Chemical Health Site and Chart Audits
BHP began a site and chart audit process for chemical health providers in 2012. The purpose of these
audits is to learn more about the programs offered, introduce program staff and leadership to BHP
processes and quality expectations, and to complete an audit of elements that BHP expects to be
present at the facility and in client charts. The audit elements include DHS guidelines and state statues,
as well as BHP quality initiatives.
The primary chart components audited are the comprehensive assessment and treatment. The
elements of each are listed below.
Substance Use Disorder Comprehensive Assessment
Applicable
Law or Rule
9530.6440,
subpart 3, C
9530.6422,
subpart 1
9530.6422,
subpart 1
9530.6422,
subpart 1
9530.6422,
subpart 1
9530.6422,
subpart 1,C
9530.6422,
subpart 1,D
9530.6422,
subpart 1,H
9530.6422,
subpart 1,M
9530.6422,
subpart 1,N
Required element description
Comprehensive assessment of substance use disorder present in
client file.
The comprehensive assessment was completed by an alcohol and
drug counselor (or other qualified mental health professional).
Residential programs only:
Comprehensive assessment completed within three calendar days
after service initiation.
Non-residential programs only:
Comprehensive assessment completed within three sessions.
Information gathered for the comprehensive assessment is not
more than 45 days before the date of admission.
Previous attempts at treatment for chemical use or dependency,
compulsive gambling, or mental illness are documented;
Detailed chemical use history is documented
Mental health history and current psychiatric status is
documented.
Social network is documented.
Documentation of whether the client is pregnant and if so, the
health of the unborn child and current involvement in prenatal
care is present
Substance Use Disorder Individual Treatment Plan
Applicable Law
or Rule
9530.6440,
subpart 3.F
Required element description
9530.6425,
subpart 1
The individual treatment plan is completed within seven
calendar days of completion of the assessment summary
and continually updated.
Treatment planning includes ongoing assessment in each of
the six dimensions.
9530.6425,
subpart 1;
9530.6422,
subpart 2
9530.6425,
subpart 1
9530.6425,
subpart 1
9530.6425,
subpart 1
9530.6425,
subpart 2;
9530.6422,
subpart 2,B
9530.6425,
subpart 2,A
9530.6425,
subpart 2,C
9530.6495,
subpart E
9530.6495,
subpart F
9530.6425,
subpart 3,B,1
9530.6425,
subpart 3,B,2
9530.6425,
subpart 3,B,3
The individual treatment plan present in the client file.
The plan is developed after completion of the
comprehensive assessment.
The plan provides for the involvement of the client’s family
and those people selected by the client as being important
to the success of the treatment experience at the earlier
opportunity.
The client has an opportunity to have active, direct
involvement in selecting the anticipated outcomes of the
treatment process and in developing the treatment plan.
Plan contents: The individual treatment plan is recorded in
the six dimensions and addresses each problem identified in
the assessment summary.
The individual treatment plan includes specific methods to
be used to address identified problems.
The individual treatment plan contains goals the client must
reach to complete treatment.
Documentation of active interventions to stabilize mental
health symptoms are present in treatment plans and
progress notes.
Coordination with mental health providers is present and
documented.
Treatment plan reviews occur weekly or after each
treatment service whichever is less frequent.
Treatment plan revisions address each goal in the previous
treatment plan that has been worked on since the last
review.
Treatment plan reviews indicate whether the strategies to
address the goals are effective, and if not, must include
changes to the treatment plan.
The site audit reviews required elements of policies and procedures manual and site postings. Some of
the site audit components include:
Applicable Law or
Rule
9530.6455
245A.65,
subdivision 1
Required element description
The license holder must develop a written policy and
procedure manual which is immediately accessible to staff,
consumers of services, and other authorized parties.
License holder requirements. All license holders serving
vulnerable adults shall establish and enforce written policies
and procedures related to suspected or alleged
maltreatment, and shall orient clients and mandated
reporters who are under the control of the license holder to
these procedures, as defined in section 626.5572,
subdivision 16.
9530.6455 (A)
Procedures manual must include assessment and
treatment planning policies, which include screening for
mental health concerns, and the inclusion of treatment
objectives related to identified mental health concerns
in the client's treatment plan.
9530.6455 (D)
Procedures manual must include personnel policies that
comply with part 9530.6460.
9530.6455 (H)
Procedures manual must include policies and
procedures for maintaining client records under part
9530.6440.
9530.6465,
There must be a written service initiation policy that is
posted or given to all interested persons upon request.
subpart 1
Confidentiality is maintained via locked file cabinets and
separate record storage space. Or, records are protected by
password(s) if electronic.
BHP will look for the components of each of these required elements. Although the chart audit scoring
process is focused on the comprehensive assessment and treatment plan, the additional elements
below are reviewed.
Record Keeping and Requirements at Service Initiation
Applicable Law or Rule
Required element description
9530.6440,
A license holder maintains a file of the client’s current
records on the premises where the treatment services
are provided or coordinated.
All entries in client’s record are legible, signed, and
dated.
subpart 1
9530.6425,
subpart 3,C.
9530.6470, subpart 1
9530.6470,
subpart 2
Documentation is present that the client was given a
written statement of client rights and responsibilities,
upon service initiation.
Documentation is present that the grievance procedure
information was reviewed with the client or their
representative.
9530.6440, subpart 3,A.
Substance Use Disorder Assessment Summary
Applicable Law or Rule
Required element description
9530.6440, subpart 3,D
Comprehensive assessment summary of substance use
disorder present in client file.
A risk description for each of the 6 dimensions is
documented.
9530.6422,
subpart 2,A,1;
9530.6622
9530.6422,
subpart 2,A,3
Documentation of whether the client meets the DSM
criteria for a person with a substance use disorder is
present.
Substance Use Disorder Initial Services Plan
Applicable Law or Rule
Required element description
9530.6440, subpart 3,B
Initial services plan present in client file
9530.6420;
Includes a determination of whether a client is a
vulnerable adult as defined by Minnesota Statues,
section 626.5572, subdivision 21.
If the client is determined to be a vulnerable adult an
Individual Abuse Prevention Plan is present.
626.5572, subdivision 21
9530.6420
Substance Use Disorder Summary at Termination of Services
Applicable Law or Rule
Required element description
9530.6440,
Discharge Summary/termination summary is present
in the client’s file.
subpart 3,H
9530.6425,
subpart 4,A,3
9530.6425, subpart
4,A,4;
9530.6622
9530.6425, subpart
4,B,1,2,3,4
The termination summary includes the reasons for
and circumstances of service termination.
The termination summary includes a risk description
(not just the numerical score) on the six dimensions.
For clients who successfully completed treatment,
the summary includes living arrangements,
continuing care recommendations, termination
diagnosis and prognosis.