Policies, procedures on confidentiality of member information, disclosure of information 10. Policies, procedures on treatment/case record documentation; sample of blinded records 11. Safety management policies, procedures 12. Disaster plan; evacuation plan; fire marshall inspection certificate; record of drills, etc. 13. Job descriptions 14. Human resource policies, procedures related to hiring of professional staff and other staff providing direct services; includes verification of training, experience, license checks, reference checks, drug/alcohol testing supporting documents, etc. Sample of files 15. Policies, procedures related to credentials verification of licensed professional staff, including primary source verification procedures. Sample of credentials files 16. Supervision policy, procedures and supporting documents 17. Orientation, training, ongoing professional development program tracking Proprietary: Magellan Health Services policies apply to all subsidiaries,including Magellan Behavioral Health v Page 2

3 ORGANIZATION/ FACILITY SITE REVIEW Administrative Documentation Organization/ Facility Name: Address: Contact Person: Phone Number: MIS#: Tax I.D.: Date of review: / / REVIEWER SCORING GUIDE The reviewer scoring guide indicates the levels of compliance with a standard that are expressed either quantitatively or qualitatively. The scores are based on three types of review: (1) Interviews/Discussions; (2) Document Review; and (3) Observation. The reviewer will score the site by deciding which score most accurately reflects the site s performance. All efforts are made to fully understand the reasons (contract or other) for not meeting a standard. It is expected that the facility staff will provide this full understanding so the most accurate ratings can be made. 1. Evidence/documentation indicates the standard was consistently met. 2. Evidence/documentation indicates the standard was met with a few minor exceptions. 3. Evidence/documentation indicates the standard was inconsistently met or met with some provisions. 4. Evidence/documentation indicates the standard was seldom met. 5. Evidence/documentation indicates the standard was not met. N/A Not Applicable indicates that the standard did not apply to the facility (note: enter N/A only when it is listed in the rating for the item). As the above guidelines demonstrate, Score 1 describes performance that fully meets the provisions of the standard. The descriptions of subsequent standards (Scores 2, 3, 4 and 5) cite shortcomings in performance that would result in the indicated score. They may also reflect that one or more aspects of full compliance are missing (for instance, there are two months in which QM meetings were not held). If a site meets the standard and is rated as one (1), yet does not have a policy describing their procedure, this is still rated as a one (1) with the recommendation of developing the policy. Following each of the sets of guidelines is also an area for the reviewer to document issues. Proprietary: Magellan Health Services policies apply to all subsidiaries,including Magellan Behavioral Health v Page 3

4 I. ACCREDITATION and STATE LICENSURE ACCREDITATION For all accreditations reviewed, please obtain and attach a copy of both the report and any plan of correction developed in response to the survey and its findings that pertains to the programs being reviewed by the site visitor. 1. The facility is accredited fully by review of the most recent survey of the facility and any plans of correction required. Accreditation is by one or more of the following (circle applicable) NA TJC; HFAP: CARF; COA; AAAHC For TJC: score 1 if the facility accreditation decision is: Accredited ; score 4 if decision is Conditional Accreditation ; score 5 for any other decision. For HFAP accreditation, score 1 if the facility received a substantial compliance rating (with 3 years to the next review), score 3 if the facility received accreditation with some deficiencies (2 years to the next review) and 4 if the facility has been given accreditation as a new facility on a 1 year new basis OR has a 1 year status as conditional. For CARF accreditation, score 1 if the facility received a substantial compliance rating (with 3 years to the next review), score 3 if the facility received accreditation with some deficiencies ( 1 year to the next review) and 4 if the facility had been given accreditation as a new facility on a 12 month advance basis. For COA accreditation, score 1 if the facility received a substantial compliance rating (with 3 years to the next review), score 3 if the facility received accreditation with some deficiencies ( 1 year to the next review) and 4 if the facility had been given accreditation as a new facility on a 12 month advance basis. STATE LICENSURE 2. Where applicable, program must have a current state license and a copy available for visitor to inspect (if licensure if available for the organization and services it provides), NA YES (1) NO (5) If applicable and NO: site will be disqualified II. GOVERNANCE Documents to be reviewed include, but are not limited to: organizational table; organizational charter; job descriptions 1. The organization has either: a governing body, or sole proprietorship/partnership or individual who is/has overall responsibility for the functioning of the program. (circle the applicable condition. Score 1 if YES, 5 if NO) 2. The individual charged with the responsibility for day-to-day management of the organization is a full-time employee and dedicates at least half time to administrative/ management functions (both conditions to apply. Score 1 if YES, 5 if NO) YES(1) NO(5) YES(1) NO(5)

5 III. CLINICAL OPERATIONS Documents to be reviewed include, but are not limited to: program, services descriptions, policies & procedures The organization has: 1. Written policies and procedures for preadmission, intake, screening and referral. 2. Written policies and procedures for designing and implementing outcome-based individualized treatment or service plans that include member involvement, family involvement, clinical team involvement, discharge planning, and continuity of care. 3. A description of services that includes: purpose of service; treatment objectives, expected outcomes; intended population for these services; treatment/ services modalities provided; hours of operation. (score 1only if all factors are present; otherwise, score as in evidence) 4. A written staffing plan that includes: staff-patient (or caseload) ratios appropriate to the population served, treatment modalities employed; evidence of monitoring of and action on such plan when ratios are not met 5. Procedures for providing needed medical services, including referral, coordination with medical providers. 6. Procedures/protocols for handling behavioral health emergencies and crises. 7. Procedures/protocols for handling medical emergency and crisis cases and for providing medical referrals, including coordination with medical care. 8. IV. QUALITY MANAGEMENT Documents to be reviewed include, but are not limited to: QI documents, minutes, policies & procedures, incident logs, satisfaction surveys 1. There is a written QI program description and workplan that describes program structure, scope, goals and mechanisms for oversight, evaluation and corrective action. 2. QI Program includes: systematic monitoring of access and availability; appropriateness and safety of care and services; quality studies or quality improvement activities (QIAs); Annual evaluation of effectiveness of QI program (score 1only if all factors are present; otherwise, score as in evidence) 3. The organization has evidence of a peer review process to monitor quality of care rendered by independently licensed clinical staff. 4. The organization conducts periodic evaluations of patient satisfaction with services provided. NA

6 5. There are written policies and procedures for the reporting and resolution of critical incidents/ sentinel events 6. The organization maintains a critical incident/ sentinel event log. V. MEMBER/PATIENTS RIGHTS Documents to be reviewed include, but are not limited to: policies & procedures; forms; member materials; complaint tracking logs 1. There are policies and procedures that assures that patients are informed of their rights, describe the rights of patients, and ensure that these rights are protected. 2. Member/patients s rights statement are published and distributed 3. Member/patients materials are offered in languages other than English if a significant portion of those served is non-english speaking 4. There are written policies and procedures for reporting and resolving member and family member complaints, grievances and appeals. 5. There is evidence that the organization maintains a complaint log or other tracking system. 6. There are written policies and procedures for care and treatment of minors (and others not able to give consent for treatment) 7. (Inpatient service OR if required by local regulation):the organization has a policy and procedures regarding Advanced Directives in accordance with the federal Patient Self Determination Act. NA NA VI. CLINICAL DOCUMENTATION, TREATMENT RECORD KEEPING PRACTICES, AND CONFIDENTIALITY Documents to be reviewed include, but are not limited to: policies & procedures; observation of site; sample of blinded treatment record; medical records room 1. The organization maintains written policies and procedures that comply with state and federal laws for maintaining the confidentiality of written and verbal communication. 2. The organization maintains written policies and procedures requiring communication with primary care physicians and/or other health providers; such documentation is included in the treatment record. 3. Adequacy of Treatment Record Keeping Practices (score 1 if all elements are met; otherwise, score per what the reviewer sees in the documentation) Record is orderly, well-organized Records are easy to locate, retrieve Records are secure, maintained in a manner to assure confidentiality of member information Separate files are maintained for each member General documentation structure (examine blinded record); the record is legible, all entries include the responsible clinician's name, professional degree, and relevant identification number, if applicable, all entries are dated and current, each page in the treatment record contains the patient's name and ID number, each record should include demographic data including patient s current address,

7 employer or school, home and work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms, and guardianship status, if applicable VII. SAFETY AND PHYSICAL PLANT Documents to be reviewed include, but are not limited to: policies & procedures; safety management plan; safety committee meeting minutes; observation of site; disaster and evacuation plans; logs of drills The facilities that patients are treated or housed are designed, constructed, equipped and maintained in a manner that is physically safe for patients, staff and visitors 1. Safety Plan: There is systematic monitoring of the physical plant safety and sanitation of the plant; there is a mechanism in place for improvement when problems are found. 2. Adequacy, privacy, cleanliness: Physical space and appearance of facility and furnishing appear clean, adequate for care of patients, and assure privacy (includes waiting areas and treatment rooms) 3. Accessibility: Site is physically accessible for those with disabilities and is wheelchair accessible 4. Organization promotes a smoke-free environment 5. Fire, Safety Compliance: The organization has a certificate of compliance from the local fire marshal indicating that all fire and safety code requirements are satisfied. 6. Disaster Plan: Organization maintains a written disaster plan; there is evidence of periodic drills 7. Evacuation Plan: Organization maintains a written evacuation plan in event of fire, disaster. Evacuation routes are clearly marked with lighted exit signs 8. Fire Drills: There is evidence of periodic fire drills.

8 VIII. LICENSED PROFESSIONAL STAFF; OTHER DIRECT CARE STAFF; HUMAN RESOURCES Documents to be reviewed include, but are not limited to: policies, procedures, job descriptions, personnel files, credentialing files, training and in-service logs. The following criteria are applied to licensed professional staff and other direct care staff. The organization: 1. Has job descriptions for all positions that involve direct service provision that include roles, responsibilities, minimum qualifications, and reporting relationships. Minimum qualifications are appropriate to scope of service. 2. Conducts new employee orientation and training appropriate to staffs role and function. 3. Conducts ongoing training and professional development to enhance clinical skills and support communication of administrative materials. 4. Conducts annual performance evaluation of clinical staff. Policies and procedures includes assessment of performance of essential functions and clinical competence. 5. Has policies and procedures for clinical supervision of non-licensed staff and/or those who are required to work under supervision of a licensed practitioner. Personnel files of such staff contain evidence of this supervision. 6. Administration/ management reviews annual clinical staff turnover rate with an analysis of trends. An action plan is implemented if rates exceed 30%. 7. Has a clinical director who: Has responsibility for oversight of clinical program; Has relevant advanced degree in behavioral health and appropriate licensure or certification in behavioral health; Has responsibility for oversight of the clinical quality of organizational services. The following elements require review of policies and procedures, as well as a sample of personnel and credentialing files. Verifications for all direct care staff include: 8. Evidence of current licensure, certification, registration if required for positions NA 9. Completion of appropriate degree or training program (eg. transcripts, copies of degree) 10. Appropriate reference checks (by letter or telephone) 11. Background check, including child abuse and criminal check, per state law 12. A process of attestation prior to hire of (circle all that are evidenced): capable of performing essential functions of job with or without accomodation;

9 lack of present illegal substance use; any history of loss of license (if applicable); any history of loss or limitation of privileges or disciplinary actions (if applicable) reporting of current or past adverse actions that may present risk management concerns (malpractice actions, insurance cancellations, criminal convictions, Medicare/Medicaid sanctions; ethical violations) 13. Monitoring of staff licensed, certified, or registered at performance evaluation or recredentialing*. Monitoring includes, mimimally: currency and any practice restrictions on licensure, certification, registration; Medicare/ Medicaid sanctions; any criminal violations; any subsequent malpractice actions where judgement, settlement made on behalf of practitioner (*if licensure, etc. is required for position. See IX. 9.) 14. Where Primary Source Verification of licensed practitioners applies per Magellan Policy, the following must be included in addition to the criteria applied to all direct care staff. (Score 1 only if all elements are YES ; otherwise, score as seen in evidence) NA NA *These criteria must be verified at a primary source. PSV required only at initial credentialing or if additional education has been obtained Current professional license;* Presence of any license sanctions;* Education and training (in some instances may be covered by state licensure PSV);* Board Certification (physicians only);* Relevant work history (previous 5 years); National Practitioner Databank query results;* Medicare/Medicaid sanctions (OIG/GSA/HIPDB);* Professional liability claims history (that resulted in settlements, judgements paid on behalf of practitioner);* Current malpractice coverage facesheet (unless covered by the organization); For prescribers: DEA registration (copy of certificate) and CDS certificate (if required) 15. Recredentialing is conducted at least every three years from prior credentialing event NA

10 SITE VISIT SUMMARY Observations/Comments Please comment on any administrative practices that seem unusually strong or weak. For any ratings of 4 or 5, please briefly list the reasons: Organization Representative Name: Organization Representative Title: Interviewer s Name: Interviewer s Signature: Date of Interview: