SUD DMC-ODS Regulatory Compliance Tool - > Denotes Clinical Review - Not for NTP/OTP
Client Name:	Type of Services:
Date of Next CQRT:	InSyst/PSP#:	RU:
Clinician Review Components (Write Comments on opposite side)

Informing Materials/Releases	Yes	No	N/A
1. Informing Materials/Consent to treat complete and signed on time
>2. SUD Programs ROI signed by opening date of services
3. Additional Releases of information (ROIs), when applicable
>4. Informed consent for medication(s), when applicable
Medical Necessity (for Authorization Period)
>5. For RES UM preauthorization completed and documents filed in chart
>6. Primary diagnosis on BHCS SUD DMC Included diagnosis list
>7. Documentation supports primary diagnosis(es) for treatment
>8. Dx written basis established by LPHA. Unlicensed LPHA has co-signature.
>9. LPHA establishing the diagnosis met face-to-face or telehealth with beneficiary or SUD counselor who conducted the intake assessment (for initial) / the primary SUD Counselor (for CSJ)
>10. Initial diagnosis and medical necessity complete within required timeframes: 48 hrs for WM RES, 5 days for residential, and 30 days for all other SUD programs.
>11. ALOC indicates level of service provided (or clinical rationale)
>12. ALOC Initial Assessment completed as required: WM RES >48 hrs, RES by day 5, All other SUD providers by day 30
>13. ALOC Re-assessment completed as required (from date of admission): RES every 30 days, IOS every 60 days, and OS/RS every 90 days
>14. For Cont. Just. of Services, Counselor recommendation is complete
>15. Medical Necessity, including diagnosis for Cont. Just. of Services complete within required timeframe: 5-6 months from EOD or date of last CSJ.
Chart Maintenance
>16. Writing is legible
>17. Required signatures present and include legibly printed name, signature, and date
18. Discharge/Termination date noted when applicable
19. Emergency contact information up to date with ROIs
20. Emergency Info. Is in a designated location in file/EHR/InSyst
21. Progress note documents the language that the service is provided in, as needed
22. Progress note indicates interpreter services were used, and relationship to client is indicated, as needed
>23. Service provided while client was not in lock-out setting, IMD, jail, JH
Medical
>24. Physical exam requirements are met (or goal in plan)
25. Physical exam completed by an external physician meets agency exam requirements and was reviewed by agency MD, PA, or NP within 30 days of admission
26. Allergies/adverse reactions/sensitivities or lack thereof noted prominently on charts’ cover or in EHR
27. Physician consultation services are between agency physician and BHCS specified physician consultant
>28. For perinatal beneficiaries, record contains medical documentation of pregnancy or birth
>29. AOD programs have completed Health Questionnaire (DHCS 5103)
Assessment
>30. Intake Assess. Is complete within required timeframes: >48hrs for WM RES, 10 days for residential, and 30 for all other programs.
>31. All required elements of Intake Assessment are complete
32. Assessment updated when applicable
>33. Drug/alcohol use, history assessed
34. Medical history assessed
35. Psychiatric/psychological history assessed
36. Social/recreational history assessed
37. Financial status/history assessed
38. Educational history assessed
39. Employment history assessed
40. Criminal history, legal status, treatment history assessed
>41. For perinatal women, additional perinatal items were assessed
>42. If SUD counselor completed Intake/Assessment, LPHA reviewed and co-signed
43. Assessment includes a case formulation
Client Plan	Yes	No	N/A
>44. Initial plan complete within required timeframes (48hrs WM RES, 10 days RES, & 30 days for other SUD (use sig. date of LPHA/Counselor)
>45. Plan updated every 90 days from LPHA/Counselor signature date
>46. Plan revised when significant change (e.g. in service, diagnosis, focus of treatment, inaccurate frequency, etc.).
>47. Plan is consistent with diagnosis and medical necessity
>48. All problems identified in the assessment are addressed in the plan or deferred (with justification for deferral)
>49. Plan includes goals to be reached that addresses each problem
>50. Goals/Action Steps in plan are consistent with impairment to functioning and need for SUD treatment
>51. Goals/Action steps are specific, observable, and/or measurable with target dates
>52. Plan includes service descriptions (type of counseling) and frequency
>53. Plan includes ICD-10 code and DSM-5 name of diagnosis
>54. If physical exam indicates significant illness, plan includes goal for tx
>55. If client has not had a physical exam in past 12 months, the plan includes a goal to get an exam
>56. Client’s risk(s) have a safety plan (DTS/DTO), Harm to self, at risk for DV, Abuse, etc.)
>57. Plan has primary SUD Counselor/LPHA printed name, signature, date
>58. Plan completed by SUD Counselor has LPHA co-signature by due date
>59. Plan indicates who is client’s “primary” counselor/LPHA
60. Coordination of care is evident, when applicable
>61. Plans signed/dated by client (or legal representative when appropriate) or documentation of client refusal or unavailability within plan due dates
62. Plan contains Tentative Discharge Plan
Required # of Progress Notes to Review: For Clinical Review: 14 day or minimum of 3 notes For Quality Review: 30 days or minimum of 6 notes
Progress Notes (ALL Programs)
>63. Daily note includes date of service
>64. Planned service modalities with corresponding service codes are in applicable plan
>65. Correct procedure code or service type indicated
>66. Notes indicate location of service: in-person, telephone, telehealth
>67. All include the topic or purpose of the session
>68. All include legibly printed name, signature, and date
>69. All community services indicate how provider ensured confidentiality
>70. All notes are completed within 7 days of the service date
>71. Services are related to the current treatment plan goals
>72. Services provided do not include time claimed for clerical/ administrative/ voicemails/ no-shows
>73. Services provided do not include claiming for supervision, academic, educational services, vocational services, recreation, UA lab fees, and/or socialization, Discharge Summary, etc.
>74. Documentation time is reasonable, substantiated by content, & w/date
>75. All include a description of progress on treatment plan problems, goals, action steps, objectives, and/or referrals
>76. All include info on the beneficiary's attendance, including the date, start and end times of each service
>77. Face-to-face, travel, and total times are documented
>78. Services provided by allowable staff within their scope of practice
>79. Medication services provided are within established requirements
>80. Notes for client encounters include client and/or staff f/u plan
Progress Notes (RES ONLY)
>81. A daily note is completed for each day at the program
>82. At least one hour of clinical services documented daily
>83. 20 hours of structured therapeutic activities documented per week
>84. ASAM 3.1 = 7+ or ASAM 3.5 = 12+ of documented f2f clinical hours documented per week
>85. Only reimbursable activities are claimed in the note
>86. Daily notes include a narrative summary of progress on treatment plan, problems, goals, action steps, objectives, and/or referrals
>87. Daily notes include a record of attendance at each counseling session including date, start/end times, and topic of the session
Group Notes/Sign-In Sheets
>88. Group notes include the number of participants
>89. Group notes include co-facilitator’s name and signature
>90. Group claims with co-facilitators are documented correctly
>91. There is a group sign-in sheet for every group counseling session
>92. Group sign-in sheet includes the topic of the session
>93. Group sign-in sheet includes the date and start/end time
>94. Each participant that attended has legibly printed name, signature
>95. SUD Counselor/LPHA who conducted group has legibly printed their name and signed the sign-in sheet
>96. Adults are not in groups with beneficiaries 17 or younger unless at a certified school site

Reviewer Comments (remember to include the referenced item numbers and use additional comments sheets if necessary):
Supervisor/Reviewer Signature:	Date:
CQRT Reviewer Signature:	Date of review: