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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 450. Department of Mental Health and Substance Abuse Services |
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Chapter 55. Standards and Criteria for Programs of Assertive Community Treatment |
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Subchapter 13. Performance Improvement and Quality Management |
SECTION 450:55-13-1. Performance improvement program
Latest version.
- (a) There shall be an ongoing PACT or parent organization performance improvement program designed to objectively and systematically monitor, evaluate and improve the quality of consumer care related to PACT.(b) The performance improvement program shall also address the fiscal management of the organization.(c) There shall be an annual written plan for performance improvement activities. The plan shall include but not be limited to:(1) Outcomes management processes specific to each program component minimally measuring:(A) Efficiency;(B) Effectiveness; and(C) Consumer satisfaction.(2) A quarterly record review to minimally assess:(A) Quality of services delivered;(B) Appropriateness of services;(C) Patterns of service utilization;(D) Consumers, relevant to their orientation to the PACT and services being provided;(E) The thoroughness, timeliness and completeness of the assessment;(F) Treatment goals and objectives are based on assessment findings and consumer input;(G) Services provided were related to the goals and objectives;(H) Services are documented as prescribed by policy; and(I) The treatment plan is reviewed and updated as prescribed by policy;(3) Clinical privileging;(4) Fiscal management and planning shall include:(A) An annual budget that is approved by the governing authority and reviewed at least annually;(B) The organization's capacity to generate needed revenue to produce desired consumer and other outcomes; and(C) Monitoring of consumer records to ensure among others, documented dates of services provided coincide with billed service encounters; and,(5) Review of critical incident reports and consumer grievances or complaints.(d) The PACT or parent organization shall monitor the implementation of the performance improvement plan on an ongoing basis and makes adjustments as needed.(e) Performance improvement findings shall be communicated and made available to, among others:(1) The governing authority;(2) PACT staff; and(3) ODMHSAS if and when requested.(f) Compliance with 450:55-13-1 shall be determined by a review of the written program evaluation plan, written program evaluations annual, special or interim, program goals and objectives and other supporting documentation provided.