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OMH has developed a PROS scoring methodology to be used following the licensing recertification review as an indicator of adherence to the recently developed PROS Standards of Care. As with all OMH licensed programs, the length of the operating certificate is related to how well the program is providing services that comply with regulations and are consistent with the Standards of Care. 

The evaluation of PROS performance will be based on information from a number of sources. The record should provide documentation of assessments, individual service plans, progress notes, etc. The PROS Program Assessment by Participant and interviews with staff, recipients and collaterals can provide valuable perspective and additional information about the nature of services provided by a PROS program. Policies, procedures, committee minutes, training records, etc., can also provide evidence of a program’s efforts to establish sound procedures and to monitor and evaluate numerous aspects of service delivery. The tracer methodology should allow the reviewer to move between various information sources in examining issues related to care.

For each focus area a reviewer will gather and weigh the information derived from these multiple sources. Anchor Elements will be utilized as a basis for determining a program’s demonstrated ability to address the themes of the standards and compliance with the regulatory and programmatic intent of each focus area.

The preponderance of evidence will determine if the program’s practices meet the core performance standards. When all elements of a core practice have been satisfied, additional findings and agency wide processes may be reviewed against the exemplary category.  Significant shortcomings or missing elements of expected performance would indicate a core standard was not met, and result in a finding which the program would be expected to address in a Performance Improvement Plan.*

• This tool is only to be used for reviews subsequent to the initial 6 month review.
• During the initial implementation of the PROS Standards of Care, a program will routinely be issued no less than an 18 month duration operating certificate.
• A program that has met the core standard in 17 or more of the 21 focus areas may have an additional 3 months in duration added for each identified “exemplary” practice. The maximum duration of an operating certificate is 36 months.
• OMH has the discretion to add months to the operating certificate if the program has exemplary practices that have not previously been identified in the Standards of Care, and to issue an operating certificate for less than 18 months if there are egregious practices or concerns.

Calculations for additional months after meeting the Core Standard in at least 17 focus areas:

* Full compliance with focus area 4.6 (tobacco dependence) will not be expected until February 1, 2014.

June 14, 2013