DBHDD DUI Program Audit Process

1. DBHDD DUI Program Audit Process [date]

2. Who is subject to audit? Clinical Evaluators and Treatment Providers who appear on the Registry up to one time per year for each service provided

3. Audit Notification Sent on or around the 20th of the month for the following month Email 5 business days to comply 2nd notice is sent via email 3 business days to comply Non-compliance is communicated to DBHDD

4. Method for Record Submission Secure Email RES_GA_DUI@apshealthcare.com Fax 1-800-728-6524 Mail HIPAA allows for APS Healthcare to access client records based on Permitted Uses and Disclosures

5. Tools Used to Conduct Audit DUI Program Manual http://www.mop.uga.edu/cetp/mop/New%20Procedure%20Manual.pdf DUI Program Audit Tools Clinical Evaluator Treatment Provider

8. Tools Used to Conduct Audit DUI Program Manual http://www.mop.uga.edu/cetp/mop/New%20Procedure%20Manual.pdf DUI Program Audit Tools Clinical Evaluator Treatment Provider CFR 42 Confidentiality of Alcohol and Drug Abuse Patient Records http://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr2_03.html HIPAA http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

9. Expectations: Licensure ASAM Addictive Medicine Specialist Certified Addiction Psychiatrist by the American Board of Psychiatry and Neurology; Certified Addiction Counselor - Level II by the Georgia Addiction Counselors Association (GACA); NAADAC or ICRC Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders from the American Psychological Association’s College of Professional Psychology OR Licensure under O.C.G.A. Title 43 as a physician, psychologist, professional counselor, social worker, marriage and family therapist, advanced nurse practitioner, or registered nurse with a bachelor’s degree in nursing; AND Documented 2000 hours of addiction clinical experience with at least 500 hours of the above 2000 hours experience in the administration of substance abuse clinical evaluation (for Clinical Evaluators) Documentation of at least 3000 hours of clinical experience in the treatment of persons who are addicted to alcohol or other drugs (for Treatment Providers)

10. Expectations: CEU Record Documentation of at least 20 hours of addiction specific continuing education Must provide certificates Logs not accepted Course Title clearly depicts a topic related to addiction or Approved by an addiction certification entity Continuing education and in-service training must have been accomplished within a two-year period prior to the month of audit

11. Expectations: Approved Location Document that Evaluations and Treatment are being conducted at the address(es) listed on the Registry Business License Rental Agreement Clear listing of address on documentation ORS Documentation (Treatment Only)

12. Expectations: NEEDS Assessment Clinical Evaluators Entire NEEDS assessment present in the record If not present a statement as to why Pre-Trial Evaluation DUI School out of Business NEEDS administered more than 5 years prior Signed Release to Obtain present Treatment Providers Not applicable

13. Expectations: Case Presentation Clinical Evaluators Must indicate that the report was written within seven days of the interview Ensure start and end date of interview is present Ensure date of report preparation is present Ensure signatures are dated Must include adequate information to diagnose or rule out a DSM-IV-TR substance related disorder

14. Expectations: Case Presentation Clinical Evaluators Must document individual’s functional status in each of the six ASAM dimensions Acute Intoxication and/or Risk of Withdrawal Biomedical Conditions Emotional, Behavioral or Cognitive Conditions Readiness to Change Continued Problem Potential Living Environment

15. Expectations: Case Presentation Treatment Providers Must be present in the record Signed by the Clinical Evaluator Include recommendations If the Clinical Evaluation was conducted by the treatment provider there must be justification as to why Primary language Rural

16. Expectations: No Treatment Recommended Completion of DBHDD “Requirements Met” form Copy of form signed by a DBHDD official is included in the clinical record Clinically justified If clinical information does not support a recommendation of no treatment there is no penalty, this is documented and communicated to DBHDD

18. Expectations: Treatment Selection Form Present in record Lists a number of providers in the area from which the individual can choose It must be clear that the individual was given the information A statement from the provider is not acceptable as the only proof of “choice” Signed by individual

20. Expectation: Transfer of Records Clinical Evaluator Present in record with all fields complete Document that the transfer was made within seven days of the release being signed as evidenced by date on bottom of page Treatment Provider Present in the record with all fields complete

22. Expectations: Contract Clinical Evaluator A signed copy of the contract is included in the clinical record Signature is dated on or before the date of Clinical Evaluation interview Is maintained for a period of 6 years for evaluations conducted 7/1/09 or later Treatment Provider A signed copy of the contract is included in the clinical record Signature is dated on or before the intake/first day of treatment Is maintained for a period of 6 years for evaluations conducted 7/1/09 or later

25. Expectations: Please Read Statement Separate forms for First Offenders and Multiple Offenders Must have a signed copy in the clinical record

28. Expectations: Confidentiality/Disclosure Statement DBHDD Consent for the Release of Confidential Information DUI Intervention Program Accessed on the CTEP Reporting Website under forms

30. Expectations: Signed Release Clinical Evaluator May be the DBHDD form or your own Releases records from Clinical Evaluator to Treatment Provider Should be signed within seven days prior to the transfer of records Treatment Providers May be DBHDD form or your own Releases records to interested parties

32. Expectations: Fee Structure Treatment Provider Document fees to be collected Document use of sliding scale

33. Expectations: Intake Paperwork Treatment Providers Current Demographics Current Mental Status Current Substance Use

34. Expectations: Treatment Plan Must be one in every record Individualized Documents what will be achieved in treatment Should not be limited to compliance or regaining driver’s license

35. Expectations: Progress Notes Each session clearly documented in client record Date Type of Contact Duration of Contact Progress Note Entry Areas of concern which are reported to DBHDD Clients filling out their own note No narrative section Running Log

36. Expectations: Certificate of Treatment Completion DBHDD form Certificate of Treatment Completion is included in the record Signed by a DBHDD Official

37. Expectations: Completed Minimum Number of Sessions ASAM Level 1, Short Six to twelve weeks Minimum of 18 hours total ASAM Level 1, Long Four months to one year Minimum of 120 days Minimum of 3 hours of treatment per week

38. Expectations: CFR42 and HIPAA All records are expected to be compliant with CFR42 and HIPAA A statement similar to this is NOT acceptable as your only proof of compliance: My DUI records are locked in a storage cabinet. Two keys are required to gain access. One for the door of the storage room and one for the cabinet itself. I am the only one with a key. No one can access the records without a release.

39. Expectations: CFR42 and HIPAA So what are we looking for? There is no one right answer. But here are some suggestions: Policy and Procedures Staff Training Log Client Rights Privacy Notices

40. HIPAA Training is available from the Department of Health and Human Services:http://www.hhs.gov/ocr/privacy/hipaa/understanding/training/index.html If you are a covered entity it should be apparent in your record; we are not scoring on level of compliance If you are not a covered entity you should state that you are not If you do not demonstrate compliance in some form or provide the affidavit you will get scored “NO” on this question

41. CFR 42 You are required to comply with CFR42 if: Individual or entity providing, alcohol or drug abuse diagnosis, treatment or referral for treatment Unit within a general medical facility which provides, alcohol or drug abuse diagnosis, treatment or referral for treatment Medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or drug abuse diagnosis, treatment or referral for treatment and who are identified as such providers.

42. HIPAA: Covered Entity https://www.cms.gov/HIPAAGenInfo/Downloads/CoveredEntitycharts.pdf

43. CFR 42: Restrictions on disclosure Any information, whether or not recorded, which: Would identify a patient as an alcohol or drug abuser either directly, by reference to other publicly available information, or through verification of such an identification by another person Drug abuse information obtained by a federally assisted drug abuse program for the purpose of treating alcohol or drug abuse, making a diagnosis for that treatment, or making a referral for that treatment

44. CFR42: Restrictions on Use Use of information to initiate or substantiate any criminal charges against a patient or to conduct any criminal investigation of a patient Use of information by third party payers Limited to that information which is necessary to carry out the purpose of the disclosure Applies even when the holder of the information believes that the person seeking the information already has it, has other means of obtaining it, is a law enforcement or other official, has obtained a subpoena, or asserts any other justification

45. CFR42: Exceptions Veteran’s Administration Armed Forces Communication within a program or between a program and an entity having direct administrative control over that program (i.e.. DBHDD) Crimes on program premises or against program personnel Reports of suspected child abuse and neglect

46. CFR42: Acknowledging Presence Only with the patient’s written consent Authorizing court order Permit acknowledgement of the presence of an individual if the facility is not publicly identified as only an alcohol or drug abuse facility, and if the acknowledgement does not reveal that the patient is an alcohol or drug abuser Regulations do not restrict a disclosure that an identified individual is not and never has been a patient

47. CFR42: Security of Records Maintained in a secure room, locked file cabinet, safe or other similar container when not in use Each program shall adopt in writing procedures which regulate and control access to and use of written records which are subject to these regulations. THIS IS WHAT I AM LOOKING FOR!!!

48. CFR 42: Notice of Federal Confidentiality Laws At the time of admission the individual should be provided with a written summary of the federal law and regulation General Description of the circumstances where presence can be identified Statement that violation of the law by the facility is a crime Commission of a crime on the premises is not protected Suspected child abuse and neglect is not protected Citation of the law OR THIS!

49. CFR42: Disclosures with Written Consent The mandatory components of the release are identified in the federal codehttp://edocket.access.gpo.gov/cfr_2003/octqtr/pdf/42cfr2.33.pdf Name Name of program making disclosure Name of party receiving the information Purpose Signature and Date Revocation statement and end date of release Statement prohibiting redisclosure

50. CFR42: Disclosure to Criminal Justice System and Court Orders This area is addressed in the code Seek support from counsel to determine course of action