Safety & Escalation Cheat Sheet updated—use the latest steps.
Announcements / Alerts
Announcements / Alerts
Medicaid audit reminder (due dates)
Policy updates (like COMAR changes)
Staff meeting reminders
Psychiatric Rehabilitation Program – Adults (PRP-A)
Psychiatric Rehabilitation Program – Adults (PRP-A)
Rehabilitation Specialist (RS):
Oversee all rehab services.
Complete Functional Assessment (DLA-20 or BHA-approved tool) at admission.
Complete Comprehensive Rehab Assessment and Rehab Plan within 30 days or 10 visits.
Update plan every 6 months.
Ensure continued need certification by independent treating clinician every 6 months.
Documentation: Rehab assessments, individualized plans, service notes, progress summaries.
Direct Care Workers (DCWs):
Provide skills training (daily living, community integration, wellness) using structured methods (instruction, modeling, role-play).
Document interventions per encounter, focusing on skill taught, method, and client response.
Maintain daily service logs (signed).
Case Managers:
Ensure linkage to natural/community supports.
Track supported employment referrals.
Documentation: Note communication with therapists, community resources, and employment services.
Psychiatric Rehabilitation Program – Minors (PRP-M)
Psychiatric Rehabilitation Program – Minors (PRP-M)
Rehabilitation Specialist:
Same duties as PRP-A, but with youth-focused assessments (resiliency, family/teacher interaction, regulatory skills).
Ensure parent/guardian informed consent clearly documents that PRP is rehabilitative, not therapy.
Timelines:
Functional/Rehab Assessment & Plan: 30 days/10 visits.
Update plan every 6 months.
Documentation: Assessments, rehab plan, certification notes, family engagement records.
Direct Care Workers (Youth Specialists):
Provide interventions on self-care, peer interaction, regulatory skills, community integration.
Document sessions with emphasis on skill taught + youth’s response.
Timeline: Document each service provided same day.
Family/Parent Liaisons:
Provide education/support to guardians.
Document parent sessions separately in the minor’s record.
Ensure guardian signature on updates every 6 months.
Policy & Procedure Manual
To provide a method in which to evaluate the ongoing standards and practices at a facility based on standards of care
Audit Checklist
1. Has the PRP documented the consumer’s eligibility for Federal or State entitlements and assisted the individual in applying for all entitlements for which he/she may be eligible, if he/she does not currently have entitlements? Yes / No
2. Has the consumer (or their legal guardian) consented to rehabilitation services?10.21.17.04 A Y?N
3. Does the medical record contain a completed BHA Documentation for Uninsured Eligibility Benefit form or Uninsured Eligibility Registration form and verification of uninsured eligibility status? BHA Guidelines Yes / No / NA
4. Is there documentation present indicating that the consumer (over the age of 18) has been given information on making an advance directive for mental health services? 10.21.17.04 C Yes / No
5. Is there documentation present indicating that the adult consumer was referred for PRP services by a licensed mental health professional who is providing inpatient, residential treatment, or outpatient services to the adult? Yes / No **Name of referring clinician?
6. Does the diagnosis match the Utilization Guidelines for the Target Population and is there supporting documentation for establishing the medical necessity? 10.21.21.05 A (1-2) Yes / No
7. When required, does the medical record document the consumer’s choice to receive only off-site or only on-site PRP services? Yes / No / NA
8. Was a screening assessment completed within 10 working days of the program’s receipt of a PRP referral to determine medical necessity for rehabilitation services? Yes / No / NA
9. Is there a comprehensive PRP Rehabilitation Assessment that was completed within 30 calendar days of initiation of PRP services? Yes / No / NA
10. Was an initial IRP completed within 30 calendar days of initiation of PRP services; do the initial and concurrent IRPs contain goals, objectives or outcomes , related to assessment, that are individualized , specific, and measurable with an achievable timeframe and congruent interventions? Yes / No / NA
11. Are IRP reviews completed at a minimum of every 6 months, and do the IRPs include all required signatures with dates and is it documented the consumer accepted or declined a copy of the IRP? Yes / No / NA
12. Within 10 working days after an individual is discharged from a program, has the service coordinator completed and signed a discharge summary that includes, at a minimum: reason for admission, reason for discharge, services provided, progress made, diagnosis at the time of discharge, current medications, continuing service recommendations and summary of the transition process, and extent of individual’s involvement in the discharge plan? Yes / No / NA
13. Does the record reflect the development of a transition plan, if the individual is discharged?
14. Does the record contain complete contact/monthly progress notes which reflect goals and interventions on the IRP are being implemented; and reflect consumer response to the interventions and progress towards goals? Yes / No / NA
15. Are the Assessment, IRP and Progress Notes consistent with the current BHA guidelines? Y/N/NA
16. Is there evidence that the program organizes services and supports to promote the use of community resources and self-help organizations and documents recommendations for and collaboration with other service to support the individual’s recovery? Yes / No / NA
17. Is there documentation of the consumer’s past and current somatic/medical history and documentation of ongoing communication and collaboration with a Primary Care Physician?Y/N/NA
Fundamental Rights Policy
Fundamental rights are a group of rights that have been recognized by a high degree of protection from encroachment. These rights are specifically identified in a constitution, or have been found under due process of law. The United Nations' Sustainable development Goal 17, established in 2015, underscores the link between promoting human rights and sustaining peace.
HIPAA Quick Reference
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Gives patients more control over their health information Sets boundaries on the use and disclosure of health information Establishes appropriate safeguards to protect the privacy of health information Holds Violators accountable with civil and criminal penalties that can be imposed if they violate a member’s privacy rights
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