CAPS

APPENDIX C- INFORMED CONSENT **

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 02/21/2018
Revised: 
Wed, 02/21/2018
Attached File: 

APPENDIX I- INITIAL ASSESSMENT TEMPLATE **

Effective Date: 
Fri, 09/01/2017
Reviewed: 
Wed, 03/14/2018
Revised: 
Wed, 03/14/2018
Attached File: 

APPENDIX F- STUDENT QUESTIONNAIRE **

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 02/21/2018
Revised: 
Wed, 02/21/2018
Attached File: 

II.T QUALITY ASSURANCE PEER REVIEW PROCESS *

Effective Date: 
Mon, 02/24/2014
Reviewed: 
Mon, 05/07/2018
Revised: 
Fri, 02/03/2017
Policy: 

Subject: Quality Assurance Peer Review Process for CAPS clinical staff, an overview with reference to specific CAPS policies and procedures for counseling and psychiatry chart reviews.

I. PURPOSE

To identify the mechanism and process for the active, organized, and ongoing peer review process for CAPS clinical staff.

II. POLICY

 A. Counseling and Psychological Services (CAPS) is responsible for the quality of care provided by CAPS clinical staff.  Ongoing peer review is performed on a regular basis to evaluate Clinical Staff within their scope of practice in an educational, non-punitive manner.

 B. The CAPS Director is responsible for regular reports to the Executive Director on the performance of all Mental Health staff functions.  The CAPS Director may delegate to one or more of the CAPS Associate Directors appropriate roles and responsibilities in the Mental Health Staff appointment, reappointment, re-credentialing, privileging, and peer review processes. The CAPS Director retains oversight and authority for any responsibilities delegated to the CAPS Associate Directors.

 C. Peer Review is consistent with CAPS Policies & Procedures and UCSC Human Resources Policies & Procedures.

 D. Quality Assurance Peer Review is provided through monitoring important aspects of care.  Individual and aggregate clinical staff performance is measured through quality improvement, risk management, and peer review. Data related to established criteria are collected in an ongoing manner and periodically evaluated to identify potential trends or occurrences that affect client/patient outcomes.

 E. Quality Assurance Peer Review must be conducted by a member(s) of the clinical staff in good standing, of the same or similar specialty service and at least equal in education and training as the individual whose performance is under review (i.e., nurse practitioners may not peer review psychiatrists, and psychiatrists may not peer review psychologists, etc.).

 G. Clinical staff participate in the development and application of evidenced based criteria used to evaluate the care they provide.

 H. The results of peer review activities for clinical staff are reported to the CAPS Director.

 I. The results of Peer Review are used as part of the process for granting clinical staff reappointment.

 J. Quality Assurance Peer Review activities for mental health staff are coordinated by the CAPS Quality Assurance Peer Review Committee (QA), which is protected under California State Evidence Code §1157.

 K. All members of the clinical staff are reviewed in the Peer Review process.

III. DEFINITIONS

Allied Health Professions:  Allied Health Practitioners are defined as those licensed health care professionals, other than physicians, podiatrists, and psychologists, who are authorized to make independent patient care treatment decisions by virtue of their appointment or professional licensure.  At CAPS these providers are psychiatric mental health nurse practitioners, licensed clinical social workers, and licensed marriage and family therapists.

Clinical Staff: Includes Medical, Mental Health, and Allied Health Practitioner Staff.

Mental Health Staff Peer Review:  Review of specified cases of Mental Health Staff by a peer member of the same or similar specialty service.

Mental Health Staff:  Includes Psychiatrists, Psychologists, Licensed Marriage and Family Therapists, Postdoctoral Fellows, Psychology Interns, and Licensed Clinical Social Workers

Ongoing Provider Performance Measures:  Provider performance reviews based on comparison with accepted professional guidelines and benchmarking.

Peer: A member of the clinical staff in good standing, of the same or similar specialty service as the individual whose performance is under review.

Procedure: 

IV. PROCEDURES FOR CLINICAL STAFF PEER REVIEW

 A.  Standard Individual Client/Patient Record Review Process (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to standard peer review for counseling and psychiatry, respectively)     
   1. 
Medical staff who are not CAPS staff are directed to the relevant Policy & Procedure manual for medical services provided outside of CAPS.
   2. Mental Health Staff (members of CAPS staff)
     a. Mental Health Staff will conduct individual Case Record Reviews at least once per academic year
     b. At least fifteen (15) cases per individual provider are reviewed every three (3) year appointment period.
     c. Individual Case Record Reviews are chosen at random or other criteria as deemed appropriate by the CAPS Director or delegated CAPS Associate Director (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to peer review for counseling and psychiatry, respectively).
     d. All cases in which a recommendation for review by the CAPS Quality Assurance Peer Review Committee is identified in the overall rating will undergo review and discussion at by CAPS Quality Assurance Peer Review Committee. If the provider(s) whose review is being discussed is a member of the CAPS Quality Assurance Peer Review Committee, they will be asked to excuse themselves from the discussion.
         i. The provider whose review is being discussed may be contacted for comment and/or clarification. 
         ii. Conclusions and recommendations will be referred to the CAPS Director for review.
         iii.  CAPS Director and the provider’s supervisor will review, and the supervisor will provide feedback to the provider whose review is being discussed.
     e.  The provider’s peer review results will be included as a component of performance appraisals/evaluations.
     f. Copies of all reviews will be given to respective Mental Health staff member with originals filed in the individuals’ confidential personnel/credentialing file for re-credentialing assessment, after all prior steps have been completed.
 
 B.  Special Case Reviews (see the form “Special Referral Cases for CAPS Quality Assurance Peer Review Committee” for a checklist of procedures)

   1. Cases are identified through multiple sources such as:  CAPS Director referral, CAPS Management Team member referral, sentinel events, adverse events, incident reports, chart review findings, client/patient complaints, negative patient care outcomes, legal/risk management issues, provider concerns, and provider self-referral/request for case review.

   2. Issues identified for possible case review are submitted to and evaluated by the CAPS Quality Assurance Peer Review Committee Chairperson.  Issues may be submitted verbally or in writing.

   3. Providers involved in a referred case are informed by the CAPS Quality Assurance Peer Review Committee Chairperson and informed they may present the case (in writing or person) to the CAPS Quality Assurance Peer Review Committee and the date of the review, allowing sufficient time to review the electronic health record.  If the provider is a member of the CAPS Quality Assurance Peer Review Committee, that provider is excused from the CAPS Quality Assurance Peer Review Committee reviews and discussions.  If the provider is the CAPS Quality Assurance Peer Review Committee Chairperson, the CAPS Quality Assurance Peer Review Committee Chairperson is excused and a temporary chair is appointed by the CAPS Director.

   4. All members of the CAPS Quality Assurance Peer Review Committee are notified a case has been referred for review prior to the committee meeting. Review date is indicated with sufficient time to review the chart.

   5. The CAPS Quality Assurance Peer Review Committee reviews/discusses the case as a group.

   6. CAPS Quality Assurance Peer Review Committee reaches a consensus.  Individual care management, educational issues, and appropriate training /systems issues are identified, if relevant.  A summary of important findings/recommendations is gathered by the CAPS Director on a quarterly basis, which is then shared with the Student Health Services Quality Management (QM) Committee.

   7. The CAPS Director determines appropriate department-level follow up and notifies the CAPS Quality Assurance Peer Review Committee, and Providers involved, as appropriate.

 D. Findings of the Peer Review Process are placed in a secure file in the CAPS Director’s or delegated CAPS Associate Director’s office.

VII.F MENTAL HEALTH CLEARANCES FOR TRAVEL PROGRAMS COORDINATED BY USCS DIVISION OF GLOBAL ENGAGEMENT **

Effective Date: 
Wed, 04/24/2013
Reviewed: 
Thu, 02/01/2018
Revised: 
Thu, 02/01/2018
Policy: 

Students participating in specified travel programs coordinated by the UCSC Division of Global Engagement are required to complete the designated Confidential Health History form accurately and truthfully. Confidential disclosure will allow medical professionals to help students make arrangements or plans to facilitate a successful travel experience. Identifying mental health problems allows everyone involved in the process the opportunity to work to anticipate potential complications.  Failure to provide complete and accurate information may be grounds for non-participation in the UCSC coordinated travel program.

Procedure: 

The following process is overseen by a designee of the CAPS Director.

  • If a student is currently in treatment at CAPS, the student will bring the clearance form to their CAPS provider for consideration.
  • Students identified by UCSC SHC RN staff as having previous (within the past 12 months) appointments with UCSC CAPS but are no longer in treatment will be referred to the designee to determine next steps:
    • Students with evidence of serious mental health concerns warrant an evaluation by the previous CAPS counselor or the designee.
    • Mild or moderate concerns may result in chart review by the previous CAPS counselor or the designee prompting further evaluation, clearance sign-off, or no further action.
  • If a student has not been seen in CAPS for greater than 12 months, and that student makes no mention of mental health concerns in their travel Confidential Health History, no additional mental health review is required, unless previous serious mental health concerns are evident.
  • If a student's sole contact with CAPS was an initial assessment or phone triage and a subsequent referral off campus, no additional mental health review by CAPS is required, unless serious mental health concerns are evident.
  • If a student has seen an off-campus provider for psychiatric or counseling services since terminating with CAPS, the student needs to ask the off-campus provider to complete the clearance form.

If CAPS provider has signed the clearance form it should then be forwarded to Student Health Travel RN for final clearance sign-off.

II.S TREATMENT OF MINORS *

Effective Date: 
Mon, 01/28/2013
Reviewed: 
Mon, 05/07/2018
Policy: 

According to Health and Safety Code 124260 (effective January 1, 2011), minors may consent for outpatient services as long as they are at least 12 years old and sufficiently mature to participate in services.  The minor’s therapist must involve the parents/legal guardians in the treatment unless the therapist determines, after consulting with the minor, that parental/legal guardian involvement would be inappropriate for any reason.  Note:  Unlicensed clinicians must always work with their primary supervisor to make this determination.
If parental/legal guardian involvement is deemed appropriate, do so only to the extent that it is appropriate.  If parental/legal guardian involvement is deemed inappropriate, state directly in the case note that you are not involving the parents/legal guardians and why.
Parental/legal guardian consent is required for minors to receive psychotropic medications or inpatient mental health treatment.
Note:  Parents/legal guardians do NOT have automatic access to the minor’s file/confidential information.  The client must give written authorization to disclose any records/confidential information, except that which is absolutely necessary to include the parents/legal guardians in treatment, if deemed appropriate to do so.

II.R SICK STUDENT *

Effective Date: 
Mon, 06/11/2012
Reviewed: 
Mon, 05/07/2018
Policy: 

When confronted with students who present at CAPS with obvious medical illness (coughing, fever, chills, rash etc.) every effort is made to send the student home or to the Student Health Center for a medical evaluation.  If a student insists on being seen, or is in a crisis that necessitates an immediate psychological evaluation, the student is to be given a mask to limit the spread of airborne infection.  Masks should be available at the front desk at all times as well as available in college offices.  Staff are encouraged to wash hands thoroughly following any contact with an ill student and to disinfect any area they come in contact with. Phone consults are an option if the situation warrants it.

Sick Student Policy

Effective Date: 
Mon, 06/11/2012
Policy: 

When confronted with students who present at CAPS with obvious medical illness (coughing, fever, chills, etc.), every effort is made to send the student home or to the Student Health Center for a medical evaluation.  If a student insists on being seen, or is in a crisis that necessitates an immediate psychological evaluation, the student is to be given a mask to limit the spread of airborne infection.  Masks should be available at the front desk at all times as well as available in college offices.  Staff are encouraged to wash hands thoroughly following any contact with an ill student and to disinfect any area they come in contact with.  A phone consult with the student is another option if the situation warrants it.

VII.D ALLEGATIONS OF UNPROFESSIONAL CONDUCT **

Effective Date: 
Wed, 09/01/2004
Reviewed: 
Thu, 02/01/2018
Revised: 
Thu, 02/01/2018
Policy: 

To thoroughly evaluate allegations against a member of the licensed SHC medical or CAPS staff regarding unprofessional conduct.

Procedure: 

1)      Concerns or allegations are immediately brought to the attention of the Medical Director or CAPS Director.  If there is a concern about the Medical Director or CAPS Director, then the Executive Director will be notified.   If there is concern about the Executive Director then the AVP for Student Success is notified.

2)      Upon receipt of an allegation, the Medical Director or CAPS Director may require staff members to disclose his/her knowledge of the case/event.  The case/event will be carefully investigated and reported to the Executive Director.

3)      Communications in response to the allegations are discretionary and are the responsibity of the Medical Director or CAPS Director.

a.       All written responses/communications are reviewed with the involved licensed professional

4)      Unresolved allegations of negligent care or requests for financial compensation are reported to Campus Risk Management and Chief Campus Counsel as appropriate.   Allegations of criminal behavior will be reported to appropriate police jurisdiction and allegations of sexual harassment will be reported to the UCSC Campus Sexual Harassment office as per University Policy.

5)      If the Medical Director or CAPS Director determines corrective action may be indicated, the process proceeds in accordance with Medical Staff by-laws, University Personnel Policies, California State license reporting requirements.  This may result in disciplinary action up to and including termination from University employment.

6)      The University Whistle Blower program is also an option if someone believes that there has been inadequate evaluation or response to alleged unprofessional conduct.  Staff making reports to the University Whistle Blower program are protected from retaliation by UC policy.

 

In the event of allegation or Concerns involving licensed providers  (examples:  impaired behavior suggestive of substance misuse, negligent reckless behavior,  suspected breach of privacy or confidentiality, corruption, stealing, bribery, forgery, altering of records, diversion of prescriptions or medicines, suspected sexual harassment) staff are to proceed through the following steps until the issue is properly addressed:

  • Medical Director/CAPS Director notified immediately of concern
  • Executive Director
  • AVP of Student Success
  • Risk Management Office:  Stefani Khaleel 831-459-3261 (skhaleel@ucsc.edu)
  • Campus Counsel Office:  831-459-1948 campuscounsel@ucsc.edu
  • Title IX Office/Sexual Violence and Sexual Harassment Complaints: 831-459-2462
  • Whistle Blower Office:  800-403-4744 (universityofcalifornia.edu/hotline)
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