PERINATAL PROGRAM REVIEW TOOL
AGENCY:
REVIEWER:
ADMINISTRATOR:
PARTICIPANTS:
DATE(S) OF REVIEW (mm/dd/yyyy):
-
Criteria for Compliance
DATE OF REPORT (mm/dd/yyyy):
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
I. ALL PERINATAL SERVICES
A. Perinatal Health State General Funds are used for services for women
during the perinatal period. (Perinatal period is defined as one year
prior to conception through one year postpartum.) PE 42 (2)(g)(i)(C)
B. Maintain linkages and communication with other community
organizations to ensure sharing of resources and collaborative decision
making. Minimum Standards for Local Health Departments in Oregon
approved by CLHO June 2008 (Standards 4.1, 4.2)
1. Evidence of ongoing meetings, communication or updates with
community partners.
C. Provide outreach and referral services in coordination with other social
and health care providers. Minimum Standards for Local Health
Departments in Oregon approved by CLHO June 2008 (Standard 7.1)
1. Evidence of referrals with other community agencies
2. Evidence of outreach to the community
D. Advocate and implement health care delivery and promotion services
that reduce disparities, assure adequate health care and decrease
barriers for vulnerable populations. Minimum Standards for Local
Health Departments in Oregon approved by CLHO June 2008
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
(Standards 7.1)
1. Processes in place to serve communities at risk
2. Staff with cultural knowledge of populations being served or
language competency
E. Health education materials are culturally and linguistically appropriate
for the population. Minimum Standards for Local Health Departments
in Oregon, approved by CLHO June 2008 (Standard 3.1)
1. Educational materials or information are available in languages of
populations served.
2. Culturally appropriate resources, information or educational
materials are available.
F. At a minimum, by September 30 of each year, all client visit data for
the previous fiscal year (July1–June 30) has been entered into the
Oregon Child Health Information Data System (ORCHIDS), or in an
electronic file structure defined by OHA. PE42 (3)(c)(ii)(a)
G. There are written guidelines for patient education appropriate for
gestational age.
1. Describe how health education is done (e.g., class, one-to-one).
2. Individual teaching outlines are available for class sessions.
3. Printed materials are current, accurate and appropriate for the
population served
4. Printed materials are available in English and other languages as
appropriate.
H. Breast-feeding is encouraged.
II. MATERNITY CASE MANAGEMENT (MCM)
A. The provider coordinates care to ensure that duplicate claims are not
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
submitted to DMAP. Agency has a policy/procedure to ensure that
only one provider at a time is providing MCM services to the client.
OAR 410-130-0595(4)
B. PHNs use nursing process that includes assessing, making nursing
diagnoses, planning, intervening and evaluating.
OAR 851-045-0030 (2)(m)
C. Initial and ongoing PHN nursing assessments reflect the collection of
subjective and objective data. OAR 851-045-0060 (2)(a)(A)
D. PHNs maintain adequate and accurate client records documenting
nursing process. OAR 851-045-0070 (3)
E. The initial assessment systematically collects and documents the
current status of needs and strengths in the following areas:
OAR 410-130-0595(5)(g) Note: A correctly completed DMAP Form
2470, pg. 1 (07/11), or its equivalent, meets minimum documentation
requirements. OAR 410-130-0595(8)(b)
1. Physical
2. Psychosocial
3. Behavioral
4. Developmental
5. Educational
6. Mobility
7. Environmental
8. Nutritional
9. Emotional
F. The client record contains the client service plan (CSP), a client
coordinated plan of care that lists goals and actions required to meet
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
the needs of the client as identified in the initial assessment. The CSP
includes written updates to the plan and a client discharge plan or
summary when case management services are discontinued. OAR
410-130-0595(5)(c),(10)(b)(A) Note: A correctly completed DMAP
Form 2470, pg. 2 (07/11) or its equivalent meets minimum
documentation requirements. OAR 410-130-0595(8)(b)
G. The CSP has, at a minimum, documentation of case management that
includes: OAR 410-130-0595 (5)(c),(10)(b)(B),(10)(h)
1. Determining the client’s strengths and needs
2. Setting specific goals
3. Planning of interventions
4. Using appropriate resources in a cooperative effort between the
client and the maternity case manager
5. Advocating to facilitate access to benefits or services
H. The client record contains documentation of the name of the recipient
and the date that the initial assessment and CSP were forwarded to the
prenatal care provider. OAR 410-130-0595(9)(a)(D),(c)
I. Client record includes documentation of care coordination activities as
follows: OAR 410-130-0595(3),(10)(c)(B)
1. Maintaining contact with prenatal care provider to ensure service
delivery, share information, and assist with coordination.
2. Notifying prenatal care provider any time there is significant
change in the health, economic, social or nutritional factors of the
client.
J. Client record includes documentation of linkage to client services
indicated in the CSP as follows: OAR 410-130-0595(10)(d)(A-C)
1. Making linkages and providing information, and assisting the client
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
in self-referral.
2. Providing linkage to labor and delivery services.
3. Providing linkage to family planning services, as needed.
K. Client record includes documentation of:
Note: The ongoing evaluations are in addition to the referral to
nutritional counseling. OAR 410-130-0595(10)(e)
1. Ongoing nutritional evaluation with basic counseling and referrals
to nutritional counseling, as indicated.
L. Client record includes documentation of: OAR 410-130-0595(10)(f)
1. Uses “5 As” brief intervention protocol for addressing tobacco use.
M. For services provided on or after 07-01-09, there is documentation of
patient training and education for the following mandatory topics:
OAR 410-130-0595 (10)(g); Table 130-0595-2;
OAR 410-130-0595(15)(a)(B),(17)
Note: A correctly completed DMAP Form 2471 (07/11), or its equivalent,
meets minimum documentation requirements. OAR 410-130-0595(8)(b)
1. Alcohol, tobacco, and other drug exposure
2. Maternal oral health
3. Breastfeeding promotion
4. Perinatal mood disorders
5. Prematurity and pre-term birth risks
6. Maternal/fetal HIV (Human Immunodeficiency Virus) and hepatitis
B transmission
7. Nutrition, healthy weight and physical activity
8. Intimate partner violence (IPV)
N. There is documentation of at least two educational topics covered at
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
each case management visit. OAR 410-130-0595(15)(a)(B),(17)
Note: If using the optional DMAP Form 2471 (07/11), a date and
initials on these forms meet documentation criteria.
OAR 410-130-0595(8)(b)
O. MCM services are tailored to the individual client needs. OAR 410130-0595(1)
P. High risk case management services are provided for clients identified
and documented by the maternity case manager as being high risk.
This includes: OAR 410-130-0595(5)(d)-(e)
1. Clients who have current (within the last year) documented alcohol,
tobacco or other drug abuse history; or
2. Clients who are 17 years of age or under; or
3. Clients who have other conditions identified in the initial
assessment or during the course of service delivery.
Q. Nutritional counseling is available for clients who have at least one of
the following conditions: OAR 410-130-0595(12)(a)(A)-(I)
1. Chronic disease such as diabetes, renal disease
2. Hematocrit (Hct) less than 34 or Hemoglobin (Hb) less than 11
(first trimester) or Hct less than 32 or Hb less than 10 (second
trimester or third trimester)
3. Pre-gravida weight under 100 lbs or over 200 lbs.
4. Pregnancy weight gain outside the appropriate WIC guidelines
5. Eating disorder
6. Gestational diabetes
7. Hyperemesis
8. Pregnancy induced hypertension (pre-eclampsia)
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
9. Other conditions identified for which adequate services are not
accessible through another program.
R. If this optional service is provided, the nutritional counselor is a
licensed and registered dietician. OAR 410-130-0595(7)(a)-(b)
S. When a home environmental assessment is completed, it includes an
assessment of the health and safety of the client’s living conditions
with training and education as indicated in the following areas:
Table 130-0595-1 Note: A correctly completed DMAP Form 2472
(07/11), or its equivalent, meets the minimum documentation
requirement. Note: When more than one home environmental
assessment is provided, there is documentation of the need for a repeat
assessment (e.g., client moved, house fire). OAR 410-130-0595(13)(b)
1. Housing characteristics
2. General safety
3. Food safety
4. Toxins and teratogens
5. Indoor air
6. Fire prevention
7. Emergency planning
8. Occupations and hobbies
9. Miscellaneous
T. Visits are provided face-to-face throughout the client’s pregnancy
except when not possible or practical. OAR 410-130-0595(14)(a)-(b)
1. Case management visit outside the home (including telephone case
management) includes documentation of all required components
of a case management visit including an evaluation and/or revision
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LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
of objectives and activities addressed in the CSP and at least two
educational topics covered
U. There are current written policies and procedures that support MCM
program implementation.
III. OREGON MOTHERS CARE (OMC) SITE
A. An OMC coordinator has been identified and works with Oregon
Health Authority (OHA) on developing a local delivery system for
OMC services. PE42 (4)(b)(i)
B. OMC site follows the OMC protocols, as described in OHA’s OMC
Manual, April 2005. PE42 (4)(b)(ii)
C. To ease access to early prenatal care, OMC site has developed and
maintains an outreach and referral system and partnerships for local
prenatal care and related services. PE42 (4)(b)(iii)
D. OMC services are available to all pregnant women within the county.
Special outreach is directed to low-income women and women who
are members of racial and ethnic minorities. PE 42(4)(b)(v)
E. OMC site provides follow-up services to clients referred by various
referral sources. OMC provides facilitated and coordinated intake
services and referral to the following services:
PE 42(4)(b)(ii),(iv)(A)-(B)
1. Clinical prenatal care (pregnancy testing, counseling, OHP
application assistance, PN care appointment)
2. Dental care
3. MCM services
4. WIC services
5. Health risk screening
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Page 8 of 9
LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.
Criteria for Compliance
Compliance
Yes
No
Comments/Documentation/Explanation/Timeline
6. Other pregnancy support programs
7. Other prenatal services, as needed
F. OMC site collects and submits client encounter data quarterly on
individuals who receive OMC services. Data is submitted to OHA
using approved OMC client data tracking forms. PE 42(4)(c)
G. Whether scheduled or walk-in, OMC appointments are made in a
consistent and timely manner.
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Page 9 of 9
LE 9804d Revised and Approved: 4/1/15
Shaded cells indicate items reviewed for Quality assurance only.