SAFY Surveys:

SAFY Quality Review Checklist

Introduction

Client's Name

Division

Worker

Case #

Intake Date

Discharge Date

Review Date

Reviewer Name

Assessment

Demographic and Contact information Present
(RPM 7.02(a), ASE 7.02(c))

Reason for requesting services or reason for referral
(RPM 7.02(b))

Diagnostic Assessment
(RPM 7.02(c), CR 1.07)

Presenting Problems
(Svc Sec. Assessment Stds)

Client strengths and interests identified
(Svc Sect Assessment Stds)

Assessment pertinent to presenting problems
(Svc Sect Assessment Stds)

Description of symptoms
(Svc Sect Assessment Stds)

Description of client functioning; LOC identified
(Svc Sect Assessment Stds)

Medical History, allergies and Current Medications
(Svc Sect Assessment Stds)

Mental Status
(Svc Sect Assessment Stds)

Risk Assessment
(Svc Sect Assessment Stds)

Family & Interpersonal Relationships
(Svc Sect Assessment Stds)

Educational History/School Adjustment
(Svc Sect Assessment Stds)

Assessment is culturally and spiritually relevant
(Svc Sect Assessment Stds)

Supporting criteria for diagnosis
(Svc Sect Assessment Stds)

Diagnostic Formulation – DSMIV-TR
(Svc Sect Assessment Stds)

Completed within established timeframe – 30 days
(Svc Sect Assessment Stds)

Signature of worker and/or supervisor
(Svc Sect Assessment Stds)

Specific case record comments and issues identified on the checklist:

Treatment Planning

Treatment Plan
(RPM 7.02(d), Svc Sect Svc Planning Stds)

Developed with full participation of the service recipient
(Svc Sect Svc Planning Stds, CR 1.07)

Service plan is based on the assessment
(Svc Sect Svc Planning Stds)

Diagnosis on treatment plan – consistent with assessment Dx

Includes service goals and desired outcomes
(Svc Sect Svc Planning Stds)

Includes timeframes for achieving service goals and outcomes
(Svc Sect Svc Planning Stds)

Identifies services to be provided, including service modality
(RPM 7.02(f), Svc Sect Svc Planning Stds)

Identifies who will provide specific services/supports
(Svc Sect Svc Planning Stds)

Establishes frequency of services and interventions
(Svc Sect Svc Planning Stds)

Service recipient received explanation of options and how the agency can help them; benefits, alternatives, and risk or consequences
(Svc Sect Svc Planning Stds)

Identifies the person’s & family’s unmet service/support needs
(Svc Sect Svc Planning Stds)

Plan is signed by client, guardian, worker & supervisor
(Svc Sect Svc Planning Stds)

Treatment Plan Reviews

Plan is updated when significant circumstances change
(Svc Sect Svc Planning Stds)

Regular review of progress by worker and service recipient
(Svc Sect Svc Planning Stds)

Supervisor & worker review plan at least every 90 days
(Svc Sect Svc Planning Stds)

Plan is amended in response to lack of progress on treatment goals
(Svc Sect Svc Planning Stds)

Plan is reviewed and re-developed annually
(Svc Sect Svc Planning Stds)

Plan review is signed by client, guardian, worker & supervisor
(Svc Sect Svc Planning Stds)

Specific case record comments and issues identified on the checklist:

Case Notes

Service Activity Notes
(RPM 7.05(a), RPM 7.02(g))

Entered at least monthly for protective svcs, out-of home care, or intensive counseling or treatment
(RPM 7.05(b), See Relevant Svc Stds)

Entered on a “per occurrence" basis for MH services
(SAFY/Medicaid)

Notes linked to Treatment Plan objectives
(SAFY/Medicaid)

Documentation of regular (at least quarterly) supervisory review note: frequency may vary by service section
(Svc Sect Svc Planning Stds, RPM 7.02(h))

Documented utilizing the DSTIR format
(SAFY)

Includes review of service plan implementation
(Svc Sect Svc Planning Stds)

Copies of written order for medications/special tx procedures
(RPM 7.03(b), RPM 3)

Client progress toward achieving service goals/desired outcomes
(Svc Sect Svc Planning Stds)

Continuing appropriateness of service goals
(Svc Sect Svc Planning Stds)

Evidence of primary family contact, where appropriate
(FC 7.01)

Services provided are consistent with Treatment Plan
(SAFY/Medicaid)

Documentation of contact with other involved service providers
(FC 11.01)

Service summary for each service that is discontinued prior to case closure
(SAFY)

Signed by worker with title, license and date of entry noted
(SAFY/Medicaid)

Specific case record comments and issues identified on the checklist:

Discharge / Aftercare

Case Closing & Discharge Summary

Discharge Summary within 30 days of termination
Outcome of services provided
(RPM 7.02(k))

Notification to any collaborating service providers sent
(Svc Sect Case Closing Stds)

Referrals made for persons asked to leave the program
(Svc Sect Case Closing Stds, MH 9.04)

Termination of service assessment and summary, if applicable re: contracts with public authorities
Client consent/permission
(Svc Sect Case Closing Stds, RPM 7.02(e))

Aftercare Plan
(Svc Sect Svc Planning Stds, RPM 7.02(i))

Development of aftercare plan based on wishes of client (unless mandated)
(Svc Sect Aftercare/Follow-up, CR 1.07)

Identifies needed/desired services and specific steps to obtain them
(RPM 7.02(j))

Assignment of aftercare and follow-up responsibility
(RPM 7.02(j))

Documentation of contact with suitable service providers
Client consent/permission
(Svc Sect Aftercare/Follow-up Stds, RPM 7.02(e))

Documentation of follow-up, when appropriate
Client consent/permission
(Svc Sect Aftercare/Follow-up Stds, RPM 7.02(e), FC 15.03)

Specific discharge / aftercare comments and issues identified on the checklist:

SAFY Survey Engine

SAFY Quality Review Checklist