Current through September 17, 2024
Subacute inpatient hospital psychiatric services for clients
21 and over are medically necessary short-term psychiatric services provided to
a client. The care and treatment of a subacute inpatient with a primary
psychiatric diagnosis must be under the direction of a Nebraska licensed
psychiatrist who meets the state's licensing criteria and is enrolled as a
Medicaid provider with the Department. Subacute inpatient hospital psychiatric
services must be prior-authorized by the Department-contracted peer review
organization or management designee. In addition, out-of-state subacute
hospitalizations must be approved by the Department.
006.01
Provider
Agreement
A hospital that provides subacute inpatient psychiatric
services must complete Form MC-20, "Medical Assistance Hospital Provider
Agreement," (see 471-000-91) and submit the completed form to the Department
for approval and enrollment as a Medicaid provider of subacute inpatient
hospital psychiatric services. The hospital must submit with the provider
agreement:
1. A complete description
of the psychiatric program and the elements of the program (i.e., policies and
procedures, staffing, services, etc.);
2. A statement of the total number of
licensed inpatient psychiatric beds, designated as subacute psychiatric beds
that are approved by the Nebraska Department of Health and Human Services,
Division of Public Health or agency in the state in which the facility is
located; a listing of the bed numbers for those licensed psychiatric beds; and
the size of the proposed subacute inpatient psychiatric unit;
3. Documentation that the subacute inpatient
program meets the family-centered, community-based requirements in 471 NAC
20-001;
4. A description of how individual, group,
and family psychotherapy services as well as other psycho-educational and
rehabilitation services will be provided;
5. A description of how the subacute
inpatient hospital psychiatric services will interface with community services
for discharge planning and service provision after discharge;
6. A copy of the most recent Joint Commission
Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic
Association (AOA) accreditation survey; and
7. Any other information requested.
Any facility requesting a provider agreement must make the
facility available for an on-site review before issuance of a provider
agreement.
006.02
Standards for Participation for Subacute Inpatient Hospital
Psychiatric Service Providers
A hospital that provides subacute inpatient hospital
psychiatric services must meet the following standards for participation to
ensure that payment is made only for subacute inpatient psychiatric treatment.
The hospital or unit of an acute care hospital:
1. Is maintained for the care and treatment
of patients with primary psychiatric disorders;
2. Is licensed or formally approved as a
hospital by the Nebraska Department of Health and Human Services Division of
Public Health, or if the hospital is located in another state, the officially
designated authority for standard-setting in that state;
3. Is accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or by the American
Osteopathic Association (AOA);
4.
Meets the requirements for participation in Medicare for psychiatric
hospitals;
5. Has in effect a
utilization review plan applicable to all Medicaid clients;
6. Must have medical records that are
sufficient to permit the Department to determine the degree and intensity of
treatment furnished to the client;
7. Must meet staffing requirements the
Department finds necessary to carry out an active treatment program (see 471
NAC 20-006.03);
8. Must encourage
the client and family members to be involved in the assessment of the client,
the development of the treatment plan, and all aspects of the client's
treatment unless prohibited by the client, through legal action, or because of
federal confidentiality laws;
9.
Must be available to schedule meetings and sessions in a flexible manner to
accommodate and work with a family/guardian/caretaker schedule. This includes
the ability to schedule sessions at a variety of times including weekends or
evenings; and
10. Must document
their attempts to involve the client and the family in treatment plan
development and treatment plan reviews. A variety of communication means should
be considered to involve family. These may include, but should not be limited
to, including the family via conference telephone calls, using registered
letters to notify the family of meetings, and scheduling meetings in the
evening and on weekends.
006.03
Staffing Standards for
Participation
Subacute inpatient psychiatric hospital must have staff
adequate in number and qualified to carry out a subacute psychiatric program
for treatment for individuals who are in need of further psychiatric
stabilization, treatment, rehabilitation, and recovery activities. The hospital
must meet the following standards.
1.
Hospital Personnel: Hospitals that provide subacute
inpatient psychiatric services must be staffed with the number of qualified
professional, technical, and supporting personnel, and consultants required to
carry out an intensive and comprehensive treatment program that includes
evaluation of individual and family needs; establishment of individual and
family treatment goals; and implementation, directly or by arrangement, of a
broad-range psychiatric treatment program including, at least, professional
psychiatric, medical, nursing, social services, psychological, psychotherapy,
psychiatric rehabilitation, and recovery therapies required to carry out an
individual treatment plan for each patient and their family. The following
standards must be met:
a. Qualified
professional psychiatric staff must be available to evaluate each patient at
the time of admission, including diagnosis of any intercurrent disease.
Services necessary for the evaluation include:
(1) Biopsychosocial assessment by a
multi-disciplinary team;
(2)
Psychiatric diagnostic evaluation by the attending psychiatrist;
(3) Nursing assessment by a licensed
registered nurse;
(4) Substance
abuse assessment as appropriate;
(5) Laboratory, radiological, and other
diagnostic tests as necessary;
(6)
A physical examination including a complete neurological examination when
indicated within 24 hours after admission by a licensed physician;
b. The number of qualified
professional personnel and paraprofessionals, including licensed professional
staff and technical and supporting personnel, must be adequate to ensure
representation of the disciplines necessary to establish short-range and
long-term goals; and to plan, carry out, and periodically revise a treatment
plan for each client.
(1) Qualified staff
must be available to provide treatment intervention, social interaction and
experiences, education regarding psychiatric issues such as medication
management, nutrition, signs and symptoms of illness, substance abuse
education, appropriate nursing interventions and structured milieu therapy.
Available services must include individual, group, and family therapy, group
living experiences, occupational and recreational therapy and other prescribed
activities to maintain or increase the individual's capacity to manage his/her
psychiatric condition and activities of daily living. A minimum of 42
structured, scheduled, and documented treatment hours are required per
week.
(2) The program must provide
environmental and physical limitations required to protect the client's health
and safety with a plan to develop the client's potential for return to his/her
home, supervised adult living, or skilled nursing facility. The treatment
milieu must be a safe, organized, structured environment at the least
restrictive level of care to meet the individualized treatment needs of the
client.
2.
Medical Director of Subacute Inpatient Psychiatric
Services: Subacute inpatient psychiatric services must be under
the supervision of a psychiatrist (supervising practitioner) who is identified
as medical director and is qualified to provide the clinical direction and the
leadership required for an intensive psychiatric subacute inpatient treatment
program. The number and qualifications of additional psychiatrists must be
adequate to provide essential psychiatric services. The medical director may
also serve as the attending psychiatrist for each client depending on the size
of the program. The following standards must be met:
a. The medical director and any attending
psychiatrist/s must meet the training and experience requirements for a
psychiatrist licensed to practice in the state where services are
provided;
b. The program must
identify a covering or alternative psychiatrist when the medical director is
not available to provide direction and supervision of the direct care of the
client and the treatment program;
c. The psychiatrist's personal involvement in
all aspects of the client's psychiatric care must be documented in the client's
medical record (i.e., physician's orders, progress notes, nurses
notes);
d. The medical
director/attending psychiatrist must be available, in person or by telephone,
to provide assistance and direction to the treatment team as needed.
3.
Availability of
Physicians and Other Medical Consultation: Physicians and other
appropriate professional consultants such as medical, psychopharmacological,
dental, and emergency medical services must be available to provide medical,
surgical, diagnostic, and treatment services, including specialized services.
If medical, surgical, diagnostic, and treatment services are not available
within the hospital, qualified physician consultants or attending physicians
must be immediately available, or a satisfactory arrangement must be
established for transferring patients to a general hospital certified for
Medicare.
006.04
Program Standards for Participation
Subacute inpatient psychiatric services must have available
licensed professionals and paraprofessionals with specific, identified duties
and responsibilities to meet the acute and rehabilitative psychiatric needs of
the clients being served. The following positions and services are
required:
1.
Program/Clinical Director: Must be a fully licensed
clinician such as a psychiatric registered nurse (RN), psychiatric advanced
practice registered nurse (APRN), or a licensed mental health practitioner
(LMHP) who is skilled and knowledgeable to provide leadership and clinical
direction to the treatment team.
The duties and responsibilities of a program/clinical
director are:
a. Oversee, implement,
and coordinate all treatment services and activities provided within the
program 24 hours a day;
b.
Incorporate new clinical information and best practices into the program to
assure effectiveness, viability and safety;
c. Oversee the process to identify, respond
to and report crisis situations on a 24-hour per day, 7-day per week
basis;
d. Be responsible, (in
conjunction with the medical director/attending psychiatrist) for the program's
clinical management by representation in the multidisciplinary treatment team
meetings providing supervision to all program professionals and
paraprofessional staff;
e.
Communicate with the attending psychiatrist regarding individual treatment
needs of the client;
f. Assure
quality organization and management of clinical record documentation and
confidentiality; and
g. Oversee and
be responsible for the safety of clients and staff.
2.
Nursing Services:
All nursing services must be under the supervision of a registered professional
nurse who is qualified by education and experience for the supervisory role.
The number of registered professional nurses and other nursing personnel must
be adequate to formulate and carry out the nursing components of a treatment
plan for each client. The following standards must be met:
a. The registered professional nurse
supervising the nursing program must have a master's degree in psychiatric or
mental health nursing or its equivalent from a school of nursing accredited by
the National League for Nursing, or must be qualified by education and
experience in the care of the individual with mental illness, and have
demonstrated competence to:
(1) Provide a
comprehensive nursing assessment;
(2) Participate in interdisciplinary
formulation of treatment plans;
(3)
Provide skilled nursing care and therapy; and
(4) Direct, supervise, and train others who
assist in implementing and carrying out the nursing components of each client's
treatment plan;
b. The
staffing pattern must ensure the direct nursing coverage by a registered
professional nurse 24 hours each day for:
(1)
Direct care; and
(2) Supervising
care performed by other nursing personnel;
c. The number of registered professional
nurses must be adequate to formulate a nursing care plan in writing for each
client and to ensure that the plan is carried out; and
d. Registered professional nurses and other
nursing personnel must be prepared by continuing in-service and staff
development programs for active participation in interdisciplinary meetings
affecting the planning or implementation of nursing care plans for patients.
The meetings include diagnostic conferences, treatment planning sessions, and
meetings held to consider alternative services and transitioning to the most
appropriate treatment service and community resources.
3.
Psychological
Services: Psychological services must be available through
employment or contractual arrangement with a licensed psychologist.
Psychological consultation must be available by a qualified licensed
psychologist capable of providing diagnostic and treatment services. The
following standards must be met:
a.
Psychologists, consultants, and supporting personnel must be adequate in number
and be qualified to assist in essential diagnostic formulations, and to
participate in:
(1) Program development and
evaluation of program effectiveness;
(2) Training and research
activities;
(3) Therapeutic
interventions, such as milieu, individual, or group therapy; and
(4) Interdisciplinary conferences and
meetings held to establish diagnoses, goals, and treatment programs;
and
b. Psychological
testing must be ordered and directed by a psychiatrist.
4.
Psychotherapy
Services: Licensed clinicians must be employed in the facility to
provide psychotherapy services according to the therapist's scope of practice
and according to the individualized treatment plan for the client. Licensed
clinicians may include psychologists (Ph.D.), licensed mental health
practitioners (LMHP), licensed alcohol and drug counselors (LADC), and advanced
practice registered nurses (APRNS). Individual, group, and family psychotherapy
must be available to each client and provided according to the client's
individual treatment plan. Services must be able to meet the unique needs of
each client.
Minimum requirements for psychotherapy offered and available
to the client are:
a. Individual
therapy minimum two times weekly;
b. Group therapy minimum three times
weekly;
c. Family therapy and
intervention as appropriate and consented to by the client. With consent of the
client, family therapy must be provided at the frequency and intensity to meet
the unique needs of client and the family.
5.
Licensed Addiction and Drug
Abuse Services: Substance abuse assessment and treatment must be
available to clients whose problems and symptoms indicate the possibility of or
an established substance abuse problem, in addition to the primary psychiatric
diagnosis. Licensed clinicians able to provide assessment and treatment of
substance abuse problems must provide services according to and within their
scope of practice. Usually, services are provided by a licensed alcohol and
drug counselor.
6.
Psycho Educational Services: Psychoeducational
services, such as medication education, activities of daily living, social
skill development must be offered in the program and providers must have
psychoeducational services available to clients on a daily basis. Services may
include education for diagnosis, treatment and relapse, life skills, medication
management and symptom management. Services must be provided by a qualified
professional or paraprofessional staff. Medication education must be provided
by a registered nurse. Other psychoeducational services may be provided by a
paraprofessional whose education and training provides competency to provide
the service.
7.
Case
Management Services/Social Services Staff: Case Management/social
services must be under the supervision of the program/clinical director. The
case management/social service staff must be adequate in numbers and be
qualified to fulfill responsibilities related to the specific needs of
individual clients and their families. These responsibilities include, but are
not limited to:
a. The development of
community resources;
b.
Consultation with other staff and community agencies;
c. Aggressive preparation for transitioning
the client to the next level of service and safe living environment according
to the treatment plan.
Daily case management services are required for each client
and must be summarized in the client's clinical record.
8.
Ancillary
Services: Recreational or activity therapy services must be
available and offered to the client daily and directly supervised by the
program/clinical director who has supervisory responsibility to the entire
treatment team and the services they provide.
9.
Psychiatric
Technicians: The program must have available paraprofessional
staff who are members of the multi-disciplinary team.
The role and responsibility of the psychiatric technician is
to:
a. Intervene in the treatment
milieu;
b. Provide treatment
interventions to the client which meet the specific psychiatric needs of the
client as identified in the treatment plan;
c. Demonstrate competency in applying the
learned treatment interventions;
d.
Have direct knowledge of policies and procedures of the agency.
Psychiatric Technicians must have completed the program's
initial training program and continued ongoing training requirements.
Seventy-five percent of the psychiatric technician staff must have completed a
BS/BA degree in the Human Services field or have five years experience
providing health care services.
006.05
Coverage Criteria for
Subacute Inpatient Psychiatric Hospital Services
The Nebraska Medical Assistance Program covers subacute
inpatient hospital psychiatric services for clients age 21 and over when the
services meet the criteria in 471 NAC
20-001 and when the following
requirements are met:
1. The attending
psychiatrist must personally and face-to-face evaluate the client and document
the psychiatric evaluation and diagnosis formulation within 24 hours of
admission;
2. The attending
psychiatrist assumes accountability to direct the care of the client at the
time of admission;
3. The client
must be treated by a psychiatrist personally and face-to-face a minimum of
three times per week or more often, if medically necessary and the interaction
must be documented in the client's clinical record;
4. The attending psychiatrist describes the
medical necessity and active treatment requirements for the client;
5. The attending psychiatrist provides
certification and recertification of the client's need for subacute inpatient
psychiatric services; and
6.
Clinical supervision of the multi-disciplinary treatment team and treatment
team planning meetings as necessary to meet the individualized treatment needs
of the client.
006.06
Treatment Planning
An initial treatment plan must be implemented upon
admission. The master/comprehensive treatment plan must be developed within 72
hours and reviewed by the treatment team a minimum of three times weekly. The
master/comprehensive treatment plan must be developed from the recommendations
made by the attending psychiatrist who has provided face-to-face evaluation of
the client and the input from all other assessments completed following
admission to subacute inpatient treatment services. Comprehensive treatment
plans must meet medical necessity requirements.
Discharge planning must be a part of the comprehensive
treatment plan. Discharge planning must be specific, realistic and
individualized for the client from the time of admission and revised as
medically necessary with treatment planning reviews.
006.07
Therapeutic Passes and
Unplanned Leave of Absence
Therapeutic passes for clients with a primary psychiatric
diagnosis from a subacute inpatient psychiatric hospital are a part of
treatment transitioning. Therapeutic passes are an essential part of the
treatment of some psychiatric clients. Documentation of the client's continued
need for psychiatric care must follow the overnight therapeutic passes.
Unplanned leaves of absence from subacute inpatient
psychiatric care occur at times but are not reimbursable services to the
program. The Department-contracted peer review organization or management
designee must be notified immediately when the client returns.
006.08
Professional and Technical
Components for Hospital Diagnostic and Therapeutic Services
For regulations regarding professional and technical
components for diagnostic and therapeutic hospital services, the elimination of
combined billing, and non-physician services and items provided to hospital
patients, see 471 NAC 10-003.05C, 10-003.05D, 10-003.05E, and
10-003.05F.
006.09
Criteria for Subacute Inpatient Psychiatric Hospital
Services
One or more of the following criteria must be
present:
1. The client can benefit
from longer-term evaluation, stabilization, and treatment services;
2. The client is at moderate to high risk to
harm self/others;
3. The client has
active symptomatology consistent with the current version of the American
Psychiatric Association's Diagnostic and Statistical Manual (DSM) (axes IV)
diagnoses;
4. The client has the
ability to respond to intensive structured intervention services;
5. The client is at moderate to high risk of
relapse or symptom reoccurrence;
6.
The client has high need of professional structure and intervention
services;
7. The client can be
treated with short term intensive intervention services.
006.10
Prior Authorization
Procedures
All subacute inpatient psychiatric admissions must be
prior-authorized by the Department-contracted peer review organization or
management designee. If the admission is approved, the Department-contracted
peer review organization or management designee must assign a specific
prior-authorization number. Providers must follow the Department-contracted
peer review organization or management designee guidelines for facilitating
prior authorization and continued stay review. Continued stay authorization is
provided at a frequency appropriate for this short-term subacute program by the
Department-contracted peer review organization or management
designee.
006.11
Documentation in the Client's Clinical Record
The medical records maintained by a hospital permit
determination of the degree and intensity of the treatment provided to clients
who receive services in a subacute inpatient psychiatric program. Clinical
records must stress the psychiatric components of the record, including history
of findings and treatment provided for the psychiatric condition for which the
client is hospitalized. The clinical record must by legible and include:
1. The identification data, including the
client's legal status (i.e., voluntary admission, Board of Mental Health
commitment, court mandated);
2. A
provisional or admitting diagnosis which is made on every patient at the time
of admission and includes the diagnoses of intercurrent diseases as well as the
psychiatric diagnoses;
3. The
complaint of others regarding the client, as well as the client's
comments;
4. The psychiatric
evaluation, including a medical history, which contains a record of mental
status and notes the onset of illness, the circumstances leading to admission,
attitudes, behavior, estimate of intellectual functioning, memory functioning,
orientation, and an inventory of the client's strengths in a descriptive, not
interpretative, fashion;
5. A
complete neurological examination, when indicated, recorded at the time of the
admitting physical examination;
6.
Reports of consultations, psychological evaluations, electroencephalograms,
dental records, and special studies;
7. The client's treatment plan and treatment
plan reviews;
8. The treatment
received by the client, which is documented in a manner and with a frequency to
ensure that all active therapeutic efforts, such as individual, group, and
family psychotherapy, drug therapy, milieu therapy, occupational therapy,
recreational therapy, nursing care, and other therapeutic interventions, are
included;
9. Progress notes which
are recorded by the psychiatrist or physician, nurse, social worker, and, when
appropriate, others significantly involved in active treatment modalities. The
frequency is determined by the condition of the client, but progress notes must
be recorded daily by nursing staff, and at each contact by psychiatrist or
physician and by all other treatment staff. Progress notes must contain a
concise assessment of the client's progress and recommendations for revising
the treatment plan as indicated by the client's condition;
10. The psychiatric diagnosis contained in
the final diagnosis written in the terminology of the current American
Psychiatric Association's Diagnostic and Statistical Manual (DSM);
11. Therapeutic leave days prescribed by the
psychiatrist under the treatment plan. The client's response to time spent
outside the hospital must be entered in the client's hospital clinical
record;
12. Transition and
discharge planning documentation including relapse and crisis prevention
planning;
13. Proof of family and
community involvement;
14. The
discharge summary, including a recapitulation of the client's hospitalization,
recommendations for appropriate services concerning follow-up, and a brief
summary of the client's condition on discharge.
All documents from the client's medical record submitted to
the Department must contain sufficient information for identification (that is,
client's name, date of service, provider's name).
006.12
Certification and
Recertification by Psychiatrists for Subacute Inpatient Hospital Psychiatric
Services
The Department pays for covered subacute inpatient hospital
psychiatric services only if a psychiatrist certifies, and recertifies at
designated intervals, the medical necessity for the admission to and continued
hospitalization for subacute inpatient psychiatric treatment services.
Appropriate supporting material may be required. The psychiatrist's
certification or recertification statement must document the medical necessity
for the admission to and continued hospitalization for short-term inpatient
psychiatric treatment, based on a current evaluation of the client's
condition.
For clients admitted to a subacute program, a psychiatrist's
certification by written order for admission is required at the time of
admission.
20-006.12A
Failure to Certify or Recertify: If a hospital fails
to obtain the required certification and recertification statements for the
client's stay, the Department will not make payment for the services that are
not certified.
006.13
Hospital Utilization Review (UR)
See 471 NAC
10-012 ff. A site visit by Medicaid
staff for purposes of utilization review may be required for further
clarification.
006.14
Payment for Subacute Inpatient Hospital Psychiatric
Services
See 471 NAC 10-010.03D3.
20-006.14A
Billing:
Providers must submit claims for subacute inpatient hospital psychiatric
services on Form HCFA-1450 (UB-04). Providers must enter the prior
authorization number as required for subacute inpatient services.
006.15
Other
Regulations
In addition to the policies regarding psychiatric services,
all regulations in Title 471 NAC apply, unless stated differently in this
section.
006.16
Limitations
For subacute inpatient hospital psychiatric services, the
following limitations apply:
1. Care
must be provided by and directly supervised by a licensed psychiatrist. The
psychiatrist must be licensed in the state where the service is being
delivered.
2. All subacute
inpatient hospital psychiatric services must be prior-authorized; and
3. Payment for subacute inpatient hospital
services is made according to 471 NAC 10010.03D.
006.17
Documentation
Additional documentation from the client's medical record
may be requested by the Department's psychiatric consultants prior to
considering authorization of payment of subacute psychiatric
care.
006.18
Emergency Protective Custody (EPC) in a Subacute Inpatient
Program
A hospital may be reimbursed for clients under an EPC order
in an acute care hospital without designated psychiatric beds for an average of
three to five days, up to seven days under the following conditions:
1. The hospital is licensed by the Nebraska
Department of Health and Human Services Division of Public Health;
2. The hospital is accredited by the Joint
Commission on the Accreditation of Health Care Organizations or the American
Osteopathic Association;
3. The
admitting and attending physician is a psychiatrist;
4. The hospital provides a setting that is
separate from the rest of the hospital activities and is a safe, therapeutic
environment;
5. The hospital
provides an active treatment program in the form of assessment and diagnostic
interventions;
6. The hospital EPC
program is approved by the Department's Medicaid staff; and
7. The hospital EPC program meets all other
standards for inpatient hospital psychiatric care.
