Mental Health Outpatient Treatment and Rehabilitative Services Satellite Recertification Protocol

A Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) program satellite is a physically separate site to a certified MHOTRS program, which provides either a full or partial array of outpatient services on a regularly or routinely scheduled basis. Satellites throughout the state vary greatly in terms of volume and range of services provided, staffing, hours of operation and many other factors. Some satellite programs are extensive, operate independently and require a more thorough review to ensure that quality services are provided. Other sites may be limited in size and scope of operation, and an extensive review would be inefficient and would add little value to the survey process.

Satellites which are staffed by 1 full time equivalent (FTE) or less will not require a site visit, unless there is a compelling reason identified by the Field Office licensing staff. Recipients served at the site will not be included in the sample of individuals chosen for a tracer review.

The administrative review of the MHOTRS program conducted at the main site will include the arrangements for clinical supervision of staff and administrative oversight of the satellite operation. In addition, licensing staff will ascertain if there are special populations served or specialized services provided at the satellite which require additional scrutiny.

For MHOTRS program satellites which are staffed by more than 1 FTE but less than 5.5 FTE, recipients served at the site will be included in the available pool for sampling using the tracer methodology if they meet the criteria for high risk/complexity, but additional records from the site will not routinely be reviewed. A site visit will be conducted if a recipient served at the satellite is chosen for a tracer review. The visit will focus on record review, interviews, issues of clinical supervision and administrative oversight, provision of specialized services and premises.

MHOTRS program satellites staffed by more than 5.5 FTE will receive a site visit and a more comprehensive review. This will include the selection of 2 to 4 open records of individuals whose care will be reviewed using the tracer methodology and 2 to 4 closed records to be reviewed. This survey will include a review against all standards of care anchors.