Ala. Admin. Code r. 580-2-20-.07

Performance Improvement

This regulation requires Alabama Department of Mental Health-certified mental health and substance abuse service providers to establish and maintain a written Performance Improvement (PI) System covering quality improvement, incident prevention and management, utilization review, recipient and family satisfaction, treatment plan review, and restraint/seclusion monitoring. Providers must collect and report outcome measures, conduct periodic record reviews, and communicate PI findings to governing bodies, clinical leadership, and staff. The rule applies to both mental health and substance abuse programs, including residential and outpatient levels of care certified by ADMH.

Ala. Admin. Code r. 580-2-20-.07 - Performance Improvement 

 State Regulations 

 Compare

(1)
 The
 Performance Improvement (PI) System shall provide meaningful opportunities for
 input concerning the operation and improvement of services from recipients,
 family members, recipient groups, advocacy organizations, and advocates. The
 provider shall operate and maintain a Performance Improvement (PI) System that
 is designed to:
(a)
 Identify and assess
 important processes and outcomes.

(b)
 Correct and follow-up on identified
 problems.

(c)
 Analyze
 trends.

(d)
 Improve the quality of
 services provided, and to improve recipient and family satisfaction with
 services provided.

(2)

 The PI System shall be described in writing and shall include, at a minimum,
 the following characteristics:
(a)
 Identifies
 and covers all program service areas and functions including subcontracted
 recipient services.

(b)
 Is reviewed
 and approved by the Board of Directors/Governing Body at least every two (2)
 years and when revisions are made.

(c)
 Outlines the agency's mission related to
 Performance Improvement.

(d)

 Contains the agency's goals and objectives related to Performance
 Improvement.

(e)
 Defines the
 organization of PI activities and the person(s) responsible for coordinating
 the PI System.

(f)
 Defines the
 methodology for the assessment, evaluation, and implementation of improvement
 strategies for important processes and outcomes.

(g)
 Specifies the manner in which
 communication of Performance Improvement findings and recommendations for all
 six (6) PI components is done at the governing body, clinical and
 administrative supervisory levels, staff levels, recipients, families and
 advocates and the manner in which it is documented.

(h)
 At a minimum, identifies and monitors
 important processes and outcomes for the six (6) components of Performance
 Improvement, Quality Improvement, Incident Prevention and Management,
 Utilization Review, Recipient and Family Satisfaction, Review of Treatment
 Plans, and Seclusion and Restraint (if applicable) consistent with the
 definitions described in this section.

(i)
 Specifies that the agency will
 participate in all required performance indicators and Quality Improvement
 Reporting requirements as specified by the ADMH Mental Health and Substance
 Abuse Services.

(j)
 Requires that
 the person(s) responsible for coordinating the agency's PI System or designee
 attend training on ADMH MHSAS approved Incident Management process.

(k)
 Specifies the manner of
 cross-departmental and cross-discipline staff input from all levels of the
 agency regarding the selection of QI indicators to be monitored and improvement
 activities to be implemented. 

(l)

 Specifies the manner of recipient and family member input regarding the
 selection of QI indicators to be monitored and improvement activities to be
 implemented.

(m)
 Where applicable,
 ensures that the manner of data collection assures recipient/family member
 confidentiality.

(n)
 The plan is
 implemented as written.

(3)
 The Quality Improvement component of the
 PI System shall, at a minimum, include indicators to be monitored including any
 system level performance measures as specified by the ADMH MHSAS and the
 following:
(a)
 A description of a process for
 periodic and timely review of any deficiencies, requirements, and Quality
 Improvement suggestions related to critical standards from DMH Certification
 site visits, Advocacy visits, and/or from other pertinent regulatory,
 accrediting, or licensing bodies. This shall include a specific mechanism for
 the development, implementation, and evaluation of the effectiveness of Action
 Plans designed to correct deficiencies and to prevent reoccurrence of
 deficiencies cited.

(b)
 A
 description of a process for conducting an administrative review of a
 representative sample of recipient records to determine that all documentation
 required by these standards and agency policy/procedure is present, complete,
 and accurate. This function may be performed by the agency's Electronic Health
 Record (EHR)._

(c)
 A review of
 aggregate findings from the administrative review of recipient records at least
 annually with recommendations and actions taken for improvement as indicated by
 the data, unless performed by the agency's EHR.

(d)
 The Plan shall specify frequency of
 monitoring for each indicator and the period of time that monitoring will
 continue after goal attainment is achieved.

(e)
 The Plan shall specify that the agency
 shall participate in System Level activities (including the use of DMH
 sanctioned External Monitoring) to assess and to identify actions for
 improvement.

(f)
 Substance Abuse
 Only Outcome Measures:
1.
 At a minimum, the
 entity shall collect information at time of assessment and at transfer or
 discharge to provide measures of outcome as specified in the following domains:
 
(i)
 Reduced Morbidity: 
 
(I)
 Outcome: Abstinence from drug/alcohol
 use.

(II)
 Measure: Reduction/no
 change in frequency of use at date of last service compared to date of first
 service.

(ii)

 Employment/Education:
(I)
 Outcome:
 Increased/Retained Employment or Return to/Stay in School.

(II)
 Measure: Increase in/no change in number
 of employed or in school at date of last service compared to first
 service.

(iii)
 Crime and
 Criminal Justice:
(I)
 Outcome: Decreased
 criminal justice involvement.

(II)

 Measure: Reduction in/no change in number of arrests in past thirty (30) days
 from date of first service to date of last service.

(iv)
 Stability in Housing: 
 
(I)
 Outcome: Increased stability in
 housing.

(II)
 Measure: Increase
 in/no change in number of recipients in stable housing situation from date of
 first service to date of last service.

(v)
 Social Connectedness: 
 
(I)
 Outcome: Increased social supports/social
 connectedness.

(II)
 Measure:
 Increase in or no change in number of recipients in social/recovery support
 activities from date of first service to date of last service.

2.
 The entity shall
 provide reports of outcomes to DMH in the manner, medium and period
 specified.

(4)
 The Incident Prevention and Management
 System component of the PI System shall include, at a minimum, the following: 
 
(a)
 PI review of special incident
 data.

(b)
 Includes and describes a
 process for the timely and appropriate review of special incident data at least
 quarterly via the PI System. Such reviews shall focus on the identification of
 trends and actions taken to reduce risks and to improve the safety of the
 environment of care for recipients, families, and staff members.

(c)
 Identify and implement a quality
 improvement plan for medication errors for residential programs.

(d)
 Findings and recommendations from the
 quarterly Special Incident reviews shall be reported at least quarterly to the
 executive and clinical leaders including the Board of Director/Governing
 Body.

(e)
 Pertinent data regarding
 improvement strategies shall be communicated to staff level
 employees.

(5)
 The
 Recipient and Family Satisfaction component of the PI System shall include
 tools to assess the satisfaction of recipients and families with services
 provided and to obtain input from recipients and their families regarding
 factors which impact the care and treatment of recipients. This component shall
 include at a minimum the following characteristics: 
 
(a)
 A description of the mechanism for
 obtaining recipient input regarding satisfaction with service delivery and
 outcomes.

(b)
 A description of the
 mechanisms for obtaining family member input regarding satisfaction with
 service delivery and outcomes for recipients.

(c)
 A description of the mechanism for
 obtaining input from recipients and family members when either are deaf,
 limited English proficient, or illiterate.

(d)
 A periodic review (at least annually) of
 data collected via the tools as described above.

(e)
 A periodic review (at least annually) of
 complaints/grievances filed according to the process required in
 
580-2-9-.02
(3)
.

(f)
 Identifies agency specific performance
 indicators for recipient and family satisfaction.

(g)
 Substance abuse agency's shall assess the
 satisfaction of recipients and families, including but not limited to the
 following:
1.
 The recipient's perception of
 the outcome of services.

2.
 The
 recipient's perception of the quality of the therapeutic alliance.

3.
 Other perceptions of recipients and
 families that impact care and treatment, including, but not limited to: 
 
(i)
 Access to care.

(ii)
 Knowledge of program information,

(iii)
 Staff
 helpfulness.

(6)
 The Utilization Review (UR) component of
 the PI system shall include the following:
(a)

 The agency shall perform at least quarterly reviews of the findings from the UR
 monitor for all MI_ residential programs and for all SA levels of care. At a
 minimum, this review will assess the agency's compliance with Length of Stay
 (LOS) expectations and will determine and implement actions to improve
 performance when variations in Length of Stay (LOS) expectations
 occur.

(b)
 The agency shall review
 at least annually a representative sample in each certified program to assess
 the appropriateness of admission to that program relative to published
 admission criteria.

(7)

 The treatment review component shall include, at a minimum, the following
 characteristics:
(a)
 A description of the
 process for conducting a clinical review of a sample of all direct service
 staff records every 12 months to determine that the case has been properly
 managed. The review shall include an assessment of the following: 
 
1.
 The appropriateness of admission to that
 program is relative to published admission criteria.

2.
 Treatment plan is timely.

3.
 Treatment plan is
 individualized.

4.
 Documentation of
 services is related to the treatment plan and addresses progress toward
 treatment objectives.

5.
 There is
 evidence of attempts to actively engage recipient, family and collateral
 supports in the treatment process to include linguistic and/or auxiliary
 support services for people who are deaf, hard of hearing, or limited English
 proficient as well as any other accommodations for other
 disabilities.

6.
 Treatment plan
 modified (if needed) to include linguistic and/or auxiliary support services
 for people who are deaf, hard of hearing, or limited English proficient as well
 as any other accommodations for other disabilities.

(b)
 An aggregate review of the clinical
 review findings described above at least annually to assess trends and patterns
 and to determine actions for improvement based on findings.

(8)
 The organization collects
 restraint and seclusion data in order to ascertain that restraint and seclusion
 are used only as emergency interventions, to identify opportunities for
 incrementally improving the rate and safety of restraint and seclusion use, and
 to identify any need to redesign care process.

(9)
 Using a recipient identifier, data on all
 restraint and seclusion episodes are collected from and classified for all
 settings/units/locations at the frequency determined by the agency on by: 
 
(a)
 Time.

(b)
 Staff and title of who initiated the
 process.

(c)
 Length of each
 episode.

(d)
 Date and time each
 episode was initiated.

(e)
 Date and
 time each episode was ended.

(f)

 Day of the week each episode was initiated.

(g)
 Type of restraint used.

(h)
 Description of injuries sustained by the
 individual or staff, if applicable.

(i)
 Age of the individual.

(j)
 Gender of the individual.

(k)
 Multiple instances of restraint or
 seclusion experienced by an individual within a 12-hour timeframe.

(l)
 Number of episodes per
 individual.

(m)
 Instances of
 restraint or seclusion that extend beyond two (2) consecutive hours.

(n)
 Use of psychoactive medications,
 including name of medication and dosage, as an alternative to, or to enable
 discontinuation of, restraint and seclusion.

(o)
 Documentation of the one hour face to
 face physical and behavioral assessment.

(p)
 Documentation of the debriefing/trauma
 check within twenty-four (24) hours.

Notes

Ala. Admin. Code
 r. 
580-2-20-.07

Adopted by
 
Alabama
 Administrative Monthly Volume XXXVII, Issue No. 01, October 31,
 2018
, eff. 
11/30/2018
.

Author:
 Division of Mental Health and Substance
 Abuse Services, DMH

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

State regulations are updated quarterly; we currently have two versions available.
 Below is a 
comparison between our most recent version and the prior quarterly release.

 More comparison features will be added as we have more versions to compare.

 No prior version found.

 State Regulations Toolbox