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The NC Division of MH/DD/SAS has developed a comprehensive protocol, encapsulated within the 2010-2011 DWI Monitoring Tool 2 – Assessment/E508 system, designed to ensure meticulous evaluation and documentation practices for individuals with DWI (Driving While Impaired) offenses. This detailed monitoring tool serves as a critical resource for providers, offering a structured framework for assessing individuals’ needs and compliance with prevailing regulations. Essential areas covered by the tool include staff credentials, clinical assessments based on the DSM-IV diagnoses and ASAM Patient Criteria, documentation of client consent, and the procedural management of the e508 system for certification completion. Additionally, the tool provides guidelines for dealing with Driving While License Revoked (DWLR) assessments, incorporating specific diagnostic criteria and referral procedures for treatment based on these diagnoses. The instrument mandates thorough documentation of findings, requires acknowledgment of non-compliance areas and necessitates the development of Plans of Correction as guided by Division Policy ACC002 and the Office of DWI Services directives. By setting forth these stringent standards, the tool underscores the importance of rigorous assessment, accurate record-keeping, and proactive measures aimed at addressing identified deficiencies, thus reflecting a commitment to enhancing the quality of care and oversight for individuals involved in DWI cases.

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

Areas deemed not met are documented on the Review Findings and Exit Form. Forms are signed by the Provider indicating acknowledge of findings that result in Plan(s) of Correction as required by Division Policy ACC002 and the Office of DWI Services.

PROVIDER/FACILITY NAME:

PROVIDER CODE:

 

 

CLIENT NAME:

RECORD #:

 

 

ASSESSMENT DATE:

CONTROL #:

SYSTEM COMPLIANCE FOR ASSESSMENT/CERTIFICATE OF COMPLETION

0 = NOT MET; 1 = MET; 9 = NOT APPLICABLE

RATING

Check if this is a Driving While License Revoked (DWLR) Assessment

SECTION I: STAFF CREDENTIALS/APPROVALS – ASSESEMENT PROVIDERS

In accordance with 10A NCAC 27G.0104

1. Staff is qualified to complete assessments as verified by NCSAPPB.

1.

SECTION II: CLINICAL ASSESSMENT

2. Evidence of DSM-IV diagnosis is present as determined by clinical assessment.

DSM IV Codes: Alcohol Dependence 303.90:

_____

Alcohol Abuse 305.00:

_____

Other: Indicate Disorder or Code: _____

ADETs: No Diagnosis

_____

NOTE: FOR DWLR ASSESSEENTS: Enter “9” and complete Section IV.

3.Evidence of ASAM Patient Criteria is present as determined by clinical assessment.

4.Client Signature is present indicating they were given an updated list of all DWI Providers within their service area.

5.The client signature is present on the Consent Form for Release of Information and includes the various agencies for communicating and reporting findings. (10A NCAC 27G .3807 (d).

2.

3.

4.

5.

SECTION III: DOCUMENTATION: CERTIFICATE OF COMPLETION – e508 SYSTEM

In accordance with Division Policy 0108 eff. 2/1/2008 and Division Policy 1207 eff. 12/1/2007

6.There is evidence that Certificate of Completion was submitted within two (2) weeks of the assessment date.

Assessment Date:_____________ Date Sent to State Office: ____________

7.There is evidence that the provider has managed the e508 system to ensure every step of the process has been completed for the assessment. (Exceptions Noted).

8.The provider has made efforts to resolve holds/rejects within the e508 system that are associated with this client record. (Exceptions Noted).

6.

7.

8.

2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

Areas deemed not met are documented on the Review Findings and Exit Form. Forms are signed by the Provider indicating acknowledge of findings that result in Plan(s) of Correction as required by Division Policy ACC002 and the Office of DWI Services.

9.Certificate of Completion Form which indicates date sent to State Office has been signed by professional staff and placed within client file. (Date Sent to State Office does not indicate <blank>).

9.

SECTION IV: DRIVING WHILE LICENSE REVOKED – DWLR

In accordance with Statutory Reference G.S. 20-28

10.Diagnosis was based on clinical assessment that indicates:

a.Early Full Remission _____

b.Sustained Remission _____

c. Partial Remission

_____

d. Other:

_____

11.Client was referred to treatment based on diagnosis of partial remission.

OVERALL

10.

a.

b.

c.

d.

11.

COMMENTS: (Use Additional Comments Sheet as needed)

Findings require corrective actions: (Circle) YES

NO

Auditor Instructions

Use Comments section to indicate areas of noncompliance that result in a Plan of

Correction (POC) and provide details to support findings

Reviewer Signature:

Date:

2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

Areas deemed not met are documented on the Review Findings and Exit Form. Forms are signed by the Provider indicating acknowledge of findings that result in Plan(s) of Correction as required by Division Policy ACC002 and the Office of DWI Services.

ADDITIONAL COMMENTS

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2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

Areas deemed not met are documented on the Review Findings and Exit Form. Forms are signed by the Provider indicating acknowledge of findings that result in Plan(s) of Correction as required by Division Policy ACC002 and the Office of DWI Services.

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2010-2011 DWI Monitoring Tool 2

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File Characteristics

Fact Detail
Form Purpose This form is used for documenting the assessment and certification process for DWI (Driving While Impaired) services in North Carolina.
Governing Laws and Policies Assessments and certifications must adhere to Division Policies ACC002, 0108, and 1207, and comply with statutory references G.S. 20-28 and 10A NCAC 27G.0104 and 27G .3807(d).
Assessment Criteria Criteria include staff credentials, evidence of a DSM-IV diagnosis, evidence of ASAM Patient Criteria, and client's consent for release of information.
e508 System Compliance Evidence that the Certificate of Completion was submitted within two weeks of the assessment date and that all steps of the e508 system process have been completed are required.
Driving While License Revoked (DWLR) Assessment For DWLR cases, the form includes a section to enter a diagnosis and necessary referrals based on clinical assessment outcomes.
Provider Responsibility The provider must sign the form, acknowledging findings and indicating the need for plans of correction as required by Division Policy ACC002 and the Office of DWI Services.

Steps to Writing 508 From Nc Dwi Services

When a person faces the consequences of a DWI charge in North Carolina, one critical step in the process may involve completing the 508 Form from NC DWI Services. This document is designed to assess and document compliance with DWI service requirements. To properly complete this form, attention to detail and accuracy in providing the requested information are critical. Below are the step-by-step instructions to fill out the form accurately.

  1. Start with the Provider/Facility Name. Enter the name of the institution or provider handling the DWI service.
  2. Fill in the Provider Code. This is a unique identifier for the service provider.
  3. Proceed to the Client Name. Here, enter the full name of the individual receiving the assessment.
  4. Input the Record #. This is the client's specific record number for tracking and documentation purposes.
  5. Record the Assessment Date. Mark the date the assessment was conducted.
  6. Fill out the Control #. This number helps to control and track the assessment documentation.
  7. In the section marked System Compliance for Assessment/Certificate of Completion, mark the appropriate rating (0 = NOT MET, 1 = MET, 9 = NOT APPLICABLE) for each listed item.
  8. If applicable, check the box for Driving While License Revoked (DWLR) Assessment.
  9. Under Section I: Staff Credentials/Approvals, verify the staff's qualifications to perform the assessments.
  10. In Section II: Clinical Assessment, ensure to:
    • Indicate the presence of a DSM-IV diagnosis with corresponding codes.
    • Mark evidence of ASAM Patient Criteria.
    • Ensure the client's signature is present, indicating they have received a list of DWI providers.
    • Confirm the client’s signature on the Consent Form for Release of Information.
  11. For Section III: Documentation: Certificate of Completion:
    • Provide evidence that the Certificate of Completion was submitted timely.
    • Show management of the e508 system for assessment completion.
    • Document any efforts to resolve holds/rejects within the e508 system.
  12. In Section IV: Driving While License Revoked – DWLR, fill out the diagnosis based on the clinical assessment and record if the client was referred to treatment based on this diagnosis.
  13. Lastly, use the Additional Comments section for any further details or observations not covered in the form. This is crucial for a comprehensive understanding of the assessment outcome.
  14. Ensure the Reviewer Signature and Date at the bottom of the form are completed to validate the assessment.

After the form is fully completed, it's essential to review all entries for accuracy and completeness. This document plays a significant role in the management and monitoring of DWI services, facilitating the necessary interventions and support for individuals. Ensuring the form is correctly filled out and submitted in accordance with division policies promotes compliance and effective tracking of DWI assessments and outcomes.

Important Details about 508 From Nc Dwi Services

What is the purpose of the 508 Form from NC DWI Services?

The 508 Form from North Carolina DWI Services serves as a monitoring tool for ensuring that assessments and treatments for individuals charged with or convicted of Driving While Impaired (DWI) meet specific standards. It documents compliance with state regulations, including staff qualifications, the execution of clinical assessments, and the management of documentation such as the Certificate of Completion.

Who needs to complete the 508 Form?

Providers who are conducting assessments or offering treatment services to individuals with DWI charges are required to complete the 508 Form. This includes professionals who are qualified under the North Carolina Substance Abuse Professional Practice Board (NCSAPPB) and are working within DWI Services-approved facilities.

What are the key sections of the 508 Form?

The 508 Form features several key sections including Staff Credentials/Approvals, Clinical Assessment, Documentation, and specific considerations for Driving While License Revoked (DWLR) Assessments. Each section has various criteria that must be met or deemed not applicable, with evidence of compliance documented appropriately.

What happens if a provider does not meet the required standards on the 508 Form?

Areas not meeting the required standards are documented on the Review Findings and Exit Form. The provider must acknowledge these findings and develop a Plan of Correction as mandated by Division Policy ACC002 and the Office of DWI Services. This is part of ensuring quality and compliance in the treatment of DWI offenders.

How is the Certificate of Completion related to the 508 Form?

The Certificate of Completion is a critical document that demonstrates a client has successfully met the assessment and/or treatment requirements. The 508 Form requires evidence that this certificate was submitted to the state office within two weeks of the assessment date, ensuring timely and proper documentation of client progress.

What are DSM-IV codes, and why are they important in the 508 Form?

DSM-IV codes refer to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, a guideline for diagnosing and classifying mental disorders. Including DSM-IV codes in the 508 Form ensures that a clinical assessment has accurately identified any alcohol or substance use disorders, which is crucial for designing an effective treatment plan.

What criteria must be documented in the Clinical Assessment section?

In the Clinical Assessment section, documentation must include evidence of a DSM-IV diagnosis, ASAM (American Society of Addiction Medicine) Patient Placement Criteria, and client consent for the release of information, among other requirements. This section ensures that assessments are thorough and that clients are informed about their treatment options.

What steps are involved in managing the e508 system?

Managing the e508 system involves ensuring that every step of the assessment process is completed, resolving any holds or rejections associated with the client's record, and documenting efforts to address these issues. Proper management of the system is crucial for accurate tracking and reporting of compliance and treatments.

What is the significance of the client’s signature on the Consent Form for Release of Information?

The client's signature on the Consent Form for Release of Information indicates their agreement to share relevant assessment and treatment information with designated agencies. This step is important for coordinating care and ensuring that all involved parties are informed about the client’s progress and compliance.

Can a diagnosis affect the type of treatment or assessment an individual receives?

Yes, the diagnosis can significantly influence the treatment plan or assessments required. The 508 Form accommodates this by allowing for specific documentation related to the client’s diagnosis, including for those individuals assessed for Driving While License Revoked (DWLR). Treatment referrals are often based on the nature of the diagnosis, whether it’s for alcohol dependence, abuse, or another disorder.

Common mistakes

Filling out the 508 Form from NC DWI Services can be a meticulous process, and quite often, people make errors that could delay their proceedings. One common mistake lies in the provider/facility name and provider code section, where some individuals fail to provide accurate identification details. This oversight can result in forms being misfiled or returned for correction, creating unnecessary delays.

Another frequent error involves the client name and record number sections. These must be filled out precisely as they appear in official documents. Variations or typos in this information can lead to significant confusion and may complicate the client’s assessment process.

Additionally, the assessment date and control number fields are often overlooked or incorrectly filled out. These details are critical for tracking the progress and validity of the assessment, and inaccuracies here can raise questions about the assessment's legitimacy.

When it comes to the section on staff credentials and approvals, some individuals forget to verify whether the staff is qualified to complete assessments as confirmed by the NCSAPPB. The omission of this verification step can lead to doubt regarding the assessment's credibility.

Evidence of DSM-IV diagnosis and presence of ASAM Patient Criteria, as determined by clinical assessment, are also commonly mishandled. Either through misunderstanding or oversight, some forms are submitted with incomplete information in these areas, undermining the assessment's thoroughness and potentially the client's treatment plan.

The client's understanding and agreement are crucial, making the omission of the client's signature on consent forms a critical mistake. These signatures are necessary to indicate that clients have been given a comprehensive list of DWI Providers and agree to the release of their information to relevant agencies, as per policy requirements. Without these signatures, the assessment process can be deemed incomplete.

Errors related to the documentation, including the timely submission of the Certificate of Completion, can also occur. Some providers may delay submitting this certificate within the required two-week period post-assessment, risking the assessment's prompt recognition by the state.

Management of the e508 system and efforts to resolve any holds or rejects associated with the client's record is another area prone to error. Failure to efficiently manage these aspects can result in unnecessary setbacks in successfully finalizing the client's assessment and certification process.

Lastly, a common mistake involves not properly signing and dating the Certificate of Completion Form and ensuring it is placed within the client file. Missing or incorrect dates and signatures can bring the entire assessment's validity into question.

In conclusion, while filling out the NC DWI Services' 508 Form might seem straightforward, attention to detail is paramount to avoid common mistakes. Accurate and complete documentation supports a smoother assessment process and ensures compliance with the requirements set by the Division Policy ACC002 and the Office of DWI Services.

Documents used along the form

When dealing with the aftermath of a DWI (Driving While Impaired) charge, understanding the necessary forms and documents can significantly ease the process for individuals involved. The 508 Form from NC DWI Services is crucial in this regard, as it helps document assessment and compliance within the DWI monitoring tools and systems. However, this form is just one component of a broader network of documents often required for a comprehensive response to DWI charges. Below is a list of other forms and documents frequently used alongside the 508 Form.

  • Assessment and Treatment Plan: Provides detailed information on the individual's diagnosis and recommended treatment plan, following the assessment.
  • Consent for Release of Information (ROI) Form: Enables the sharing of an individual's assessment and treatment information with relevant parties, such as legal representatives and the DMV.
  • Certificate of Completion for DWI Education or Treatment Program: Official document proving that an individual has completed a state-approved education or treatment program.
  • DSM-IV or DSM-5 Diagnostic Report: A report that includes the individual's diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders criteria, relevant to the assessment section of the 508 Form.
  • ASAM (American Society of Addiction Medicine) Patient Placement Criteria: Assessment tool used to provide a detailed account of recommended treatment levels of care.
  • Court Order for Assessment and Treatment: Legal document issued by a judge requiring an individual to undergo a DWI assessment and follow through on prescribed treatment plans.
  • Proof of Insurance (SR-22): A document required by the DMV confirming that an individual holds liability insurance, which is often necessitated following a DWI charge.
  • Driving Record: A comprehensive report of an individual's driving history, including any violations, suspensions, or revocations, which may be considered during assessment and treatment planning.
  • Limited Driving Privilege (LDP) Forms: Necessary for individuals seeking to restore driving privileges on a limited basis during a period of license suspension.

Understanding and effectively managing these documents can significantly impact the resolution of DWI charges and the recovery process. It is important for individuals dealing with DWI charges to obtain accurate information and support to navigate through the legal and rehabilitative measures required by their state or jurisdiction effectively.

Similar forms

The 508 Form from NC DWI Services bears similarities to a variety of important documents utilized in regulatory and compliance processes, emphasizing on the critical role of documentation in ensuring the adherence to standards and policies. One such similar document is a Compliance Audit Report, which also highlights areas of noncompliance, requires actions to correct the deficiencies, and is often accompanied by an auditor's signature to validate the findings. The purpose of both documents is to identify gaps in compliance and initiate improvements.

Another document resembling the 508 Form is the Patient Assessment Form commonly used in healthcare settings. This form evaluates the condition and needs of a patient, much like the assessment and diagnosis sections of the 508 Form, which assess a client's condition based on DSM-IV codes and ASAM patient criteria. Both documents are crucial for planning subsequent interventions and ensuring the provision of appropriate services.

Similarly, the Treatment Plan Document in healthcare and rehabilitation services aligns with the purpose of the 508 Form. It outlines the recommended treatment based on an individual's assessment, documenting goals, and prescribed interventions. This planning is essential in both contexts for tracking progress and adjusting care as necessary, ensuring the client or patient receives the most effective treatment tailored to their needs.

The Consent for Release of Information Form shares similarities with the section of the 508 Form that requires client signatures for consent. In both instances, the client or patient's permission is obtained for sharing their information among various agencies or providers. This step is crucial for coordinated care and compliance with privacy regulations, ensuring information is shared legally and ethically.

A Quality Assurance Review Document, used to assess and ensure the quality of services or processes, has parallels with the 508 Form. It includes evaluations against set standards, identification of areas needing improvement, and suggestions for corrective actions. Both documents are instrumental in promoting continuous improvement and high standards of practice within organizations.

The Certificate of Completion Document, often issued at the end of a course or treatment program, is directly referenced in the 508 Form. It signifies that an individual has met certain requirements or standards, similar to how the 508 Form documents completion of assessment and compliance aspects. This documentation is key for accountability and recognizing achievement or compliance.

Lastly, the Plan of Correction (POC) Document closely resembles the directive in the 508 Form for developing correction plans in response to noncompliance. Both documents are critical for outlining the steps necessary to address deficiencies identified during assessments or audits, focusing on remedial actions to meet established standards and improve outcomes.

Dos and Don'ts

Filling out the 508 Form from NC DWI Services is an important step in ensuring compliance and proper documentation for DWI assessments and treatments. To make this process smoother and more efficient, consider the following dos and don'ts:

  • Do ensure that staff completing the assessments have the required qualifications verified by NCSAPPB, as noted in Section I of the form.
  • Do include evidence of DSM-IV diagnosis and evidence of ASAM Patient Criteria as determined by clinical assessment to comply with Section II requirements.
  • Do obtain the client's signature on the Consent Form for Release of Information, indicating they were provided with a list of all DWI providers in their service area.
  • Do submit the Certificate of Completion within two weeks of the assessment date, as required in Section III, to demonstrate compliance with Division Policies.
  • Do make efforts to manage and resolve any holds or rejects within the e508 system to ensure all steps of the assessment process are completed.
  • Don't leave the "Date Sent to State Office" blank on the Certificate of Completion Form. Ensure it is signed by professional staff and placed within the client file.
  • Don't forget to use the comments section or additional comments sheets to document any areas of noncompliance, which can help in creating an effective Plan of Correction if required.

By following these guidelines, you can streamline the 508 Form process, ensuring accuracy and compliance with NC DWI Services' regulations. Remember, thorough documentation and compliance with the process not only supports the provider but also significantly aids individuals in their rehabilitation and recovery journey.

Misconceptions

Many people have misconceptions about the 508 Form from North Carolina DWI Services, which can lead to confusion about its purpose and requirements. Here we address some common misunderstandings:

  • Misconception 1: The 508 Form is only for those who have been convicted of driving while impaired (DWI).
  • While the 508 Form is used in the DWI assessment process, it also applies to individuals assessed for Driving While License Revoked (DWLR) due to an impairment-related revocation.

  • Misconception 2: Anyone can perform the assessment documented on the 508 Form.
  • Only qualified staff verified by the North Carolina Substance Abuse Professional Practice Board (NCSAPPB) are allowed to complete these assessments.

  • Misconception 3: The form doesn't require a DSM-IV diagnosis.
  • The form explicitly requires evidence of a DSM-IV diagnosis as determined by clinical assessment, along with specifying the type of alcohol use disorder when applicable.

  • Misconception 4: Client consent is not necessary for information sharing.
  • Client signature on the Consent Form for Release of Information is required, ensuring that clients are aware of and agree to the sharing of their information with various agencies.

  • Misconception 5: The Certificate of Completion for the assessment does not need to be submitted quickly.
  • There is a strict requirement that the Certificate of Completion must be submitted within two weeks of the assessment date.

  • Misconception 6: Once the assessment is completed, the provider's role is over.
  • Providers are responsible for managing the e508 system to ensure every step of the process is completed and resolving any holds or rejections associated with the client's record.

  • Misconception 7: The form is a one-time requirement for individuals dealing with DWLR assessments.
  • For DWLR assessments, certain sections of the form are still applicable, and a "9" rating is entered to denote this in the system compliance section.

  • Misconception 8: Documentation within the client's file is not mandatory after submission.
  • Even after the Certificate of Completion is sent to the State Office, a signed copy must be placed within the client's file for documentation purposes.

  • Misconception 9: The form lacks an appeal or correction process for noncompliance findings.
  • The form includes a section for the review findings and the exit form, where areas not met are documented, and findings that result in plans of correction as per division policy are acknowledged by the provider.

Understanding the 508 Form from North Carolina DWI Services is crucial for providers and their clients in the DWI assessment and treatment process.

Key takeaways

Filling out the 508 Form from North Carolina DWI Services requires attention to detail and an understanding of several key requirements. This document serves an important role in the DWI assessment and treatment process. Here are four key takeaways to consider when dealing with this form:

  • Staff Qualifications: It's imperative that the staff completing the assessment possess the necessary qualifications as verified by the North Carolina Substance Abuse Professional Practice Board (NCSAPPB). This ensures the reliability and validity of the DWI assessment process.
  • Comprehensiveness: The form mandates the inclusion of a clinical assessment that evidences a DSM-IV diagnosis and adheres to ASAM Patient Placement Criteria. Additionally, the client's understanding and agreement need to be confirmed through their signature on a consent form for the release of information, thus fostering transparency and consent in the evaluation process.
  • Timeliness and System Compliance: Providers must submit the Certificate of Completion within two weeks of the assessment date, reflecting timely communication with state offices. Managing the e508 system efficiently to ensure all process steps are completed and addressing any holds or rejects promptly is crucial for compliance and operational efficiency.
  • Documentation and Corrective Actions: The form highlights the importance of proper documentation, including the signature of professional staff on the Certificate of Completion and its placement within the client file. Should there be areas of noncompliance, the form facilitates a structured response through its section on review findings and exit form, which could lead to required plans of correction in adherence to Division Policy ACC002.

Understanding these key aspects ensures that providers can navigate the complexities of the 508 Form from North Carolina DWI Services effectively, ultimately contributing to a more streamlined and compliant DWI assessment and treatment process.

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