Current through September 17, 2024
008.01 Psychiatric Residential Treatment
Facilities (PRTFs) for Children/Adolescents
A Psychiatric Residential Treatment Facility (PRTF) is a
facility, other than a hospital, that provides inpatient psychiatric services
to individuals under the age of 19. A PRTF must provide the inpatient
psychiatric services under the direction of a physician, must be accredited and
must comply with all the requirements of applicable state and federal
regulations.
008.02 Prior
Authorization
In order for an admission to a PRTF to be reimbursed by
Medicaid, the individual must meet the Certification of Need for Services
requirements set forth in 32-008.03 and be prior authorized by Medicaid or its
designee. Prior authorization applies to all admissions described in
32-008.04.
008.03
Certification of Need for Services
A team specified in Section 32-008.04 must certify, prior to
admission, that:
1. Ambulatory care
resources available in the community do not meet the treatment needs of the
individual;
2. Proper treatment of
the individual's psychiatric condition requires services on an inpatient basis
under the direction of a physician; and
3. The services can reasonably be expected to
improve the individual's condition or prevent further regression so that the
services will no longer be needed.
008.04 Team Certifying Need for Services
Certification of the need for services specified in 32-008.03
must be made by an independent team that:
1. Includes a physician;
2. Has competence in diagnosis and treatment
of mental illness, preferably in child psychiatry; and
3. Has knowledge of the individual's
situation.
32-008.04A
Individuals Who Become Eligible for Medicaid While in
PRTF: For an individual who applies for Medicaid while in the
PRTF, the certification must be:
1. Made by
the team responsible for the Plan of Care as specified in 32-008.07;
and
2. Cover any period before
application for which claims are made.
32-008.04B
Emergency
Admissions: For emergency admissions, the certification must be
made by the team responsible for the Plan of Care within 14 days after
admission.
008.05 Active
Treatment
Inpatient psychiatric service must involve "active treatment"
which means implementation of a professionally developed and supervised
individual plan of care, as described in 32-008.06, that is developed and
implemented no later than 14 days after admission and is designed to achieve
the individual's discharge from inpatient status at the earliest possible
time.
008.06 Individual Plan
of Care
The plan of care means a written plan developed for each
individual to improve his/her condition to the extent that inpatient care is no
longer necessary. The plan of care must:
1. Be based on a diagnostic evaluation that
includes examination of the medical, psychological, social, behavioral and
developmental aspects of the individual's situation and reflects the need for
inpatient psychiatric care;
2. Be
developed by a team of professionals specified in 32-008.07 in consultation
with the individual and the parents, legal guardian or others in whose care the
individual will be released after discharge;
3. State treatment objectives;
4. Prescribe an integrated program of
therapies, activities and experiences designed to meet the objectives;
and
5. Include post-discharge plans
and coordination of inpatient services with partial discharge plans and related
community services to ensure continuity of care with the individual's family,
school and community upon discharge. The discharge plan must:
a. Identify the custodial parent or custodial
caregiver anticipated at discharge;
b. Identify the school the patient will
attend;
c. Include individualized
educational program (IEP) recommendations as necessary;
d. Outline the aftercare treatment plan;
and
e. List barriers to community
reintegration and progress toward resolving these barriers since the last
review. Include the needs of the custodial parent or custodial
caregiver.
008.07 Team Developing Individual Plan of
Care
1. The individual plan of care shall be
developed by an interdisciplinary team of physicians and other personnel who
are employed by, or provide services to individuals in the facility.
2. Based on education and experience,
preferably including competence in child psychiatry, the team must be capable
of:
a. Assessing the individual's immediate
and long-range therapeutic needs, developmental priorities and personal
strengths and liabilities;
b.
Assessing the potential resources of the individual's family;
c. Setting treatment objectives;
and
d. Prescribing therapeutic
modalities to achieve the plan's objectives.
3. The team must include, as a minimum,
either:
a. A Board-eligible or
Board-certified psychiatrist; or
b.
A licensed psychologist and a physician licensed to practice medicine or
osteopathy; or
c. A physician
licensed to practice medicine or osteopathy with specialized training and
experience in the diagnosis and treatment of mental diseases and a licensed
psychologist.
4. The
team must also include one of the following:
a. A psychiatric social worker;
b. A licensed registered nurse with
specialized training or one year's experience in treating mentally ill
individuals;
c. A licensed
occupational therapist who has specialized training or one year of experience
in treating mentally ill individuals.
d. A licensed psychologist.
008.08 Reports of
Evaluations and Plans of Care
A written report of each evaluation and plan of care must be
entered in the individual's record:
1.
At the time of admission; or
2. If
the individual is already in the PRTF, immediately upon completion of the
evaluation or plan.
008.09 Review of Plan of Care
The Plan of Care must be reviewed every 30 days by the team
specified in 32-008.07, to:
1.
Determine that services being provided continue to be required on an inpatient
basis, and
2. Recommend changes in
the plan as indicated by the individual's overall progress from the treatment
provided at this level of care.
008.10 Treatment Services Provided by the
PRTF
Providers of PRTF services shall provide 40 hours of
psychotherapy and other treatment interventions per week. The following
services and frequency of services are included in the PRTF rate and must be
available to the individual unless clinically contraindicated:
1. Twice weekly individual psychotherapy
and/or substance abuse counseling;
2. Minimum three times a week group
psychotherapy and/or substance abuse counseling;
3. Weekly family psychotherapy and/or family
substance abuse counseling. A family therapy session is provided on the day of
admission and the day prior to discharge;
4. Occupational therapy as clinically
indicated;
5. Physical therapy as
clinically indicated;
6. Speech
therapy as clinically indicated;
7.
Laboratory services;
8.
Transportation; and
9. Medical
Services, as necessary; and
10.
Nursing service availability 7 days a week, 365 days a year by an onsite nurse
during awake hours and by an on-call availability during sleep hours.
008.11 Psychoeducation Services
Provided in PRTF
Psychoeducational services must be available from the PRTF
and must be modified to meet the unique treatment needs of the individual as
described in the individual's Plan of Care:
1. Crisis intervention and aftercare
planning;
2. Life survival skills
as clinically indicated;
3. Social
skills building;
4. Substance abuse
prevention interventions;
5.
Self-care services as clinically indicated;
6. Medication education, compliance and
information regarding the effectiveness of medication;
7. Health care issues which may include
nutrition, hygiene and personal wellness;
8. Vocational/career planning as clinically
indicated; and
9. Recreational
activity (recreational activity is not considered in 40 hours per week of
therapy but healthful outcomes of recreation and exercise may be a part of a
psycho-educational group service).
008.12 Individual Participation in PRTF
Services
Every individual need not partake in all treatment services
that are available in the PRTF if such services are clinically contraindicated.
If individual, group or family psychotherapy services are not appropriately
beneficial to the individual's need and Plan of Care, the Plan of Care shall
identify the rationale for this omission. However, in no case should a
child/adolescent receive less than 40 hours of PRTF services each
week.
008.13 Staffing
Standards for PRTFs
A PRTF shall be available 24 hours a day, 7 days a week, 365
days per year with 24-hour awake staffing. Staffing ratios should be 1:4 during
awake hours and 1:6 during sleep hours. The following positions are required to
be staffed, with a minimum of the stated qualifications.
32-008.13A
Supervising
Practitioner: The PRTF Supervising Practitioner shall be a
licensed physician.
32-008.13B
Program/Clinical Director: A program/clinical director
shall be a LMHP, licensed RN, licensed APRN, LIMHP, licensed physician with a
specialty in psychiatry, or licensed psychologist. Dual-credentialing (e.g.,
LMHP/LADC or LMHP/PLADC) is required for PRTF services when co-occurring
conditions (e.g. mental health and substance abuse) occur. The Program/Clinical
Director shall have two years professional experience in a treatment setting
similar to a PRTF. The Program/Clinical Director may not also serve in the role
of the program's therapist.
32-008.13C
PRTF
Therapist: A PRTF therapist shall be a licensed practitioner whose
scope of practice includes mental health and/or substance abuse services,
including a LMHP, LIMHP, PLMHP, LADC, licensed psychologist, provisionally
licensed psychologist, licensed APRN, or licensed physician with a specialty in
psychiatry.
32-008.13D
Registered Nurse or Advanced Practicing Registered Nurse (RN or
APRN): Nursing services shall be provided by a Registered Nurse or
APRN licensed by the State in which she or he practices.
32-008.13E
Direct Care
Staff: Direct care staff shall meet the following requirements: Be
21 years of age or older and at least three years older than the oldest
resident and have a high school diploma or its equivalent. Direct care staff
shall be appropriately trained and responsible for basic interaction care such
as supervision, daily living care and mentoring of the residents as well as
assisting in the implementation of the plan of care that is within their scope
of practice.
008.14
Restraint and Seclusion
Restraint and seclusion activities utilized by the PRTF shall
be in compliance with federal standards for restraint and
seclusion.
008.15 Services
Provided Outside the PRTF
The following services must be available to the individual
and may be billed separately to Medicaid:
1. Medically necessary services and/or
supplies, including dental, vision, diagnostic/radiology and prescribed
medications, not otherwise included in the PRTF rate when that care is
reflected in the plan of care.
2.
The PRTF shall:
a. Arrange for and oversee
the provision of such services and/or supplies;
b. Maintain all medical records of care
furnished to the individual; and
c. Ensure that all services and/or supplies
are furnished under the direction of a physician.
