Current through September 17, 2024
007.01 Introduction
Residential treatment services are available to clients age
20 or younger when the client participates in a HEALTH CHECK (EPSDT) screen,
the treatment is clinically necessary, and the need for care at this level has
been identified on the Initial Diagnostic Interview.
Residential treatment services must be family-centered,
culturally competent, community based, and developmentally appropriate.
Providers must encourage 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.
Providers must be available to schedule meetings and sessions
in a flexible manner to accommodate and work with a family's schedule. This
includes the ability to schedule sessions at a variety of times including
weekends or evenings.
The provider must document their attempts to involve the
family in treatment plan development and treatment plan reviews. A variety of
communication means should be considered. 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.
Residential treatment services for children covered by
Medicaid include residential treatment for children age 20 and younger who are
eligible for Medicaid. These regulations also cover children age 18 or younger
who are wards of the Department.
Residential treatment services must be provided under the
direction of a supervising practitioner as designated in 471 NAC
32-001.06.
007.02
Residential Treatment for Children
The Department's philosophy is that all care provided to
clients must be provided at the least restrictive and most appropriate level of
care. Care must be family-centered, community-based, culturally competent, and
developmentally appropriate. Medicaid will cover more restrictive levels of
care only when all other resources have been explored and deemed to be
inappropriate. If hospital-based inpatient care is deemed appropriate, see 471
NAC
32-008.
Residential treatment center services are clinically
necessary services provided to a client who requires professional care and
highly structured 24-hour awake care at a greater intensity than that available
at the treatment group home and foster home levels.
In keeping with the philosophy that children are better
served in more family-like settings, the total number of approved beds for a
residential treatment center will not exceed two units of up to 20 beds each,
and the center must provide a home-like atmosphere commensurate with the size
and scope of the program. Exception: A state owned and operated residential
treatment center may exceed two units provided that each unit has no more than
20 beds each. When a state owned and operated residential treatment center
exceeds two 20 bed units, children may be placed there for treatment only if
all other in state residential treatment center providers have declined to
serve the child within a reasonable period of time. This exception shall expire
two years after the effective date of the exception.
007.03 Standards for Participation for
Residential Treatment Centers
32-007.03A
Provider Agreement: A provider of residential
treatment center services shall complete Form MC-19 or Form MC-20, "Medical
Assistance Provider Agreement," and submit the completed form to the Department
for approval. The Department is the sole determiner of which centers are
approved for participation in this program. The facility will be advised in
writing when its participation is approved.
The provider shall submit the following with Form MC-19 or
Form MC-20:
1. A written overview of
the program's philosophy and objectives of treating children and youth
including:
a. A description of each available
service;
b. A list of treatment
modalities available and the capacity for individualized treatment
planning;
c. A statement of the
qualification, education, and experience of each staff member providing
treatment and the therapy service each provides;
d. A schedule covering the total number of
hours that the program operates;
e.
The Department approved cost reporting document; and
f. The target population.
2. Facility/Program Changes: A
residential treatment facility shall report to the HHS Licensing Unit and to
the Medicaid Division any major changes in its program and/or facilities,
before the change is made. The HHS Licensing Unit will determine whether the
license must be modified or reissued. Any change in the capacity of a licensed
facility requires that a license be reissued showing the number of youth who
can be cared for under the new plan. The Medicaid Division will determine if
the facility maintains appropriate therapeutic programming for NMAP.
3. Confirmation that the staffing standards
in 471 NAC 32-007.04D are met.
4.
Current licensure as a child caring agency. If the child caring agency license
is denied or revoked, this requirement is not met; therefore, the provider is
not eligible for participation. Licensure as a child caring agency is not
required for hospital-based services.
5. Copy of JCAHO, CARF, AOA, or COA
accreditation certificate.
32-007.03B
Place of
Service: Residential treatment services may be provided in the
following locations when the requirements listed in 471 NAC 32-007.04B have
been met:
1. A residential type
community-based treatment facility appropriately licensed by the Nebraska
Department of Health and Human Services, Division of Public Health;
or
2. A hospital that is licensed
as a hospital by the Nebraska Department of Health and Human Services, Division
of Public Health, is accredited by the Joint Commission on Accreditation of
Health-Care Organizations (JCAHO) or the American Osteopathic Association
(AOA), meets the requirements for participation in Medicare, and has a
utilization review plan applicable to all Medicaid clients in effect.
32-007.03B1
Facility
Requirements: In order to be approved as a provider of Residential
Treatment Services, the program must insure that the following requirements are
met:
1. Adequate access to recreational
facilities for both indoor and outdoor activities, commensurate with the size
and scope of the program. (This may be provided on-site or through
contract);
2. Separation of the
treatment group home program from inpatient hospital operations, including
laboratory, radiology, surgery, patient rooms, dining areas, patient lounges,
etc.;
3. The doors to the unit and
to the outside may be locked from the outside to allow for safety, but they
must be unlocked or easily unlocked from the inside;
4. Kitchen and laundry facilities easily
accessible to the unit;
5. Staff
offices must be located on the unit;
6. Secure storage for medications and
clinical charts must be on the unit;
7. A general living or lounge area must be on
the unit;
8. A home-like
atmosphere;
9. Program is staffed
by awake personnel 24 hours per day; and
10. Other requirements as listed in this
chapter.
32-007.03C
Other
Requirements: The residential treatment center must -
1. Be in conformance with all applicable
federal, state, and local laws;
2.
Meet the program and operational definitions and criteria contained in the
Nebraska HHS Finance and Support Manual;
3. Meet the definition of a residential
treatment center as stated in 471 NAC 32007.02;
4. Maintain documentation in each client's
treatment record that provides a full and complete picture of the nature and
quality of all services provided (see 471 NAC 32-007.07);
5. Have the capacity to meet the needs of the
individual Medicaid client either through employment of or contracts with
appropriate staff (see 471 NAC 32-007.04D);
6. Be licensed by the Department under the
minimum regulations for child caring agencies. If the child caring agency
license is denied or revoked, this requirement is not met; therefore, the
provider is not eligible for participation (See 474 NAC 6-005, Licensing Group
Homes and Child Caring and Placing Agencies and Nebraska State Statute
81-505.01, 1983.) Hospitals are not required to be licensed as a child caring
agency.
32-007.03D
Accreditation: The residential treatment center must
have -
1. Be accredited by JCAHO, CARF, COA or
AOA; or
2. Include a copy of the
accreditation certificate with the initial and updated enrollment materials and
forward a copy of all survey visit reports and provider responses.
If the most recent survey required a plan of corrections, the
plan must also be submitted; or
Agencies accredited through these accrediting bodies are
eligible for NMAP reimbursement of treatment and maintenance (room and board)
costs and must maintain accreditation in order to qualify as a residential
treatment services provider. Treatment and maintenance costs are reimbursed as
a per diem rate. See NMAP Fee Schedule, (Appendix 471-000-532).
Interpretive Note: Agencies that have applied for
accreditation with one of these entities may be enrolled on a provisional
status and receive reimbursement for treatment only.
32-007.03E
Staffing
Standards for Participation: A residential treatment center for
children shall meet the following standards to participate in NMAP:
1. The center's staff must include -
a. An executive director who has a sufficient
background and experience to administered a treatment program;
b. A program director who meets the
requirements of a clinical staff person in 471 NAC 32-001.04 and is operating
within his/her scope of practice, with two years of professional experience in
the treatment of children and adolescents with mental illnesses or emotional
disturbances;
c. Clinical staff
professionals (who meet the requirements of a clinical staff person in 471 NAC
32-001.04) who provide psychotherapy and counseling, including face-to-face
individual, family, and group counseling, who are directed by the supervising
practitioner;
d. Child care staff
who are age 21 or older and have specialized training and experience sufficient
to equip them for their duties and are under the supervision of the program
director. 75% of child care staff must have a bachelor's degree
or five years of experience in human services
field;
e. Supervisory staff will
meet the standards outlined in 471 NAC 32-001.04 and four years experience in a
related field.
f. Training must be
approved by the Department and must meet the minimum standards for pre-service
and on-going training in licensing requirements;
g. A supervising practitioner who is a
licensed psychologist, physician, or doctor or osteopathy;
h. Each facility shall show by employment
records or on a contractual basis the ability to provide the needed services as
indicated by the scope of the program, including necessary medical/psychiatric
evaluations, and access to emergency care. The clinical services of a
psychologist, psychiatrist, and physician may be obtained on a consultation
basis; and
j. Educators, when
on-site education is provided. Services must be provided in accordance with
applicable state and federal laws. NMAP does not make payment for educational
services;
2. Volunteer
services may be used to augment and assist other staff in carrying out program
or treatment plans. Volunteers who work directly with youth must receive
orientation training regarding the program, staff, and children of the center
and the functions that volunteers can perform. However, the services performed
by a volunteer cannot be substituted for necessary medical/psychiatric and
therapeutic patient/staff ratios;
3. Staff must be mentally and physically
capable of performing assigned duties and demonstrate basic professional
competencies as required by the job description. Every staff member shall have
an annual physical examination and obtain a statement that no medical condition
exists that may interfere with his/her ability to perform assigned duties. This
is addressed in policy governing licensure regulations. All applicable state,
federal, and local laws must be followed.
4. All program personnel having access to
clients, including full-time, part-time, paid, volunteer or contract, must be
checked through the Central Registry, Adult Protective Services Registry, and
the motor vehicle records. A criminal check must also be done through a law
enforcement agency. A person whose name appears on any of the above registries
must not have access to clients.
5.
The ratio of professional staff to children is dependent on the needs of the
children and commensurate with the size and scope of the program, however -
a. The minimum ratio of Master's level
therapists providing direct face-to-face therapy services to children and
families must be 1:10;
b. The
supervising practitioner must be available to spend approximately 45 minutes
(or more often as clinically necessary) per month, per client, in the facility
as a minimum. This includes face-to-face time with the client, treatment plan
reviews, and supervision;
c. There
must be sufficient supervising practitioner consultation hours on a regular
basis to meet the requirements for active treatment (see 471 NAC 32-007.06) and
to properly supervise the Master's level therapists (see 471 NAC 32-007.03F).
Youth at this level of care must be seen and interviewed by the supervising
practitioner a minimum of once every 30 days.
6. The ratio of child care staff to children
during prime time hours is dependent on the needs of the children and the
requirements of the individualized treatment plans. The ratio of staff to
children must be commensurate with the size and scope of the program; however,
minimum ratio is 1:4. This may be increased depending on the intensity of the
program and the child's needs.
7.
The ratio of child care awake staff during sleeping and non-prime hours is
dependent on the needs of the children and must be commensurate with the size
and scope of the program; however, the minimum ratio is 1:6. This may be
increased depending on the intensity of the program and the individual child's
needs.
8. The facility must be able
to call back child care staff to provide staff and client safety in crisis
situations.
9. If the facility has
a level program that requires intense observation for admissions, the direct
care staff to youth ratio will need to be more intense during that observation
period.
10. Access to emergency
services such as additional supervision and medical/psychiatric care must be
available on a 24-hour basis.
11.
Those facilities providing this service prior to the effective date of this
policy may apply to become an approved provider with their current staffing
levels provided:
a. Any new staff hired must
meet the criteria stated in these policies; and
b. Staff ratios are upgraded to policy
standards within four months of the policy's effective date.
32-007.03F
Service Standards for Participation for Residential Treatment
Centers: Residential treatment centers shall -
1. Make every effort to keep the child in
contact, when appropriate and possible, with the child's family and relatives,
when reunification or reconciliation is the plan;
2. Involve the parents and family, when
appropriate and possible, in the treatment planning. For wards of the
Department, the case manager must be included in all
phases of assessment, treatment planning, evaluation of services, and
discharge/after care arrangements;
3. Provide a minimum of 42 hours of scheduled
treatment intervention per week. These include, but are not limited to:
a. Group psychotherapy by a practitioner
operating within his/her scope of practice;
b. Individual therapy by a practitioner
operating within his/her scope of practice;
c. Family intervention (one hour per week
minimum);
d. Face-to-face sessions
with the supervising practitioner; and
e. Other approved group or individual
therapeutic activities.
4. Provide or arrange for face-to-face family
therapy a minimum of twice a month. Depending on the child's needs, this may
include reunification/reconciliation therapy and may also include biological
families, foster families, adoptive families, and/or extended family;
5. Provide the following mandatory services -
a.
Clinically Necessary Nursing
Services: Medical services directed by a Qualified Registered
Nurse who evaluates the particular nursing needs of each client and provides
for the medical care and treatment that is indicated on the Department approved
treatment planning document approved by the supervising practitioner.
Reimbursement for psychological diagnostic services is included in the per
diem.
b.
Clinically
Necessary Psychological Diagnostic Services: Testing and
evaluation services must reasonably be expected to contribute to the diagnosis
and plan of care established for the individual client. Testing and evaluation
services may be performed by a Clinical Psychologist acting within his/her
scope of practice. Clinical necessity must be documented by the program
supervising practitioner.
c.
Clinically Necessary Pharmaceutical Services: If
medications are dispensed by the program, pharmacy services must be provided
under the supervision of a registered pharmacy consultant; or the program may
contract for these services through an outside licensed/certified facility. All
medications must be stored in a special locked storage space and administered
only by a physician, registered nurse, licensed practical nurse, or a staff
person approved by the Nebraska Department of Health and Human Services,
Division of Public Health as a Medication Aide.
d.
Clinically Necessary Dietary
Services: The meal services provided must be supervised by a
registered dietitian, based on the client's individualized diet needs. Programs
may contract for these services through an outside licensed certified
facility.
e. Transition and
discharge planning must meet the requirements of 471 NAC 32-001.07A.
6.
Optional
Services: The program must provide two of the following optional
services. The client must have a need for the services, the supervising
practitioner must order the services, and the services must be a part of the
client's treatment plan. The therapies must be restorative in nature, not
prescribed for conditions that have plateaued or cannot be significantly
improved by the therapy, or which would be considered maintenance therapy:
a. Services provided or supervised by a
licensed or certified therapist may be provided under the supervision of a
qualified consultant or the program may contract for these services from a
licensed/certified professional as listed below:
(1) Recreational Therapy;
(2) Speech Therapy;
(3) Occupational Therapy;
(4) Vocational Skills Therapy;
(5) Self-Care Services: Services supervised
by a registered nurse or occupational therapist who is oriented toward
activities of daily living and personal hygiene. This includes toileting,
bathing, grooming, etc.
b. Psychoeducational Services: Therapeutic
psychoeducational services may be provided as part of a total program.
Therapeutic psychoeducational services must be provided by teachers specially
trained to work with child and adolescents experiencing mental health or
substance abuse problems. These services may meet some strictly educational
requirements, but must also include the therapeutic component. Professionals
providing these services must be appropriately licensed and certified for the
scope of practice.
c. Social Work
Services by a Bachelor's Level Social Worker: Social services to assist with
personal, family, and adjustment problems which may interfere with effective
use of treatment, i.e., case management type services.
d. Crisis Intervention (may be provided in
home);
e. Social Skills
Building;
f. Life Survival
Skills;
g. Substance abuse
prevention, intervention, or treatment by an appropriately licensed alcohol and
drug counselor.
7.
Provide appropriate conferences involving the youth's interdisciplinary
treatment team, the parents, the referring agency, and the child, to review the
case status and progress at least every month. This does not substitute for
documentation requirements. The need for conferences with interested parties is
indicated by the individual child's circumstances and needs, which may indicate
conferences occurring more frequently. For wards of the Department, this need
will be jointly determined with the case manager;
8. Allow for more than one type of activity
to be scheduled at one time allowing for specialized and individualized
treatment planning;
9. Provide a
progress report to the referring agency, and the parents or legal guardian
every month for the purpose of service coordination. For wards of the
Department, monthly reports must be provided to the Division of Children and
Family Services case manager. The documentation from the Monthly Treatment Plan
review may serve this purpose;
10.
The services of specialists in the fields of medicine, psychiatry, psychology,
and education must be used as needed.
32-007.03G
Annual
Update/Renewal: The residential treatment center shall submit the
following information with the provider application and agreement, and
update/renewal the information annually to coincide with submission of the cost
report:
1. A written overview of the
program's philosophy and objectives of treating children and adolescents
including:
a. A description of each available
service;
b. A list of treatment
modalities available and the capacity for individualized treatment
planning;
c. A statement of the
qualification, education, and experience of each staff member providing
treatment and the therapy service each provides;
d. A schedule covering the total number of
hours that the program operates;
e.
The cost report; and
f. The target
population.
2.
Confirmation that the staffing standards in 471 NAC 32-007.03E are
met;
3. Copy of child caring agency
licensure certificate; and
4. Copy
of accreditation certificate.
The Division of Medicaid and Long-Term Care or its designee
may request this information on an intermittent basis and the provider must
comply by promptly supplying the requested information.
007.04 Covered Services
NMAP limits payment for residential treatment services to
those services for medically necessary to treat primary diagnoses. NMAP covers
residential services as delineated in 471 NAC 32-007 when the services are
medically necessary and provide active treatment.
32-007.04A
Pre-Admission
Authorization: For residential treatment center services to be
covered by NMAP, the need for admission to this level of care must be
determined by a supervising practitioner through a thorough pre-treatment
assessment (see 471 NAC 32001.01) and prior authorized through the Medicaid
Division or its designee. For wards of the Department, consent for treatment
for wards of the Department must be obtained from the Department case manager
or supervisor. See 471 NAC
32-001.
32-007.04B
Guidelines for Use of
Residential Treatment Services for Children: A youth must have a
diagnosable condition listed in the current diagnostic and statistics manual of
the American Psychiatric Association (excluding V-codes and developmental
disorders) for this level of care. NMAP applies the following guidelines to
determine when residential treatment services for children or adolescents are
medically necessary for a client:
1. The
child/adolescent requires 24-hour awake supervision with high staff
ratios;
2. Utilization of
residential treatment services is appropriate for individualized treatment and
is expected to improve the client's condition to facilitate moving the client
to a less restrictive placement;
3.
The child/adolescent's problem behaviors are persistent, unpredictable, and may
jeopardize the health or safety of the client and/or
others;
4. The child/adolescent's
daily functioning must be significantly impaired in multiple areas, such as
family relationships, education, daily living skills, community, health,
etc.;
5. The child/adolescent has a
documented history of previous placement disruptions due to on-going
behaviors/psychiatric issues; and
6. Less restrictive treatment approaches have
not been successful or are deemed inappropriate by the referring supervising
practitioner.
32-007.04C
Therapeutic Passes for
Clients Involved in Residential Treatment Services: Therapeutic
passes are an essential part of the treatment for client/families involved in
residential treatment services. Documentation of the client's continued need
for residential treatment services must follow overnight therapeutic passes.
Therapeutic passes must be indicated in the treatment plan as they become
appropriate. NMAP reimburses for only 60 therapeutic pass days per client per
year. This includes all treatment services in which the client is involved
during the year.
Therapeutic leave days are counted by the entity reimbursing
for the care. Because the NMAP fee-for-service program reimburses for
therapeutic leave days on a post-service basis and because providers have one
year to bill for services, the Department cannot guarantee that an accurate
account of the therapeutic leave days that have been used.
32-007.04D
Vacations: If a residential treatment program takes
the clients on a "vacation," NMAP will reimburse for those days under the
following conditions -
1. The trip is prior
authorized by the Division of Medicaid and Long-Term Care or its
designee;
2. There is a clear
statement of goals and objectives for the individual client's participation in
the trip;
3. At least 50% of the
scheduled treatment interventions must occur during the "vacation";
4. A clinical staff person must accompany the
"vacation" trip; and
5. The
"vacation" must be included in the treatment program.
NMAP will reimburse for up to seven "vacation" days per year
for clients in residential treatment program.
007.05 Additional Requirements
32-007.05A
Work
Experience: When a center has a work program, it must -
1. Provide work experience that is
appropriate to the developmental age and abilities of the
child/adolescent;
2. Differentiate
between the chores that children/adolescents are expected to perform as their
share in the process of living together, specific work assignments available to
children/adolescents as a means of earning money, and jobs performed in or out
of the center to gain vocational training;
3. Give children/adolescents some choice in
their work experience and offer change from routine duties to provide a variety
of experiences;
4. Not interfere
with the child/adolescent's time for school, study periods, play, chores,
sleep, normal community activities, visits with the family, or individual,
group, or family therapy.
5.
Children/adolescents may not be solely responsible for any major phase of the
center's operation or maintenance, such as cooking, laundering, housekeeping,
farming, or repairing; and
6.
Comply with all state and federal labor laws.
32-007.05B
Solicitation of
Funds: A center may not use a child/adolescent for advertising,
soliciting funds, or in any other way that may cause harm or embarrassment to
the child/adolescent or the family. Written consent of the parent or guardian
must be obtained before the center uses a child's picture, person, or name in
any form of written, visual, or verbal communication. Before obtaining consent,
the center shall advise the parent or guardian of the purpose for which it
intends to use the child's picture, person, or name, and of the times and
places when and where this use would occur.
32-007.05C
Special Treatment
Procedures: If a youth needs behavior management and containment
beyond unlocked time outs or redirection, special treatment procedures may be
utilized. Special treatment procedures in psychiatric RTC's are limited to
physical restraint, locked time out (LTO), and a locked unit. Mechanical
restraints and pressure point tactics are not allowed. Parents or legal
guardians or the Department case manager must approve use of these procedures
through informed consent and must be informed within 24 hours each time they
are used.
Facilities must meet the following standards regarding
special treatment procedures:
1.
De-escalation techniques must be taught to staff and used appropriately before
the initiation of special treatment procedures;
2. Special treatment procedures may be used
only when a child/adolescent's behavior presents a danger to self or others, or
to prevent serious disruption to the therapeutic environment; and
3. The child/adolescent's treatment plan must
address the use of special treatment procedures and have a clear plan to
decrease the behavior requiring LTO, physical restraints, or a locked unit.
These standards must be reflected in all aspects of the
treatment program. Attempts to de-escalate, the special treatment procedure and
subsequent processing must be documented in the clinical record and reviewed by
the supervising practitioner.
32-007.05D
Medical
Care: The center shall ensure that the following medical care is
provided for each child/adolescent:
1. Each
child/adolescent must receive a medical examination (EPSDT/Health Check exam)
before or at the time of admission;
2. Each child/adolescent must have current
immunizations as required by the Nebraska Department of Health and Human
Services;
3. The center shall
arrange with a physician and a psychiatrist for the medical and psychiatric
care of the clients;
4. Each
child/adolescent must have a medical examination annually as allowed in 471 NAC
33-000 ff.;
5. The center shall
inform staff members of what medical care, including first aid, may be given by
staff without specific physician orders. Staff must be instructed on how to
obtain further medical care and how to handle emergency cases. The center shall
ensure that -
a. Staff members on duty must
have satisfactorily completed current first aid and cardiopulmonary
resuscitation training and have on file at the center a certificate of
satisfactory completion as required by Department of Health and Human Services,
Division of Public Health regulations;
b. Each staff member must be able to
recognize the common symptoms of illnesses in children/adolescents and to note
any marked physical defects of children.
c. A sterile clinical thermometer, a complete
first aid kit, and clearly posted emergency phone numbers must be available,
according to Department of Health and Human Services.
32-007.05E
Hospital
Admissions: The center shall make arrangements for the emergency
admission of children from the center in case of serious illness, emergency, or
psychiatric crisis. Parents, legal guardians, or the Department case manager or
the case manager's supervisor must give permission and consent to treat for
admission.
In the event that a client does require hospitalization while
in a residential treatment center, NMAP will reimburse the treatment program
for up to 15 days per hospitalization. This reimbursement is only available if
the treatment placement is not used by another client.
32-007.05F
Hospitalization or
Death Reports: The center shall report any accident or illness
requiring hospitalization to the parents or guardian immediately. The center
shall immediately report any death to the parents or guardian, the Division of
Medicaid and Long-Term Care, a law enforcement agency, and the county coroner.
If the child is a Department ward, see 474 NAC 4-009.28D 8.
32-007.05G
Dental
Care: Each child/adolescent must have an annual dental
examination. If a child/adolescent has not had a dental exam in the twelve
months before admission, an examination must occur within 90 days following
admission. See 471 NAC 6-000 and 33-000 and 474 NAC 6-005.26F.
32-007.05H
General
Health: The center shall ensure the following:
1. Each child/adolescent must have enough
sleep for the child/adolescent's age and physical and emotional condition at
regular and reasonable hours, and under conditions conducive to rest. While
clients are asleep, at least one staff member must be within hearing
distance;
2. Children/adolescents
must be encouraged and helped to keep themselves clean;
3. Bathing and toilet facilities must be
properly maintained and kept clean;
4. Each child/adolescent must have a
toothbrush, comb, an adequate supply of towels and washcloths, and personal
toilet articles;
5. Menus must
provide for a varied diet that meets a child/adolescent's daily nutritional
requirements;
6. Each
child/adolescent must have clothing for their exclusive use. The clothing must
be comfortable and appropriate for the current weather conditions;
and
7. The center must provide
safe, age-appropriate equipment for indoor and outdoor play.
See 471 NAC 33-000.
32-007.05J
Education: Educational services, when required by law,
must be available. Education services must only be one aspect of the treatment
plan, not the primary reason for admission or treatment. Educational services
are not eligible for payment by the NMAP.
32-007.05K
Religious
Education: Children/adolescent must be provided with an
opportunity to receive instruction in their religion. No child/adolescent may
be required to attend religious services or to receive religious instructions
if the child/adolescent chooses not to attend the services or receive
instruction.
32-007.05L
Discipline: Discipline must be diagnostic and remedial
rather than punitive. Corporal punishment, verbal abuse, and derogatory remarks
about the child/adolescent, the family, religion, or cultural background are
prohibited. A child/adolescent may not be slapped, punched, spanked, shaken,
pinched, or struck with an object by any staff of the center. Only staff
members of the center may discipline children (see 474 NAC 6-005.26K) while in
treatment.
32-007.05M
Transition and Discharge Planning: Whenever a child or
adolescent is transferred from one setting to another, discharge planning must
be performed and documented, beginning at the time of admission (see 471 NAC
32-001.07A and 474 NAC 6-005.27H).
Facilities must meet the following standards regarding
discharge planning:
1. Discharge
planning must be based on the multidisciplinary treatment plan designed to
achieve the client's discharge from residential treatment status to a less
restrictive level of care at the most appropriate time;
2. Discharge planning must address the
client's need for ongoing treatment, continuing education, and support for
normal development following discharge;
3. Discharge planning must include
identification of and transition into services needed following
discharge;
4. The residential
treatment facility shall arrange for prompt transfer of appropriate records and
information to ensure continuity of care following the client's
discharge;
5. A written discharge
summary must be provided as part of the clinical record; and
6. The client's family and caseworker must be
active participants in discharge planning. This participation must be clearly
documented in the client's record.
32-007.05N
Notification of
Runaway Children: See 390 NAC 7-001.05.
32-007.05P
Interstate Compact on
the Placement of Children: The center shall comply with the
interstate compact on the placement of children (see 474 NAC 6-005.27J
).
32-007.05Q
Medications: The center may possess a limited quantity
of nonprescription medications and administer them under the supervision of
designated staff. The center must follow all applicable regulations through the
Department of Health and Human Services, Division of Public Health for storing
and administering medications.
The center shall have written policies governing the use of
psychotropic medications. Parents or the guardian of a client who receives
psychotropic medication must be informed of the benefits, risks, side effects,
and potential effects of medications. A parent or legal guardian's written
informed consent for use of the medication must be obtained before giving the
medication and filed in the client's record.
A child/adolescent's medication regime must be reviewed by
the attending physician at least every seven days for the first 30 days and at
least every 30 days thereafter.
007.06 Individual Treatment
To be covered by NMAP, individual treatment services must
include -
1.
Program
philosophy: Residential treatment facilities must provide
intensive family-centered, community-based, developmentally appropriate
services under the direction of a supervising practitioner.
a. These services must be able to meet the
special needs of families, including the "identified client" in the treatment
facility. Families must be involved in treatment and discharge planning. For
wards of the Department, the case manager must also be involved in treatment
and discharge planning.
b. The
program intensity must be such that direct care staff, the client in treatment,
and/or the client's family have access to professional staff on an "as needed"
basis, determined by the client's condition.
2.
Active treatment,
which must be -
a. Treatment provided under a
multi-disciplinary treatment plan reviewed and approved by the supervising
practitioner. This plan will be developed within 14 days of admission by a
multi-disciplinary team of professional staff members. The treatment plan must
be for a primary psychiatric diagnosis and must be based on a thorough
evaluation of the client's restorative needs and the client's potential. The
treatment plan must be reviewed at least every 30 days by the
multi-disciplinary team.
The goals and objectives documented on the treatment plan
must reflect the recommendations from the Initial Diagnostic Interview, the
supervising practitioner and the therapist. The treatment interventions
provided must reflect these recommendations, goals, and objectives. Evaluation
of the treatment plan by the therapist and the supervising practitioner should
reflect the client's response to the treatment interventions based on the
recommendations, goals and objectives.
b. In compliance with 471 NAC 32-001.07,
Treatment Planning; and
c. In
compliance with 471 NAC 32-001.06, Active Treatment.
3.
Medically necessary
services, which must be an appropriate level of care based on
documented Initial Diagnostic Interview including a comprehensive diagnostic
workup and supervising practitioner-ordered treatment.
007.07 Documentation in the Client's Clinical
Record
The center must maintain accurate clinical records
indicating the degree and intensity of the treatment provided to clients who
receive services in the residential treatment facility. For residential
services, clinical records must stress the treatment intervention components of
the clinical record, including history of findings and treatment provided for
the psychiatric condition for which the client is in the facility. The clinical
record must include the requirements stated in 471 NAC 32-001.05 and -
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 determined for every client at the
time of admission and includes the diagnoses of intercurrent diseases as well
as the psychiatric diagnoses;
3.
The statements of others regarding the client's problems and needs, as well as
the client's statement of their problems and needs;
4. The pre-treatment assessment, including a
medical/psychiatric history, which contains a record of mental status and notes
the onset of illness/problems, 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 psychological evaluation;
6. A complete neurological examination, when
indicated;
7. A social history
sufficient to provide data on the client's relevant past history, present
situation, social support system, community resource contacts, and other
information relevant to good treatment and discharge planning;
8. A thorough family assessment;
9. Reports of consultations, psychological
evaluations, electroencephalograms, dental records, and special
studies;
10. 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;
11. Progress notes must
be recorded by all professional staff and, when appropriate, others
significantly involved in active treatment modalities, following each contact.
The frequency is determined by the individual treatment plan and the condition
of the client, but should be recorded at least daily. 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. Child care
workers must maintain 24-hour documentation of a client's whereabouts and
activities;
12. The transition plan
and discharge summary, including a summary of the client's and family's
treatment, recommendations for appropriate services concerning follow-up, and a
brief summary of the client's condition on discharge;
13. The psychiatric diagnosis contained in
the final diagnosis written in the terminology of the American Psychiatric
Association's Diagnostic and Statistical Manual; and
14. The client's response to therapeutic
leave days prescribed by the supervising practitioner under the treatment plan.
The client's, family's, or guardian's response to time spent outside the
facility must be entered in the client's clinical record.
All documents from the client's medical record submitted to
the Division of Medicaid and Long-Term Care must contain sufficient information
for identification (i.e., client's name, date of service, provider's
name).
007.08
Utilization Review
All facilities must have a utilization review protocol for
their services.
007.09
Inspection of Care (IOC)
The Division of Medicaid and Long-Term Care or its
designee's inspection of care team will conduct inspection of care reviews for
psychiatric residential treatment facilities. See 471 NAC 32-001.09 and 471 NAC
32-001.10.
007.10
Documentation for Claims
The following documentation is required and kept in the
client's clinical record for all claims for residential treatment services. The
facility will be notified in writing if that occurs:
1. The treatment plan;
2. Orders by the supervising practitioner;
and
3. Progress notes for all
disciplines.
All claims are subject to utilization review by the
Department prior to payment.
32-007.10A
Exception: Additional documentation from the client's
clinical record may be requested by the Department prior to considering
authorization of payment.
007.11 Costs Not Included in the Residential
Treatment Per Diem
The mandatory and optional services are considered to be
part of the per diem for residential treatment services. The following charges
can be reimbursed separately from the residential treatment per diem when the
services are necessary, part of the client's overall treatment plan, and in
compliance with NMAP policy:
1. Direct
client services performed by the supervising practitioner;
2. Prescription medications (including
injectable medications);
3. Direct
client services performed by a physician other than the supervising
practitioner; and
4. Treatment
services for a physical injury or illness provided by other professionals.
If the client is enrolled with another managed care vendor
for medical-surgical services, it may be necessary to pursue prior
authorization or referral with that entity.
007.12 Procedure Code and Description for
Residential Treatment Services
HCPCS/CPT procedure codes used by NMAP are listed in the
Nebraska Medicaid Practitioner Fee Schedule at 471-000-532.
