Residential Treatment Services (RTC) Level C

1. Department of Medical Assistance Services Residential Treatment Services (RTC)Level C DMAS Office of Behavioral Health 2013 www.dmas.virginia.gov 1

2. Department of Medical Assistance Services Disclaimer These slides contain only highlights of the Virginia Medicaid Psychiatric Services Manual (PSM) and is not meant to substitute for the comprehensive information available in the manual or state and federal regulations. *Please refer to the manual, available on the DMAS website portal, for in-depth information on Psychiatric Services criteria.Providers are responsible for adhering to related state and federal regulations. www.dmas.virginia.gov 2

3. Department of Medical Assistance Services Training Objectives • To define the criteria needed to establish a Level C Residential Treatment Center (RTC) and licensing requirements; • To identify staff qualifications; • To identify required activities; • To clarify the expectations for Seclusion & Restraint Reporting; • To clarify eligibility criteria; • To review the Medicaid Required Documentation for CSA and Non-CSA Admissions and Plans of Care; • To review limitations of the service; and • To review service authorization requirements. www.dmas.virginia.gov 3

4. Department of Medical Assistance Services Service Definition “Residential inpatient care” means a 24-hour-per-day specialized form of highly organized, intensive, and planned therapeutic interventions, which shall be utilized to treat severe mental, emotional, and behavioral disorders. It is a definitive therapeutic modality designed to deliver specified results for a defined group of problems for children or adolescents for whom outpatient day treatment or other less intrusive levels of care are not appropriate, and for whom a protected, structured milieu is medically necessary for an extended period of time. www.dmas.virginia.gov 4

5. Department of Medical Assistance Services Service Definition • A program for children and youth under age 21 to treat severe mental, emotional and behavioral disorders; • Is designed to meet the needs when outpatient and day treatment fails; • Provides inpatient psychiatric treatment; • Is a 24-hour per day program; • Provides child-specific care and treatment planning; • Provides highly organized and intensive services; • Provides planned therapeutic interventions; • Required services are provided on-site, including academic programming; AND • Is physician-directed mental health treatment. www.dmas.virginia.gov 5

6. Department of Medical Assistance Services Licensing www.dmas.virginia.gov 6

7. Department of Medical Assistance Services Licensing Requirements Individuals under the age of 21 may receive residential psychiatric care in: 1. A residential treatment program for children and adolescents licensed by the Department of Behavioral Health Developmental Services (DBHDS) that is located in a psychiatric hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 2. A residential treatment program for children and adolescents licensed by DBHDS that is located in a psychiatric unit of an acute general hospital accredited by the JCAHO; or 3. A psychiatric facility that is (i) accredited by JCAHO, the Commission on Accreditation of Rehabilitation Facilities, the Council on Quality and Leadership in Support for People with Disabilities, or the Council on Accreditation Services for Families and Children and (ii) licensed by DBHDS as a residential treatment program for children and adolescents. www.dmas.virginia.gov 7

8. Department of Medical Assistance Services Staff Qualifications www.dmas.virginia.gov 8

9. Department of Medical Assistance Services Staff Qualifications Psychiatric Services and Substance Abuse Services may be provided by: • A psychiatrist who is a licensed physician who has completed at least three years of postgraduate residency training in psychiatry; • A licensed clinical psychologist licensed by the Department of Health Professions, Board of Psychology; • A licensed clinical social worker (LCSW) licensed by the Department of Health Professions, Board of Social Work; • A licensed professional counselor (LPC) licensed by the Virginia Board of Counseling; • A psychiatric clinical nurse specialist - psychiatric (CNS) licensed by the Virginia Board of Nursing and certified by the American Nurses Credentialing Center; • A psychiatric nurse practitioner, licensed by the Virginia Board of Nursing; • A marriage and family therapist/counselor licensed by the Virginia Board of Counseling; • A school psychologist licensed by the Virginia Department of Health Profession’s Board of Psychology; and • An individual who has completed his or her graduate degree and is under the direct personal supervision of an individual licensed under Virginia state law. The individual must be working towards licensure and supervised by the appropriate licensed professional in accordance with the requirements of the individual profession. www.dmas.virginia.gov 9

10. Department of Medical Assistance Services Staff Qualifications Substance Abuse Services: • In addition to the previous listed licensure requirements, substance abuse treatment providers must also be qualified by training and experience in all of the following areas of substance abuse/addiction counseling: • clinical evaluation; • treatment planning; • referral; • service • coordination; • counseling; • client, family, and community education; • documentation; and • professional and ethical responsibilities. www.dmas.virginia.gov 10

11. Department of Medical Assistance Services Facility Reporting www.dmas.virginia.gov 11

12. Department of Medical Assistance Services Provider Requirement-Attestation A Restraint & Seclusion (R&S) attestation letter must be submitted to DMAS for initial enrollment and no later than July 1st annually thereafter; or if there is a change in Facility Director. *There is a sample attestation letter in the Psychiatric Services manual at the end of chapter II. www.dmas.virginia.gov 12

13. Department of Medical Assistance Services Facility Reporting Federal Regulation § 483.374   • (a) Attestation of facility compliance. Each psychiatric residential treatment facility that provides inpatient psychiatric services to individuals under age 21 must attest, in writing, that the facility is in compliance with CMS's standards governing the use of restraint and seclusion. This attestation must be signed by the facility director. • (1) A facility with a current provider agreement with the Medicaid agency must provide its attestation to the State Medicaid agency by July 1. • (2) A facility enrolling as a Medicaid provider must meet this requirement at the time it executes a provider agreement with the Medicaid agency. www.dmas.virginia.gov 13

14. Department of Medical Assistance Services Facility Reporting Federal Regulation § 483.374   (b) Reporting of serious occurrences. The facility must report each serious occurrence to both the State Medicaid agency and, unless prohibited by State law, the State-designated Protection and Advocacy system. Serious occurrences that must be reported include a resident's death, a serious injury to a resident, and a resident's suicide attempt. • (1) Staff must report any serious occurrence involving a resident to both the State Medicaid agency and the State-designated Protection and Advocacy system by no later than close of business the next business day after a serious occurrence. The report must include the name of the resident involved in the serious occurrence, a description of the occurrence, and the name, street address, and telephone number of the facility. www.dmas.virginia.gov 14

15. Department of Medical Assistance Services Facility Reporting Federal Regulation § 483.374   (b. continued) • (2) In the case of a minor, the facility must notify the resident's parent(s) or legal guardian(s) as soon as possible, and in no case later than 24 hours after the serious occurrence. • (3) Staff must document in the resident's record that the serious occurrence was reported to both the State Medicaid agency and the State-designated Protection and Advocacy system, including the name of the person to whom the incident was reported. A copy of the report must be maintained in the resident's record, as well as in the incident and accident report logs kept by the facility. www.dmas.virginia.gov 15

16. Department of Medical Assistance Services Facility Reporting Federal Regulation § 483.374   (c) Reporting of deaths.In addition to the reporting requirements contained in paragraph (b) of this section, facilities must report the death of any resident to the Centers for Medicare & Medicaid Services (CMS) regional office. • (1) Staff must report the death of any resident to the CMS regional office no later than close of business the next business day after the resident's death. • (2) Staff must document in the resident's record that the death was reported to the CMS regional office. www.dmas.virginia.gov 16

17. Department of Medical Assistance Services Facility Reporting § 483.352 Definitions • Psychiatric Residential Treatment Facility means a facility other than a hospital, that provides psychiatric services, to individuals under age 21, in an inpatient setting. • Restraint means a “personal restraint,” “mechanical restraint,” or “drug used as a restraint” as defined in this section. • Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. • Serious injury means any significant impairment of the physical condition of the resident as determined by qualified medical personnel. This includes, but is not limited to, burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else. www.dmas.virginia.gov 17

18. Department of Medical Assistance Services Facility Reporting • Remain in compliance with signed agreement regarding seclusion and restraint • In case of injury requiring medical attention off-site or a suicide attempt, DMAS must be notified by fax within one business day of occurrence: • child’s name, Medicaid number • facility name & address of incident, facility’s NPI number • location & date of incident • names of staff involved • description of incident • outcome, including persons notified • current location of child Fax Reports to The DMAS Office of Behavioral Health (804) 612-0045 www.dmas.virginia.gov 18

19. Department of Medical Assistance Services Facility Reporting For additional information regarding the Centers for Medicare & Medicaid Services (CMS): www.cms.gov Or 7500 Security Boulevard, Baltimore, MD 21244 • Toll-Free: 877-267-2323 (Employee directory available) • Local: 410-786-3000 • TTY Toll-Free: 866-226-1819 • TTY Local: 410-786-0727 www.dmas.virginia.gov 19

20. Department of Medical Assistance Services CSA or Non-CSA Determination www.dmas.virginia.gov 20

21. Department of Medical Assistance Services CSA or Non-CSA • If the case is an Adoption Subsidy case, it is NON-CSA • The education payment source is not considered; • If the education is paid for by the Dept. of Education/CSA funded, it is a CSA case; • If a child has been receiving CSA funding for other services, it is a CSA case; • If the child is in foster care, it is a CSA case. www.dmas.virginia.gov 21

22. Department of Medical Assistance Services CSA or Non-CSA • The following slides describe the required documentation for CSA and Non-CSA admissions; • All documentation whether CSA or Non-CSA must be complete, timely and include all required dated signatures; • All Sample forms are available in the manual; www.dmas.virginia.gov 22

23. Department of Medical Assistance Services Eligibility Criteria www.dmas.virginia.gov 23

24. Department of Medical Assistance Services Eligibility Severity of Illness (both 1 and 2 must be met):  1. Care and treatment shall be provided in the least restrictive treatment environment possible. The following shall be reviewed by DMAS to determine whether a lower level of care or ambulatory care was considered and found inappropriate to meet the needs of the individual. One or more must be present: • The individual is currently receiving community-based care with evidence of failure at a less restrictive level of care; • The individual’s identified condition is escalating; or • The individual’s condition is a reoccurrence of a previous acute psychiatric condition. 2. Individuals admitted for inpatient residential level of care must have been diagnosed with a psychiatric disorder. www.dmas.virginia.gov 24

25. Department of Medical Assistance Services Eligibility There must be documented evidence of recent onset of one or more of the following conditions: • The individual is unable to function in a less restrictive environment evidenced by dysfunction in interpersonal, family, education, or development; • The individual has had a history of acute psychiatric episodes and currently is not making progress or cooperating with the treatment plan in a less restrictive level of care; • There are recent increased threats of harm or aggression towards self or others; www.dmas.virginia.gov 25

26. Department of Medical Assistance Services Eligibility There must be documented evidence of recent onset of one or more of the following conditions (cont’d): • The individual is unable to function safely in the community without jeopardizing the safety of self or others; • There has been recent stabilization of symptoms during a psychiatric hospitalization but the individual needs a structured 24-hour therapeutic environment to prevent regression, solidify gains, and/or further resolve complex psychiatric symptoms; or • Recent outpatient treatment has failed. Ambulatory care resources available in the community do not meet treatment needs because the individual suffers one or more complicating concurrent medical disorders which the family is not effectively addressing (e.g., conduct disorder with seizures, depression with insulin-dependent diabetes mellitus). www.dmas.virginia.gov 26

27. Department of Medical Assistance Services Certificate of Need(CON) www.dmas.virginia.gov 27

28. Department of Medical Assistance Services Certification of Need (CON) For both CSA and NON-CSA: • The CON should reflect the child’s current condition and must be completed within 30 days of admission; • The CON is required to be completed prior to admission with all necessary dated signatures; • If the child is discharged and readmitted, a new CON is required; and • If the child transfers to an acute psychiatric facility, the acute care team can do the new CON. www.dmas.virginia.gov 28

29. Department of Medical Assistance Services Certification of Need (CON) CSA Cases: • CON must be completed by both the physician and at least 3 members of the FAPT; • Must include dated signatures of the physician and FAPT; • Authorization can begin no earlier than the date of the latest signature; • Must be child-specific and relate to the need for an RTC (level C) level of care; and • Must be available in the medical record. www.dmas.virginia.gov 29

30. Department of Medical Assistance Services Certification of Need (CON) Certification of Need(Independent Team Certification) NON-CSA Cases: • The CSB is responsible for completing the Independent Team Certification; and • The CSB completes the DMH224 and must include a physician’s dated signature, as well as the screener’s dated signature. (The CSB may use the sample CON in the manual in place of the DMH224) www.dmas.virginia.gov 30

31. Department of Medical Assistance Services Required Uniform Assessment(UAI) - CANS www.dmas.virginia.gov 31

32. Department of Medical Assistance Services Required Uniform Assessment (UAI) - CANS The State Uniform Assessment Instrument (CANS) is required for CSA Cases • CSA Cases Only: • The CANS is the only uniform assessment instrument that is accepted. • For admission, the CANS should reflect the requested level of care and must be current. • It must be completed at least every 90 days. and must be in the medical record. • It should be updated by the fiscally responsible locality when the child’s level of impairment changes significantly. • Completion information must be submitted to KePRO for SA. • Scoring notes the level of impairment that supports the need for the level of care. www.dmas.virginia.gov 32

33. Department of Medical Assistance Services Required Uniform Assessment (UAI) - CANS At a minimum: • The CANS summary sheet should indicate the child’s behavioral and emotional needs, and risk behaviors; and • The CANS must also be available in the medical record and current within 90 days throughout the stay. www.dmas.virginia.gov 33

34. Department of Medical Assistance Services Initial Plan of Care (IPOC) www.dmas.virginia.gov 34

35. Department of Medical Assistance Services IPOC IPOC MUST: • Be completed at admission • Include diagnoses, symptoms, complaints, and complications indicating need for admission; • Include a description of the functional level of the individual; • Include treatment objectives (short-term and long-term goals); • Include ANY orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures (health & safety recommendations); www.dmas.virginia.gov 35

36. Department of Medical Assistance Services IPOC – cont’d IPOC MUST: • Include plans for continuing care, including review and modification to the plan of care; • Prognosis; • Include plans for discharge; and • Signature and date by the physician (i.e. Name, title, handwritten date) www.dmas.virginia.gov 36

37. Department of Medical Assistance Services Comprehensive Individual Plan of Care (CIPOC) www.dmas.virginia.gov 37

38. Department of Medical Assistance Services CIPOC CIPOC MUST: • Be completed within 14 days after admission; • Include the dated signatures of the team members (including physician) specified in the federal requirements (42 CFR 441.156); i.e. Name, title, handwritten date • Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the recipient's situation and must reflect the need for inpatient psychiatric care; • Be developed by an interdisciplinary team of physicians and other personnel, who are employed by, or provide services to, patients in the facility in consultation with the recipient and his parents, legal guardians, or appropriate others in whose care he will be released after discharge; www.dmas.virginia.gov 38

39. Department of Medical Assistance Services CIPOC – cont’d CIPOCMUST: • State treatment objectives that must include measurable short-term and long-term goals and objectives, with target dates for achievement; • Prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives related to the diagnosis; • Describe comprehensive discharge plans and coordination of inpatient services and post-discharge plans with related community services to ensure continuity of care upon discharge with the recipient's family, school, and community. www.dmas.virginia.gov 39

40. Department of Medical Assistance Services Reviews of CIPOC The CIPOC MUST: • Be reviewed every 30 days by the team ; • Include the dated signatures of the team members (including physician) specified in the federal requirements (42 CFR 441.156); i.e. Name, title, handwritten date • Determine that services are being provided are/were required on an inpatient basis; and • Recommend changes in the plan as indicated by the recipients overall adjustment as a resident. www.dmas.virginia.gov 40

41. Department of Medical Assistance Services Required Activities www.dmas.virginia.gov 41

42. Department of Medical Assistance Services Required Activities Treatment must relate to the severity of illness with the goal of improving the individual’s condition so services will no longer be needed, or preventing progression to an acute stage. The active treatment plan must relate to the admission diagnosis and reflect all ofthe following: A licensed professional (psychiatrist, clinical psychologist, licensed clinical social worker, licensed professional counselor, clinical nurse specialist psychiatric, school psychologist, psychiatric nurse practitioner, or marriage and family therapist with education and experience with children and adolescents) provides individual therapy three out of seven days. No more than one session per day is billable. www.dmas.virginia.gov 42

43. Department of Medical Assistance Services Required Activities The active treatment plan must relate to the admission diagnosis and reflect all ofthe following (cont’d): A minimum of 21 distinct sessions (excluding individual treatment, school attendance, and family therapy) of appropriate treatment interventions are provided each week (i.e., group therapy with specific topics focused to patient needs; insight-oriented and/or behavior modifying). (Group medical psychotherapy coverage is limited to once per day. Services for sensory stimulation, recreational activities, art classes, excursions, or eating together are not included as separately billable group psychotherapy sessions. There is a maximum of ten individuals per group psychotherapy session). Play/art/music therapy, occupational therapy, and physical therapy may be included; however, these modalities of treatment must not be the major treatment modality. www.dmas.virginia.gov 43

44. Department of Medical Assistance Services Required Activities The active treatment plan must relate to the admission diagnosis and reflect all ofthe following (cont’d): The family, guardian, caretaker, or case manager is involved on an ongoing basis with treatment planning. The family, guardian, or caretaker participates in family therapy at a minimum of twice monthly except when the family dysfunction is a reason for admission, then family therapy should be at least once per week. At least one of these family therapy sessions must be face-to face each month. Family therapy is limited to one unit per day, regardless of the number of participants or family members in the session. If the family, guardian, or caretaker is not involved as required, documentation must demonstrate why it is not feasible or not in the best interest of the child for the family to participate. Alternatives for treatment due to the lack of a family’s involvement should be addressed (telephonic therapy is a non-reimbursable service) and the discharge plan revised to address the lack of family involvement. www.dmas.virginia.gov 44

45. Department of Medical Assistance Services Required Activities Active treatment and comprehensive discharge planning for aftercare placement and treatment must begin at admission. • The discharge planning MUST start at admission. • Both of the Initial Plan of Care (IPOC) and Comprehensive Individual Plan of Care (CIPOC) require a discharge plan to be completed. • The discharge plan identifies the needed services to assist the youth to maintain stability within the community. www.dmas.virginia.gov 45

46. Department of Medical Assistance Services Limitations www.dmas.virginia.gov 46

47. Department of Medical Assistance Services Limitations The Comprehensive Individual Plan of Care (CIPOC) is a written plan developed for each individual. The CIPOC must be completed no later than 14 days after admission for residential treatment and must include the dated signatures of the team members specified in the federal requirements (42 CFR 441.156). The CIPOC must be completed before requesting continued stay. www.dmas.virginia.gov 47

48. Department of Medical Assistance Services Limitations Continued residential level of care is not appropriate and will not be covered when one or more of the following exist (severity of illness and intensity oftreatment should be reviewed): • The stabilization of presenting symptoms with demonstrated ability to perform ADLs appropriate for age and to function appropriately within residential environment and a community setting; • The required treatment can be provided in a less restrictive environment; • There is documented evidence, from the use of day and an overnight pass, that the recipient has been able to function safely and satisfactorily within the community; • There has been no documented evidence of a change in treatment plan when the individual has not responded for a 20-day period; or • The individual refuses to cooperate with the treatment plan. www.dmas.virginia.gov 48

49. Department of Medical Assistance Services Reimbursement RateCSA or Non-CSA www.dmas.virginia.gov 49

50. Department of Medical Assistance Services Reimbursement Rate Certification For CSA Cases Only: • Negotiated rate between locality and facility; • Total rate can be no more than the Medicaid maximum; • Payment from any other source such as Title IV-E, must be deducted prior to establishing the rate. www.dmas.virginia.gov 50