BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

# S P

1

2

3

4

5

6

7

8

9

10

Supervision Sub-total 0 0

Scoring: 1 point possible per case

manager per month (as indicated by

competency rating)

Case Manager Name

CASE MANAGER SUPERVISION

Points

Comments

IDAPA 745.06 Supervision. The case management program must provide and document at least one (1) hour of case management supervision per month for each case manager or as

defined by Clinical Supervision if clinician

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Question #

1 1 point possible for each date audited

2

1 point possible for each of the 4

items

No or N/A = 0 points

3

Yes = 1 point per 90 days

No or N/A = 0 points

4

Yes = 1 point

No or N/A = 0 points

5

Yes = 1 point

No or N/A = 0 points

Scoring

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC, other

providers]

1. Client ID #

Standard

Progress Notes. Notes for each service charting the client's progress must include:

* Date of session

* Beginning and ending time of session

* Description of the session

* Signature of person conducting the session

Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include:

* Assessment of the client and client family strength and needs

* Service planning

* Linkage to other services

* Client advocacy and monitoring

Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days.

Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or

have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written

plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client.

S P Comments

PointsCase Management Files - Pull up to 5 client files

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Scoring Earned Possible

1 1 point possible for each date audited

2

1 point possible for each of the 4

items

No or N/A = 0 points

3

Yes = 1 point per 90 days

No or N/A = 0 points

4

Yes = 1 point

No or N/A = 0 points

5

Yes = 1 point

No or N/A = 0 points

Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days.

Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or

have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written

plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC, other

providers]

Progress Notes. Notes for each service charting the client's progress must include:

* Date of session

* Beginning and ending time of session

* Description of the session

* Signature of person conducting the session

Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include:

* Assessment of the client and client family strength and needs

* Service planning

* Linkage to other services

* Client advocacy and monitoring

2. Client ID #

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Scoring Earned Possible Comments

1 1 point possible for each date audited

2

1 point possible for each of the 4

items

No or N/A = 0 points

3

Yes = 1 point per 90 days

No or N/A = 0 points

4

Yes = 1 point

No or N/A = 0 points

5

Yes = 1 point

No or N/A = 0 points

3. Client ID #

Progress Notes. Notes for each service charting the client's progress must include:

* Date of session

* Beginning and ending time of session

* Description of the session

* Signature of person conducting the session

Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include:

* Assessment of the client and client family strength and needs

* Service planning

* Linkage to other services

* Client advocacy and monitoring

Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days.

Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or

have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written

plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC, other

providers]

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Scoring Earned Possible Comments

1 1 point possible for each date audited

2

1 point possible for each of the 4

items

No or N/A = 0 points

3

Yes = 1 point per 90 days

No or N/A = 0 points

4

Yes = 1 point

No or N/A = 0 points

5

Yes = 1 point

No or N/A = 0 points

Progress Notes. Notes for each service charting the client's progress must include:

* Date of session

* Beginning and ending time of session

* Description of the session

* Signature of person conducting the session

Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include:

* Assessment of the client and client family strength and needs

* Service planning

* Linkage to other services

* Client advocacy and monitoring

Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days.

Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or

have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written

plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC, other

providers]

4. Client ID #

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Scoring Earned Possible Comments

1 1 point possible for each date audited

2

1 point possible for each of the 4

items

No or N/A = 0 points

3

Yes = 1 point per 90 days

No or N/A = 0 points

4

Yes = 1 point

No or N/A = 0 points

5

Yes = 1 point

No or N/A = 0 points

Case Management File Sub-Total: 0 0

Case Management Total: 0 0

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC, other

providers]

5. Client ID #

Progress Notes. Notes for each service charting the client's progress must include:

* Date of session

* Beginning and ending time of session

* Description of the session

* Signature of person conducting the session

Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include:

* Assessment of the client and client family strength and needs

* Service planning

* Linkage to other services

* Client advocacy and monitoring

Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days.

Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or

have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written

plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client.

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date:

Reviewer:

Comments

PR-31-10/06/2015 Case Management

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

Question #

S P

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1

1 point possible for each date audited

2Yes = 1 point

No or N/A = 0 points

0

00

3. Client ID #

Standard

Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a

treatment provider agency, results should be communicated to the PO.]

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC,

other providers]

Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a

treatment provider agency, results should be communicated to the PO.]

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC,

other providers]

1. Client ID #

2. Client ID #

Scoring

DRUG AND ALCOHOL TESTING

Comments

Points

Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a

treatment provider agency, results should be communicated to the PO.]

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC,

other providers]

PR-31-10/06/2015 Drug and Alcohol Testing

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer: 0

00

DRUG AND ALCOHOL TESTING

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

D & A Testing Total 0 0

Comments

Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a

treatment provider agency, results should be communicated to the PO.]

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC,

other providers]

5. Client ID #

4. Client ID #

Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a

treatment provider agency, results should be communicated to the PO.]

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards. [Referral agencies examples: IDOC,

other providers]

PR-31-10/06/2015 Drug and Alcohol Testing

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

S P

1

Yes = 1 point

No = 0 points

2

Yes = 1 point

No = 0 points

Child Care Facility Sub-total 0 0

Question #

S P

3

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

4

Yes = 1 point

No or N/A = 0 points

2. Client ID #

Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services.

The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and

names of individual(s) providing care.

Comments

CHILD CARE

CHILD CARE

Points

CommentsQuestion # ScoringStandard

Setting Ensures Safety. Provide a setting that promotes and ensures the health, well-being, and safety of the child or children in

care. [CORE] [yes=15]

Medicines, cleaning products, and other dangerous substances and articles are kept away from children at all times.

Standard

Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services.

The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and

names of individual(s) providing care.

1. Client ID # Scoring

0 0

Points

0

PR-31-10/06/2015 Child Care

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

5

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

6

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

7

Yes = 1 point

No or N/A = 0 points

Child Care Sub-total 0 0

Child Care Total 0 0

Comments

Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services.

The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and

names of individual(s) providing care.

3. Client ID #

4. Client ID #

5. Client ID #

Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services.

The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and

names of individual(s) providing care.

Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services.

The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and

names of individual(s) providing care.

PR-31-10/06/2015 Child Care

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

Question #

S P

1

1 point possible per date audited

Yes = 1 point

No or N/A = 0 points

2

Yes = 1 point

No or N/A = 0 points

LIFE SKILLS

CommentsScoring

Encounter note for dates billed [review note and life skills plan]

There is an identified curriculum/lesson for the Life Skills program being billed.

1. Client ID #

0 0

0

PointsStandard

PR-31-10/06/2015 Life Skills Page 13 of 26

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

1

1 point possible per date audited

Yes = 1 point

No or N/A = 0 points

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1

1 point possible per date audited

Yes = 1 point

No or N/A = 0 points

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1

1 point possible per date audited

Yes = 1 point

No or N/A = 0 points

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1

1 point possible per date audited

Yes = 1 point

No or N/A = 0 points

2

Yes = 1 point

No or N/A = 0 points

Life Skills Total 0 0

Comments

3. Client ID #

5. Client ID #

4. Client ID #

There is an identified curriculum/lesson for the Life Skills program being billed.

Encounter note for dates billed [review note and life skills plan]

There is an identified curriculum/lesson for the Life Skills program being billed.

Encounter note for dates billed [review note and life skills plan]

There is an identified curriculum/lesson for the Life Skills program being billed.

Encounter note for dates billed [review note and life skills plan]

Encounter note for dates billed [review note and life skills plan]

There is an identified curriculum/lesson for the Life Skills program being billed.

2. Client ID #

PR-31-10/06/2015 Life Skills Page 14 of 26

Provider: Site ID:

Date: Reviewer:

S P

1

2

3

4

5

6

7

8

9

10

Supervision Sub-total 0 0

Question # Scoring

S P

1

Yes = 1 point

No or N/A = 0 points

S P Comments

1

Yes = 1 point

No or N/A = 0 points

S P Comments

1

Yes = 1 point

No or N/A = 0 points

S P Comments

1

Yes = 1 point

No or N/A = 0 points

S P Comments

1

Yes = 1 point

No or N/A = 0 points

Wellness Plan Sub-total 0 0

Recovery Coach Total 0 0

Comments

0 0

0

Recovery Coach Supervision

Recovery Coach is Receiving Supervision Points

CommentsEmployee Name

Scoring: 1 point possible per

recovery coach per month

RECOVERY COACH

Standard Points

Comments1. Client ID #

Recovery Wellness Plan in Place

2. Client ID #

Recovery Wellness Plan in Place

3. Client ID #

Recovery Wellness Plan in Place

Recovery Wellness Plan in Place

4. Client ID #

Recovery Wellness Plan in Place

5. Client ID #

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

S P

1

2

3

4

5

6

7

8

9

10

Transportation Total 0 0

Comments

Each Vehicle Used

0 0

0

TRANSPORTATION

The minimum insurance required for all programs is professional liability, commerical general liability, and comprehensive liability for all program vehicles. All facilities must maintain

professioanl liability insurance in the amount of at least five hundred-thousand to one million dollars ($500,000/$1,000,000) and general liability and automobile insurance in the amount

of at least one million to three million dollars ($1,000,000/$3,000,000). Copies of the declarations face-sheet for all policies must be included with the application. Individual providers

must carry at least the minium insurance requried by Idaho law. If an agency permits employees to transport clients in employee's personal vehicles, the agency must ensure that

insurance coverage is carried to cover those circumstances. Points

Comments

Scoring: Per Vehicle

Yes = 1 point

No = 0 points

PR-31-10/06/2015 Transportation

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

S P

1

Yes = 1 point

No = 0 points

2

Yes = 1 point

No = 0 points

3

Yes = 1 point

No = 0 points

4

Yes = 1 point

No = 0 points

5

Yes = 1 point

No = 0 points

Facility Sub-total 0 0

Question #

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

1. Client ID #

Standard

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

Scoring

2. Client ID #

Documentation that client was in the facility on billed date.

S P Comments

SAFE AND SOBER HOUSING

No facility concerns with regard to bedroom size, bed spacing or safety issues were noted.

A minimum of one (1) fire drill must be held at last every thirty (30) days at unexpected times and under varying conditions to

simulate unusual circumstances encountered in case of a fire. A record of drills must be maintained which includes the date and

time of the drill, response of the personnel and clients, problems encountered and recommendations for improvements.

Adult Staffed Safe and Sober housing facilities must provide information regarding community resources to persons recovering

from alcohol and substance use disorders. Sections 370 and 380 of these rules do not apply to this level of care in this setting.

Staffing of Safe and Sober Housing Facility. A house manager on-site a minimum of twenty (20) hours a week or a housing

coordinator who is off-site but monitors house activities on a daily basis.

Facility Inspection of an Adult Staffed Safe and Sober Housing Facility. Adult Staffed Safe and Sober Housing facilities must

be inspected by staff weekly to determine if hazards or potential safety issues exist. A record of the inspection must be maintained

that includes the date and time of the inspection, problems encountered, and recommendation for improvement.

Points

CommentsQuestion # ScoringStandard

PR-31-10/06/2015 Safe and Sober Housing

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

3. Client ID #

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

4. Client ID #

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

PR-31-10/06/2015 Safe and Sober Housing

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

SSH Documentation Sub-total 0 0

SSH Total 0 0

Comments

5. Client ID #

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

PR-31-10/06/2015 Safe and Sober Housing

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

S P

1

Yes = 1 point

No = 0 points

2

Yes = 1 point

No = 0 points

3

Yes = 1 point

No = 0 points

Facility Sub-total 0 0

Question #

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

S P Comments

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

Standard

1. Client ID #

2. Client ID #

Scoring

Supervision for Adults Level III.1. A Level III.1 treatment facility must be supervised by a qualified substance use disorders

professional.

Staffing for Adults Level III.1. A staff person must be available to residents twenty-four (24) hours per day, seven (7) days a week.

The staff to client ratio must not exceed twelve (12) clients to one (1) staff person.

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

Halfway House

Question # Scoring

Points

CommentsStandard

No facility concerns with regard to bedroom size, bed spacing or safety issues were noted.

PR-31-10/06/2015 Halfway Housing Page 23 of 26

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

4. Client ID #

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

3. Client ID #

Documentation that client was in the facility on billed date.

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

PR-31-10/06/2015 Halfway Housing Page 24 of 26

BPA HEALTH

RECOVERY SUPPORT SERVICES AUDIT

Provider: Site ID:

Date: Reviewer:

0 0

0

Scoring S P Comments

1 1 point possible for each date audited

2

Yes = 1 point

No or N/A = 0 points

Halfway House Documentation

Sub-total 0 0

Halfway House Total 0 0

Comments

5. Client ID #

Signed and dated releases with referral agencies. Must meet 42 CFR and HIPPA standards.

Documentation that client was in the facility on billed date.

PR-31-10/06/2015 Halfway Housing Page 25 of 26

DATE DUE:

DATE CONDUCTED:

PROVIDER:

PROVIDER SITE ID:

AUDIT CONDUCTED BY:

Section

Score

Earned

Score

Possible %

Case Management: 0 0 0%

D&A Testing: 0 0 0%

Child Care: 0 0 0%

Life Skills & Rec. Coach: 0 0 0%

Transportation: 0 0 0%

SSH 0 0 0%

Halfway House 0 0 0%

TOTAL 0 0 0%

Date Results Sent:

Date Next Audit Due:

None (passed):

Action Plan (failed):

Perf. Imp. Plan (passed):

Date Plan Due:

Follow-Up [yes=1, no & NA=0]

# Claims Recouped:

0

0

Case Management

Drug & Alcohol Test.

Child Care

0

Life Skills & Rec. Coach

Transp.

SSH

Halfway House

Recovery Support Services (yes=1, no=0)

RECOVERY SUPPORT SERVICES AUDIT TOTALS

BPA HEALTH

PR-31-10/06/2015 Totals