On-Site Facility Evaluation by r900ws

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									L. Gale Buckner, Commissioner                                      DEPARTMENT OF JUVENILE JUSTICE
Office Health Services                                            3408 Covington Highway Decatur, Georgia 30032
Michelle Staples-Horne, MD, MPH                                   404-508-6681   FAX: 404-508-7330
Medical Director


                                       Office of Health Services
                                   RHSA Quarterly Medical Unit Report
Facility Name:

Facility Visits Dates:                                                Quarter Facility Report

DHA Name:                                                       Facility Director Name:

NP/PA Name:                                                     Facility Physician Name:

Dentist Name:                                                   Facility Bed Capacity:

Clinic Hours M-F:                                               Clinic Hours Sat-Sun:


Medical Unit Staffing Patterns-Recruitment Activities-Concerns/Issues Compliance Rating: C         NC

Total # of FT RN Positions:

Total # of PT RN Positions:

Total # of Medical Staff Vacancies:

Date of Vacancy:

Hiring Status with dates and timeframes:

Hiring outcome:

Detailed RHSA comments and observations:

RHSA Recommendation:          N     Y:


QA/CQI – monthly/quarterly meetings, reports, -----Compliance Rating: C         NC

Monthly Medical Staff Meetings Dates:

Monthly Infection Control Reports Dates and Results:

10% Medical Records Audit Dates and Results with detailed CAP’s implemented:

Medical Records Storage/Order:

JTS User Compliance/Issues:

DJJ and Vendor Pharmacy Audit Dates and Results:

Medical Unit Supplies and Equipment Inventory Audit Dates/Results:

Detailed RHSA comments and observations:

RHSA Recommendation:          N     Y:




Rev. 10/11
                    (RHSA must submit this report to the OHS no later than the 15th business of the month)
L. Gale Buckner, Commissioner                                        DEPARTMENT OF JUVENILE JUSTICE
Office Health Services                                              3408 Covington Highway Decatur, Georgia 30032
Michelle Staples-Horne, MD, MPH                                     404-508-6681   FAX: 404-508-7330
Medical Director



Medical Intakes Rating Percentage : C      NC       N/A    (explain)          JTS STATS REPORTS

Number Required for the Quarter:

Number completed on time:

Number completed late:

Number not completed:

On-Time Percentage Rating for the current Quarter:

On-Time Percentage Rating for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:        N      Y:


Nurse Health Appraisals Rating Percentage : C        NC       N/A      (explain)   JTS STATS REPORTS

Initial NHA - number required for the Quarter:

Initial NHA - number completed On-Time:

Initial NHA - number completed late:

Initial NHA - umber not completed:

Initial NHA - On-Time Percentage for the Quarter:

Review NHA - number required for the Quarter:

Review NHA - number completed late:

Review NHA – not completed:

Review NHA - number completed On-Time:

Review NHA – On-Time Percentage for the Quarter:

Total On-Time NHA percentage for the current Quarter:

Total On-Time NHA percentage for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:        N      Y:


INITIAL Physical Exams Rating Percentage : C         NC     N/A        (explain)     JTS STATS REPORTS

3 Day PE - number required for the Quarter:


Rev. 10/11
                  (RHSA must submit this report to the OHS no later than the 15th business of the month)
L. Gale Buckner, Commissioner                                         DEPARTMENT OF JUVENILE JUSTICE
Office Health Services                                               3408 Covington Highway Decatur, Georgia 30032
Michelle Staples-Horne, MD, MPH                                      404-508-6681   FAX: 404-508-7330
Medical Director

3 Day PE - number completed On-Time:

3 Day PE - number completed late:

3 Day PE – not completed:

3 Day PE - On-Time Percentage for the current Quarter:

3 Day PE - On-Time Percentage for the last reported Quarter:

7 Day PE - number required for the Quarter:

7 Day PE - number completed On-Time:

7 Day PE - number completed late:

7 Day PE – not completed:

7 Day PE – On-Time Percentage for the current Quarter:

7 Day PE – On-Time Percentage for the last reported Quarter:

Total On-Time PE percentage for the current Quarter:

Total On-Time PE percentage for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:        N     Y:


REVIEW Physical Exams Rating Percentage: C           NC        N/A     (explain)      JTS STATS REPORTS

3 Day Review PE - number required for the Quarter:

3 Day Review PE - number completed On-Time:

3 Day Review PE - number completed late:

3 Day Review PE – not completed:

3 Day Review PE - On-Time Percentage for the current Quarter:

3 Day Review PE - On-Time Percentage for the last reported Quarter:

7 Day Review PE - number required for the Quarter:

7 Day Review PE - number completed On-Time:

7 Day Review PE - number completed late:

7 Day Review PE – not completed:

7 Day Review PE – On-Time Percentage for the current Quarter:

7 Day Review PE – On-Time Percentage for the last reported Quarter:

Rev. 10/11
                 (RHSA must submit this report to the OHS no later than the 15th business of the month)
L. Gale Buckner, Commissioner                                         DEPARTMENT OF JUVENILE JUSTICE
Office Health Services                                            3408 Covington Highway Decatur, Georgia 30032
Michelle Staples-Horne, MD, MPH                                   404-508-6681   FAX: 404-508-7330
Medical Director

Total On-Time Review PE percentage for the current Quarter:

Total On-Time Review PE percentage for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:         N     Y:


ANNUAL Physical Exams Rating Percentage: C            NC        N/A     (explain)            JTS STATS REPORTS

Annual PE - number required for the Quarter:

Annual PE - number completed On-Time:

Annual PE - number completed late:

Annual PE – not completed:

Annual PE - On-Time Percentage for the current Quarter:

Annual PE - On-Time Percentage for the last reported Quarter:

RHSA Recommendation:         N     Y:


Dental Exams JTS Task Report (60) & (6 months)---Compliance Rating : C              NC        N/A    (explain) (JTS Task Reports)

60 Days Dental Exams Results/Findings

6 Months Dental Exams Results/Findings

RHSA Recommendation:         N     Y:


Routine Screenings and Evaluations -Compliance Rating: C          NC        N/A          (explain)   (JTS Task Reports)

Chronic Care Clinic Visits for the current Quarter

Chronic Care Clinic Visits for the last reported Quarter

Total number of outside treatment referrals for the current Quarter

Total number of outside treatment referrals for the last reported Quarter

Detailed RHSA comments and observations:

RHSA Recommendation:         N     Y:


Medical Request for Services Compliance Rating: C          NC         N/A   (explain) (JTS Task Reports)

Total Number of Help Requests for the current Quarter:

Total Number of Help Requests for the last reported Quarter:

Rev. 10/11
                  (RHSA must submit this report to the OHS no later than the 15th business of the month)
L. Gale Buckner, Commissioner                                      DEPARTMENT OF JUVENILE JUSTICE
Office Health Services                                            3408 Covington Highway Decatur, Georgia 30032
Michelle Staples-Horne, MD, MPH                                   404-508-6681   FAX: 404-508-7330
Medical Director

Help Requests completed On-Time:

Help Requests completed late:

Help Requests not completed:

Total Help Requests On-Time percentage for the current Quarter:

Total Help Requests On-Time percentage for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:         N     Y:


Special Incidents Reports (Body Sheets) Compliance Rating: C         NC          N/A    (explain)

Total Number of SIR Reports of Youth Injuries (ROYI) for the current Quarter:

Total Number of SIR Reports of Youth Injuries (ROYI) for the last reported Quarter:

Detailed RHSA comments and observations:

RHSA Recommendation:         N     Y:


RHSA ADDITIONAL ACTIVITIES: TECHNICAL ASSISTANCE, FACILITY SUPPORT, ETC. (MANDATORY)



REPORT FINDINGS SHARED AND DISCUSSED WITH FACILITY DIRECTOR/DESIGNEE: (MANDATORY)




Regional Health Service Administrator:

Date of Report:




Rev. 10/11
                  (RHSA must submit this report to the OHS no later than the 15th business of the month)

								
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