Current through September 17, 2024
Secure Psychiatric Residential Rehabilitation is a secure
facility-based, non-hospital or non-nursing facility program for individuals
disabled by severe and persistent mental illness, who are unable to reside in a
less restrictive setting. These facilities are integrated into the community
and provide programming in an organized, structured setting, including
treatment and rehabilitation services and offer support to clients with a
severe and persistent mental illness and/or co-occurring substance abuse
disorders. These individuals demonstrate a moderate to high risk for harm to
self/others and are in need of recovery, treatment, and rehabilitation
services. The clients who are in need of this level of care have long standing
limitations with limited ability to live independently over an extended period
of time. These individuals have needed a high level of psychiatric intervention
and have limitations in all three functional areas, vocational/educational,
social skills and activities of daily living. See definitions in 471 NAC
35-001.01. The Secure Psychiatric Residential Rehabilitation program provides
skill building and other related recovery oriented psychiatric rehabilitation
services as needed to meet individual client needs. The Secure Psychiatric
Residential Rehabilitation Program is designed to:
1. Increase the client's functioning while
improving psychiatric stability so that s/he can eventually live successfully
and safely in a less restrictive residential setting of his/her choice and
capabilities;
2. Decrease the
frequency and duration of hospitalization;
3. Decrease and/or eliminate all high risk,
unsafe behavior to self or others; and
4. Improve the ability to function
independently by improving ability to function.
014.01 Program Components
A secure psychiatric residential rehabilitation program
provides a variety of on-site psychosocial rehabilitation and skill acquisition
activities and treatment each day. The program must facilitate client driven
skills training and activities as appropriate. A secure psychiatric residential
rehabilitation program must provide services identified on the client specific
Individual Treatment, Rehabilitation, and Recovery Plan, providing
culturally-sensitive and trauma-informed care. The activities must include, but
are not limited to:
1. Ongoing
assessment;
2. Arrangement for
general medical care including laboratory services, psychopharmacological
services, psychological services, as necessary;
3. Provision of a minimum of 42 hours per
week of on-site staff led psychosocial rehabilitation activities and skill
acquisition;
4. Programming focused
on relapse prevention, recovery, nutrition, daily living skills, social skill
building, community living, substance abuse, education, medication education
and self-administration, symptom management, and focus on improving the level
of functioning to get to a less restrictive level of care;
5. Educational and vocational focus as
appropriate; and
6. Access to
community-based rehabilitation/social services to assist in transition to
community as symptoms are managed and behaviors are stabilized.
35-014.01A
Assessments: The following assessments must be
completed:
1. A comprehensive mental health
and substance abuse assessments by a licensed mental health practitioner must
occur prior to admission;
2.
Following admission and within 24 hours of stay, a assessment by the program's
psychiatrist must be completed;
3.
A history and physical must be completed by a physician or Advanced Practice
Registered Nurse (APRN) within 24 hours of admission or one must be completed
within 60 days of admission and available in the clinical record;
4. Comprehensive strength-based
biopsychosocial assessment must be completed within 14 days of admission to
assess the client according to the requirements described in 471 NAC 35-014.01A
1;
5. A nursing assessment must be
completed by a Registered Nurse within 24 hours of admission; and
6. A functional assessment must be completed
initially upon admission and annually with continued stay at this level of
service.
35-014.01A1
Components of the Biopsychosocial Assessment: The
biopsychosocial assessment must be completed within the timeframe specified in
the Secure Psychiatric Residential Rehabilitation program's policies and
procedures, however, no more than 14 days after admission. Components 1 through
9 of this assessment must be completed by a licensed mental health
practitioner. Clinical impressions, including diagnosis and recommendations for
treatment and rehabilitation, must be completed by the program's psychiatrist.
The assessment must be in narrative form and include the following components:
1. Client name, Medicaid identification
number, emergency contact (name, relationship, and contact information), and
other information of the client that is relevant;
2. Provider demographics including: provider
name, address, phone number, fax number, and e-mail address, and other contact
information;
3. Presenting problem,
primary complaint including:
a. Signs,
symptoms, problems and dysfunctions relating to mental illness;
b. Reason for referral to Secure Psychiatric
Residential Rehabilitation services and referral source;
c. Name and title of the referral
professional (MD, psychologist, APRN, or LIMHP);
d. Presenting problem from the client's and
provider's perspective; and
e.
External leverage to seek evaluation (courts, family and other);
4. Medical History:
a. Dental history and current
needs;
b. Current medication
list;
c. Compliance with medication
(historical and current);
d.
Current primary care physician (name and contact information);
e. Date of last physical exam and physician
providing that assessment;
f.
Recent hospitalizations; and
g.
Major health concerns (such as STD's, HIV, Tuberculosis, Hepatitis, and
pregnancy);
5.
Employment/Education/Military History:
a.
History of employment;
b.
Educational history;
c. Military
involvement; and
d.
Strengths;
6.
Alcohol/Drug History:
a. Primary drug(s) of
choice;
b. Amount, frequency and
duration of use;
c. Prior
treatment(s), location and length of stay;
d. Current compliance with relapse prevention
plan;
e. Periods of abstinence
(supports needed);
f. Tolerance
level/withdrawal/history of complications from withdrawal;
g. Prior alcohol/drug
evaluations/recommendations, including scores and results of screening
tools;
h. Family history of
alcohol/drug use; and
i. Other
addictive behaviors (gambling, food, etc.);
7. Legal History (Information from Criminal
Justice System):
a. Criminal history and
consequences of criminal involvement;
b. Connection to alcohol/drug use;
c. Current legal charges/disposition of
charges;
8.
Family/Social/Peer:
a. Family members (age
and level of involvement with client);
b. Adult or minor children (names, ages and
level of involvement);
c. Parenting
knowledge or skill level, history of system involvement (courts);
d. Social supports utilized by client
(previous and current);
e. Housing
(ability to maintain housing, type of current housing, need for
assistance);
f. Recreational
activities (client's preference);
g. Collateral information;
h. Client strengths as perceived by client
and collateral contacts;
9. Psychiatric/Behavioral History:
a. Current diagnosis(s);
b. Previous treatment(s) and outcome(s) of
treatment(s);
c. Current mental
health and substance abuse providers and treatment currently
provided;
d. Current psychiatric
medication list;
e. Compliance with
medication (historical and current);
f. History of self harm or threats to harm
others;
g. Board of mental health
commitments (reason and dates of commitment);
h. Abuse (to include sexual abuse, physical
abuse, emotional abuse, neglect, witness domestic violence, victim/witness of
community violence, physical assault; and
i. Trauma (serious accident/injury, sexual
assault/rape, life-threatening medical illness, traumatic loss of a loved one,
terrorist act, war/political violence/torture, disasters (tornado,
earthquakes), sanctuary trauma (trauma while institutionalized),
prostitution/sex trafficking;
10. Clinical Impressions: (must be completed
by the licensed psychiatrist supervising the program and must be consistent
with the psychiatrist's initial diagnostic interview):
a. Information that supports/justifies the
recommendations; and
b. DSM
diagnosis, Axis 1-5;
11.
Recommendations by the program's psychiatrist:
a. Primary/ideal level of care;
b. Available level of care/barriers to ideal
level of care; and
c.
Client/family's response to recommendations;
12. Signature of psychiatrist and the
licensed mental health practitioner completing the assessment; and
13. Date of signature.
35-014.01B
Individual
Treatment, Rehabilitation, and Recovery Planning: An initial
Individual Treatment, Rehabilitation, and Recovery Plan must be completed
within 24 hours of admission. Secure Psychiatric Residential Rehabilitation
Service providers must develop an individual treatment, rehabilitation, and
recovery plan with the client within 30 days following admission to the
program. The plan must include substance abuse issues. The client's family
and/or guardian must be included in all assessment and treatment,
rehabilitation, and recovery planning. The provider must make every effort to
be available and responsive to the client's family and/or guardian to assist
their involvement in the client's recovery. The plan must be reviewed and
revised with the client, discussing and documenting the discharge plan a
minimum of every 7 days according the following requirements.
35-014.01B1
Individual Treatment,
Rehabilitation, and Recovery Plan: The master individual
treatment, rehabilitation, and recovery plan must be based upon a comprehensive
assessment and completed within 30 days of admission. This plan must:
1. Be oriented to the principles of recovery
and meaningful client participation;
2. Apply the principles of recovery - to
include meaningful client participation, and a life in the community of the
client's choosing;
3. Incorporate
and be consistent with best practices;
4. Include the client's individualized goals
and expected outcomes;
5. Contain
prioritized objectives that are measurable and time-limited;
6. Describe therapeutic interventions to be
used in achieving the goals and objectives that are recovery-oriented,
trauma-informed, and strength-based;
7. Identify staff responsible for
implementing the therapeutic interventions;
8. Specify the planned frequency and duration
of each therapeutic method;
9.
Delineate the specific behavioral criteria to be met for discharge or
transition to a lower level of care and reviewed weekly;
10. Include a plan developed with the client
that includes strategies to avoid crisis or admission to a higher level of care
using principles of recovery and wellness;
11. Include the signature of the client
and/or parent/guardian;
12. Include
health care proxy and trauma safety form when available and with client's
consent;
13. Document that the
individual treatment, rehabilitation, and recovery plan is completed within the
timeframe specified in the program's policies and procedures;
14. Document that the plan has been reviewed,
updated every 30 days, and revised according to client needs and progress;
and
15. Document that the plan was
reviewed by the program's treatment practitioners a minimum of every 30 days
and that written revisions were approved, signed, and dated each 30 days by the
program psychiatrist.
35-014.01C
Treatment
Services: The program must offer structured, planned treatment and
rehabilitation services as prescribed by the individualized treatment,
rehabilitation, and recovery plan. The following services must be available and
offered to the client.
1. Individual
Psychotherapy: An individual treatment and rehabilitation service between an
identified client and a qualified licensed practitioner who focuses upon the
identified goals of the individual treatment, rehabilitation, and recovery
plan;
2. Group Psychotherapy: A
service provided by a licensed clinician who is practicing within his/her scope
of practice and provides a psychotherapy service in groups of no less than
three and no more than twelve clients;
3. Family Therapy: Family therapy is a
therapeutic service between the client and his/her family and a qualified
licensed practitioner who provides intervention as identified by the
family-focused goals of the individual treatment, rehabilitation, and recovery
plan. Consent from the client must be documented prior to the involvement of
the family and delivery of the service; and
4. Psychoeducational services, such as
medical education by a registered nurse and skill development groups by a
trained and skilled staff able to facilitate these groups supervised by a
licensed mental health practitioner.
35-014.01D
Supportive
Services: The program must provide the following supportive
services for all active clients: referrals as necessary, problem
identification/solution, and coordination of the Secure Psychiatric Residential
Rehabilitation program treatment and activities with other services the client
may be receiving.
014.02 Staffing
The Secure Psychiatric Residential Rehabilitation provider
must contract with or employ a licensed psychiatrist for the program. The
psychiatrist's hours must be at a sufficient level to provide weekly direct
contact with the client; to provide assessment; to review the individual
treatment, rehabilitation, and recovery plan; to evaluate client's level of
progress; to assist in eliminating barriers to recovery; and to provide
psychiatric consultation as necessary on a 24/7 basis. Programs must have staff
available in skill and numbers to meet the acuity of the clients being served.
Programs must have ability to call staff back when necessary.
35-014.02A
Staffing
Standards: Secure Psychiatric Residential Rehabilitation providers
must meet the following minimum staffing requirements. The program must employ
a:
1. Program Director;
2. Licensed Mental Health Practitioner (LMHP)
or a Licensed Mental Health Practitioner/Licensed Alcohol and Drug Counselor
(LMHP/LADC). A dual Licensed Practitioner is preferred;
3. Registered nurse;
4. Direct care staff.
35-014.02A1
The Program Director
must:1. Be fully licensed as a
Mental Health Practitioner (APRN, RN, LMHP, LIMHP or psychologist);
and
2. Possess leadership,
supervisory, and management skills.
35-014.02A1a
Responsibilities of
the Secure Psychiatric Residential Rehabilitation Program
Director: The program director must:
1. Complete and sign a comprehensive
Biopsychosocial Assessment for each client within 14 days of admission or
delegate responsibility for the assessment to the program's licensed
practitioner who functions as the therapist for the program;
2. Develop, approve, and sign an initial
individual treatment, rehabilitation, and recovery plan within the first 24
hours of admission;
3. Supervise
and participate in the development of a comprehensive individual treatment,
rehabilitation, and recovery plan with the client and the program staff within
30 days of admission. The program director must approve and sign the plan prior
to implementation;
4. Supervise the
professional staff and direct care staff by on site presence during
programming;
5. Assure adequate
staff training through initial and ongoing training sessions and provide
supervision of staff competency checks;
6. Supervise and provide direction regarding
all documentation requirements, including organization and completeness of
clinical records; and
7. Supervise
and direct the development and implementation of the discharge plan.
35-014.02A2
Responsibilities of the Registered Nurse: The
registered nurse must:
1. Complete a nursing
assessment within 24 hours of admission;
2. Participate in the development of the
individual treatment, rehabilitation, and recovery plan and the plan
updates;
3. Oversee and monitor
daily medication administration;
4.
Provide medication education as necessary;
5. Communicate with the psychiatrist and
physician consultants as necessary;
6. Monitor, supervise, and oversee the
program's daily activities in conjunction with and in the absence of the
Program Director.
35-014.02A3
Responsibilities of
the Mental Health Practitioner: The mental health practitioner
must:
1. Complete a biopsychosocial
assessment within 14 days of admission when this responsibility is delegated by
the program director;
2.
Participate in the development of the individual treatment, rehabilitation, and
recovery plan and the updates;
3.
Provide individual, group and family psychotherapy according to the client's
individual treatment, rehabilitation, and recovery plan;
4. Communicate with the Program Director and
psychiatrist regarding the clinical needs of the client as necessary;
5. Monitor, supervise, and oversee the
program's daily treatment and activities in the absence of the Program Director
as assigned by the Program Director;
6. Assist with aggressive discharge planning;
and
7. Maintain a maximum staffing
ratio of 1 to 8 clients.
35-014.02A4
Direct Care
Staff: The Secure Psychiatric Residential Rehabilitation Program
must employ direct care staff who:
1. Are on
site and available to the clients at a ratio of one staff per four clients
during awake hours and a minimum of one awake direct care per staff per six
clients during overnight hours;
2.
Staff to client ratios must be enhanced to meet client need as
necessary.
3. Direct Care staff
having a bachelor's degree in psychology, sociology or related human services
field but two years of course work in the human services field and two years of
experience/training or two years of lived recovery experience is acceptable.
Each staff must have demonstrated skills and competency in treatment with
individuals with mental health diagnosis.
014.03 Discharge Planning
Throughout a client's care and whenever the client is
transitioned from one level of care to another, discharge planning must occur
in advance of this discharge. It must include the client's and client's
family/legal guardian's input and be documented in the client's clinical
record. The plan must be recovery-oriented, trauma-informed, and
strength-based.
Providers must meet the following standards regarding
recovery and discharge planning:
1.
Discharge planning must begin on admission to the service with input and
participation of the client and client's family/guardian;
2. Discharge planning must include the client
and family input and be consistent with the goals and objectives identified in
the individual treatment, rehabilitation, and recovery plan and clearly
documented in the clinical record;
3. Discharge planning must address the
client's needs for ongoing services to maintain the gains and to continue as
normal functioning as possible following discharge. A crisis/relapse/safety
plan must be in place;
4. Providers
must make or facilitate referrals and applications to the next level of care
and/or community support services, such as use of medications, housing,
employment, transportation, and social connections;
5. Providers must arrange for the prompt
transfer of clinical records and information to ensure continuity of care;
and
6. A written discharge summary
must be provided as part of the clinical record. It must identify the readiness
for discharge and contain the signature of a fully licensed clinician and date
of signature and must identify a summary of the services provided.
014.04 Clinical Documentation
Secure Psychiatric Residential Rehabilitation service
providers must maintain a clinical record that is confidential, complete,
accurate, and that contains up-to-date information relevant to the client's
care and services. The record must sufficiently document comprehensive
assessments; individual treatment, rehabilitation, and recovery plans; and plan
reviews. The clinical record must document client contacts describing the
nature and extent of the services provided, so that a clinician unfamiliar with
the service is able to identify the client's service needs and services
received. The documentation must reflect the rehabilitative services provided;
that the care is consistent with the goals in the individual treatment,
rehabilitation, and recovery plan; and that the care is based upon the
comprehensive assessment. The absence of appropriate, legible, complete records
may result in the recoupment of previous payments for services. Each entry must
identify the date, beginning and ending time spent providing the service and
location of service, and identify by name and title the staff person entering
the information.
Clinical records must be maintained at the client's primary
rehabilitation site. Records must be kept in a locked file when not in use. For
purposes of confidentiality, disclosure of rehabilitation information is
subject to all the provisions of applicable State and Federal laws. The
client's clinical record must be available for review by the client (and
his/her guardian with appropriate consent) unless there is a specific medically
indicated reason to preclude this availability. The specific reason must be
documented in the clinical record and reviewed periodically.
014.05 The clinical record must include, at a
minimum
1. Client identifying data, including
demographic information and the client's legal status;
2. Assessment and Evaluations:
a. Psychiatric assessment, including the name
of the clinician and the date of the assessment;
b. Comprehensive Biopsychosocial Assessment;
and
c. Other related
assessments;
3. The
client's diagnostic formulation (including all five axes);
4. The Individual Treatment, Rehabilitation,
and Recovery Plan and updates to plans;
5. Documentation of review of client rights
with the client;
6. A chronological
record of all services provided to the client. Each entry must include the date
the intervention was performed, the duration of the intervention (beginning and
ending time), the place of the service, and the staff member's identity and
legible signature (name and title);
7. Documentation of the involvement of family
and significant others;
8.
Documentation of treatment and recovery services and discharge
planning;
9. A chronological
listing of the medications prescribed (including dosages and schedule) for the
client and the client's response to the medication;
10. Documentation of coordination with other
services and treatment providers;
11. Discharge summaries from previous levels
of care;
12. Discharge summary
(when appropriate); and
13. Any
clinical documentation requirements identified in the specific
service.
014.06 Clients'
Rights
Individual staff and the treatment, rehabilitation, and
recovery team must provide interventions in a manner that support and maintain
the client's rights with a continuous focus on client empowerment and movement
toward recovery. Secure Psychiatric Residential Rehabilitation programs must
have written a client rights and responsibility policy. Staff must review
client rights, responsibilities, and grievance procedures with each new client
at admission and on an ongoing manner, and must document this review in the
clinical record. Secure Psychiatric Residential Rehabilitation programs must
comply with all state and federal clients' rights requirements.
The following rights apply to clients receiving secure
psychiatric residential rehabilitation services through Medicaid. The client
has the right to:
1. Be treated with
respect and dignity regardless of state of mind or condition;
2. Have privacy and confidentiality related
to all aspects of care;
3. Be
protected from neglect; physical, emotional, or verbal abuse and exploitation
of any kind;
4. Be part of
developing an individual treatment, rehabilitation, and recovery plan and
decision-making regarding his/her mental health treatment and rehabilitative
services;
5. Refuse treatment or
therapy (unless ordered by a mental health board or court);
6. Receive care which does not discriminate
and is sensitive to gender, race, national origin, language, age, disability,
and sexual orientation;
7. Be free
of any sexual exploitation or harassment; and
8. Voice complaints and file grievances
without discrimination or reprisal and to have those complaints and grievances
addressed in a timely manner.
014.07 Provider Participation
To participate in Medicaid as a provider of secure
psychiatric residential rehabilitation services, a program must be enrolled as
a Nebraska Medical Assistance Program provider according to the Medicaid
regulations. Providers must complete the credentialing into the Medicaid
Managed Care network prior to providing services to Medicaid Managed Care
beneficiaries. The provider must complete and sign Form MC-19, "Medical
Assistance Provider Agreement," and be approved for enrollment in Medicaid. In
addition, eligible providers must also provide documentation as requested.
Providers must notify Medicaid and/or its designee of any substantive changes
in the program or staff providing services. Providers are required to provide
annual updates of program information and cost information to determine ongoing
compliance with Medicaid regulations. Providers must maintain documentation of
policies and procedures that meet the standards and regulations described in
this chapter.
014.08
Licensure and Accreditation Requirements
The program must be licensed as a Mental Health Center by
the Department of Health and Human Services, Division of Public Health, and it
must be accredited by a national accrediting agency such as Commission on
Accreditation of Health Care Organization (JCAHO), the Commission on
Accreditation of Rehabilitation Facilities (CARF), or Council on Accreditation
(COA). Providers must have maintained their licensure and accreditation as a
condition for continued participation in Medicaid.
014.09 Bed Limitation
The maximum capacity for the provider of secure psychiatric
residential rehabilitation services must not exceed 16 beds. There must be no
waiver of this regulation over the 16-bed limitation.
014.10 Treatment Prior Authorization
All Secure Psychiatric Residential Rehabilitation Services
must be prior authorized by the Division of Medicaid and Long-Term Care or its
designee. These reviews include prior authorization and continued stay reviews.
Referrals for Secure Psychiatric Residential Rehabilitation Services must be
directed to the Division of Medicaid and Long-Term Care or its designee and
must follow established protocols for prior authorization and utilization
management.
014.11
Therapeutic Pass Days
Therapeutic passes are an essential part of the
rehabilitation process for clients involved in secure psychiatric residential
rehabilitation services. Documentation of the client's continued need for
secure psychiatric residential rehabilitation services must follow overnight
therapeutic passes. Therapeutic passes must be indicated in the individual
treatment, rehabilitation, and recovery plan as therapeutic passes become
appropriate. Medicaid reimburses for 21 therapeutic pass days per client per
calendar year when the client is on therapeutic leave for purposes of testing
ability to function and transition to lesser level of care.
014.12 Hospitalizations
In the event that a client does require hospitalization
while in a secure psychiatric residential rehabilitation program, Medicaid will
reimburse the Secure Psychiatric Residential Rehabilitation Program for up to
ten days per hospitalization. This reimbursement is only available if the bed
is not used by another client and the client returns to the bed occupied prior
to hospitalization.
014.13
Inspections of Care (IOC)
The Division of Medicaid and Long-Term Care or its designee
may periodically inspect the care which includes the treatment, rehabilitative,
and recovery services provided to clients in each type of service. The
Inspection of Care team will include staff who are knowledgeable about mental
health and rehabilitative psychiatric services and may include clients and/or
Division of Medicaid and Long-Term Care consultants.
The purpose of the Inspection of Care is to assess compliance
with Medicaid regulations and provide technical assistance to providers.
The activities of the Inspection of Care may include, but are
not limited to:
1. Review of clinical
documentation;
2. Client
interviews;
3. Program review with
staff;
4. Review of physical
plant;
5. Review of provider policy
and procedures;
6. Staff
interviews;
7. Financial and
payroll records; and
8. Employment
records of staff qualification and training issues.
After an Inspection of Care, the IOC team will develop a
report summarizing the findings of the visit. If deficiencies are noted,
providers must submit a plan of correction.
