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Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
LOCUS MIFAST Fidelity Scale (Version 2/13/18)
Today’s Date: 5/23/2018
Assessor’s Names:
1. Dana Fuller
2. Julie Hudson
3. Denequa Mixon-Young
Organization Name: Ausable Valley Community Mental Health
Organization Address: Street: 1199 W. Harris Avenue Suite:
City: Tawas City State/Zip: MI, 48764
Organization Contact: Name: Trish Otremba Title: Chief Quality Officer
Phone Number: 989-362-8636 Email: [email protected]
PIHP/CMHSP Name: Northern Michigan Regional Entity
PIHP Region #: 2
Sources Used for Fidelity and GOI Assessment Number of trained LOCUS Trainers: 1
Check all that apply. Indicated number as requested.
☒ Chart/Record Review
☒ Team/Practitioner Observation/Interview
☒ Supervisor Observation/Interview
☒ LOCUS Trainer Observation/Interview
☐ LOCUS Training Observation
☒ LOCUS Case Scoring #10 completed:
☒ Organizational Document Review
☐ Other staff Interview
☒ Consumer Interview #1 Interviewed:
☐ Family Member Interview #0 Interviewed:
Number of adult consumers served by organization: 600
Date LOCUS implemented within organization: 11/2016
LOCUS Implementation Work Plan from Site Review Outcome Scoring
Purpose: Michigan Fidelity Assistance Support Team (MIFAST) has
prepared this work-plan to assist with implementation and process
improvement based on the scoring of the Level of Care Utilization System
(LOCUS) Site Review Report. The astute implementation work group will
be able to use this work plan as agenda, minutes and tracking of the agencies
efforts to implement the LOCUS, as well as for a guide in choosing the focus
for the next year’s efforts to improve supports and services. We recommend
that you choose the areas from the scoring chart and use this work plan to
chart the activities around improvement of those items.
L1. Program Support
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Definition: The organization has clearly articulated purpose and use processes for LOCUS
Rationale: Within behavioral health services staff members at all levels embrace and support the use of the LOCUS as a consistent measure of the
level of care.
1 2 3 4 5 L1. Program Support.
The organization has clearly articulated
purpose and use processes for LOCUS,
based on the following sources:
1. PIHP/CMHSP Organizational
Leadership
2. Organizational Leadership (as
applicable): Executive Director,
Clinical Director, Program Managers 3. LOCUS Trainers and/or Supervisors
4. Practitioners using LOCUS
5. Written materials (e.g., brochures,
policies, procedures, etc.).
Sources: Interviews, discussion, written
materials.
No more than 1 of the 5
sources shows clear
understanding of the
program philosophy
OR
All sources have
numerous major areas
of discrepancy
☐
2 of the 5 sources show
clear understanding of
the program philosophy
OR
All sources have
several major areas of
discrepancy
☐
3 of the 5 sources show
clear understanding of
the program philosophy
OR
Sources mostly aligned
to program philosophy,
but have one major area
of discrepancy
☐
4 of the 5 sources show
clear understanding of
the program philosophy
OR
Sources mostly aligned
to program philosophy,
but have one or two
minor areas of
discrepancy
☒
All 5 sources display a
clear understanding and
commitment to the
program philosophy.
☐
Strengths:
● There is evidence of enthusiasm and buy in that was consistently expressed in all interviews with Chief Clinical Officer, Chief Operating
Officer, Practitioner, Trainer, and Program Manager. Upper leadership is reported to have participated in formal training for LOCUS as well.
● Implementation of LOCUS was described by both leadership and clinical staff as being well received, positive and reported to feel like a
natural shift to support level of care and services provided.
● Leadership has demonstrated support for LOCUS by requiring all new staff to be trained.
Recommendation of the site review team (None if the score is a 5):
1. It is suggested that the organization develop written policies and procedures, including procedural steps, on how LOCUS supports overall
operations, including quality. Recommend that written policies are developed which address:
a. Purpose of LOCUS
b. Rationale and reason for determining frequency of use.
c. Use of LOCUS within the person centered planning process.
Work Plan Activity Log – Based upon Score and Recommendations (to be completed by the organization):
L2. Eligibility/Client Identification
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Definition: All individuals in adult behavioral health/substance use programs receive a LOCUS for level of care determination.
Rationale: To ensure that individuals seeking and receiving services receive consistently appropriate services for the care needs.
1 2 3 4 5 L2. Eligibility / Client Identification.
A LOCUS Level of Care is identified for
all individuals with severe mental illness within the organization. Elements:
1. LOCUS is used as part of eligibility
determination.
2. LOCUS is used for initial level of care
determination.
3. LOCUS level of care is used for
transitions
4. LOCUS level of care is used for
discharge.
Sources: Written documents such as
policies/procedures, record reviews, etc. (based on expected number of LOCUS
scores for consumer).
No elements are
observed or it is highly
inconsistent.
☐
The majority of records
(greater than 51%) have
at least one element.
☐
The majority of records
(greater than 51%) have
at least two elements.
☒
The majority of records
(greater than 51%) have
at least three elements.
☐
The majority of records
(greater than 51%) have
all four elements
☐
Strengths:
● Once the agency started using LOCUS, a score has been completed at time of eligibility, initial level of care assessments and at annual
review.
● Clinician and Program Manager alerts have been installed within PCE EMR to support staff in completing LOCUS for each individual.
● Clinical rationale is required for all clinical overrides and must be reviewed by Program Manager.
Recommendation of the site review team (None if the score is a 5):
1. While it is clear that LOCUS is being used for initial LOC determination, it is not evident that it is being used for transit ions and discharge.
It is recommended that agency consider developing a written process that can serve as a guideline for clinician’s use of LOCUS during
transitions and discharge planning. This would assist with monitoring progress and provide outcome measures.
2. It is suggested that clinician trends, such as interpretation of independent criteria and clinical overrides, in scoring LOCUS be identified by
pulling data and sharing data with staff.
3. Documentation for clinical justification for the LOCUS assessments regarding overrides were either not documented or did not support the
recommended level of care. It is suggested that clinician trends be identified and appropriate action planning occur to address the need for
including clinical rationale for overrides in the EHR record. (This may include supervision, training, measurement tracking, policy
development, etc). This would also assist with monitoring progress, identifying needs, and measuring outcomes.
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Work Plan Activity Log – Based upon Score and Recommendations:
L3. LOCUS Completion
Definition: A LOCUS is completed for all adults eligible for behavioral health/substance use services.
Rationale: Completing a LOCUS for eligible adults creates a system or consistency and equity in service delivery.
1 2 3 4 5 L3. Use Measurement.
The LOCUS is used with eligible
individuals within the organization.
1. A LOCUS level of care is determined
for all individuals with severe mental
illness within the organization
regardless of service (i.e. ACT, case management, outpatient therapy, etc.)
Sources: Interview, Written documents
such a policy/procedures, record reviews,
etc.
‹20% of individuals
have LOCUS
completed.
☐
21%-40% of
individuals have
LOCUS completed.
☐
41%-60% of
individuals have
LOCUS completed.
☐
61%-80% of
individuals have
LOCUS completed.
☐
81%+ of individuals
have LOCUS
completed.
☒
Strengths:
● The organization has displayed positive commitment and support to LOCUS utilization. Based on staff and supervision interview, chart
review, management alerts, it is clear that the LOCUS is being utilized consistently at time of intake and annual review.
Recommendation of the site review team (None if the score is a 5):
N/A
Work Plan Activity Log – Based upon Score and Recommendations:
L4. Timeliness
Definition: LOCUS is completed within a timely manner based on organizational policy.
Rationale: Timely completion of the LOCUS results in improved quality of service.
1 2 3 4 5
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L4. Timeliness
LOCUS is used within a timely manner
(minimum annually or per organizational
policy).
(Look back three years or when LOCUS was implemented, whichever is earlier).
Sources: Interview, Record Review
‹20% of individuals
have LOCUS
completed in a timely
manner.
☐
21%-40% of
individuals have
LOCUS completed in a
timely manner.
☐
41%-60% of
individuals have
LOCUS completed in a
timely manner.
☐
61%-80% of
individuals have
LOCUS completed in a
timely manner.
☐
81%+ of individuals
have LOCUS
completed in a timely
manner.
☒
Strengths:
● Based on chart review and staff/leadership interviews, there is evidence that the LOCUS is completed consistently at time of intake and
annual review.
● The electronic notification system within PCE EMR is a positive support to completing the LOCUS in timely manner.
Recommendation of the site review team (None if the score is a 5):
N/A
Work Plan Activity Log – Based upon Score and Recommendations:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L5. Assessment
Definition: The LOCUS is used in conjunction with other relevant tools to provide a full picture of individuals/ needs
Rationale: Comprehensive assessments will identify individuals’ level of care needs and progress toward recovery.
1 2 3 4 5 L5. Assessment.
The LOCUS is used in conjunction with
other relevant tools to provide a full picture
of consumer needs. Scoring of the LOCUS
is based upon feedback obtained from
review of clinical history, current level of
functioning, related documentation from
ancillary sources, direct input from
individual receiving services, etc. Based on interviews with Intake/Assessment
Clinical, Primary Clinician, and
Supervisory staff. Comprehensive
assessments completed prior to LOCUS
scoring include:
1. LOCUS
2. Biopsychosocial
3. Psychiatric Evaluation/Medication
Review
4. Medical Information 5. Substance Use Assessment (as
applicable)
Sources: Interviews, written documents
such as record reviews.
LOCUS alone
Or
None
☐
One assessment prior
plus the LOCUS
☐
Two assessments prior
plus the LOCUS
☐
Three assessments prior
plus the LOCUS
☒
Four assessments prior
plus the LOCUS
☐
Strengths:
● Once the LOCUS was implemented, it has been done consistently and in conjunction with Patient Health Questionnaire (PHQ-9) to assist
with initial level of care decisions.
● For 9/10 charts reviewed, it was documented that additional comprehensive assessments, including Biopsychosocial, Psychiatric
Evaluation/Medication Review, Medical Information, and Substance Use Assessments (when applicable) were completed within 4-6 weeks
of the LOCUS score being done.
Recommendation of the site review team (None if the score is a 5):
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
1. While the intent of the relationship of the LOCUS being based on the assessments and the treatment plan was verbalized by clinical trainer
and clinician; it is not clearly evident within the clinical charts viewed and how it is part of the person centered planning process. It is
suggested that the golden thread be observed throughout treatment planning. Assessments should naturally support the scoring of the
LOCUS which then assists with determining the appropriate level of care and further guides with goal development and treatment planning.
The organization will want to consider developing policy and processes which promote this concept.
Work Plan Activity Log – Based upon Score and Recommendations:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L6. Training Approach
Definition: The organization has a LOCUS training approach that promotes reliability, fidelity, and sustainability.
Rationale: The design of a consistent and thorough training approach reduces drift and promotes consistency of level of care decisions.
1 2 3 4 5 L6. Training Approach
The organization has a LOCUS training
approach that promotes reliability, fidelity,
and sustainability.
1. The LOCUS training approach
promotes reliability within training.
2. The LOCUS training approach
promotes fidelity to the use of the LOCUS tool.
3. The LOCUS training approach
contains elements promoting
sustainability of training across time.
4. The LOCUS training approach is
supported by written documentation
(i.e. policies, procedures, processes,
etc.)
5. The LOCUS training approach is
implemented successfully across the
organization.
Sources: Interviews, organizational
process documents.
No more than 1 of the 5
measures are evident
OR
All measures have
numerous major areas
of incompleteness.
☐
2 of the 5 measures are
evident
☒
3 of the 5 measures are
evident
☐
4 of the 5 measures are
evident
☐
All 5 measures are
evident
☐
Strengths:
● The organization is committed to training all clinical staff.
● Initial training of all existing staff has occurred.
● The organization is using materials from the original source.
● The LOCUS trainer has demonstrated enthusiasm, commitment to the tool and has expressed interest in refresher training.
Recommendation of the site review team (None if the score is a 5):
1. It is recommended that a plan be developed for trainer sustainability. Adding additional trainers/coaches to assist with collaboration and
availability should be considered.
2. It is suggested that the agency develop written policies that address approach for initial and ongoing trainings/coaching.
3. Develop plan for ongoing training/coaching and competency assessment that assists with determination of individual level competency in
LOCUS use.
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
4. The agency may consider creating and utilizing organizationally specific vignettes in their LOCUS training, which reflect the organization’s
levels of care.
Work Plan Activity Log – Based upon Score and Recommendations:
L7. Training Implementation
Definition: LOCUS training is implemented to promote reliability, fidelity, and sustainability.
Rationale: Practitioner training and retraining are warranted to ensure that services are provided in a standardized manner across practitioners and
over time.
1 2 3 4 5 L7. Training Implementation
Based on the LOCUS training approach,
LOCUS training is implemented that
promotes reliability, fidelity, and
sustainability.
1. LOCUS training is taught by certified
LOCUS Trainers who have completed
a LOCUS train-the-trainer course.
2. The LOCUS curriculum used for
training promotes reliability and fidelity. (Yes/No)
3. Existing practitioners successfully
complete LOCUS training. (Yes/No)
4. Practitioners successfully complete
LOCUS training within the agency
defined orientation period for new
hires.
5. The agency has a written plan to
ensure that practitioners have the
opportunity to refine their LOCUS use
skills at regular intervals as defined by
the organization’s written guidelines (policy, procedure, process, etc.).
Sources: HR Documents, Interviews,
record of staff trainings, procedures and
written documents.
No more than 1 of the 5
measures are evident
OR
All measures have
numerous major areas
of incompleteness
☐
2 of the 5 measures are
evident
☐
3 of the 5 measures are
evident
☒
4 of the 5 measures are
evident
☐
All 5 measures are
evident
☐
Strengths:
● The agency has a training plan.
● There is an identified system in place for training new clinical staff.
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
● The agency’s identified LOCUS trainer has displayed positive regard and commitment to the LOCUS tool. She was trained through
MDHHS Train the Trainer and utilizes the original material.
Recommendation of the site review team (None if the score is a 5):
1. Develop a plan for trainer sustainability.
2. It is recommended that the organization implements a process for enhancing LOCUS skills. This may include: ongoing/annual training,
clinician competency assessment, clinician specific skill refinement.
3. The organization should consider developing a coaching process to assist with clinical collaboration and availability.
4. It is suggested that the process is supported by written policies/procedures.
Work Plan Activity Log – Based upon Score and Recommendations:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L8. Supervision
Definition: Practitioners have the opportunity to receive documented structured/scheduled, person-centered, and supportive feedback on their use of
the LOCUS. This can include one-on-one as well as group supervision. However team or similar meetings are not considered supervision.
Rationale: Regular supervision is critical for individualizing treatment but also for ensuring the standardized use of the LOCUS to adults served.
1 2 3 4 5 l.8. Supervision
Practitioners have the opportunity to
receive documented structured/scheduled, person-centered, and supportive feedback
on their use of the LOCUS. Each
supervision session includes one or more
of the following:
● Review of LOCUS reports by
clinician.
● Level of care maintenance
● Clinician trends in LOCUS scoring
(example: loading stress into all
dimensions, scoring individuals to a
desired setting, difficulties with independent criteria).
● Clinician challenges in using LOCUS
● Clinical development needs and
opportunities for improvement are
documented
Sources: Interviews, written documents,
meeting schedules, group/meeting agendas
and/or minutes.
Practitioners receive no
documented
supervision (group or
individual) and/or they express not feeling
supported in use and
understanding of
LOCUS
☐
Supervision is available
upon request or is
unstructured and/or
inconsistent in practice.
☒
Scheduled group
supervision and/or team
meetings are evident at
least once per quarter and include
documented LOCUS
discussion.
☐
1:1 or group
supervision is provided
monthly and includes
documented LOCUS discussion.
☐
1:1 structured
supervision that
includes documented
LOCUS discussion is provided at least
monthly.
☐
Strengths:
● Documented supervision notes address LOCUS training completion.
● Supervisors and Program Managers are reported to be approachable and there is an “open door” policy. They are alerted to clinical overrides
and review clinical rationale provided.
● Clinical supervision is provided by the agency at least twice monthly.
Recommendation of the site review team (None if the score is a 5):
1. It is suggested that supervision include documented discussions of LOCUS usage including clinician trends, level of care maintenance, and
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
specific clinician challenges.
2. Recommend that clinical overrides are reviewed with staff during supervision, and it is ensured that clinically sound documentation of the
override is included in the EMR.
3. Recommend collaboration with clinical staff in determining what type of data reports will be collected and analyzed. Clarify plan as to how
these reports will be utilized in improving individual outcomes and identifying needs for additional supports/services.
Work Plan Activity Log – Based upon Score and Recommendation:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L9. Process Monitoring
Definition: The organization uses a standardized approach to LOCUS related data collection, analysis, and use.
Rationale: Systematic and regular collection of process data is imperative in evaluating fidelity to the LOCUS.
1 2 3 4 5 L9. Process Monitoring
Supervisors and program leaders monitor
the process of implementing the LOCUS
consistent with organizational policy or
procedure. Monitoring involves a
standardized approach.
1. There is a standardized approach.
2. There are predetermined timeframes
for monitoring of no less than every six (6) months.
3. Implementation of LOCUS is tied to
quality management.
4. The results of monitoring are used to
guide LOCUS use improvements.
Sources: Policies, procedures, protocols
No attempt at monitoring
process is made
☒
Informal process
monitoring is used at
least annually
☐
Process monitoring is
deficient on 2 of these 3
criteria: (1)
Comprehensive &
standardized; (2)
Completed every 6
months; (3) Used to
guide program
improvements
OR Standardized
monitoring done
annually only
☐
Process monitoring is
deficient on 1 of these 3
criteria: (1)
Comprehensive &
standardized; (2)
Completed every 6
months; (3) Used to
guide program
improvements
☐
Standardized
comprehensive
process monitoring
occurs at least every
6 months and is used
to guide program
improvements
☐
Strengths:
● The organization is in discussion and has expressed an interest in developing a process for monitoring data obtained through LOCUS
implementation.
Recommendation of the site review team (None if the score is a 5):
1. It is recommended that identification of LOCUS related data collection, analysis, and utilization be determined and implemented.
Some ideas include: percent of charts with “override” disposition, focusing on levels of care and the “reason” for doing LOCUS (initial,
transitions, discharges, other times as identified), percent of up vs down override dispositions, and timeframes between assessment, LOCUS
scores, and treatment planning.
2. It is suggested that plan for data collection and utilization is supported by policies/procedures/protocols.
Work Plan Activity Log – Based upon Score and Recommendation:
L10. Outcome Monitoring
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Definition: Program leaders share LOCUS data with practitioners in an effort to improve services.
Rationale: Systematic and regular collection of LOCUS outcome data is imperative in evaluating level of care effectiveness. Outcome monitoring
involves a standardized approach that uses the results to improve the quality of services provided.
1 2 3 4 5 L10. Outcome Monitoring
Supervisors / organizational leaders
monitor the outcomes of LOCUS use.
Consider:
1. Are individuals served receiving
services reflective of the LOCUS level
of care (LOC) recommendation?
2. Do prior LOCUS scores reflect the
appropriate LOC? “Example: Does the LOCUS score support a transition
to an ACT team?”
3. The frequency of override use is less
than 10 percent within a program and
across the agency.
4. Clinical rationale for overrides is
documented and appropriate.
Sources: Quality documents/reports,
clinical records, etc.
No outcome monitoring
occurs.
OR
Organization has not
begun LOCUS outcome
planning.
☐
Outcome monitoring
occurs at least once a
year, but results are not
shared with
practitioners
OR
Organization is in the
beginning phases of
LOCUS outcome monitoring planning.
☒
Standardized outcome
monitoring occurs at
least once a year, and
results are shared with
practitioners
OR
Organization has a
beginning LOCUS
outcome monitoring plan in place and it
includes sharing results
with practitioners.
☐
Standardized outcome
monitoring occurs at
least twice a year, and
results are shared with
practitioners
☐
Standardized
outcome monitoring
occurs quarterly and
results are shared
with practitioners
☐
Strengths:
● Leadership has asked staff about what data they would need and this is being discussed in clinical meetings.
● Program Manager reviews clinical overrides when notified by clinician or EMR alert.
Recommendation of the site review team (None if the score is a 5):
1. While the recommended frequency of override use is less than 10%, the organization should make a determination regarding their acceptable
override use. It is recommended that the agency’s current use of overrides be clarified.
2. It is suggested that the organization collect and review override data to understand clinical trends.
3. Develop a monitoring process to support the reduction and appropriate use of overrides.
4. It is recommended that completing a LOCUS score at time of transitions and discharges is implemented. This will assist with providing
clinical rationale and support for level of care changes, assist with identifying current needs, and help to measure progress.
Work Plan Activity Log – Based upon Score and Recommendation:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
L11. Quality Assurance (QA)
Definition: A good quality assurance approach or plan helps to guide and sustain the implementation, makes recommendations for improvement,
and monitors outcomes.
Rationale: Systematic and regular collection of outcome data is imperative in evaluating program effectiveness.
1 2 3 4 5 L11. Quality Assurance (QA)
The agency has a QA Committee,
clinical/implementation steering committee, or similar mechanism with an
explicit plan to review LOCUS
trends/gaps/outcomes/ organizational needs
a minimum of every 6 months, reports to
leadership, and implements corrective
changes/approaches.
Sources: Agendas, minutes documents,
interviews, etc.
No review or no
committee
☐
QA committee has been
formed, but no reviews
have been completed
☒
Explicit QA review
occurs less than
annually
OR QA review is
superficial (does not
fully address the issues
at hand)
☐
Explicit QA review
occurs annually
☐
Explicit review
every 6 months by a
QA group
☐
Strengths:
● Staff from all programs are represented at the Clinical Quality Improvement Committee (CQIC).
● It is reported that LOCUS training and utilization is discussed within the quality assurance process.
● It is documented in agency notes that LOCUS training is being supported and addressed.
Recommendation of the site review team (None if the score is a 5):
1. It is recommended that agency develop an explicit plan to review LOCUS trends/gaps/outcomes/organizational needs including identifying
frequency of review periods and clarifying what type of data will be collected and analyzed.
2. It is recommended that these findings are shared with leadership and all levels of the organization.
3. It is suggested that a process be developed to address corrective changes/approaches as needed.
Work Plan Activity Log – Based upon Score and Recommendation:
L12. Individual Choice
Definition: Use of the LOCUS is integrated and reflective of clinical best-practice and person-centered philosophy within the organization.
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Rational: Individuals served play a vital role in managing their illness, making progress toward goals, and becoming effective participants in the
treatment process.
1 2 3 4 5 L12. Individual Choice
All individuals receiving services are offered choices consistent with their
recovery choices and clinical needs even if
outside of the LOCUS level of care
recommendation. Individuals are able to
access chosen services if clinically
necessary. Evidence is reflected in the
following sources:
1. Individuals receiving services
2. Clinician interviews
3. Documentation in the record
4. Supervisor and/or administrative
interviews 5. Organizational policy and
procedure (LOCUS/Person-
centered planning specific).
Sources: Individuals receiving services,
clinician interviews, documentation in the
record, supervisor/administrative
interviews, organizational policy and
procedure.
Evidence is reflected in
only one source.
☐
Evidence is reflected in
two sources.
☒
Evidence is reflected in
three sources.
☐
Evidence is reflected in
four sources.
☐
Evidence is reflected
in all five sources.
☐
Strengths:
● Individual interviewed was pleased with services that they were receiving. Stated that therapist had offered more services at multiple times,
and she knows that services are available if needed.
● Per chart review, it appeared as though individuals were consistently satisfied with their services.
● Based on staff and individual interview, a person centered culture was fostered and was evident.
Recommendation of the site review team (None if the score is a 5):
It was noted that the LOCUS score and recommended level of care did not consistently match the level of care services utilized by the individual. It
was unclear if reason for this inconsistency was due to clinician error in scoring tool, a resource issue, or client preference.
1. It is recommended that the organization review these inconsistencies and develop an approach to encourage improvement in the areas
identified.
Work Plan Activity Log – Based upon Score and Recommendation:
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Developed by the MDHHS LOCUS MIFAST Project Team (2017). Based on LOCUS, GOI, and other fidelity instruments.
Use with written permission only.
Agency Name: Ausable Valley Community Mental Health Date of Visit: 5/23/2018
Reviewers Names: Dana Fuller, Julie Hudson
Reviewer 1 Reviewer 2 Consensus
L1 Program Support
4
L2 Eligibility/Client Identification
3
L3 LOCUS Completion
5
L4 Timeliness
5
L5 Assessment
4
L6 Training Approach
2
L7 Training Implementation
3
L8 Supervision
2
L9 Process Monitoring
1
L10 Outcome Monitoring
2
L11 Quality Assurance
2
L12 Individual Choice
2
Total Sum of Consensus Row 35
Consensus Row Sum Divided by 12 2.92
Total Mean Score 35