Momentum-cares | PRP AUDIT TOOL

Date(Required)

Reviewing Staff Name:(Required)

First Last

Signature:(Required)

Assigned Staff Name:(Required)

First Last

Consumer Name:(Required)

First Last

Type of Consumer:(Required)

Referral Date:(Required)

Proof of Guardianship:(Required)

Was an initial screening completed?(Required)

Date of Initial Screening:(Required)

5 days from the referral date.

Is a PDF Intake Packet Included?(Required)

Was verbal consent documented for assessment, intake, and ongoing services?(Required)

Intake packet items (Due annually):(Required)

Initial Assessment:(Required)

Date of Assessment:(Required)

DLA-20:(Required)

Initial IRP:(Required)

Date of IRP:(Required)

Have other IRPs been completed?(Required)

How many?(Required)

Has this consumer been discharged?(Required)

Date of Discharge:(Required)

Completed discharge summary:(Required)

Date of Summary:(Required)

Has a discharge letter been sent?(Required)

Date Sent:(Required)

Discharged from Optum:(Required)

Date Discharged:(Required)

Additional notes:

Email:(Required)

PRP AUDIT TOOL