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Office of Mental Health

Clinic Satellite Recertification Protocol

Clinic satellites throughout the state vary greatly in terms of volume and range of services provided, staffing, hours and many other factors. Some satellite programs are extensive, operate virtually independently and require a more thorough review to insure that all aspects of quality services are attended to. Other sites may be very limited in size and scope of operation, and an extensive review would be inefficient and would add little value to the survey process.

It was agreed that satellites which are staffed by 1 FTE or less will not require a site visit, unless there is a compelling reason identified by the Field Office licensing staff. Recipients served at the site will not be included in the sample of individuals chosen for a tracer review.

The review of Clinic Administration conducted at the main site will include the arrangements for clinical supervision of staff and administrative oversight of the satellite operation. In addition, licensing staff will ascertain if there are special populations served or specialized services provided at the satellite which require additional scrutiny.

For Clinic satellites which are staffed by more than 1 FTE but less than 5.5 FTE, recipients served at the site will be included in the available pool for sampling using the tracer methodology if they meet the criteria for high risk/complexity, but additional records from the site will not routinely be reviewed. A site visit will be conducted if a recipient served at the satellite is chosen for a tracer review. The visit will focus on record review, interviews, issues of clinical supervision and administrative oversight, provision of specialized services and premises.

Clinic satellites staffed by more than 5.5 FTE will receive a site visit and a more comprehensive review. This will include the selection of 2 to 4 open cases of individuals whose care will be reviewed using the tracer methodology and 2 to 4 closed cases to be reviewed. This survey will include a review against all of the standard of care anchors.