ASAM PPC-2 - Florida Department of Children & Families

Department of Children and Families - Substance Abuse
Validation Tool – Florida Supplement to the American Society of Addictions Medicine - Patient Placement
Criteria-2
Provider Agency: Date of Review: ____/____/____
ASAM Level of Care: ADM Reviewer: ____________________________
Is this an enrolled substance abuse client who is funded in whole or in part by ADM or Medicaid funds?___(Y/N)
TABLE 1: CLIENT DEMOGRAPHICS/PLACEMENT INFORMATION
ASAM Form = Item is completed on the ASAM form
Client Record = Item is found in the client record
Match = Items on the ASAM form and in the client record match
ID#:_______________________________
Specify Source:
(circle one) SSN PseudoSSN MIS MR SISAR
ASAM Level of Care Recommendation: ____________________________
Date on ASAM Form: ADMISSION ___/___/___
Continue, if there is a match in each of the above columns.
TABLE 2: QUALITATIVE ANALYSIS
ASAM Form = Question is answered on the ASAM form
Client Record = Question is answered in the client record
Match = Answers on the ASAM form and in the client record match
*REFERENCE AT LEAST 1 DOCUMENTATION WITHIN THE CLIENT RECORD
Dimension 1 Criteria: Intoxication and Withdrawal
*Psychosocial report (substance abuse history, diagnostic impression,
recommendations); progress notes
Dimension 2 Criteria: Biomedical Conditions
*Psychosocial report (medical history, recommendations); physical exam (as
appropriate for level of care); lab tests; progress notes
Dimension 3 Criteria: Emotional/Behavioral Conditions
*Psychosocial report (psychiatric/psychological history, diagnostic impression,
recommendations); past evaluations; progress notes
Dimension 4 Criteria: Treatment Acceptance/Resistance
*Psychosocial report (summary); treatment plan; progress notes
Dimension 5 Criteria: Relapse/Continued Use Potential
*Psychosocial report (summary); treatment plan; progress notes
Dimension 6 Criteria: Recovery Environment
*Psychosocial report (summary); treatment plan, progress notes
NOTES:
ASAM
FORM
�=yes
X = no .
ASAM
FORM
�= yes
X = no.
CLIENT
RECORD
�= yes
X = no .
CLIENT
RECORD
� = yes
X = no.
MATCH
� = yes
X = no
MATCH
�= yes
X= no
______(6) _______ (6) ______(6)
Validity Score: 75% (13/18) must be “met” for “Appropriate Placement” Score/Total: ______(18)
APPROPRIATE PLACEMENT: YES NO
(Circle one)
_______%

Department of Children and Families - Substance Abuse
Validation Tool – Florida Supplement to the American Society of Addictions Medicine - Patient Placement
Criteria-2
Provider Agency: Date of Review: ____/____/____
ASAM Level of Care: ADM Reviewer: ____________________________
Is this client still enrolled and funded in whole or in part by ADM or Medicaid funds? _______ (Y/N)
TABLE 1: CLIENT DEMOGRAPHICS/PLACEMENT INFORMATION
ASAM Form = Item is completed on the ASAM form
Client Record = Item is found in the client record
Match = Items on the ASAM form and in the client record match
ID#:_______________________________
Specify Source:
(circle one) SSN PseudoSSN MIS MR SISAR
ASAM Level of Care Recommendation: ____________________________
Date on ASAM PPC-2 Form: CONTINUED STAY ____/____/____
Continue, if there is a match in each of the above columns.
TABLE 2: QUALITATIVE ANALYSIS
ASAM Form = Question is answered on the ASAM form
Client Record = Question is answered in the client record
Match = Answers on the ASAM form and in the client record match
*REFERENCE AT LEAST ONE DOCUMENTATION IN THE CLIENT RECORD
Dimension 1 Criteria: Intoxication and Withdrawal
*Treatment plan(s); lab tests; progress notes
Dimension 2 Criteria: Biomedical Conditions
*Treatment plan(s); medical updates or referrals; progress notes
Dimension 3 Criteria: Emotional/Behavioral Conditions
*Treatment plan(s); results of psychiatric/psychological evaluations; progress
notes (referrals, follow-up appointments, medications)
Dimension 4 Criteria: Treatment Acceptance/Resistance
*Treatment plan(s); progress notes
Dimension 5 Criteria: Relapse/Continued Use Potential
*Treatment plan(s); progress notes
Dimension 6 Criteria: Recovery Environment
*Treatment plan(s); progress notes
NOTES:
ASAM
FORM
� =yes
X =no .
ASAM
FORM
�=yes
X =no .
CLIENT
RECORD
�=yes
X =no .
CLIENT
RECORD
�= yes
X = no .
MATCH
�=yes
X =no
MATCH
�=yes
X =no
______(6) _______ (6) ____ (6)
Validity Score: 75% (13/18) must be “met” for “Appropriate Placement” Score/Total: _____(18)
APPROPRIATE PLACEMENT: YES NO
(CIRCLE ONE)
_______%

Department of Children and Families - Substance Abuse
Validation Tool – Florida Supplement to the American Society of Addictions Medicine - Patient Placement
Criteria-2
Provider Agency: Date of Review: ____/____/____
ASAM Level of Care: ADM Reviewer: ____________________________
Has the client still been enrolled and funded in whole or in part by ADM or Medicaid funds? _______ (Y/N)
TABLE 1: CLIENT DEMOGRAPHICS/PLACEMENT INFORMATION
ASAM Form = Item is completed on the ASAM form
Client Record = Item is found in the client record
Match = Items on the ASAM form and in the client record match
ID#:_______________________________
Specify Source:
(circle one) SSN PseudoSSN MIS MR SISAR
ASAM Level of Care Recommendation: ____________________________
Date on ASAM Form: DISCHARGE/TRANSFER ____/____/____
Continue, if there is a match in each of the above columns.
TABLE 2: QUALITATIVE ANALYSIS
ASAM Form = Question is answered on the ASAM form
Client Record = Question is answered in the client record
Match = Answers on the ASAM form and in the client record match
*REFERENCE AT LEAST ONE DOCUMENTATION IN THE CLIENT RECORD
Dimension 1 Criteria: Intoxication and Withdrawal
*Treatment plan(s) completion; Discharge Summary; progress notes
Dimension 2 Criteria: Biomedical Conditions
*Treatment plan(s) completion; Discharge Summary; progress notes
Dimension 3 Criteria: Emotional/Behavioral Conditions
*Treatment plan(s) completion; Discharge Summary; progress notes
Dimension 4 Criteria: Treatment Acceptance/Resistance
*Treatment plan(s) completion; Discharge Summary; progress notes
Dimension 5 Criteria: Relapse/Continued Use Potential
*Treatment plan(s) completion; Discharge Summary; progress notes
Dimension 6 Criteria: Recovery Environment
*Treatment plan(s) completion; Discharge Summary; progress notes
NOTES:
ASAM
FORM
�=yes
X =no.
ASAM
FORM
�= yes
X = no.
CLIENT
RECORD
�=yes
X =no.
CLIENT
RECORD
�= yes
X = no.
MATCH
�=yes
X =no
MATCH
�= yes
X= no
______(6) _______ (6) _______ (6)
Validity Score: 75% (13/18) must be “met” for “Appropriate Placement” Score/Total: _______(18)
APPROPRIATE PLACEMENT: YES NO
(CIRCLE ONE)
________%

1. Is ASAM in client file?
ASAM PPC-2 Monitoring Tool
2. Were admission, continued stay, and discharge columns completed?
3. What was the client’s total length of stay?
4. Was it filled out correctly for level of treatment?
6. Did client meet all six dimensions for treatment placement?
7. Had the client been placed elsewhere prior to current placement?
8. Had there been a progress evaluation midway through treatment?
9. Were there any comments in the recommendation/notes section?
10. Had the client been placed after intake or at placed level of service?
11. How long did the client wait to be admitted into current level of
service?
12. Had the client been transferred from different levels of service?
13. Was the client-transferred to/from another level of service?
14. Did the client successfully complete treatment at discharge?
15. Did the counselor state that she was adequately trained?
16. Did the counselor see ASAM as a helpful placement and discharge tool?