ADAA Grant Monitoring Review Form

Program Name:

Address:

      City:

    State:    Zip Code:    Clinic ID:

Date(s) of Review:

      Reviewer Name:

         Reviewer Email:

Instructions: Using the key below, please complete all applicable sections of this checklist by placing the letter that best describes the program’s compliance with each requirement:

Check “Yes” if the program meets all the conditions of the requirement.

Check “No” if the program does not meet any of the conditions of the requirement.

Check “Partial” if the program meets some but not all of the conditions of the requirement.

Check “N/A” if this requirement is not applicable to the program.

If the program is in partial or noncompliance, use the Corrective Action Plan (CAP) column to identify whether a corrective action plan will be developed to address the requirement. If a corrective action plan will not be developed, use the Comments section to describe how the requirement will be met.

Utilization:

Interview Program Director.

Utilization rate is calculated for the previous three month period, from   to .

Utilization equals census divided by slots. Utilization parameters: over 120% = overutilized; under 80% = underutilized

Level of Care	Slots	Census	Utilization	Compliance	CAP
Level 1 Adult				yes no prtl n/a	yes no
Level I Adolescent				yes no prtl n/a	yes no
Level II.1 Adult				yes no prtl n/a	yes no
Level II.1 Adolescent				yes no prtl n/a	yes no
Level II.5 Adult				yes no prtl n/a	yes no
Level II.5 Adolescent				yes no prtl n/a	yes no
Level III.1				yes no prtl n/a	yes no
Level III.3 Adult				yes no prtl n/a	yes no
Level III.3 Adolescent				yes no prtl n/a	yes no
Level III.5				yes no prtl n/a	yes no
Level III.7 Adult				yes no prtl n/a	yes no
Level III.7 Adolescent				yes no prtl n/a	yes no
OMT				yes no prtl n/a	yes no

Comments:

Outcome Measures:

Interview Program Director.

Outcome measures are calculated for the previous three month period, from   to .

Measure	Program Data	Compliance	CAP
62% of patients in outpatient programs are retained in treatment at least 90 days.		yes no prtl n/a	yes no
60% of patients in halfway house programs are retained in treatment at least 90 days.		yes no prtl n/a	yes no
45% of adolescent patients completing/transferred/referred from intensive outpatient programs enter another level of treatment within thirty days of discharge.		yes no prtl n/a	yes no
55% of adult patients completing/transferred/referred from intensive outpatient programs enter another level of treatment within thirty days of discharge.		yes no prtl n/a	yes no
78% of the patients completing/transferred/referred from detoxification programs enter another level of treatment within 30 days of discharge.		yes no prtl n/a	yes no
The number of adolescent patients using substances at completion/transfer/referral from treatment will be reduced by 80% from the number of patients who were using substances at admission to treatment.		yes no prtl n/a	yes no
The number of adult patients using substances at completion/transfer/referral from treatment will be reduced by 78% from the number of patients who were using substances at admission to treatment.		yes no prtl n/a	yes no
The number of employed adult patients at completion of treatment will increase by 24% from the number of patients who were employed at admission to treatment.		yes no prtl n/a	yes no
The number of adolescents arrested during the 30 days before discharge will decrease by 70% from the number arrested during the 30 days before admission.		yes no prtl n/a	yes no
The number of adults arrested during the 30 days before discharge will decrease by 75% from the number arrested during the 30 days before admission.		yes no prtl n/a	yes no

Comments:

Evidence Based Practices:

Interview Program Director.

Practice	Status
Relapse Prevention (Cognitive Behavioral)	yes no
Motivational Enhancement Therapy / Motivational Interviewing	yes no
Multisystemic Therapy (MST)	yes no
Community Reinforcement Approach (CRA) plus vouchers	yes no
Voucher-Based Reinforcement Therapy	yes no
The Matrix Model	yes no
Moral Reconation Therapy	yes no
Other:	yes no
Other:	yes no
Other:	yes no
Other:	yes no

Comments:

Conditions of Federal Block Grant Award: Drug-Free Workplace Requirements

Review policies and procedures, documentation of implementation, sample of personnel records.

The program provides a drug-free workplace in accordance with 45 CFR Part 76 by:

	Compliance	CAP
a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violation of such prohibition.	yes no prtl n/a	yes no
b) Establishing an ongoing drug-free awareness program to inform employees about 1) The dangers of drug abuse in the workplace 2) The program’s policy of maintaining a drug-free workplace 3) Any available drug counseling, rehabilitation and employee assistance programs 4) The penalties that may be imposed upon employees for drug abuse violations in the workplace.	yes no prtl n/a	yes no
c) Providing a copy of the published statement to employees.	yes no prtl n/a	yes no
d) Notifying the employee in the statement required by paragraph (a) above, that as a condition of employment under the grant, the employee will: 1) Abide by the terms of the statement; and 2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction.	yes no prtl n/a	yes no
e) Notifying the Addiction Coordinator and taking one of the following actions, within 30 calendar days of receiving Notice under paragraph (d)(2), with respect to any employee who is so convicted: 1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or 2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State or local health, law enforcement, or other appropriate agency.	yes no prtl n/a	yes no
f) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), and (e).	yes no prtl n/a	yes no

Comments:

Conditions of Federal Block Grant Award: § 96.132 Additional Requirements

Review sample of personnel records, policies and procedures.

	Compliance	CAP
The program makes continuing education available to employees who provide services.	yes no prtl n/a	yes no
The program has in effect a system to protect patient records from inappropriate disclosure, and the system: a) Is in compliance with all applicable State and Federal laws and regulations, including 42 CFR part 2 b) Includes provisions for employee education on the confidentiality requirements and the fact that disciplinary action may occur upon inappropriate disclosure.	yes no prtl n/a	yes no

Comments:

COMAR: Continuous Quality Review

Review documentation of Quality Improvement Team activities, i.e. meeting minutes, reports.

	Compliance	CAP
The program’s quality review team identifies problems based on data.	yes no prtl n/a	yes no
The problems that are identified are relevant to the quality of services being delivered.	yes no prtl n/a	yes no
Problem correction is monitored for effectiveness of changes incorporated.	yes no prtl n/a	yes no

Comments:

Conditions of Federal Block Grant Award:

§ 96.126 Capacity of Treatment for Intravenous Drug Abusers

Review intake log, waiting list contact log, documentation of provision of interim services to persons on waiting list.

	Compliance	CAP
Within 7 days of reaching 90 percent of its treatment capacity, the program notifies the Addiction Coordinator that 90 percent of the capacity has been reached.	yes no prtl n/a	yes no
The program admits each individual who requests and is in need of treatment for intravenous drug abuse not later than 14 days after making the request or 120 days if the program has no capacity to admit the individual on the date of the request; and, within 48 hours after the request, the program makes interim services available until the individual is admitted to a substance abuse treatment program.	yes no prtl n/a	yes no
When applicable, the program offers interim services that include, at a minimum, the following: a) Counseling and education about HIV and tuberculosis (TB), the risks of needle-sharing, the risks of transmission to sexual partners and infants, and steps that can be taken to ensure that HIV and TB transmission does not occur b) Referral for HIV or TB treatment services, if necessary c) Counseling on the effects of alcohol and other drug use on the fetus for pregnant women and referrals for prenatal care for pregnant women.	yes no prtl n/a	yes no
The program has established a waiting list that includes a unique patient identifier for each injecting drug abuser seeking treatment, including patients receiving interim services while awaiting admission.	yes no prtl n/a	yes no
The program has a mechanism that enables it to: a) Maintain contact with individuals awaiting admission b) Admit or transfer waiting list patients at the earliest possible time to an appropriate treatment program within a reasonable geographic area.	yes no prtl n/a	yes no
The program takes patients awaiting treatment for intravenous substance abuse off the waiting list only when one of the following conditions exists: Such persons cannot be located for admission into treatment or Such persons refuse treatment.	yes no prtl n/a	yes no

Comments:

Conditions of Federal Block Grant Award: § 96.127 Requirements Regarding Tuberculosis

Review policies and procedures, random sample of patient records

	Compliance	CAP
To prevent the transmission of TB, the program addresses the following: a) Screening patients and identification of those individuals who are at high risk of becoming infected b) Meeting all State reporting requirements while adhering to Federal and State confidentiality requirements, including 42 CFR part 2 c) Case management activities to ensure that individuals receive the services outlined below.	yes no prtl n/a	yes no
The program directly, or through arrangements with other public or nonprofit private entities, routinely makes available the following TB services to each individual receiving treatment for substance abuse: a) Counseling the individual with respect to TB b) Testing to determine whether the individual has been infected with mycobacteria TB to determine the appropriate form of treatment for the individual c) Providing for or referring the individuals infected by mycobacteria TB appropriate medical evaluation and treatment.	yes no prtl n/a	yes no
The program reports all individuals with active TB to the local Health Department as required by State law and in accordance with Federal and State confidentiality requirements, including 42 CFR part 2.	yes no prtl n/a	yes no

Comments:

Conditions of Federal Block Grant Award: § 96.128 Requirements Regarding HIV
Review policies and procedures, random sample of patient records

	Compliance	CAP
The program directly, or through arrangements with other public or nonprofit entities, makes appropriate pretest counseling for HIV and AIDS available and provides assertive linkages to services.	yes no partial n/a	yes no
The program directly, or through arrangements with other public or nonprofit private entities, makes available appropriate HIV/AIDS testing, including tests to diagnose the extent of the deficiency in the immune system and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating conditions arising from the disease.	yes no partial n/a	yes no
The program directly, or through arrangements with other public or nonprofit private entities, makes available appropriate post-test counseling.	yes no partial n/a	yes no
The program directly, or through arrangements with other public or nonprofit private entities, makes available therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating conditions arising from the disease.	yes no partial n/a	yes no
The program has established linkages with a comprehensive community resource network of related health and social services organizations to ensure a wide-based knowledge of the availability of these services and to facilitate referral.	yes no partial n/a	yes no
The program ensures that HIV early intervention services are undertaken voluntarily, provided with patients’ informed consent, and are not required as a condition of receiving substance abuse treatment or any other services.	yes no partial n/a	yes no

Comments:

Conditions of Federal Block Grant Award:

§ 96.128 Treatment Services for Pregnant Women

Review policies and procedures, patient records of pregnant women in treatment

Number of pregnant women enrolled in program in the past three months:

	Compliance	CAP
The program gives preference in admission to pregnant women who seek or are referred for and would benefit from Block Grant-funded treatment services.	yes no prtl n/a	yes no
Pregnant women are admitted to the program within 48 hours of request for treatment.	yes no prtl n/a	yes no

Comments:

ADAA General Conditions of Grant Award: Program Certification

Review certificates, sample of patient records in Level .5 Early Intervention Level of Care.

	Compliance	CAP
The program possesses current certification for all levels of care that are being provided.	yes no prtl n/a	yes no
A program that is funded to provide Early Intervention Services (ASAM Level 0.5) shall provide: (1) Assessments within 2 weeks of admission; (2) An individualized treatment plan, completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment and updated every 90 days; (3) Group or individual counseling, or both, as clinically indicated; (4) Family counseling, as clinically indicated; (5) Alcohol and drug education; and (6) Referral for further assessment or to another level of treatment, as clinically indicated. Documentation. The clinical staff providing the service shall write a patient progress note after each counseling session and shall place the note in the patient's record.	yes no partial n/a	yes no

Comments:

ADAA General Conditions of Grant Award: Fee Assessment

Review random sample of patient records, billing log.

	Compliance	CAP
The program has competent fee assessment practices. The program assesses each patient’s ability to pay fees for program services. The program requires documentation of patient income as part of the fee assessment process.	yes no partial n/a	yes no
The program has competent fee collection practices. If a patient is eligible for Medicaid coverage, the program actively facilitates the application process. The program bills insurance companies for eligible patient services.	yes no partial n/a	yes no

Comments:

ADAA Specific Conditions of Grant Award: Buprenorphine Initiative

Review Medication Diversion Plan, sample of patient records.

Number of buprenorphine patients enrolled in program in the past three months:

	Compliance	CAP
The program annually reviews and updates, as needed, their medication diversion prevention plan.	yes no prtl n/a	yes no
The program provides case management services to all patients in this initiative for the purpose of pursuing insurance coverage, linking with community physicians, and referring to ancillary services. Ancillary services include, but are not limited to community mental health, housing, education, and employment.	yes no partial n/a	yes no
The program actively pursues insurance coverage/benefits (PAC, MA, etc.) for all patients in the initiative.	yes no prtl n/a	yes no

Comments:

COMAR: Family Involvement

Review random sample of patient records.

	Compliance	CAP
The program obtains an assessment of the treatment needs of each patient’s family.	yes no prtl n/a	yes no
The program provides alcohol and drug education to family members.	yes no prtl n/a	yes no
The program, when clinically appropriate, provides or refers family members for family counseling.	yes no prtl n/a	yes no

Comments:

COMAR: Individualized Treatment

Review random sample of patient records.

	Compliance	CAP
Patient treatment plans are individualized.	yes no prtl n/a	yes no
Each patient’s length of stay in the program is based upon the patient’s level of illness severity and response to treatment; there is no predetermined length of stay.	yes no prtl n/a	yes no

Comments:

Program Corrective Action Plan Activities:

Describe steps taken to address any current corrective action plans.

Conditions of Federal Block Grant Award:

§ 96.124 Certain Allocations: (Required Services for Programs Receiving Block Grant Funds Set Aside for Pregnant Women and Women with Dependent Children)*

Review random sample of patient records, policies and procedures.

	Compliance	CAP
1) The program treats the family as a unit and, therefore, admits both women and their children into treatment services, if appropriate.[1]	yes no prtl n/a	yes no
2) The program provides or arranges for primary medical care for women who are receiving substance abuse services, including prenatal care.	yes no prtl n/a	yes no
3) The program provides or arranges for child care while the women are receiving services.	yes no prtl n/a	yes no
4) The program provides or arranges for primary pediatric care for the women’s children, including immunizations.	yes no prtl n/a	yes no
5) The program provides or arranges for gender-specific substance abuse treatment and other therapeutic interventions for women that may address issues of relationships, sexual abuse, physical abuse, and parenting.	yes no prtl n/a	yes no
6) The program provides or arranges for therapeutic interventions for children in custody of women in treatment which may, among other things, address the children’s developmental needs and their issues of sexual abuse, physical abuse, and neglect.	yes no prtl n/a	yes no
7) The program provides or arranges for sufficient case management and transportation services to ensure that the women and their children have access to the services provided by (2.) through (6.) above.	yes no prtl n/a	yes no

Comments:

*This applies only to those programs who receive this specific funding.


[1] Such an admission may not be appropriate, however, if for example, the father of the child(ren) is able to adequately care for the child(ren).