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Office of Mental Health

New York State Office of Mental Health
Bureau of Inspection and Certification
2010 Clinic Recertification Letter

Attachment A

Private Office Space should be designated for use by the Surveyors

Any or all of the following will be part of the survey process:

  1. On-site opening conference regarding the purpose of and plan for the visit
  2. Review of the course of care of four (4) individuals currently receiving services at the clinic utilizing the tracer methodology.  This will entail:
    1. Case record reviews
    2. Interviews with program recipients, involved family members
    3. Interviews with program clinical, professional and administrative staff and collateral service providers
    4. Review of clinic policies, procedures, meeting minutes, administrative materials, data etc
  3. Review of four (4) closed records
  4. Tour of the premises including any medication storage areas
  5. Exit conference and summation of findings

At the time of the survey visit, it is necessary for the following materials/information to be available:

  1. List of scheduled appointments for the days of the visit
  2. Log or process for identifying recipients at risk
  3. Referral/screening/admission process and logs
  4. Referred/not opened, screened out log
  5. Process for assigning cases
  6. Staffing patterns/waivers/staff development and training documentation
  7. Clinical supervision schedule
  8. After-hours services plan
  9. Meeting minutes of the Special Review Committee
  10. Grievances/complaint documentation
  11. Mechanism for recipient input into clinic operations
  12. Quality improvement process
  13. Selected personnel files
  14. Clinic policy and procedure manual