North Country Community Mental Health
Contract Provider Site Review
Service Site Name:
Phone:
Address:
County:
Site Review Date:
# of Licensed Beds:
Service Type:
Service Provider Agency:
(if different than the service site)
Submitting Reviewer:
Required Standards
The standards referenced in this form are not intended to represent exact statutory language. For complete and comprehensive language, refer to
the statutory citation(s) referenced including the Michigan Mental Health Code, Act 258 of 1974, as amended, the Michigan Department of
Community Health Administrative Rules, the MDCH/CMHSP and MDCH/PIHP Specialty Services and Support Contract (Attachments for
Recipient Rights and Grievance and Appeals), 42CFR482 (Seclusion and Restraint), 45CFR (HIPAA) and 42CFR400, 430, 431, 434, 435, 438,
440, and 447 (BBA Grievance and Appeals), CARF Behavioral Health Standards Manual, Adult Foster Care Licensing, and National Fire
Protection Agency Life Safety Code.
# Yes
A. Recipient Rights
B. Safety and Infection Control
C. Training
Total Points
Total Possible (Excludes those not applicable to site)
Rev 06/13/12
(x2)
Total Score
# Partial
(x1)
# No
(x0)
Total Possible
(x2)
% Compliance
Page 1 of 4
A. Recipient Rights
COMPLIANCE
Yes
Partial
CATEGORY / DIMENSION / INDICATOR
No
COMMENTS
REQUIRED ACTION
N/A
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
18.0
19.0
20.0
Current signed consents to emergency and ongoing medical care were
found in each recipient’s record.{ AR7051(2); AR7158(8) MHC§748(6)}
Guardianship papers are current and licensee, staff or member of
household are not guardian of any resident living in the home.
{AFCR1420(12)}
A copy of each recipients current Individual Plan of Service (IPOS) and
Annual Assessment was found in each record.{MHC§712; AR7199;
CMHSP Provider Contract}
Evidence was found that indicates the IPOS is being implemented.
{AR7199}
If a recipient’s rights are limited or restricted, these are specifically
agreed to in his/her IPOS.{AR7199(g)}
Consumer Funds Part ll is complete and in each clients file with current
disbursements/receipts documented.{MHC§730}
Program rules are posted including limitations (property, phone use,
visiting hours, etc.).{MHC§726; §728; AR7139}
Program rules do not include limitations not allowed by statute or
rule.{MHC§708(3)}
Home license is valid and posted in the home. Exp. Date:
{AFCFLA§727}
Appropriate accommodations are made for persons with physical
disabilities and facility is barrier free.{ADA Title III; MI HCRA}
Recipients are not prevented from moving freely within and from the site
except to prevent injury to him/her or others. {MHC§744(1)}
Recipients are not prevented access to entertainment, reading materials,
or other leisure activities.{AR7139}
There is no indication that recipients are secluded or placed in physical
restraint.{MHC§740; MHC§742; AR7243}
Records or other confidential information are not open for public
inspection.{MHC§748(1)}
Know Your Rights booklets were readily available.{MHC§706;
MHC§755(b)}
The current recipient rights poster was conspicuously posted and visible
to recipients and staff (unless SIP). {MHC§755(5) (c)}
Abuse and neglect poster was posted in an area for easy staff review.
{AR7035(2)(a)}
Incident Report forms and complaint forms were readily available.
{AFCR§15311; MHC§776; CMHSP Provider Contract}
A summary of the Whistleblower’s Act was posted. {CMHSP Provider
Contract}
North Country CMH recipient rights policies/procedures were found onsite (Provider Manual) or readily accessible and are current. {MHC§752}.
NCCMH Contract Provider Site Review-Revised 6/13/12
Page 2 of 4
B. Safety and Infection Control
COMPLIANCE
Yes
Partial
CATEGORY / DIMENSION / INDICATOR
No
COMMENTS
REQUIRED ACTION
N/A
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
Diagram of primary and secondary exit routes (two exits) is posted and
written protection plans are available {R400.2361 (2)}.
Flammables, combustibles, and cleaners are properly stored and the area
behind dryer/vent is clear and the dryer has a sturdy exhaust hose NFPA
Life Safety 10/01/98}.
Self-closing doors return automatically to a closed, latched position {NFPA
Life Safety 10/01/99}.
Fire door is installed at the top of the basement stairwell; all stairwell doors
operate properly {R400.14511(1)}.
Paths of travel to the fire exits are free of obstructions {R400.14507(1)(2)}.
Fire extinguishers (ABC) are present (at least one per occupied floor of the
building), are properly mounted on the wall, and are properly charged
(indicator arrow is within the green gauge) and are monitored monthly and
serviced annually (documentation available). {R400.14506, (1)/ (2)}
Smoke detectors are mounted properly: ceiling mounted detectors are 6
or more inches from the wall; wall mounted detectors are not less than 6
or more than 12 inches from the ceiling; are tested monthly, and batteries
replaced annually (documentation available). {R400.14505(3)/(4)/(5)}.
Smoke detectors are found on each level, including basement, common
living areas and all sleeping areas {R400.14501(1a)/(1b)}.
Sprinkler heads are not obstructed (18” clearance) and inspected annually
by certified company and a copy of the inspection report is available {NFPA
Life Safety 10/01/98}.
Alarm system is interconnected with battery backup, meets sensory needs
of consumers (i.e. strobe lights for hearing impaired individuals) and
inspected annually by certified company and a copy of the inspection
report is available (4-6 beds or more) {NFPA Life Safety 10/01/98}.
Emergency and evacuation drills are conducted during daytime, evening,
and sleeping hours, under varied conditions (i.e. unannounced to staff,
mealtime, med passing, etc.) at least once per quarter and are clearly
documented {R400.14318 (5)}.
Evacuation assessment scores are completed for each consumer in the
home, are updated at least annually or within 30 days of a placement
{NFPA Life Safety 10/01/97}.
Emergency bags shall be maintained and contain items that meet the
needs of the particular setting/consumers {CMHSP Provider Contract;
MDCH Contract}.
Procedures for infection surveillance, prevention and control are available
{CMHSP Provider Contract}.
NCCMH Contract Provider Site Review-Revised 6/13/12
Page 3 of 4
15.0
Documentation of equipment monitoring (safety, cleanliness, etc.) is
current and available {CMHSP Provider Contract}.
B. Safety and Infection Control (cont.)
COMPLIANCE
Yes
Partial
CATEGORY / DIMENSION / INDICATOR
No
COMMENTS
REQUIRED ACTION
N/A
16.0
17.0
Staff receives orientation and annual training on infection control and
documentation available for review (Bloodborne Pathogens booklet)
{CMHSP Provider Contract}.
Staff tested for TB annually {R400.14205(4)(5)}.
C. Training
COMPLIANCE
Yes
Partial
CATEGORY / DIMENSION / INDICATOR
No
COMMENTS
REQUIRED ACTION
N/A
1.0
2.0
3.0
4.0
5.0
6.0
All staff are trained in recipient rights within 30 days of hire: attending the
CMHSP ORR approved training or use of a prior approved curriculum.
(CMHSP Provider Contract).
Evidence of staff training on False Claims Recovery (Deficit Reduction)
{CMHSP Provider Contract}.
Staff are current in CPR and First Aid {R400.14204}.
All staff are trained in CPI® physical management techniques or the
CMHSP approved equivalent (CMHSP Provider Contract).
NCCMH Quarterly Home Brochure training updates are current and signed
by all staff {CMHSP Provider Contract}.
Staff have completed all required training in 90 days {CMHSP Provider
Contract}.
Reviewed By:
Date:
Safety Specialist:
Date:
Recipient Rights Specialist:
Date:
Recipient Rights Officer:
Comments:
cc: NCCMH Program Supervisor ______________________________
NCCMH Contract Provider Site Review-Revised 6/13/12
Page 4 of 4