On Site Review Manuel

The Indian Health Care Improvement Act (IHCIA), at 25 U.S.C. § 1655, states that the Indian Health Service (IHS or the Service) will annually review and evaluate each urban Indian organization (UIO) funded under the law. The IHCIA also requires IHS to develop procedures for evaluating compliance with awards made under the statute. Section 1655 states, in part:

(a) Contract compliance and performance

The Secretary, through the Service, shall develop procedures to evaluate compliance with grant requirements under this subchapter and compliance with, and performance of contracts entered into by [UIO] under this subchapter. Such procedures shall include provisions for carrying out the requirements of this section.

(b) Annual onsite evaluation

The Secretary, through the Service, shall conduct an annual on-site evaluation of each [UIO] which has entered into a contract or received a grant under Section 1653 of this title for purposes of determining the compliance of such organization with, and evaluating the performance of such organization under, such contract or the terms of such grant.

To meet statutory compliance, the Urban Indian Organization On-Site Review Manual will be used to conduct structured annual on-site reviews. The requirements in this manual are based on best-practice standards for delivering safe and high-quality health care and similar to standards used by accrediting organizations.

Core Requirements

The on-site review manual consists of 21 sections and associated appendices. The first seven sections of the manual are considered core requirements. All UIOs (comprehensive, limited, outreach and referral, and residential treatment) must meet core requirements. The core requirements are as follows:

Section 1 – Legislative Requirements (see page 7)

Section 2 – Governance Requirements (see page 10)

Section 3 – Administrative Requirements (see page 17)

Section 4 – Financial Management Requirements (see page 22)

Section 5 – Human Resources Requirements (see page 27)

Section 6 – Environmental Safety Requirements (see page 32)

Section 7 – Outreach and Community Services Requirements (see page 43)

Limited Review Approvals

A limited review may be requested if a UIO is accredited by an accrediting body recognized by IHS. Accrediting organizations include The Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC), and Commission on Accreditation of Rehabilitation Facilities (CARF). The UIO must submit a request and current accreditation documentation to the IHS Area Office (AO) and Office of Urban Indian Health Programs (OUIHP) for limited review approval. An approved waiver will limit the annual on-site review to the seven core requirements named above.

A limited review may be requested if a UIO is funded by the Health Resources and Services Administration (HRSA) as a Health Center under section 330 of the Public Health Service Act, 42 U.S.C. § 254b. The UIO must submit a request and most recent HRSA site review documentation to the AO and OUIHP for limited review approval. An approved waiver will limit the annual on-site review to the seven core requirements named above.

A limited review may be requested if the AO considers state or county licensure reviews resulting in good standings, and meets specific requirements (for example, pharmacy, laboratory, outpatient and residential mental health and substance abuse license reviews). The UIO must submit a request and state and country licensure review documentation to the AO for limited review approval. The AO will determine if the UIO is meeting all applicable requirements for limited review approval. An approved waiver will limit the annual on-site review to the seven core requirements named above.

Full Review Consultations

A UIO can request a review of additional sections from the AO. These reviews will be done as consultations rather than structured annual on-site reviews. Consultations may assist the UIO in preparing for licensure, accreditation, or other certifications.

Instructions – IHS Area Offices

Scheduling the On-Site Review

The AO will contact the UIO Director to schedule the annual on-site review dates. Then, the AO and UIO Director will collaborate to set the agenda and ensure it includes all relevant sections of the Review Manual.

The AO will provide written notification through email to the UIO Director to confirm the review dates and schedule the on-site review activities identified in the agenda. This email will provide a list of documents the UIO Director will need to have available during the on-site review. Additionally, the UIO should reserve a conference room for opening and exit meetings. The UIO will need to complete a UIO Profile to summarize their program before the on-site review (See APPENDIX A. Urban Indian Organization Profile).

The AO will identify members of the Onsite Review Team (Review Team) and share the team’s credentials with the UIO. Ideally, the Review Team will be scheduled together for the same review dates. However, some review activities may need to be conducted on separate dates based on the availability of Review Team members. (See APPENDIX B. Documentation of On-Site Review Teams).

The On-Site Review Process

When arriving at the UIO, the Review Team will have identification to introduce themselves. The IHS expects the UIO Director and key staff participating in the review to be part of the opening and exit conferences. UIO board members may also participate but are not required.

During the opening meeting, the Review Team Lead will review the agenda, review process, scoring, and list of documents needed for the review. The UIO leadership can use this opportunity to ask questions about the on-site review process. The IHS Review Team will request from the UIO a semi-private workspace to complete review activities.

The Review Team will review documentation as evidence the UIO has met review requirements. The Review Team may request additional information to further demonstrate compliance. Some additional requirements may apply, such as Section 6, Environmental Safety Requirements. For patient confidentiality, the UIO may request the Review Team to sign statements before observing health care areas.

At the end of the on-site review, the Review Team and UIO will hold an exit conference. (See APPENDIX E. Exit Conference). During this meeting, the Review Team will share the review findings with UIO leadership and discuss the UIO’s strengths, weaknesses, recommendations and, if any, corrective actions. The Review Team will also identify any high-risk issues that need immediate response or correction. The Review Team will review the scores with the UIO before leaving. (See APPENDIX C. Scoring System Summary and APPENDIX D. Scoring Table).

Final Report

The AO will send a final report to the UIO within 30 calendar days of the exit conference. The final report will also be sent to the appropriate IHS Area Director and OUIHP. This report will summarize strengths, weaknesses, recommendations and, if any, corrective actions. (See APPENDIX F. Instructions for Reviewer to Complete Report). Following receipt of the final report, the UIO will be required to respond to the findings and recommendations including any corrective actions. (See APPENDIX G. Responding to Report of UIO Review). The AO will provide technical assistance at the UIO’s request.

Section 1 – Legislative Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists.

1. Legislative Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has estimated the population of urban Indians who are residing in the urban center in which such organization is situated and who are or could be recipients of health care or referral services.
			The UIO has completed a current community health needs assessment, including an estimate of the current health status and any gaps between unmet health needs and the resources available in the urban center.
			The UIO has identified the health care needs of its urban Indian user population over the past fiscal or calendar year.
			The UIO has a process for connecting urban Indians in the urban center to other public and private health services and resources.
			The UIO assists public and private health resources in providing services to urban Indians living in the urban center.
			The UIO has submitted recommendations to IHS, federal, state, local, and other resource agencies on methods of improving health programs to meet the needs of urban Indians.
			The UIO provides basic health education, including health promotion/disease prevention (HP/DP) education, to urban Indians.
			Where necessary, the UIO, either directly or through contracts, provides for the provision of health care services for urban Indians.
			The UIO has identified the use of public and private health service resources by urban Indians residing in the urban center.
			The UIO established and implemented training programs to accomplish the referral and education tasks set forth in items 4, 5, and 8 above.
			TOTAL

Legislative Requirements Compliance Rating ((Y+N/A)/10x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–20% (0–2 elements met)	30–40% (3–4 elements met)	50–70% (5–7 elements met)	80–90% (8–9 elements met)	100% (10/10 elements met)

Section 2 – Governance Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists.

2. Governance Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO is a nonprofit corporate body situated in an urban center, governed by an urban Indian-controlled Board of Directors (51%) whose members reside in the local community.
			The Board of Directors establishes written policies and procedures governing the role and responsibilities of the Board and its members, e.g., conflicts of interest.
			Term limits for Board of Directors’ members are defined in the bylaws and are enforced.
			The Board of Directors establishes written policies and procedures governing organizational bylaws.
			Governing documents demonstrate that corporate bylaws have been updated every 3 years.
			Bylaws or rules and regulations define the responsibility of the Board of Directors’ members, officers, and standing committees.
			Records show the Board of Directors meet as frequently as needed but at a minimum quarterly as required in the bylaws and keep meeting minutes.
			The Board of Directors establishes written policies and procedures governing training for members of the Board, including new member training and annual training requirements.
			The standing committees meet as frequently as required in the bylaws and keep meeting minutes.
			The Board of Directors establishes the position description and written policies and procedures governing roles and responsibilities of the CEO/Executive Director, as well as other key positions in the organization.
			The Board of Directors selected the UIO Director, and the UIO Director reports directly to the Board.
			The Board of Directors defines the authority, responsibility, and function of its officers and administrators it elects, appoints, or employs.
			The Board of Directors reviewed and approved the UIO mission, strategic plan, goals, and objectives within the past 3 years.
			The UIO administration has a defined organizational structure.
			The Board of Directors approved the scope of clinical services offered by the UIO.
			The Board of Directors establishes written policies and procedures governing business ethics and conduct.
			The Board of Directors reviews and approves any research or data collection to answer a research question that is conducted at or by the UIO.
			The Board of Directors approved the annual budget and, if required, the capital expenditure plan.
			The Board of Directors establishes written policies and procedures governing personnel files.
			The Board of Directors approved a UIO-wide quality assessment and improvement plan in the last 12 months, and there is evidence that the Board of Directors received an annual report, as defined in the plan.
			The Board of Directors approved a UIO-wide risk management plan in the last 12 months that includes the roles and reporting responsibilities for the Risk Management Team, and there is evidence that the Board of Directors received an annual report, as defined in the plan.
			The Board of Directors establishes written policies and procedures governing internal controls.
			The Board of Directors approves major contracts, memoranda of understanding, or other formal agreements with external agencies.
			The Board of Directors approves the appointment and reappointment of medical/professional staff. The Board also approves clinical privileges granted to Licensed Independent Practitioners.
			The Board of Directors approves any changes, suspension, or termination of clinical privileges and any appeals.
			The Board of Directors received an annual report on peer reviews in the last 12 months.
			The Board of Directors received an annual report on significant personnel actions involving clinical staff who did not receive clinical privileges in the last 12 months.
			The Board of Directors received an annual report on environmental safety in the last 12 months.
			The Board of Directors received reports from the last IHS on-site review and, if accredited, from the last accreditation survey, including the status of any corrective actions.
			The Board of Directors establishes written policies and procedures governing employee performance.
			The Board of Directors is kept informed of specific events, including legal charges, criminal indictments, guilty pleas, or verdicts in criminal proceedings that involve the UIO, its officers, administrators, providers, staff, or contractors in their role in the UIO.
			The Board of Directors establishes written policies and procedures governing equal opportunity employment, sexual harassment, and employee grievances.
			The Board of Directors’ members receive new-member orientation and annual training.
			The UIO Director receives orientation and annual training.
			The Board of Directors received recommendations from the financial audit and put a corrective action plan in place, if needed.
			TOTAL

Governance Requirements Compliance Rating ((Y+N/A)/35x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–20% (0–7 elements met)	23–46% (8–16 elements met)	49–69% (17–24 elements met)	71–91% (25–32 elements met)	100% (35/35 elements met)

Section 3 – Administrative Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable = N/A

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists.

3. Administrative Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO reviewed and approved its administrative and finance policies and procedures within the last 3 years.
			The UIO reviewed and approved its clinical policies and procedures within the last 12 months.
			The UIO has policies and procedures for the confidentiality and security of patient and staff information.
			The UIO has policies and procedures for emergency management response (e.g., active shooter), including assistance from law enforcement, a communications plan, a lock-down process/procedures, training and drilling employees, and post-event debriefings and assistance.
			The UIO has policies and procedures for handling inquiries from governmental agencies, attorneys, subpoenas, consumer advocacy groups, and the media.
			The UIO has an information technology infrastructure in place and an electronic health records system for clinical services.
			The UIO has an organization-wide, integrated patient safety system that includes a written safety program, policies, and procedures that UIO leadership review and approve regularly.
			The UIO has a conflict-of-interest policy and procedure for leadership and key staff.
			The UIO has a process for involuntarily discharging patients and a process for patients to regain rights and privileges.
			The UIO evaluates clinical service contracts (contracted care) to determine if performance expectations have been met.
			If a clinical service contract is terminated, the UIO maintains continuity of patient care.
			The UIO has set priorities for data collection to support performance improvement goals.
			Executive leadership maintains a lease and/or ownership of the facility. Policies and procedures address facility needs when a facility or service closes, consistent with federal and state laws and regulations.
			Executive leadership has identified and regularly monitors performance expectations related to productivity, service volume, staffing patterns, and other management use reviews.
			Executive leadership receives and monitors data to assess achievement of Government Performance and Results Act (GPRA) goals.
			Marketing and advertising information and materials accurately represent ownership services, licensure, and accreditation, if applicable.
			TOTAL

Administrative Requirements Compliance rating ((Y+N/A)/16x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–19% (0–3 elements met)	25–44% (4–7 elements met)	50–69% (8–11 elements met)	75–94% (12–15 elements met)	100% (16/16 elements met)

Section 4 – Financial Management Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists and the documentation or evidence is in accordance with established policies to provide internal control and prevent waste, fraud, and abuse.

4. Financial Management Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			In the last year, the UIO has had an annual, independent, comprehensive financial audit. If appropriate, the annual audit complied with 45 C.F.R. Part 75, Subpart F.
			Purchasing policies and procedures describe a process for bidding for services.
			Purchasing policies and procedures describe the use of government supply sources.
			Inventory policies and procedures include identifying equipment, its condition, and replacement.
			Policies and procedures cover banking and signature approvals and functions.
			Policies and procedures cover accounts receivable and accounts payable functions.
			The UIO maintains current credit card payments to avoid unallowable interest payments.
			Policies and procedures cover cash transaction functions.
			Policies and procedures cover petty cash and/or credit card use, the number of credit cards, who has them, and who can use them.
			Policies and procedures cover patient billing functions.
			Policies and procedures cover the collection of fees due, including writing off old collectibles.
			Policies and procedures cover the aging of receivables function.
			Policies and procedures cover the expenditure of third-party revenue, including compliance with 25 U.S.C. § 1621e.
			Policies and procedures cover recording, controlling, and other accounting for all program income, including compliance with 25 U.S.C. § 1621e.
			Policies and procedures cover staff, Board of Directors, and other agency-paid travel.
			Policies and procedures cover posting journal entries.
			Policies and procedures cover preparing income statements and balance sheets.
			Policies and procedures prohibit drawing of checks to “cash.”
			Policies and procedures prohibit signing blank checks and “stamped signature” checks.
			Policies and procedures cover the recording and disposal of voided checks.
			Staff maintain security of paper and electronic fiscal records.
			Staff submit patient bills for payment within 30 days of service.
			Staff review and respond to payment denials within appropriate timeframes (3–5 days).
			Policies and procedures cover approvals of capital improvements.
			The UIO submits accurate and timely IHS financial reports.
			The UIO records and annually inventories accountable personal property (assets with barcode tags) on the IHS property system.
			TOTAL

Financial Management Requirements Compliance Rating ((Y+N/A)/26x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–6 elements met)	27–50% (7–13 elements met)	54–77% (14–20 elements met)	81–96% (21–25 elements met)	100% (26/26 elements met)

Section 5 – Human Resources Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX H. Professional Staff Credential File Review and APPENDIX I. Human Resource File Review for more information.)

5. Human Resources Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO complies with laws and regulations regarding the verification of eligibility for employment, such as the I-9 form (Immigration and Naturalization) and visas, as required.
			The UIO conducts employee background investigations and additional state criminal background histories, as required by the Indian Child Protection and Family Violence Protection Act, 25 U.S.C. §§ 3201-3211, and the Crime Control Act, codified at 34 U.S.C. § 20351, which are documented in the employees’ records.
			Position descriptions include requirements; qualifications; responsibilities; supervisory authority; and required licensure, registration, or certification.
			Staff possess required credentials.
			If the position requires licensure, registration, or certification, the UIO verifies this information initially, and annually thereafter, to ensure credentials remain current. For licensed independent practitioners, the UIO conducts primary source verification.
			The UIO includes copies of employees’ current credentials and verification documentation in the employees’ files.
			If the position requires educational degrees, the UIO verifies this information and documents it in the employee’s record. For licensed independent practitioners, the UIO conducts primary source verification.
			New staff complete orientation and training on policies, procedures, processes, and practices relevant to their role.
			The UIO conducts an annual appraisal of each staff member’s job performance and validates their current competency in their position.
			The UIO maintains records of work injuries and illnesses consistent with state or other reporting requirements.
			The UIO evaluates employees annually and provides development/training plans.
			Position descriptions define competencies if the employee provides patient care, treatment, or services.
			The individuals assigned to conduct competency assessments have the education, experience, and knowledge to objectively evaluate staff competency.
			The UIO assesses position competence for nonprofessional employees involved in patient care at least annually and provides documentation in the employees’ records.
			The UIO takes appropriate action when staff competence does not meet expectations.
			All clinical support staff with direct patient contact maintain basic life support skills from an accredited organization.
			The UIO defines policies and procedures for students and volunteers’ roles, if appropriate.
			The UIO keeps employee files, including those for independent practice associations and memoranda of agreement, complete and up-to-date. The UIO maintains all pertinent information for recruitment actions in these files.
			TOTAL

Human Resources Requirements Compliance Rating ((Y+N/A)/18x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–4 elements met)	28–44% (5–8 elements met)	50–72% (9–13 elements met)	78–94% (14–17 elements met)	100% (18/18 elements met)

Section 6 – Environmental Safety Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists.

6. Environmental Safety Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendation	Corrective Action Plan
			The UIO Director has designated a safety officer(s) to intervene, as needed, whenever environmental conditions immediately threaten life, health, or damage to equipment or buildings.
			The UIO has defined adverse (sentinel) event and communicated the definition and reporting requirements to all staff.
			The UIO has scheduled fire response drills and conducts them at least annually.
			Staff can access and regularly review emergency codes.
			The UIO regularly reviews environmental safety incident reports and takes actions, as appropriate.
			All exits, including exits from each floor or hall, display illuminated exit signs with emergency power capability.
			Stairwells are protected by fire doors, when applicable.
			Exits are easily accessed and unobstructed. The UIO has no storage in egress passages.
			The UIO constructed and maintains examination rooms, dressing rooms, and other patient care rooms to ensure patient privacy during interviews, examinations, treatment, and consultation.
			In accordance with the requirements of the Americans with Disabilities Act, the UIO has appropriate accommodations available for individuals with disabilities.
			The UIO ensures areas used by patients are clean and well maintained.
			The UIO has emergency access to all locked and occupied spaces.
			The UIO has identified security-sensitive areas and controls access to them.
			All UIO staff receive an orientation at initial hire and when conditions change, with annual refreshers, regarding their responsibilities to identify, report, respond to, and manage environmental safety risks.
			Staff participate in annual premises evacuation drills.
			Staff receive training on safe patient handling and mobility.
			Staff receive annual fire prevention training and training on the use of safety, emergency, and fire extinguishing equipment.
			Staff receive training on workplace violence de-escalation.
			The UIO has security policies and procedures for restricting observers in patient care areas and addressing those persons authorized to perform or assist in procedure areas.
			The UIO maintains a current inventory of regulated hazardous materials and waste that are used, stored, or generated. The UIO retains pertinent records per applicable requirements.
			The UIO has a process to minimize the risks associated with selecting, handling, storing, transporting, using, monitoring, and disposing of hazardous gases and mercury. (Hazardous gases include glutaraldehyde; ethylene oxide; vapors generated while using cauterizing equipment and lasers; and nitrous oxide).
			The UIO makes required permits, licenses, manifests, and safety data sheets used to manage hazardous materials and waste available to staff.
			The UIO labels hazardous materials and waste storage areas with signs that identify contents and provide hazard warnings.
			The UIO has an adequate number of portable fire extinguishers available in adequate locations, inspects them at least monthly, and has documented maintenance at least every 12 months.
			Qualified persons complete safety, operational, and functional checks on new clinical equipment before use.
			Staff receive education before using new biomedical devices or products.
			The UIO monitors and reports all incidents in which clinical equipment is suspected in, or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act.
			The UIO has a procedure for staff to follow in the event of medical equipment failure.
			Qualified persons inspect, test, and maintain all equipment in accordance with manufacturer recommendations.
			The ventilation system designed to control airborne contaminants (such as biological agents, gases, fumes, or dust) provides appropriate pressure relationships, air exchange rates, and filtration efficiencies.
			The UIO has labeled utility system controls to facilitate partial or complete emergency shutdowns.
			The UIO has policies and procedures for utility system disruptions.
			The UIO has battery-powered systems available and checks them quarterly to ensure the batteries are functional.
			The UIO inspects and tests fire alarms and fire suppression equipment in accordance with the National Fire Protection Association and equipment manufacturer guidelines.
			The UIO has policies and procedures to monitor items that must be kept frozen, refrigerated, and/or heated, as required by the manufacturer, including required temperature range information.
			The UIO has a product recall policy addressing drugs and vaccines, medical devices, equipment, supplies, and food products.
			Staff have access to recall information sources (the U.S. Food and Drug Administration (FDA); the Centers for Disease Control and Prevention (CDC); manufacturers; and other local, state, or federal sources).
			The UIO has methods in place to determine if a recalled product is used in the UIO or has been given or administered to patients.
			The UIO has methods in place to dispose of or return recalled products and notify patients if needed.
			The UIO monitors products that carry an expiration date, including medications, reagents, and solutions.
			The UIO has policies and procedures for the disposal or return of expired medications, unused opioid prescription medications, and supplies, in compliance with local, state, and federal guidelines.
			The UIO has a comprehensive emergency preparedness plan that addresses internal and external emergencies and describes the UIO’s role in community health emergency or disaster preparedness.
			The emergency preparedness plan addresses patient, visitor, and staff evacuation during an emergency, especially for those at greatest risk.
			The UIO conducts at least one drill annually to test staff knowledge of cardiopulmonary resuscitation (CPR).
			The UIO identified at least two priority emergency events and conducts at least one drill annually for each identified event (e.g., active shooter, extreme weather, hazardous chemical spill, security breach, missing child, etc.).
			The UIO debriefs and documents the evaluation of each drill to include issues identified in the drill, any corrective actions or needed modifications to the emergency response plan, and/or any needed staff retraining.
			The UIO maintains and enforces policies prohibiting smoking, including e-cigarettes, in its facilities.
			TOTAL

Environmental Safety Requirements Compliance Rating ((Y+N/A)/47x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–11 elements met)	26–49% (12–23 elements met)	51–72% (24–34 elements met)	74–98% (35–46 elements met)	100% (47/47 elements met)

Section 7 – Outreach and Community Services Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This core section applies to all UIOs including those with approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists.

7. Outreach and Community Services Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO maintains formal and informal arrangements with community resources to meet identified community needs.
			Staff have access to eligibility requirements for community resources and how to refer for services.
			Staff obtain patient consents and releases for referrals and exchange of information with referral agencies, as needed.
			The UIO has a written description of services offered.
			The UIO has written policies and procedures for applicable services.
			UIO leadership receive monthly reports that include data on the number and types of services provided with comparison to projections.
			The UIO holds meetings with appropriate staff to review difficult cases.
			UIO leadership receive an annual evaluation and report addressing patient satisfaction with services and recommendations for improvement.
			Outreach/community service staff ensure referrals receive necessary follow up.
			Staff provide presentations and information about services available for the community.
			Staff connect with community agencies, including health departments for public health nursing or case management, as needed.
			If the UIO provides transportation, it has policies and procedures in place for driver approval, including driver requirements, such as valid state driver’s license; monitoring of license expiration dates; and any restrictions.
			The UIO educates drivers at their initial hire, with annual refreshers, on proper techniques for assisting patients with disabilities.
			The UIO educates drivers at their initial hire, with annual refreshers, on addressing emergency situations, including CPR training.
			The UIO maintains current liability insurance for all vehicles used for patient transportation.
			Transportation policies address patient eligibility criteria and service areas covered.
			Transportation policies address seat belt and child restraint use.
			The UIO maintains transportation activity reports, vehicle logs, and vehicle maintenance schedules.
			If the UIO provides traditional health services, these services are consistent with community cultures, traditions, practices, beliefs, and norms.
			If the UIO provides traditional health services, these services are provided by individuals with experience in traditional health services and ceremonies and in collaboration with the urban Indian community and local tribes, as appropriate.
			Any traditional health services provided are within the scope of services designated and approved by the UIO.
			If the UIO prepares or serves food, it ensures that staff have appropriate food service permits and follow environmental standards for storage, preparation, and serving.
			The UIO maintains safe, clean, and appropriate facilities for services.
			TOTAL

Outreach and Community Services Requirements Compliance Rating ((Y+N/A)/23x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–5 elements met)	26–48% (6–11 elements met)	52–74% (12–17 elements met)	78–96% (18–22 elements met)	100% (23/23 elements met)

Section 8 – Patient Rights and Responsibilities Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive and limited ambulatory UIOs that are not accredited and did not receive approved limited review waivers. This section does not apply to residential treatment or outreach and referral sites. A requirement is met when there is documentation or evidence to show it exists.

8. Patient Rights and Responsibilities Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			Staff provide patients with appropriate privacy during registration, examination, and treatment.
			Staff provide patients with a notice of privacy practices and updates in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
			The UIO has interpretation and translation services available based on languages spoken by the patient population, including American Sign Language.
			Staff provide patients with information concerning their diagnosis, evaluation, treatment, and prognosis.
			Staff encourage and empower patients to participate in their health care.
			Staff communicate patient rights to the patients and provide them in writing when requested.
			The UIO has its hours of operation and locations of care and services readily available to patients.
			The UIO entrance displays information on how to access care when the UIO is closed.
			The UIO provides information on service fees and payment policies to patients.
			The UIO provides information and assistance for patients completing advance directives.
			The UIO has a list of providers, their positions, and professional designations available to patients.
			Staff inform patients about how to voice a complaint or grievance.
			The UIO has a grievance policy and procedure for recommending changes in policies and services at the UIO and Board of Directors.
			The UIO has a defined process to manage complaints that includes providing timely feedback to patients about their concerns and resolutions.
			Staff inform patients of their responsibility to provide complete and accurate information about health status; medications, including over-the-counter products and dietary supplements; and any allergies or sensitivities.
			Staff inform patients of their responsibility to follow the treatment plan established with their provider.
			Staff inform patients of their responsibility to be respectful to UIO staff, guests, and other patients.
			Patients have the right to change providers if other qualified providers are available.
			UIO staff respect patients’ cultural beliefs, personal values, and preferences.
			UIO staff communicate with patients who have hearing, vision, speech, or other cognitive impairments in a manner that meets the patients’ needs.
			Patients have the right to refuse care, treatment, or services in accordance with law and regulation.
			The UIO’s policy on informed consent identifies the specific care, treatment, or services that require informed consent.
			The UIO has an informed consent form for the production of health recordings, films, or other images and a release form for their use.
			The UIO reviews research protocols for any patient who is participating in or is a subject of a research study.
			Patients have the right to refuse research participation.
			TOTAL

Patient Rights and Responsibilities Requirements Compliance Rating ((Y+N/A)/25x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–24% (0–6 elements met)	28–48% (7–12 elements met)	52–76% (13–19 elements met)	80–96% (20–24 elements met)	100% (25/25 elements met)

Section 9 – Infection Control Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

9. Infection Control Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendation	Corrective Action Plan
			Infection control and prevention activities follow recognized national guidelines established for health care facilities (e.g., CDC or the Association of Professionals in Infection Control).
			A designated staff member with education and training in infection control oversees policy and plan development to identify and prevent the spread of infectious disease and to direct interventions to prevent infection.
			All providers, staff, contractors, and volunteers receive orientation and annual education on infection control policies and procedures.
			The UIO has policies and procedures to address preventing, minimizing, and controlling infection risk.
			The UIO has implemented a Hepatitis B vaccination program.
			The UIO places sharps containers in appropriate care areas that are secured from tampering.
			The UIO monitors the replacement of sharps containers when the fill line is reached.
			Staff heat sterilize critical and semi-critical items before each use and allow them to dry before handling.
			Staff use sterile gloves for appropriate procedures and between each patient, and they change gloves if they are torn.
			The UIO screens patients for latex sensitivity and provides a latex-free environment for patients/staff with latex sensitivity.
			The UIO surveils health care-acquired infections and investigates outbreaks of infectious disease.
			The UIO makes screenings for exposure and/or immunity to infectious disease available to staff who may come in contact with infections at the workplace.
			The UIO makes immunizations for infectious risks available to staff.
			The UIO makes tuberculosis respiratory protection available to staff.
			Staff wear protective wear (gown, lab coat) when their skin/personal clothing is likely to be soiled, and staff remove protective wear before leaving the facility.
			Staff wear surgical masks and eye protection with solid side shields or a face shield during procedures likely to generate splattering of blood or other body fluids.
			The UIO refers staff for assessment, testing, prophylaxis/treatment, or counseling if they have or are suspected of having an infectious disease that puts others at risk.
			The UIO has an annual influenza vaccination program in place and educates providers and staff about the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza.
			The UIO offers the influenza vaccination on-site to providers, staff, contractors, and volunteers, or facilitates how to obtain influenza vaccination offsite.
			The UIO has masks available to staff, contractors, patients, and volunteers to help prevent the spread of influenza.
			The influenza program has a goal to improve influenza vaccination rates.
			The UIO collects and reviews reasons why staff decline the influenza vaccination.
			The UIO calculates influenza vaccination rate data and reports on it annually to leadership.
			The UIO regularly checks clinical supplies for expiration, damage, and compromised sterility. The UIO stores sterile packages in a closed/covered cabinet.
			Staff mark wrapped instruments with the date of sterilization, sterilizer, and load.
			Containers or wrapping systems are compatible with the methods of sterilization.
			Staff do not reuse disposable items.
			Staff regularly monitor temperatures to ensure products are not compromised due to out-of-range temperatures.
			The UIO has a mechanism to notify public health authorities about reportable conditions.
			The designated infection control staff conducts infection control rounds to identify risks in the environment and to observe provider and staff infection control practices.
			The UIO has a process to identify and address potential infection risk based on geographic location, community, and population served.
			The UIO has a process for health care-acquired infection and control surveillance and data analysis.
			The UIO addresses how it would handle an influx of potentially infectious patients.
			TOTAL

Infection Control Requirements Compliance Rating (Y+N/A)/33x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–21% (0–7 elements met)	24–48% (8–16 elements met)	52–73% (17–24 elements met)	76–97% (25–32 elements met)	100% (33/33 elements met)

Section 10 – Health Records and Health Information Management Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

10. Health Records and Health Information Management (HIM) Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has a designated privacy official responsible for developing and implementing the HIPAA Privacy Rule.
			The UIO has a designated security official responsible for developing and implementing the HIPAA Security Rule.
			The UIO has completed a security risk analysis.
			The UIO has a designated staff person who is responsible for the confidentiality, security, and physical safety of patient health records.
			The HIM supervisor or designee reviews health records for the provider’s accurate and timely completion. The UIO has a process to address incomplete and delinquent records.
			The HIM supervisor oversees the timely and accurate completion of health record requests, subpoenas, court orders, Freedom of Information Act requests, law enforcement requests, and other requests.
			The UIO has a process for securing and tracking health records to determine who accessed them and to block unauthorized access.
			Staff establish an individual clinical health record for each patient receiving care.
			The UIO makes patient information readily available for authorized personnel anytime the UIO is open.
			The UIO makes patient health records available to the patient and other providers, when requested by the patient.
			The UIO organizes health records in a consistent manner to facilitate continuity of care. Each clinical discipline has sequential and uniform record content and formats.
			Staff incorporate documentation of consultations, hospital notes, and other notes from external providers into the patient’s heath record if it has been reviewed and approved by the treating provider.
			Staff provide requested information to external health care professional(s) if the patient approves the release of information and/or in accordance with HIPAA.
			Staff who access patient health records have completed security training.
			The UIO has a process in place for timely and accurate coding and provider query. The UIO conducts audits to track coding accuracy.
			Clinical health records policies and procedures address active record retention, inactive record retirement, and transfer of records in the event that the UIO closes or is otherwise unable to continue services.
			Clinical health records policies and procedures address the release and security of clinical record content, including accountability for record editing, deletion, and access.
			Clinical health records policies and procedures identify the timeframe for entering information and completing record documentation.
			Health records include an appropriate and current health history with a list of current medications and dosages, physical exams, and pertinent diagnostic studies no more than 30 days prior to a scheduled procedure.
			The UIO documents informed consent for a treatment or procedure.
			The performing provider immediately documents a post-procedure note with findings and techniques after the procedure.
			The ordering provider or other provider responsible for the patient’s care dates, times, and authenticates all orders, including verbal and telephone orders, within the specified timeframe.
			The UIO has defined a process for pre-printed standing orders, order sets, and protocols for approval.
			Providers follow a list of prohibited abbreviations, acronyms, symbols, and dose designation.
			The individual identified by the signature stamp or method of electronic authentication is the only individual who uses it.
			The provider reviews and signs the transcription of dictated information and includes the date and time it was dictated and transcribed.
			The UIO has a clinical records disaster recovery plan in place for possible disasters, such as a loss of electricity, flood, fire, tornado, or earthquake.
			Each provider who documents patient events in the health record has a permanent signature index.
			TOTAL

Health Records and HIM Requirements Compliance Rating ((Y+N/A)/28x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–21% (0–6 elements met)	25–46% (7–13 elements met)	50–71% (14–20 elements met)	75–96% (21–27 elements met)	100% (28/28 elements met)

Section 11 – Quality Assessment and Performance Improvement Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all UIOs that are not accredited and did not receive approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists. (See Section 2 – Governance Requirements—Requirement 15: The Board of Directors approved the scope of clinical services offered by the UIO.).

11. Quality Assessment and Performance Improvement (QAPI) Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The QAPI plan designates a QAPI Committee composed of administrative and clinical staff representing the UIO’s range of services.
			The QAPI Committee meets regularly, documents meetings, and carries out required functions.
			The QAPI plan includes goals and objectives, activity scope, and reporting responsibilities for each clinical component.
			The QAPI plan bases annual QAPI activities on identified priorities and specifies assignments, responsibilities, data collection processes, and methods organized in a Plan-Do-Study-Act or other QAPI model.
			The UIO has conducted at least one QAPI study in the past year.
			The QAPI plan defines adequate resources to conduct QAPI activities, including sufficient staff access to data, education, and time allocation for planning, data collection, summary, analysis, and deliberation.
			The UIO implements data processes and methods to capture and assess results.
			Designated UIO staff prepare an annual evaluation of QAPI activities and communicate results to UIO staff, leadership, and the Board of Directors.
			The UIO incorporates benchmarking activity with external agencies’ results into QAPI activities and reports them to the Board of Directors and to UIO staff.
			TOTAL

QAPI Requirements Compliance Rating ((Y+N/A)/9)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–2 elements met)	33–44% (3–4 elements met)	56–67% (5–6 elements met)	78–89% (7–8 elements met)	100% (9/9 elements met)

Section 12 – Patient Safety Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

12. Patient Safety Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has literature and advisories relevant to patient safety available.
			The UIO has a well-defined process for identifying, reporting, and analyzing adverse events and near misses that identifies causal factors underlying the event and potential improvements to reduce the likelihood of future events.
			Policies and procedures address patient behavior warranting dismissal or refusal of care.
			Policies and procedures identify corrective actions to address a health care professional who is or appears to be impaired or is incapacitated.
			Policies and procedures address communicating reportable events, as required by law and regulation.
			The UIO identifies and maintains a current list of look-a-like/sound-a-like medications.	.
			The UIO has a written list of high-alert and hazardous medications generated from manufacturers, state pharmacy boards, and internal data.
			The UIO has a written process to respond to actual or potential adverse drug events, including significant adverse drug reactions and medication errors.
			Staff use at least two unique patient identifiers, as recommended by the National Patient Safety Goals for Ambulatory Care, when providing care, treatment, or services.
			Staff label containers used in blood and specimen collections in the patient’s proximity.
			The UIO stores biopsy specimens in sterile, leak-proof containers labeled with the biohazard symbol.
			In perioperative and other procedural settings, staff responsible for medication management label medications and solutions on and off the sterile field that are not immediately administered or have been transferred from the original packaging to another container.
			If dispensing medications from multi-level vials, staff use sterile needles and syringes for each patient.
			Staff verify all medication or solution labels verbally and visually whenever the person preparing the medication or solution is not the person who will be administering it.
			Staff label each medication or solution as they prepare them, unless they will immediately administer the medication or solution.
			Staff immediately discard any medication or solution found unlabeled.
			Staff remove all labeled containers on the sterile field and discard their contents at the conclusion of the procedure.
			The UIO has a procedure to systematically obtain and/or update patient medication information.
			The UIO has a crash cart and/or emergency kit available, and staff maintain current emergency supplies.
			The UIO has a procedure to provide patients with written information on the medications they should be taking at the conclusion of their visit.
			The UIO has an oxygen tank with the appropriate valve, tubing, and mask available, and staff are familiar with its location.
			The UIO has formally adopted evidence-based practices derived from CDC or relevant professional associations to prevent surgical site infections.
			The UIO has a process for monitoring compliance to surgical site prevention practices.
			The UIO has a written pre-procedure process, such as conducting a “time out,” to verify the correct procedure, patient, and provider team and confirm the correct procedure site.
			The UIO has a process to identify items that must be available for the procedure and a standardized list to verify the items’ availability (e.g., documentation of the history, physical, test results, blood, devices, equipment, etc.).
			TOTAL

Patient Safety Requirements Compliance Rating ((Y+N/A)/25)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–24% (0–6 elements met)	28–48% (7–12 elements met)	52–72% (13–18 elements met)	76–96% (19–24 elements met)	100% (25/25 elements met)

Section 13 – Professional Staff Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive UIOs that are not accredited and did not receive approved limited review waivers. This section also applies to limited ambulatory UIOs that have more than one licensed independent practitioners (LIPs) in a discipline. This section does not apply to Residential Treatment or Outreach and Referral Sites. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX H. Professional Staff Credential File Review.)

13. Professional Staff Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action
			The UIO maintains policies and procedures describing the process, timelines, and responsibilities for the initial and reappointment credentialing and privileging of LIPs. Reappointment occurs at least every 2 years.
			The UIO only grants clinical privileges for treatments and procedures approved by the appropriate clinical agency and the Board of Directors.
			The UIO grants clinical privileges based on the applicant’s qualifications, including documentation of current unrestricted license(s) and continuing education.
			The UIO utilizes the National Practitioner Data Bank (NPDB) to report or query credentialed providers.
			The UIO has a process for granting temporary clinical privileges to a new provider to meet important patient needs.
			Following the appointment or reappointment of credentialed providers by the Board of Directors, providers receive a written list of approved clinical privileges granting initial, renewed, or revised privileges and a written list of any denied privileges.
			At the time of reappointment, the UIO will check if a peer review was completed before granting clinical privileges.
			At the time of reappointment, the UIO reviews any clinical performance that is outside of acceptable standards before granting clinical privileges.
			At the time of reappointment, the UIO verifies providers have adhered to policies, procedures, rules, and regulations.
			The UIO orients newly credentialed providers to clinical policies, procedures, and practices.
			The UIO has written procedures addressing the fair hearing and appeal process for credentialed providers.
			Credentialed providers participate in a peer review process that includes monitoring important aspects of care provided by physicians, dentists, and other health care professionals.
			Credentialed providers participate in the development and application of criteria used to evaluate patient care.
			Credentialed providers establish criteria by ongoing data collection and periodic evaluation to identify acceptable or unacceptable trends or occurrences affecting patient outcomes.
			TOTAL

Professional Staff Requirements Compliance Rating ((Y+N/A)/14x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–21% (0–3 elements met)	29–43% (4–6 elements met)	50–64% (7–9 elements met)	71–93% (10–13 elements met)	100% (14/14 elements met)

Section 14 – Quality of Care Provided Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

14. Quality of Care Provided Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO’s health care protocols are consistent with current standards of care.
			The UIO supports a peer review program with written by-laws in which all health care professionals participate.
			The UIO defines quality of care, in writing, to include the scope and content of screening, assessment, and reassessment of information it collects.
			Quality of care criteria identify when additional, specialized, or more in-depth assessments are required.
			Quality of care criteria have established timeframe(s) to complete the initial assessment.
			When warranted by the patient’s condition, the patient’s provider conducts or refers the patient for a comprehensive pain assessment.
			Providers use methods to assess pain consistent with the patient’s age, condition, and ability to understand.
			Providers assess and respond to patient pain based on reassessment criteria and manage pain with non-opioid medications when possible.
			At each patient visit, the provider documents updates to the patient’s condition in the clinical health record.
			The UIO have criteria for staff to identify patients who may be victims of abuse.
			Staff assess or refer, as appropriate, possible victims of abuse using a list of community agencies that provide or arrange for assessment and care.
			Policies and procedures specify how staff should report cases of possible abuse and neglect.
			Staff provide each patient with care, treatment, or services according to an individualized care plan.
			In the rare instances when verbal orders are necessary, staff use a “record and read back” process to verify a verbal order or verbal report of a critical test result before taking action.
			Staff perform diagnostic testing and procedures within the timeframes identified.
			When a test report requires clinical interpretation, the test order includes information necessary to interpret the results.
			Staff contact patients within a reasonable timeframe regarding significant problems or abnormal findings, depending on the immediacy of the need for following up.
			Staff provide education and training to patients based on assessed needs.
			Staff collaborate on patient education.
			The UIO provides information to patients on how to communicate concerns about patient safety issues that occur before, during, and after they receive care.
			The UIO has a system in place for conducting reviews of adverse events, i.e., patient safety medical quality assurance, or adverse event reviews.
			The UIO has equipment available to administer intravenous fluids and medications.
			The UIO provides Basic Life Support training/certification, including automated external defibrillator (AED) training and availability for use.
			The UIO has professional liability insurance that provides coverage for all employees, subcontractors, volunteers, residents, and interns, consistent with the minimum levels of professional liability insurance mandated by the laws of the state.
			Policies and procedures on the use of restraints specify the frequency, format, and content for clinical health record entries of each restraint episode.
			The UIO describes the reason(s) and conditions under which patients are discharged or transferred.
			The UIO has a process for shifting or transferring responsibility for a patient’s care from one clinician, organization, program, or service to another, including each other’s role for safe transfer.
			Staff identify any needs a transferring or discharged patient may have for continuing psychosocial or physical care.
			The UIO has arrangements in place to provide adequate specialty consultation services, as identified by patient need.
			The UIO has a detailed, written plan in place to handle medical emergencies and patient transfers.
			Staff respond to life-threatening emergencies according to written policies and procedures.
			The UIO has a mechanism in place to obtain timely reports, health records, test results, or other documents from external referral sources, providers, or health care facilities.
			Health education and health promotion staff have ready access to appropriate reference materials and consultative services.
			Health education and health promotion and disease prevention programs use a variety of data or data sources to direct programming.
			The UIO has clearly defined and communicates its range of immediate or urgent care services and hours of operation to the public and relevant organizations.
			TOTAL

Quality of Care Provided Requirements Compliance Rating ((Y+N/A)/35x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–8 elements met)	26–46% (9–16 elements met)	49–71% (17–25 elements met)	74–97% (26–34 elements met)	100% (35/35 elements met)

Section 15 – Dental Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive and limited ambulatory UIOs that provide this service and are not accredited and did not receive approved limited review waivers. This section does not apply to residential treatment, outreach and referral, or ambulatory care sites that do not provide this service. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms for the Dental Record.)

15. Dental Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO identifies dental services in writing, and these services are appropriate for patient needs.
			Appropriate American Dental Association (ADA) codes record tooth, surface, or pocket depth and documentation exists to justify all of the codes.
			The UIO conducts and periodically updates dental histories and physicals, including assessments of the hard and soft tissues of the mouth.
			Policies and procedures include the scope of practice and a description of the procedures requiring informed consent.
			Policies and procedures address protocol for the diagnosis and treatment of emergency/walk-in patients.
			Policies and procedures address the management of patients with medical issues (e.g., blood sugar for diabetics, blood pressure for hypertension, pregnancy).
			Providers develop a treatment plan after the initial exam.
			Prior to carrying out the treatment plan, staff obtain consent and inform the patient of the necessity or appropriateness of the proposed dental procedure(s), alternative treatments, and order of care.
			The dental record contains an individual prevention assessment that includes oral hygiene, preventive regimens, recommendations, etc.
			The UIO has policies and procedures for dental laboratory services.
			The UIO has policies and procedures for storing amalgam scrap in closed containers and appropriately recycling it.
			The UIO has policies and procedures for handling extracted teeth as regulated medical waste unless returned to the patient.
			The UIO gives patients protective eyewear to prevent splatter exposure during treatment.
			Staff keep a log of sterilizer spore tests and take action for positive results.
			The UIO evaluates dental unit waterlines and makes staff aware of the test results.
			The UIO disposes of liquid waste in a sanitary sewer system or in accordance with state regulations.
			The UIO monitors nitrous oxide/oxygen administration annually for exposed workers and for leaks.
			The patient has completed a health questionnaire, which the provider signed, within the past 12 months. Staff follow up on and document positive responses.
			Staff record all hard tissue findings (normal, pathologic, or abnormal) in the patient record.
			The patient record includes evidence of a soft tissue exam.
			Patient records include evidence of pre-operative x-rays, as appropriate (e.g., oral surgery, endodontics, etc.).
			The patient records note periodontal status and diagnosis for patients 15 and older.
			When the provider plans definitive periodontal therapy for patients with community periodontal index of treatment needs/periodontal screening and recording of 2 “3s,” the provider conducts a periodontal work-up that includes probing pocket depths, furca involvement, mobility, and occlusal features with documentation.
			The patient records note orthodontic status for patients ages 6 to 20 years old.
			The UIO places patients on recall programs based on their individual risk and the clinic’s reasons, rather than arbitrary time intervals.
			If the facility does not have full-scope service available, the patient’s record notes that the provider informed the patient of the need for treatment at another facility.
			Total

Dental Requirements Compliance Rating ((Y+N/A)/26x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–6 elements met)	27–46% (7–12 elements met)	50–73% (13–19 elements met)	77–96% (20–25 elements met)	100% (26/26 elements met)

Section 16 – Medical Home Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

16. Medical Home Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO provides preventive care with surveillance that includes anticipatory medical and oral health care guidance, age-appropriate screening, and well-baby care.
			The UIO provides wellness care addressing healthy lifestyle issues, such as appropriate sleep, stress relief, weight management, healthy diet, or oral health.
			The UIO conducts health risk appraisals and assessments for each patient.
			The UIO provides chronic illness management.
			The UIO provides end-of-life care and discusses advance directives, hospice, and other care options with patients.
			The UIO makes patient access available 24 hours a day, 7 days a week for appointments and scheduling.
			The UIO makes patient access available 24 hours a day, 7 days a week for prescription renewal requests.
			The UIO makes patient access available 24 hours a day, 7 days a week for clinical advice for urgent health needs.
			The UIO has flexible scheduling available to accommodate patient care needs for same-day service.
			The UIO explains and provides patients with information on the medical home’s approach to care.
			The medical home discloses any limitations for the populations it can serve to prospective patients.
			The medical home designates a primary care provider for each patient.
			A physician, nurse practitioner, or physician assistant directs patient care.
			More than 50% of medical home visits of any patient are with the same physician/nursing team.
			The UIO informs patients that they can select their primary care clinician.
			The UIO provides services within an interdisciplinary team framework.
			The UIO makes patients aware of their provider team members.
			The patient’s primary care provider ensures the interdisciplinary team provides comprehensive and coordinated care, treatment, or services and maintains the patient’s continuity of care.
			The patient’s primary care provider and the interdisciplinary team educate the patient on self-management tools and techniques based on individual needs.
			The interdisciplinary team makes and tracks internal and external referrals.
			The interdisciplinary team acts on recommendations from internal and external referrals and incorporates actions in the patient’s treatment.
			The interdisciplinary team conducts and updates a medication review at each patient visit that includes prescriptions; over-the-counter medicine; traditional medicine; diet supplements; and, if indicated, the use of recreational drugs and substances.
			The UIO manages transitions in care and provides or facilitates access, as needed, to behavioral health, substance abuse, or oral health care.
			The UIO incorporates evidence-based guidelines and performance measures in clinical services delivery.
			The UIO tracks critical referrals, critical consultations, and critical diagnostic studies and follows up, as appropriate, when it does not receive results in a timely manner.
			Staff keep the patient informed about delays in their appointment time.
			Staff use clinical decision support tools to guide decision-making.
			The UIO uses information technology to create reports for internal and external reporting.
			The UIO uses a certified electronic health care record.
			The UIO uses an electronic prescribing process.
			UIO leadership involve patients in quality assessment/performance improvement activities through patient satisfaction surveys.
			The UIO evaluates the effectiveness of the primary care provider and interdisciplinary team’s patient interactions.
			The UIO includes the effectiveness of the primary care provider and interdisciplinary team’s patient interactions in performance measures.
			The UIO evaluates disease management outcomes.
			The UIO conducts and evaluates patient satisfaction surveys to determine the patients’ experiences or perceptions of satisfaction with their appointment, services, care received, and providers.
			The UIO conducts at least one study every 3 years on each of the following topics: Patient/primary care provider relationship, Accessibility to care, Comprehensiveness of care, Continuity of care, and Clinical outcomes.
			TOTAL

Medical Home Requirements Compliance Rating ((Y+N/A)/36x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–8 elements met)	25–47% (9–17 elements met)	50–72% (18–26 elements met)	75–97% (27–35 elements met)	100% (36/36 elements met)

Section 17 – Pharmacy Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive and limited ambulatory UIOs that provide this service and are not accredited and did not receive approved limited review waivers. This section does not apply to residential treatment, outreach and referral sites, or ambulatory care sites that do not provide this service. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms.)

17. Pharmacy Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			A licensed pharmacist or, when appropriate, a physician or dentist who is qualified to assume professional, organizational, and administrative responsibility for the pharmaceutical services directs pharmaceutical services.
			The UIO educates patients about the safe and effective use of medications.
			The UIO stores all medications for external use and transfer separately from internal and injectable medications.
			The UIO stores medications according to the manufacturers’ recommendations. The UIO stores all flammable products in a safety cabinet in compliance with Occupational Safety and Health Administration guidelines.
			The UIO securely stores controlled (scheduled) medications to prevent theft or diversion.
			The UIO keeps invoices for all controlled (scheduled) medications readily retrievable and retains them for 2 years.
			The UIO keeps all Schedule II controlled substances listed on the Drug Enforcement Administration (DEA) Form 222, or its electronic equivalent, readily retrievable and retains them for 2 years.
			The UIO prepares an inventory every 2 years and keeps it readily retrievable by DEA.
			The UIO labels medications and components used in their preparation with the contents, expiration date, the person who prepared it, and any applicable warnings.
			If the UIO uses prescription pads, it controls these pads to prevent unauthorized access. The UIO prohibits pre-signed and/or post-dated prescription pads.
			The pharmacy submits reports to the State Prescription Drug Monitoring Program, as required.
			Authorized and qualified pharmacy staff conduct periodic inspections of all medication storage areas.
			The UIO uses Tall Man lettering for drug names of look-alike medications.
			The medication order policy requires a specific indication for use.
			The UIO has identified high-alert and hazardous medications, limits them to the pharmacy only, and has procedures in place to prevent errors.
			The UIO reports and addresses medication errors and adverse drug events or reactions according to an established procedure.
			The UIO notifies the prescriber and patient of an adverse drug event, significant adverse drug reaction, or medication error.
			The UIO reviews and classifies actual or potential adverse drug events, significant adverse drug reactions, or medication errors.
			The UIO prepares summary reports of an adverse drug event, significant adverse drug reaction, and medication error that address the event’s severity, drug category, location of the event, and steps taken to prevent recurrence.
			The UIO has a current, written list of medications available in the UIO formulary that includes the medications’ strengths and recommended dosages.
			The UIO has a formulary for determining which medications are available for dispensing or administering.
			The UIO has a process to select and procure medications that are not on the formulary and are needed for a one-time use or for a specific patient.
			The UIO makes information on medication shortages and outages available to providers.
			When the UIO deems emergency medications necessary, clinical leaders determine which emergency medications and supplies will be readily accessible for in-patient care areas.
			The UIO makes emergency medications available in unit-dose, age-specific, and ready-to-administer forms whenever possible.
			The UIO monitors and replaces emergency medications and supplies as soon as possible to maintain a full stock.
			If the UIO maintains pediatric medications, it has a current Broselow tape available for pediatric emergencies.
			Staff appropriately label all injectable medications drawn into syringes and oral medications removed from original packaging that are not administered immediately.
			Pharmacists or providers review all medication orders for patient allergies, sensitivities, or interactions with food and medications.
			Staff follow safe and appropriate medication preparation practices.
			When an on-site licensed pharmacy is available, pharmacy staff compound or admix all compounded sterile preparations, except in urgent situations in which a delay could harm the patient or when the product’s stability is short.
			Staff use clean or sterile techniques and maintain clean, uncluttered, and functionally separate areas for product preparation to avoid the contamination of medications.
			Staff visually inspect medications for particulates, discoloration, or other loss of integrity.
			Staff label medication containers whenever medications are prepared but not immediately administered.
			The UIO follows a standardized format for information included on medication labels.
			Staff include the patients’ names on the medication labels when preparing individualized medications for multiple patients.
			The UIO has a written policy describing medication recalls.
			The UIO informs patients as soon as possible if their medication has been recalled or discontinued by the manufacturer or FDA.
			The UIO determines under what circumstances the pharmacy will accept patients’ unused, expired, or returned medications for disposal.
			When the UIO accepts unused, expired, or returned medications, it has a process for returning the medications to the pharmacy’s control in a manner that prevents diversion.
			Before administering medication, the individual administering the medication verifies that the medication selected matches the medication order and product label.
			Before administering medication, the individual administering the medication verifies that it has not expired and that no contraindications exist.
			Before administering medication, the person administering the medication verifies that it is being administered at the proper time, in the prescribed dose, and by the correct route.
			Before administering medication, any unresolved concerns about the medication are discussed with the patient’s provider and/or staff involved with the patient’s care.
			Before administering a new medication, the patient is educated about the safe and effective use of the medication.
			The UIO has a written process that includes a review, approval, supervision, and monitoring the use of investigational medications.
			The UIO has a policy to promote the safe and effective use of prescription opioids that is monitored regularly through peer reviews and quality assessment and improvement reviews to ensure appropriate treatment; monitor misuse and diversion’ and monitor adherence to local, state, and federal regulations.
			Total

Pharmacy Requirements Compliance Rating ((Y+N/A)/47x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–11 elements met)	26–49% (12–23 elements met)	51–72% (24–34 elements met)	74–98% (35–46 elements met)	100% (47/47 elements met)

Section 18 – Laboratory Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive and limited ambulatory UIOs that provide this service, and are not accredited and did not receive approved limited review waivers. This section does not apply to residential treatment, outreach and referral sites, or ambulatory care sites that do not provide this service. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms.)

18. Laboratory Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has the appropriate Clinical Laboratory Improvement Amendments (CLIA) certificate and/or state license required based on the complexity of testing performed. If the UIO does not perform testing, it has procedures for obtaining routine and emergency laboratory services from a CLIA-certified laboratory to meet equivalent requirements, as determined by the Centers for Medicare & Medicaid Services (CMS).
			Pathology and medical laboratory services are appropriate to patient needs as demonstrated by performing tests in a timely manner, distributing test results to the provider and patient, and maintaining copies of test results.
			The UIO has policies and procedures to identify, store, and transport laboratory specimens and biological products, including patient instructions for self-collect specimens, such as a Fecal Occult Blood Test (FOBT), clean-catch urine, etc.
			Written policies and procedures ensure the positive identification and optimum integrity of a patient’s specimen from the time of collection or receipt of the specimen through completion of testing and reporting of results.
			Staff log and track specimens to ensure that the results for each specimen are obtained and reported to the ordering physician in a timely manner.
			If the UIO performs waived tests, written policies and procedures cover the clinical use and limitations of the test methodology.
			For specimen sent to an outside CLIA-certified laboratory, the external laboratory has provided a manual for specimen collection and handling, which is readily available to personnel involved in specimen collection.
			Waived testing policies and procedures address the need for confirmatory testing and result follow-up recommendations (for example, a recommendation to repeat the test when results are higher or lower than the reportable range of the test).
			Waived testing policies address the specimen type; collection; identification; required labeling; and, if applicable, specimen preservation.
			Policies and procedures address storage conditions for test components.
			Policies address reagent use, including not using a reagent after its expiration date.
			The UIO documents comparison studies if it performs the same test using different methodologies or instruments or at multiple testing sites.
			A system is in place to identify and assess patient test results that appear inconsistent with the following relevant criteria: Patient age, Sex, Diagnosis or pertinent clinical data, Distribution of test results, and Relationship with other test parameters.
			Reference intervals (normal values) specific to the test method used and the population served accompany quantitative test results in the clinical record for waived tests.
			The UIO has a policy that ensures that the ordering provider or another privileged provider reviews and documents the test results.
			The UIO retains laboratory test requisitions, authorizations, procedures, and records for at least 2 years. Retention includes the discontinuation of laboratory policies and procedures.
			The UIO is enrolled in a proficiency testing program for each specialty and subspecialty for which it seeks certification.
			The UIO has established and verified performance specifications for laboratory test systems in use.
			TOTAL

Laboratory Requirements Compliance Rating ((Y+N/A)/18x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–4 elements met)	28–44% (5–8 elements met)	50–72% (9–13 elements met)	78–94% (14–17 elements met)	100% (18/18 elements met)

Section 19 – Radiology Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all comprehensive and limited ambulatory UIOs that provide this service, and are not accredited and did not receive approved limited review waivers. This section does not apply to residential treatment, outreach and referral, or ambulatory care sites that do not provide this service. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms.)

19. Radiology Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO identifies the scope of imaging services available to meet patient needs.
			The UIO has a formal agreement in place for imaging services not provided directly by the UIO.
			The UIO interprets images with timely documentation and maintains permanent records of the interpretation report within the electronic health record.
			The UIO has policies and procedures for the safe use of diagnostic radiology equipment and other safety aspects.
			The UIO has a procedure in place for staff radiology exposure monitoring.
			The UIO posts warning signage in imaging areas to alert patients, visitors, and staff to the presence of hazardous energy fields, and they emphasize concern for particularly susceptible individuals.
			The UIO has written policies and procedures for the safe examination of women of childbearing age.
			The UIO uses appropriate shielding for patients during procedures.
			The UIO x-rays lead aprons annually to ensure no damage occurred during use or storage.
			The UIO tests imaging equipment annually with periodic inspections (at 3- to 4-year intervals) by a qualified medical physicist.
			The UIO screens patients prior to the use of intravenous contrast media, if relevant to the UIO’s services.
			A radiologist or other qualified, credentialed, and privileged provider authenticates all examination reports.
			The UIO performs diagnostic imaging tests only upon the order of a qualified health care professional and includes a concise statement of the reason for the examination.
			The UIO uses film positioners and does not hold film during exposure.
			Radiograph frequency adheres to appropriate guidelines (e.g., ADA or American Medical Association).
			The UIO maintains diagnostic images and makes reports readily accessible to providers based on its applicable laws and policies.
			Policy addresses diagnostic imaging storage, retention, and reports.
			TOTAL

Radiology Requirements Compliance Rating ((Y+N/A)/17x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–24% (0–4 elements met)	29–47% (5–8 elements met)	53–71% (9–12 elements met)	76–94% (13–16 elements met)	100% (17/17 elements met)

Section 20 – Outpatient Mental Health and Substance Abuse Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all UIOs that provide this service, and are not accredited and did not receive approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms.)

20. Outpatient Mental Health and Substance Abuse Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has a written description of the behavioral health program, including services, hours, location, and contact information.
			The UIO has a list and description of treatment approaches and therapeutic individual and group modalities.
			The UIO has written policies and procedures to intervene or restrict the rights and/or physical movement of patients if needed.
			Program staff respond in a timely manner to requests for consultation from other health care providers in the UIO.
			Program staff follow written policies and procedures for the assessment, management, notification, and referral of patients who are deemed to be an immediate danger to themselves or others or who exhibit other high-risk behaviors.
			Program staff receive annual education on the identification of, prevention of, and response to suicidal behavior.
			Written policies and procedures address service eligibility, any exclusionary criteria, who is responsible for making enrollment decisions, and how prospective patients are prioritized and informed about decisions and alternatives if ineligible.
			If the behavioral health program maintains a waiting list for services, there is documentation of each prospective patient’s placement on the list, interim contacts, and referral of persons in crises to necessary care.
			Policies and procedures for follow-up contact with prospective patients on the waiting list include expectations about timelines and frequency of contact.
			Patients receive orientation to program rules, expectations, events, and behaviors and their consequences, including infractions that will result in discharge from the program.
			Patients receive information of the process for regaining rights or privileges that have been restricted in the course of treatment.
			Patients receive an explanation of the purpose and process of assessment procedures.
			Patients receive an explanation of the establishment of a treatment plan, updates, and the patient’s role in setting and achieving treatment goals and objectives.
			If appropriate, the UIO discusses notifications, reporting, or other expectations with patients on court-ordered treatment.
			Policies and procedures address the content and timing of initial patient assessments.
			Initial and ongoing assessments of patients use valid, reliable, or standardized tools, tests, and instruments, including culturally adapted assessments, as appropriate and defined in the program policy.
			The initial assessment for each patient includes information gathered from relevant sources that is sufficient to develop a treatment plan.
			Written policies and procedures address the initial assessment for patients seen solely for short-term crisis intervention and stabilization.
			Written policies and procedures address any initial and periodic alcohol and drug screenings of patients.
			Program staff prepare an interpretive summary for each patient based on the initial assessment results for use as the basis for their referral to appropriate external services or in the development of the patient’s individualized treatment plan.
			The UIO provides the written assessment and referral summary to the patient or the patient’s legal representative upon request.
			Policies and procedures address the use of diagnostic criteria (e.g., the current Diagnostic and Statistical Manual of Mental Disorders or the International Statistical Classification of Diseases and Related Health Problems codes).
			The UIO maintains formal or informal arrangements with community emergency and crisis intervention services and has contact information readily available to staff.
			Policies and procedures address patient referrals, including referrals to community- and culturally based support services.
			The UIO has referral policies and procedures in place for substance use treatment services that are not available on-site.
			The UIO has referral policies in place for abstinence support programs, including traditional health and culturally based services.
			The UIO has referral policies in place for psychiatric treatment services that are not available on-site.
			The UIO has referral policies in place for medical services, including medication-assisted treatment.
			The UIO reviews and updates each patient’s assessment information to reflect changes in the patient’s condition, status, and treatment.
			The UIO completes a preliminary screening and review for any patient who returns requesting treatment after an absence of greater than 6 months.
			The UIO assigns a qualified staff member to coordinate the health care for each patient.
			Policy prohibits the assignment of program staff to assess or treat a patient with whom they currently or historically have had a close personal association.
			Program staff develop an individualized treatment plan for each patient to provide a continuous course of treatment.
			The UIO develops a treatment plan with the full participation and consent of the patient or parent/guardian if the patient is a minor (in accordance with state laws for minor treatment consent).
			The UIO bases patients’ treatment plans on primary assessment information and an interpretive summary.
			Patient treatment plans focus on their integration into their community and family.
			Treatment plans are appropriate to the patients’ culture and age.
			The UIO bases patients’ treatment plans on the patient’s identified strengths, needs, abilities, and preferences.
			The treatment plan has objectives that are measurable, achievable, time-specific, and appropriate to the treatment setting.
			The treatment plan specifies the frequency of interventions.
			Program staff review, at least quarterly, and update, as needed, patient treatment plans to reflect the patient’s current status and identify the current treatment issues being addressed.
			Treatment plan updates specify any modifications in goals, objectives, and treatment interventions.
			Program staff coordinate the treatment plan implementation with the patient's primary care provider, including medication-assisted treatment for opioid use disorders, as needed.
			Program staff complete progress notes for each patient following each individual or group treatment session to indicate the patient’s level of achievement of treatment goals and objectives addressed in the session.
			The UIO completes progress notes within 3 business days following the treatment session.
			Program staff who manage patients’ psychopharmacological medications regularly provide the patients with a documented review of the efficacy of the medication regimen by a licensed provider with prescribing privileges, as specified in the UIO’s policy.
			Written policies guide patient transfers to other programs or services.
			Prior to a patient’s discharge from the program, the UIO writes a discharge summary that includes the date of admission, presenting condition, and date and reason for discharge.
			The discharge summary includes a description of services provided and the extent to which the treatment goals and objectives were achieved.
			The discharge summary includes the status of the patient at last contact and recommendations for further treatment or services.
			When a patient is discharged from the UIO unexpectedly, program staff follow up as soon as possible to provide necessary notifications and clarify the reasons for the discharge.
			If the UIO provides services for children and adolescents, the treatment environment is suitable and appropriate for the age group, including appropriate physical plant, furniture, equipment, and supplies.
			The UIO does not exclude children and adolescents from behavioral health treatment services solely based on their juvenile justice status.
			The UIO ensures the confidentiality, security, and safety of clinical records, and maintains substance use disorder patient records in accordance with 42 C.F.R. Part 2 and applicable State laws and regulations.
			TOTAL

Outpatient Mental Health and Substance Abuse Requirements Compliance Rating (Y+N/A)/54x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–22% (0–12 elements met)	25–46% (13–25 elements met)	48–72% (26–39 elements met)	74–98% (40–53 elements met)	100% (54/54 elements met)

Section 21 – Residential Substance Abuse Treatment Requirements

Reviewer: Title: Date:

*Score: Compliant = Yes (Y), Non-Compliant = No (N), Not Applicable (N/A)

Instructions: This section applies to all UIOs providing residential treatment, and are not accredited and did not receive approved limited review waivers. A requirement is met when there is documentation or evidence to show it exists. (See APPENDIX J. Patient Health Record Review Forms.)

21. Residential Substance Abuse Treatment Requirements
Y	N	N/A	Requirement	Strengths	Weaknesses	Recommendations	Corrective Action Plan
			The UIO has a current written substance abuse program description and service plan that includes the program mission, goals and objectives, and population served.
			The UIO posts its business hours and contact information.
			Program services include recreational, spiritual, and traditional health, as appropriate.
			The UIO designed and maintains the physical environment where patients reside to meet patients’ needs and support therapeutic activities.
			Written admission policies specify how to conduct admissions and who is responsible for making admissions decisions.
			The admissions policies define how to prioritize prospective admissions.
			The UIO screens potential patients to determine their eligibility, level of care, and need for further assessment. Screening includes a history, physical, and status exam, and use of medications.
			If the UIO deems a prospective patient ineligible or inappropriate for program services, staff inform the patient and referring source of the reason.
			The UIO provides patients not accepted for treatment information on external resources and crisis and emergency service contacts.
			The UIO provides patients with an initial intake assessment, addressing their mental, physical, and psychosocial functioning and history of substance use and treatment.
			Program staff assess the patient’s drug and alcohol use using standardized, reliable, and culturally adapted tools approved by the Program Director.
			Unless otherwise specified in the regulations to which the program must adhere, program staff use the American Society of Addiction Medicine’s multidimensional risk profile criteria in formulating the patient’s placement and treatment recommendations.
			Written policy and procedure address obtaining additional medical or psychiatric evaluations, if indicated, as part of the patient's initial intake assessment.
			Policy and procedure address the discharge planning process, including timelines.
			The UIO performs initial and periodic alcohol drug screening tests of patients in accordance with written program policies and procedures. Screening tests may be random or in response to identified issues and specify the type of test to be performed (e.g., urine, breathalyzer, blood, or hair).
			Written policies and procedures describe referrals to other programs or services during the course of treatment and at discharge.
			Patients provide written consent for treatment or parent/guardian consent and patient assent for minors, if required by state law.
			Program staff provide an orientation for each new patient entering treatment in the language and terms that are appropriate to the patient’s cognitive functioning and culture.
			New patient orientation includes a review of the program rules and expectations, including potential restrictions on the patient’s full participation in the program.
			Patients receive orientation to their rights, responsibilities, and any financial obligations and fees.
			The UIO posts patient rights and responsibilities, including the process for grievances, and provides this information to patients upon intake for admission.
			Patients receive orientation to health and safety policies and rules.
			Patients receive orientation to policies and procedures for substances brought into the facility, including any prescription medications.
			Policies and procedures ban weapons (e.g., guns, knives, etc.) and address weapons brought into the facility, including consequences for violations. Patients receive orientation to these policies and procedures at intake.
			Policies and procedures address substances (e.g., alcohol or drugs) brought into the facility and consequences of bringing them into the facility. Patients receive orientation to these policies and procedures at intake.
			Program rules and expectations address events and behaviors and their consequences, including infractions that will result in discharge from the program.
			Program rules and expectations address the process for regaining rights or privileges that may have been restricted in the course of treatment.
			Substance abuse counselors explain the purpose and process of assessment procedures and the establishment of treatment plans and updates to their assigned patients.
			The assigned counselor explains the role of the patient in setting and achieving treatment goals and objectives.
			The assigned counselor explains the potential course of treatment.
			The primary substance abuse counselor prepares an individualized treatment plan for each assigned patient who enters treatment.
			The UIO, with participation from the patient, prepares clear, understandable treatment plans that express goals as measurable behaviors with timelines.
			Treatment plans include services to be provided to the patient, including therapeutic and educational activities, when these services will be provided, and staff members to involve in the patient's treatment.
			The UIO reviews the treatment plan with the patient at least monthly and revises it as often as necessary.
			Program staff coordinate the implementation of the treatment plan with the patient and the patient's primary medical care provider, if appropriate.
			Whenever possible, program staff do not knowingly accept assignments or referrals to treat a patient with whom they currently or historically have had a close personal relationship.
			Written policies and procedures address the discharge of patients who fail to comply with the rules of the program.
			Policies and procedures reflect the types of infractions that can lead to discharge and who has authority to discharge patients.
			Policies and procedures specify the process and timeline for appeal or review of a discharge decision or other disciplinary action.
			If program policies and procedures allow the retention of patients during lapse or relapse episodes, procedures address medical review and detox services. Relapse policies and procedures are consistent with maintaining an alcohol- and drug-free environment.
			The UIO does not deny treatment services to patients who are taking current medications prescribed by an appropriately licensed provider.
			The UIO may consider whether the nature and extent of the prescribed medications require a level of care not offered by the program, including medication-assisted treatment for opioid use.
			Program staff complete progress notes for each substance abuse patient following individual or group treatment or educational sessions.
			Progress notes include the date, time, and type of session.
			Progress notes include the level of achievement of any treatment goals and objectives addressed, the patient’s level of participation, and any significant events that occurred or were discussed in the session.
			Progress notes include changes in the patient’s life related to treatment and outcomes of specific interventions and modalities provided.
			Progress notes include changes in the frequency or level of care provided.
			The UIO develops a relapse prevention/discharge plan for each substance abuse patient as soon as possible in the course of treatment.
			Relapse prevention/discharge plans include contact and involvement with community support groups, individuals, and any changes in family and peer relationships.
			Relapse prevention/discharge plans include vocational or educational activities and cultural and spiritual aspects.
			Relapse prevention/discharge plans identify triggers, warning signs, and interventions.
			Written policies and procedures address discharge planning, beginning as soon as possible in the treatment process and continuing through treatment completion.
			When the UIO discharges a patient, the counselor documents the reason for the discharge (e.g., treatment completion, left against program advice, rule infraction, etc.).
			The UIO develops a proposed aftercare plan for discharged patients that includes placement in continuing treatment and relapse prevention measures, as appropriate.
			The UIO prepares a discharge summary that addresses the patient's progress toward treatment goals and objectives and the patient’s status at discharge.
			At discharge, the UIO provides the patient with information regarding how to reestablish contact in times of crisis.
			At discharge, the UIO provides the patient with information regarding the frequency with which the program will attempt to contact the patient for follow up.
			At discharge, the UIO provides the patient with information regarding referrals made for continuing treatment, including contact information.
			The program uses standardized formats for documenting assessments, assessment summaries, individualized plans, treatment notes, educational sessions, relapse prevention plans, transition/discharge plans, and discharge summaries that have been approved for use by the Program Director.
			Program policies define the scope and content of entries in patient health records.
			Staff receive training on patient confidentiality, including 42 CFR Part 2.
			The UIO ensures the confidentiality, security, and safety of clinical records, and complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and implementing regulations at 42 C.F.R. Parts 160-164. The UIO maintains substance use disorder patient records in accordance with 42 C.F.R. Part 2 and applicable State laws and regulations.
			TOTAL

Residential Substance Abuse Treatment Requirements Compliance Rating ((Y+N/A)/62x100%)
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–23% (0–14 elements met)	24–47% (15–29 elements met)	48–73% (30–45 elements met)	74–98% (46–61 elements met)	100% (62/62 elements met)

Appendices

APPENDIX A. Urban Indian Organization Profile

To help reviewers identify relevant sections to review and appropriate Review Team members, the UIO shall complete the information in the UIO Profile below, return it by email when notified of the scheduled review, and make it available at the on-site program review.

UIO Name

Description of Services Provided

Location(s)

Scope of Service

Types and ages of patients served
Services not provided on site for which there is a formal arrangement with an offsite facility or agency

Days and Hours of Service

Community Involvement

Planning

New services

Organizational Chart

Accreditation

Please provide a copy of the accreditation certificate and indicate the accrediting body and the date of the last accreditation survey.

Accrediting Body	Survey Date	Accreditation Date	Patient-Centered Medical Home (PCMH) Certified
☐ Accreditation Association for Ambulatory Health Care (AAAHC)			☐ Yes ☐ No
☐ Commission on Accreditation of Rehabilitation Facilities (CARF)			☐ Yes ☐ No
☐ The Joint Commission			☐ Yes ☐ No
☐ Health Facilities Accreditation Program			☐ Yes ☐ No
☐ National Committee for Quality Assurance (NCQA)			☐ Yes ☐ No

HRSA Funding

Designation	Last Site Review Date	PCMH Certified
☐ Federally Qualified Health Center (FQHC)		☐ Yes ☐ No
☐ FQHC Look-Alike		☐ Yes ☐ No
☐ HRSA 330		☐ Yes ☐ No

Awards Received

Health Resources – Agencies

For each community agency, list the services provided. Document the UIO’s relationship to the agency:
F = Formal agreement, I = Informal agreement, or N = No agreement.

Agency	Services Provided	Relationship to UIO

Board of Directors

Number of persons on full board: Number of current vacancies:

Name of Board Member	Board Position	Term Expiration	Years on Board	Tribal Affiliation	City and State

Roster of Professional Staff

List all licensed independent practitioners from the current contract year. For the category type, indicate:
S = staff hire, C = contract specialist, L = locum, T = telehealth link, or V = volunteer.

Provider Name	Degree	Category	Specialty	UIO Department or Service

Roster of Allied Clinical Staff

List all staff who provide direct or indirect patient care services, including registered nurse, licensed practical nurse, certified nursing assistant, nursing assistant, medical assistant, dental assistant, dental hygienist, radiology technician, laboratory staff, nutritionist, health promotion and disease prevention (HP/DP) staff, pharmacist, pharmacy technician, social worker, physical therapist, occupational therapist, speech therapist, wound care specialist, behavioral health counselor, substance abuse counselor, etc.

Staff Name	Degree	Position	Department or Service	Hours
Staff Name	Degree	Position	Department or Service	Full	Part

APPENDIX B. Documentation of On-Site Review Teams

Summary Sheet

UIO Name: Program Address:

Review Dates:

Title	Name	Phone	Email address	Manual Sections Assigned
Review Team Leader
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member

Provide the names of UIO staff who will participate in the annual review.

UIO Supervisory Staff Name	Department	Position	Phone	Email Address

APPENDIX C. Scoring System Summary

Overall Compliance Rating Calculation

A total of 21 sections are in the Onsite Review Manual. The number of sections completed by the Onsite Review Team will vary depending on: (1) the facility type and (2) accreditation status.

Each section breaks down into multiple standards. Compliance for each standard will be scored as Yes (Y) when the standard is met, No (N) for when it is not met, or Not Applicable (N/A). (See Table 1.)

Table 1. Legislative Requirements

Section 1 – Legislative Requirements
Y	N	N/A	Requirement
Y			The UIO has estimated the population of urban Indians residing in the urban center in which such organization is situated who are or could be recipients of health care or referral services.
		X	The UIO has completed a current community health needs assessment, including an estimate of the current health status and any gaps between unmet health needs and the resources available in the urban center.
		X	The UIO has identified the health care needs of its user population over the past fiscal or calendar year.

Overall compliance rating is scored for each section. Ratings are calculated as a percentage of the total number of requirements within a section. The number of requirements the UIO is determined to be compliant is indicated as, ‘Yes.’ Requirements not applicable (N/A) to the UIO are counted as N/A and are not counted against their compliance rating. The total number of N/A is added to the total number of ‘Yes’ divided by the total number of requirements within each section. (See Table 2.).

Table 2. Compliance Rating

Compliance Rating based on Percentage Range
☐ Non-compliant	☐ Minimally Compliant	☐ Partially Compliant	☐ Substantially Compliant	☐ Fully Compliant
0–24% of the elements were met	25–49% of the elements were met	50–74% of the elements were met	75–99% of the elements were met	100% of the elements were met

The total number of standards scored will vary depending on the number of sections scored. (See Table 3.) For example, an accredited facility is required to complete only seven sections: (1) Legislative, (2) Governance, (3) Administrative, (4) Financial Management, (5) Human Resources, (6) Environmental Safety, and (7) Outreach and Community Services. These seven sections include a total of 175 standards. If all 175 standards are found to be compliant, the overall compliance rating based on percentage would be “Fully Compliant, 100%” Alternatively, if 75% to 99% (132–174) of the standards were rated compliant, the overall compliance rating would be “Substantially Compliant.” If 50% to 75% (88–131) of the standards were rated compliant, the overall compliance rating would be “Partially Compliant,” and so forth.

Table 3. The Total Number of Standards within Each Section

Section Name	Number of Standards	Section Name	Number of Standards	Section Name	Number of Standards
Legislative*	10	Patient Rights and Responsibilities	25	Dental	26
Governance*	35	Infection Control	33	Medical Home	36
Administrative*	16	Health Records and Health Information Management	28	Pharmacy	47
Financial Management*	26	Quality Assessment and Performance Improvement	9	Laboratory	18
Human Resources*	18	Patient Safety	25	Radiology	17
Environmental Safety*	47	Professional Staff	14	Outpatient Mental Health and Substance Abuse	54
Outreach and Community Services*	23	Quality of Care Provided	35	Residential Substance Abuse	62
Total Number of Standards	604 Standards

*Core Sections

Table 4. Overall Scoring Rubric Definitions and Corrective Action

Fully Compliant	Substantially Compliant	Partially Compliant	Minimally Compliant	Non-Compliant
Meets 100% of standards.	Meets most (75–99%) standards.	Meets some (50–74%) standards.	Meets less than half (25–49%) of standards.	Meets few if any (0–24%) standards.
No corrective action plan required.	No corrective action plan required.	Corrective action plan required addressing non-compliant standards; due 90 days after review.	Corrective action plan required addressing non-compliant standards; due 90 days after review.	Corrective action plan required addressing non-compliant standards; due 60 days after review. IHS Area Offices will conduct a follow-up site review 180 days after the last review.

APPENDIX D. Scoring Table

Scoring Summary

UIO Name:

Instructions

For each of the 21 Sections of the Review Manual, indicate the Compliance Rating with an ‘X’ by selecting either: full, substantial, partial, minimal, or non-compliant. Once completed, add the total number for each column in the last row of the table by the number of sections reviewed (SR).

Requirement Section	Fully Compliant	Substantially Compliant	Partially Compliant	Minimally Compliant	Non-compliant	Reviewer
Legislative
Governance
Administrative
Financial Management
Human Resources
Environmental Safety
Outreach and Community Services
Patient Rights and Responsibilities
Infection Control
Health Records and Health Information Management
Quality Assessment and Performance Improvement
Patient Safety
Professional Staff
Quality of Care Provided
Dental
Medical Home
Pharmacy
Laboratory
Radiology
Outpatient Mental Health and Substance Abuse
Residential Substance Abuse
Total % compliance for all sections	N/SR=	N/SR=	N/SR=	N/SR=	N/SR=

APPENDIX E. Exit Conference

The purpose of the exit conference is for the On-Site Review Team to present a summary of the draft report to UIO leadership. A summary of the observations, overall conclusions, and recommendations on areas for improvement will be provided.

What to expect

Introductions of the Team leader and team members, including team members who are not present, and the sections they reviewed.
Discussion of the purpose of the exit conference.
Presentation by each team member of the findings for the sections they completed, including both findings and recommendations.
Discussion of areas of compliance, including examples.
Receipt of summary sheet that will list the following information:

The name of the team member who reviewed each section,
The overall score for each section reviewed, and
A list of high-risk issues and weaknesses identified that need immediate response for correction.

Overall recommendations for improvement.
Explanation of the final report and follow-up procedures.

APPENDIX F. Instructions for Reviewer to Complete Report

A cover letter addressed to the UIO Director providing a summary of the review.
An executive summary will be written that highlights significant findings—positive and negative—identified during the review from Area Urban Coordinator and Area Office staff. An enclosure will include a summary table with scores, findings, and recommendations for corrective action (if any).
The UIO report should be emailed to the UIO Director within 30 calendar days of the exit conference. The UIO Report should also be emailed to the appropriate IHS Area Director and the IHS Office of Urban Indian Health Programs.

Executive Summary – On-Site Program Review

UIO Name: Dates of Review:

Review Process

The survey process included interviews and discussions with staff, a tour of the facility and grounds, and a review of documents. The Program Review Report addresses findings from the review, including items determined to be compliant or non-compliant. Recommendations for corrective action need to address those sections that were found to be partially, minimally or non-compliant.

Strengths

Overall, we found many areas of compliance and several exceptional areas of performance, including:

(List examples.)

Weaknesses

During the exit conference, some priorities were mentioned that required immediate action. These include:

(List priorities from the exit conference.)

Recommendations

The following are recommendations to meet the standard. The Corrective Action Plan needs to address these recommendations.

(List recommendations.)

Corrective Action Plan
The Corrective Action Plan is left blank for the UIO staff to complete after receipt of review findings.

APPENDIX G. Responding to Report of UIO Review

Following receipt of the Report of UIO Review, the UIO is required to address the findings and recommendations in the report. The UIO may request technical assistance from the Area Office if needed to respond.

Guidance for Developing a Corrective Action Plan

The Corrective Action Plan process is designed to make corrections in areas that were found to be deficient during the review. Corrective Action Plans are required for sites that received an overall score of Partially Compliant, Minimally Compliant, or Non-Compliant. The process is as follows.

Designate staff members to develop Corrective Action Plans for deficient areas identified during the review.
Provide information on how the UIO intends to correct deficient requirements, who is responsible, and what steps will be taken to ensure future compliance.
Staff members should address high-risk requirements first, marked as ‘No’. All other requirements scored as ‘No’ should be addressed accordingly.
Corrective Action Plans should be shared with UIO Director and staff affected by action steps.

Corrective Action Plan Due Dates

Partially Compliant – Corrective Action Plan due to the IHS Area Office 90 days after site visit.

Minimally Compliant – Corrective Action Plan due to the IHS Area Office 90 days after site visit.

Non-Compliant – Corrective Action Plan due to the IHS Area Office 60 days after site visit. The Area Office will conduct a follow-up site review 180 days (6 months) after the last review.

APPENDIX H. Professional Staff Credential File Review

To conduct the Professional Staff Credential File Review, the reviewer should review a minimum of 6 staff files. Reviewers can select more depending on the size and scope of the UIO. Other than the provider’s name, other sensitive, personal information should not be written on this form. Instead, note if the information is in the file and what other documents may be needed. If other issues are identified, they should be summarized without including any sensitive, personal information. IHS will maintain the confidentiality of the information reviewed.

Provider:

Criteria	In File			Comments	Documents Needed
Criteria	Yes	No	N/A	Comments	Documents Needed
Application
License
DEA
Current copy of certificate for: Basic Life Support (BLS) D Advanced Cardiac Life Support (ACLS) D Advanced Trauma Life Support (ATLS) D and/or Pediatric Advanced Life Support (PALS) D.
Medical school/professional school education
Board certification for midlevel providers
Educational Commission for Foreign Medical Graduates (ECFMG)
Post-graduate training
References
National Practitioner Data Bank (NPDB)/ Healthcare Integrity and Protection Data Bank (HIPDB)
Health status
Evidence of malpractice insurance
Explanation of adverse actions and liability claims, if applicable
Clinical privileges
Office of Inspector General (OIG) report of sanctioned providers
Current continuing medical education (CME) listings or certificates
Reappointed within 2 years
Photo identification
Child Care National Agency Checks and Inquiries (CNACI)/background check
Peer review information

Reviewer: Date:

APPENDIX I. Human Resource File Review

To conduct the Human Resource File Review, the reviewer should review a minimum of 8 staff files. The reviewer can select more, if warranted, depending on size and services of the UIO. Sensitive, personal information should not be written on this form. Instead, note if the information is in the file and what other documents may be needed. If other issues are identified, they should be summarized without including any sensitive, personal information. IHS will maintain the confidentiality of the information reviewed.

Employee:

Hire Date:

Department/Unit:

Current Position:

File Item	In File			Comments
File Item	Yes	No	N/A	Comments
Job description
License/registration, including verification
Facility orientation
Orientation to key safety content before provision of care, treatment, and services
Department orientation
Department initial skills checklist
Annual competency checklist
Last completed annual performance appraisal
Log of in-services attended, including annual mandatory education
Other certifications, such as CPR/AED, Advanced Cardiac Life Support (ACLS), etc.
Background check
Education
Employee health, such as Tuberculosis and Hepatitis B

Reviewer: Date:

APPENDIX J. Patient Health Record Review Forms

This General Content Review should be conducted on all health records reviewed in addition to the specific record reviews that follow in the Appendix. Reviewers should request at least one medical record under each specific category per the Appendix (e.g., Clinic Visit Record, Well Child Visit Record) as applicable to the patient population served by the urban Indian organization (UIO). The reviewer may request health records under a specific category based on review findings and/or on the patient population served by the UIO.

Forms in this Appendix can be used for individual provider peer review, UIO quality assessment/performance improvement review, and by the Area Review Team conducting the annual UIO evaluation. IHS will maintain the confidentiality of the information reviewed and this form, consistent with federal law governing personally-identifiable information and health information. Sensitive, personal information and health information should not be written on this form. Instead, note if the information is in the file and what other documents may be needed. If other issues are identified, they should be summarized without including any sensitive, personal or health information.

General Content Review

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Name
Medical record number
Date of birth
Gender
Responsible party, if applicable
Address
Phone number
Name of any legally authorized representative
Sex
Height
Weight
Legal status of any patient receiving behavioral health care services
Language and communication needs
Initial diagnosis, diagnostic impression(s), or condition(s)
Findings of assessments and reassessments
Allergies to food
Allergies to medications
Conclusions or impressions drawn from the patient’s medical history and physical examination
Diagnoses or conditions established during the patient’s course of care, treatment, or services
Consultation reports
Progress notes
Medications ordered or prescribed
Medications administered, including: Strength, dose, and route Access site for medication, administration devices used, and rate of administration Patient response to medication administered
Adverse drug reactions
Plans for care and revisions
Orders for diagnostic and therapeutic tests, procedures, and results
Handwritten entries are legible

Reviewed by: Date:

Clinic Visit Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
All entries are dated
All entries are timed
Chief complaint or purpose of visit
Clinical findings
Studies ordered, such as laboratory or x-ray studies
Care rendered and therapies administered
A list of medications, including current medications, over-the-counter medications, and herbal preparations
Medication reconciliation is documented
Changes in prescription and non-prescription medication with name and dosage
Discharge diagnosis or impression
Disposition, recommendations, and instructions given to the patient
A signature of the health care professional on the clinical record entries
If a patient has three or more visits for the same condition, there is a Problem List in the record
Supplementary entries
Missed and canceled appointments
Significant medical advice given by text, email, or telephone, including medical advice provided after hours
Diagnostic or therapeutic intervention as part of clinical research
Discussions concerning the necessity, appropriateness, and risks of proposed care, surgery, or procedure and discussion of treatment alternatives
Advance directive in chart for patients who state they have an advance directive
Informed consent in chart for patients who had a procedure performed

Reviewed by: Date:

Urgent or Immediate Care Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Time of arrival
Means of arrival
Indication that the patient left against medical advice, when applicable
Conclusions reached at the termination of care, treatment, or services
Disposition
Condition
Instructions given for follow-up care, treatment, or services

Reviewed by: Date:

Surgical and Invasive Procedure Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Operative or other high-risk procedure and/or the administration of anesthesia
Provisional diagnosis before an operative or other high-risk procedure is performed
An operative or other high-risk procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care
The operative or high-risk procedure report includes:
Name(s) of the provider(s) who performed the procedure and any assistant(s)
Name of the procedure
Description of the procedure
Findings of the procedure
Estimated blood loss
Specimen(s) removed
Postoperative diagnosis
When a full operative or high-risk procedure report cannot be entered immediately into the patient’s clinical record, a note is entered immediately that includes:
Name(s) of the primary surgeon(s) and assistant(s)
Procedure performed
Description of each procedure finding
Estimated blood loss
Specimens removed
Postoperative diagnosis
Complications
The clinical record contains the following postoperative information:
Vital signs and level of consciousness
Medications, including intravenous fluids and any administered blood, blood products, and blood components
Unanticipated events or complications (including blood transfusion reactions) and the management of those events
Discharge from recovery phase either by the provider responsible for his or her care or according to discharge criteria
Use of approved discharge criteria that determine the patient’s readiness for discharge
Name of the provider responsible for discharge
Entries related to anesthesia administration

Reviewed by: Date:

Behavioral Health Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Initial bio-psychosocial assessment complete with relevant domains addressed
Psychological testing obtained, if needed
Treatment plan identifies relevant patient goals
Treatment plan updated and revised to reflect significant changes in patient status or new issues being addressed in treatment
Individual visit notes address progress to treatment goals
Individual visit notes include statement on current suicidal ideation for any patient with relevant history of depression, self-injury, or suicidal ideation
Prescribing provider reviews and incorporates medication reconciliation when prescribing new medication or changing existing prescription
Prescribing provider’s notes address patient compliance to medication regimen and effectiveness of medications prescribed
Appropriate laboratory tests ordered and results reviewed if relevant to psychotropic medications prescribed
Individual visit notes include continuing care plan for patients completing a course of treatment

Reviewed by: Date:

Provide summary results of review to the QAPI Committee.

Optometry Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Documentation of family ocular health history
External eye examination
Adnexa examination
Tissues of anterior segment examined
Tissues of posterior segment examined
Intraocular pressures measured
If presenting with monocular, visual acuity at distance documented
If presenting with monocular, visual acuity at near documented
Measure of refraction conducted
Monocular visual acuities recorded for prescription change
Magnitude and director of any distance horizontal deviation measured
Magnitude and director of any near horizontal deviation measured

Reviewed by: Date:

Prenatal Care Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Pregnancy diagnosed before third month
Initial evaluation included
Complete history, including history of STDs; diabetes mellitus; heart disease; prior pregnancies and outcomes; and Women, Infants, and Children (WIC) service participation
Measurement of height
Measurement of weight
Measurement of blood pressure
Physical examination, including exam of neck, breasts, abdomen, pelvis, rectum, and heart
Pap smear
Urinalysis
Hemoglobin or hematocrit
Rubella antibody titer
Rh factor test (N/A = Documented from prior pregnancy)
Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) test; if VDRL or RPR is positive, a fluorescent treponemal antibody absorption (FTA-ABS) test
One prenatal visit recorded every 6 weeks in the first 7 months
One prenatal visit recorded every 2 weeks in the eighth and ninth months
Recorded at each regular visit:
Weight
Blood pressure
Fetal heart tones recorded at each regular visit in the last trimester
STD screening (e.g., gonorrhea and chlamydia)
HIV screening
Alcohol, substance abuse, and tobacco screening
Domestic violence screening

Reviewed by: Date:

Well Child Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Each routine health visit includes:
Measurement of length
Measurement of weight without clothes
Measurement of head circumference through 24 months of age
Physical examination includes eyes, ears, nose, throat, heart, lungs, abdomen, hips, and feet
Appropriate screening for vision
Appropriate screening for hearing
Immunizations given according to recommended schedules

Reviewed by: Date:

Hypertension Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Known duration of hypertension in chart
Risk factors
Cardiovascular symptoms
At least annually, a physical exam included:
Measurement of height
Measurement of weight
Fundoscopic exam
Heart exam
Laboratory tests, at least annually
Urinalysis:
Blood urea nitrogen or creatinine
Serum cholesterol
Fasting serum glucose
Serum potassium
Electro-cardiogram
Chest x-ray
Triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) annually
Blood pressure was elevated on two separate visits before prescription was given; both measures were greater than 150/95
Management includes
Number of office visits consistent with treatment:
If only a diuretic is prescribed, two visits per year are required
If patient is on additional medications, three visits per year are required
After 6 months of treatment, patient's blood pressure is equal to or lower than 140/90

Reviewed by: Date:

Diabetes Mellitus Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Complete history is obtained, including past medical history, current symptoms, family history, weight gain/loss history, complications, and medication history
Physical exam is completed on new patients, including:
Ophthalmoscopic exam or Joslin Vision Network (JVN) screening
Sensory exam in lower extremities
Pulses
Foot exam
Urine dipstick
Blood glucose
EKG and chest x-ray
Appropriate medical therapy is initiated
Referral is made to nutritionist
Other appropriate referrals are made Suggested referral criteria Serum creatinine > 2.5 mg% = nephrologist Neuropathic ulcer = podiatrist or orthopedist New and/or complicated patients = public health nurse Retinopathy or decreased visual acuity = ophthalmologist
Patient education is provided on topics including causes, symptoms, treatment, urine testing, medications, foot care, weight loss, complications, and signs/symptoms and treatment of hypoglycemia and acidosis (Refer to the IHS Diabetes Education or other acceptable educational materials)
Medical follow-up is provided Suggested follow-up schedule: Each week until diabetes is stable: foot exam, urine dipstick, capillary blood glucose Yearly: pulses, eye exam, sensory exam of lower extremities, creatinine clearance

Reviewed by: Date:

Obesity Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Complete history is obtained, including:
Age of onset, if available
Family history of obesity
Previous weight reduction attempts
Physical exam is obtained, including:
Current weight
Current height
FTS T4, if indicated
Rule out underlying disease, such as hypertension, diabetes mellitus, gallbladder disease, gout, and coronary artery disease
Referral made to nutritionist
Evaluation made by nutritionist, including:
Dietary history
Current weight
Ideal body weight for height
Weight reduction goal
Appropriate caloric-level diet to achieve weight reduction
Patient education provided by nutritionist on exercise, caloric content of foods, and need for long-term follow-up care
Medical follow-up is obtained Recommended medical follow-up schedule: Counseling each week for 1 month Then every 2 weeks for 3 months Then every month for 3 months

Reviewed by: Date:

Dental Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Practitioner's name and profession (e.g., Doctor of Dental Surgery or registered dental hygienist)
Chief complaint purpose of visit
Health history reviewed and initialed at least annually
Allergies and health problems noted
Blood pressure taken routinely
Annual periodontal examination (adults)
Adequate consent forms used for local/topical anesthesia, conscious sedation, or invasive procedures (e.g., root canals, extractions)
Patient health records properly stored with limited access
Sealants routinely provided when appropriate
Topical fluoride/varnish routinely applied (children/infants)
Objective findings (description of symptoms)
Diagnosis or clinical impressions
Studies ordered, such as laboratory or x-ray studies
Therapies administered (e.g., treatment or drugs required)
Disposition, recommendations, and instructions to patient
Signature or initials of practitioners
Referral reports from and to referral specialists

Reviewed by: Date:

Patient Education Record

Medical Record Number: Clinical Service:

Date of Service: Provider:

Entries	Yes	No	N/A	Comments
Patient/family learning needs assessed
Patient/family barriers to learning assessed
Patient/family education provided:
For new patient
For new diagnosis or condition
For new or changed medication regimen
For change in self-care regimen
For patient referral for tests or procedures
Prior to procedure being performed at UIO
For initiation or change in rehabilitation status
For initiation of home medical equipment or supplies
For initiation or change in therapy regimen
Prior to referral to community resource
If patient condition has not improved due, in part, to patient non-compliance
If patient presents with chief complaint of pain
Education is provided on:
Plan for care, treatment, or services
Basic health practices and safety
Safe and effective use of medications
Nutrition interventions (e.g., supplements and exercise) and modified diets
Pain management
Oral health
Safe and effective use of medical equipment or supplies provided to the patient by the UIO
Habilitation or rehabilitation techniques
Patient education is documented
Patient/family provided educational materials

Reviewed by: Date:

APPENDIX K. Committee Lists

Reviewers should request the UIO to provide membership lists and meeting dates for the committees identified in this appendix.

Standing Committee – Human Resource Membership List

Member Name	Position Title	Department

Human Resource Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-required meetings are missed, please explain the reason for the cancellation in the Comments column.

Month	Dates	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Standing Committee – Quality Assessment and Performance Improvement Membership List

Member Name	Position Title	Department

Quality Assessment and Performance Improvement Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for the cancellation in the Comments column.

Month	Dates	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Standing Committee – Professional Staff Membership List

Member Name	Position Title	Department

Professional Staff Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for cancellation in the Comments column.

Month	Date	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Standing Committee – Environmental Safety Membership List

Member Name	Position Title	Department

Environmental Safety Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for cancellation in the Comments column.

Month	Date	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Standing Committee – Finance Membership List

Member Name	Position Title	Department

Finance Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for cancellation in the Comments column.

Month	Date	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Standing Committee – Credentialing and Privileging

Member Name	Position Title	Department

Credentialing and Privileging Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for cancellation in the Comments column.

Month	Date	Comments
January
February
March
April
May
June
July
August
September
October
November
December

Board of Directors Committee Meetings

List dates (mm/dd/yy) of meetings for the last year below. If regularly-scheduled meetings are missed, please explain the reason for cancellation in the Comments column.

Month	Date	Comments
January
February
March
April
May
June
July
August
September
October
November
December

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Author	Yvette Journey
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File Created	2023-08-27

On Site Review Manuel

UIO_Onsite_Review_Manual.docx

Urban Indian Organization On-Site Review