1. PREPARING FOR A TRIENNIAL PROGRAM OVERSIGHT AND COMPLIANCE REVIEW PRESENTED BY: ANDREA KUHLEN, ASSISTANT DIRECTOR ISABEL CHAVEZ, BEHAVIORAL HEALTH MANAGER Imperial County Behavioral Health Services

2. Learning Objectives o Are able to organize and plan for a successful audit. o Are able to ensure compliance through an ongoing monitoring system. o Are able to develop a process for collecting and updating back up documentation to support responses to Protocol questions. o Are able to identify a process that assures all areas of DHCS Protocol are in compliance.

3. Pre-Audit Years 1. Attend the DHCS Protocol Review  Identify changes to the Protocol  Identify changes in state and federal laws and regulation and /or terms of DHCS contract with the MHP.

4. Pre-Audit Years 2. Advise the clinical programs and access staff of the changes, as applicable.  Revise policies, procedures and forms as needed  Establish new policies, procedures and forms as needed.  Remind staff to continue with established processes or update processes as a result of MHP changes (i.e. new committees, change in responsibilities, etc.).

5. Pre-Audit Years 3. Advise Quality Management staff of the changes. 4. Assign staff responsibility for sections of the protocol (i.e., Access, Authorization, etc.) according to job duties & responsibilities.

6. Pre-Audit Years 5. Quality Management provides technical assistance to clinical programs and access staff to implement changes. 6. Based on assigned section(s), monitor compliance to ensure processes continue (i.e., logging, reports, test calls, etc.).

7. Pre-Audit Years 7. Monitor compliance.  Routinely complete reports (i.e. monthly, quarterly, biannually) and present to QM staff.  If opportunity for improvement is identified, presents reports to QI Committee at least quarterly  If not, schedules for QI Committee at least annually as required  Work closely with clinical/access staff on issues that need immediate attention.

8. Pre-Audit Year 8. Annually update documents used as back up to Protocol questions:  QI Work Plan  Implementation Plan  Informing Materials  Training Plan

9. Audit Year

10. 1. Attend DHCS Protocol Training. 2. Complete 2-8 above for pre-audit years. 3. Updates protocol folder tab to reflect correct numbering and section, if changed.

11. Audit Year 4. Updates cover letter to reflect changes, if any.  Cover letter identifies:  Protocol question  Supporting documentation that was submitted for the previous audit  Applicable laws or regulations

12. Audit Year – Cover Letter

13. Audit Year 5. Folder content:  Cover letter  Back-up documents  Logs  Reports  Policies & procedures  Other documents

14. Audit Year –Folder Content

15. Audit Year 6. Four months prior to review, issue folder for each question to assigned QM staff. Staff reviews folder:  Ensure applicable regulations are cited.  Replaces reports, logs and documents with the current version.  Adds any additional documentation that supports compliance.  Highlights and tabs pertinent sections of the document(s) that directly answers protocol question.

16. Audit Year –Highlights, Tabs

17. Audit Year 7. Weekly Quality Management staff meeting  Staff present completed folders.  If approved, updates cover letter as necessary.  Provides completed folder to QM clerical staff.

18. Audit Year 8. Final Steps  QM clerical staff updates cover letter and prepares a second set for DHCS, i.e., MHP = red folder DHCS = blue folder  QM manager reviews content of the folders to ensure contents are the exactly the same and in the same order.  Folders are placed in hanging folders in plastic storage boxes in the order of the protocol  Labels boxes: MHP and DHCS.

19. Audit Year

20. Audit Year-Attestation 1. Completes 2-8 above for Audit Year  Only one box  Labels box: Attestation

21. Audit Week  Boxes delivered to review room.  Subject matter expert presents response to Protocol question and answers reviewer’s question. For example:  Patients’ Rights – Beneficiary Protection  PAU Supervisor – Authorization  Privacy Officer – Program Integrity

22. Audit Week CELEBRATECELEBRATE