Current through Register Vol. 56, No. 18, September 16, 2024
(a) The PA shall
provide, or arrange for, a range of services to effectively address the
holistic needs of the consumer. Service provision shall be coordinated with
other service providers. Services must not exceed a 1:15 staff-to-consumer
ratio based upon the active daily census and direct care staff, except as
indicated in (b)4 below.
(b) The PA
shall directly provide the following core services:
1. Engagement strategies shall be designed to
connect with consumers over time in order to develop a commitment on their part
to enter into therapeutic relationships supportive of the individual's
recovery. This service may include, but is not limited to, activities such as
initial contacts with potential program participants, as well as continued
efforts to engage individuals to participate in program services;
2. Activities designed to assist a consumer
to identify, achieve and retain personally meaningful goals over time which
help the person resume normal functioning in valued life roles in self-chosen
community environments. Examples of such goals include, but are not limited to,
returning to work or school, returning to adult care-giving or parenting roles,
resuming roles as a spouse or significant other, becoming a member of a
religious community, or becoming a neighbor;
3. An Illness Management and Recovery
Program, which is comprised of a broad set of strategies and activities that
help consumers collaborate with practitioners to identify and pursue personally
meaningful recovery goals and which founded upon a core set of interventions
that include: psycho education, social skills training, cognitive-behavioral
therapy, motivational interviewing and behavioral tailoring, and relapse
prevention techniques. This is accomplished by helping people to develop coping
strategies and skills that reduce the individual's susceptibility to the
illness, provide assistance and support to effectively manage symptoms to
prevent relapse and rehospitalizations, and reduce distress to the point that
the consumer is able to enjoy an improved quality of life. They are intended to
be both didactic and practical in nature and can be provided in both group and
individual settings. Such services will be provided directly to consumers and
in support of family members and/or other significant individuals important to
the consumer. The services shall include, but are not limited to:
i. Coping skills, adaptive problem solving,
and social skills training that teach individuals strategies to self-manage
symptoms and personal stress and strengthen life skills and abilities to attain
their recovery goals;
ii. Psycho
education that provides factual information, recovery practices, including
evidence-based models, concerning mental illness that instills hope and
emphasizes the potential for recovery. Such services will be geared toward the
consumer developing a sense of mastery over his or her illness and life, and
shall also be effective in reducing relapse and rehospitalizations. It may also
provide support to the consumer's family and other members of the consumer's
social network to help them manage the symptoms and illness of the consumer and
reduce the level of family and social stress associated with the
illness;
iii. Development of a
comprehensive relapse prevention plan that offers skills training and
individualized support focused on self-management of mental illness and other
aspects of recovery, including early recognition, identification and management
of symptoms and positive coping strategies and development of supports to
reduce the severity and distress of disturbing symptoms. Special attention
shall be placed on understanding, recognizing and monitoring of stressors that
have triggered return of persistent symptoms in the past and adaptive problem
solving techniques shall be applied to avoid recurrences in the future. As this
process of mastery over the illness evolves, the practitioner will explore and
develop a new sense of personal identity with the consumer, and examine with
him or her the potential for growth beyond the mental illness;
iv. Dual disorder education which provides
basic information to consumers, family members or other significant individuals
on the nature and impact of substance use and how it relates to the symptoms
and experiences of mental illness and its treatment, as well as upon the
attainment of one's personal recovery goals;
v. Medication education to be provided within
the context of a collaborative and therapeutic relationship. Consumers will be
provided with adequate information in an understandable format regarding
medications' relative effectiveness and safety in order to make an informed
decision. Interventions, such as medication self-management, behavioral
tailoring, simplifying a consumer's medication regimen, and motivational
interviewing assist and support consumers' in adhering to their medication
regimens. Practitioners will specifically review with the consumer how
medication management issues will impact their personal recovery goals and will
be responsible for involving family members whenever possible; and
vi. Wellness activities that are consistent
with the consumer have self-identified recovery goals. Wellness activities may
address common physical health problems, such as tobacco dependency, alcohol
use, sedentary lifestyle and lack of physical exercise, and overeating and/or
poor nutrition. Other wellness services may address goals, such as constructive
use of leisure time and fulfilled spirituality and creativity
pursuits;
4. Skill
development needed for consumer-chosen community environments, facilitating
consumer-directed recovery and re-integration into valued community living,
learning, working and social roles by developing critical competencies and
skills. Skill development can be accomplished through either individual or
group instruction; however, the direct staff-to-consumer ratio in such
circumstances shall not exceed 1:12. Examples would include, but not be limited
to:
i. Cognitive skills such as researching
and recording information, decision making, identifying preferences and values,
selecting clothing, interviewing, scheduling appointments, budgeting, personal
nutrition planning, etc.;
ii.
Physical skills such as showering, grooming, cooking, cleaning personal space,
shopping, taking public transportation, parenting, etc.; and
iii. Emotional skills such as negotiating,
communicating, asking for help, avoiding risks to sobriety, greeting others,
conversing, identifying psychiatric cues, planning for psychiatric emergencies,
etc.;
5. Prevocational
services, which are an array of strategies and interventions that assist in
acquiring general work behaviors, attitudes and skills in response to the
interests and needs of consumers who are thinking about and/or intending to
take on the role of worker and which may be used in other life domains.
i. Prevocational intervention or strategies
selected are based upon an assessment of consumer interest, needs, skills and
supports and reflected in the consumer's individualized recovery
plan.
ii. Prevocational activities
might include, but not be limited to:
(1)
Understanding and choosing work settings;
(2) Gathering and researching job
information;
(3) Clarifying
occupational values and interests;
(4) Defining work preferences;
(5) Identifying personal work
criteria;
(6) Exploring barriers to
working;
(7) Identifying and
defining critical work skills;
(8)
Researching personal work supports and resources;
(9) Identifying psychiatric illness
management strategies related to working;
(10) Simulated work activities such as work
units to address work hardening, concentration, attending and other skills;
and
(11) Learning methods to
respond to criticism, negotiating for needs, dealing with interpersonal issues,
and adherence to medication requirements.
iii. Therapeutic subcontract work may be
provided within the context of partial care as prevocational therapy if already
provided.
(1) Therapeutic subcontract work
activity is the production, assembly and/or packing tasks for compensation
obtained by the organization under a contract with a vendor for which
individuals with disabilities performing the tasks are paid under a wage and
hour certificate, typically less than minimum wage.
(2) The consumer's individual service plan
shall stipulate that the therapeutic subcontract work is a form of intervention
intended to address the individual as identified in the consumer's
assessment.
(3) The therapeutic
subcontract work shall be facilitated by a qualified mental health services
worker.
(4) The therapeutic
subcontract work activity shall be performed within the line of sight of the
qualified mental health service worker.
(5) The staff-to-consumer ratio shall not
exceed a ratio of 1:12 qualified mental health services worker to
consumer;
6.
Medication-related services, as needed, which include the following:
i. Medication counseling and education, as
defined in
10:37-6.53 and 6.54;
ii. Knowledge and documentation of each
consumer's current medication treatment/therapies;
iii. Providing a mechanism for staff to share
clinical information regarding medication utilization; and
iv. Educating beneficiaries, staff and other
caregivers regarding adverse drug reactions, potential side effects and
established procedures for responding to crisis situations;
7. Goal-oriented verbal
counseling, which may include individual, group and family modalities to
address the emotional, cognitive and behavioral symptoms of mental health
illness or for engaging, motivating, stabilizing and the related effects on
role functioning including consumers with a co-occurring mental health and
substance use disorder. Goal-oriented verbal counseling may also include
motivational interviewing, connecting skills and cognitive behavioral
therapy;
8. Age-appropriate
learning activities which are directly tied to the learning of daily living or
other community integration competencies such as financial literacy, learning
basic computer literacy, recognition of directions and safety warnings. Such
basic computing, reading or writing skills are considered incidental and not
student education;
9.
Social/leisure services, which include independent living skills training,
interpersonal skills such as greeting, talking about impersonal topics,
conversing, learning about available community social and recreational
opportunities, planning for leisure time, practicing social interaction,
recreational, spiritual and cultural activities;
10. Psychiatric services, which include
assessment and ongoing treatment supervision; and
11. Other planning activities may include the
development of an advance directive, that meets the requirements of
P.L.
2005, c. 233 with
specific instructions on what steps need to be taken in the event of a relapse
and the development of a personal wellness and recovery action plan
(WRAP).
(c) The PA shall
develop written descriptions of services, outlines and curricula for activities
and interventions directly provided. Clinical records, schedules, rating forms
of group and other activities, logs and other documents shall serve as evidence
that these services have been provided.
(d) Off-site interventions can be provided as
long as the consumer is accompanied/supervised by staff and the following
conditions are met.
1. The off-site
interventions shall be:
i. Individualized for
each consumer and non-stigmatizing;
ii. Integrated as a subordinate component of
the consumer's IRP, which clearly states each specific off-site intervention
and how the intervention relates to the overall achievement of the consumer's
specific goals and objectives in the service plan, particularly in assisting to
generalize skills to community settings. Services that are solely recreational
or diversional in nature shall not be considered a PC activity;
iii. Properly documented in the consumer's
record to include when the off-site activity commenced and terminated;
and
iv. Limited to a defined and
measurable period of time.
2. Off-site services provided weekly shall be
generally less than 10 percent of an individual consumer's average active
programming time in PC during the previous month. If off-site activities are
greater than 10 percent additional justification is required in the consumer's
record and may be subject to program audit by the Division. In no case may the
time be more than 20 percent.
3.
The consumer must sign in at the site of the partial care program prior to
participating in any off-site activity and sign out of the program after
completion of the off-site activity.
4. Transportation to and from the off-site
activity shall not be counted as partial care program activity time requirement
unless the following are met:
i. The PA has a
staff person in the vehicle functioning as a counselor, and there are no more
than four consumers in the vehicle. If there are more than four consumers, then
a second staff person must accompany the counselor and function as a driver;
and
ii. The staff conducts
activities during the period of transportation that meet all the requirements
for allowable activities of a partial care program.
(e) The PA shall provide or
arrange services based on individual consumer need. The PA shall participate in
service planning, resolve identified issues, and advocate on behalf of the
consumer, as appropriate, for all services that are not provided directly. At a
minimum, the following services shall be provided or arranged:
1. Basic services, which may include
assisting consumers to procure needed food, clothing, shelter, or income
benefits;
2. Health and medical
care services, which may include assisting in procurement of, treatment or
education about health care and medication;
3. Natural support system services, which may
include consultation and education with families, friends or landlords,
facilitating self-help groups, or helping consumers connect with community
institutions;
4. Financial
literacy, which may include money management, saving strategies and
budgeting;
5. Other prevocational
services, which may include sheltered employment, job training, or volunteer
work;
6. Other vocational services
in community work settings such as supported employment, transitional
employment, consumer owned and operated entrepreneurial businesses, technical
occupational skills training, college preparation, individualized job
development and marketing to employers based upon the individual consumer need
when the consumer has achieved the prevocational skills listed in his or her
IRP or requests such services;
7.
Consumer-outreach and linkage services designed to facilitate new consumers'
participation in the program, to re-engage consumers who have discontinued
participating in the program or to effectively link them with other programs
that would meet their needs, and to promote continuity of programming for
consumers who are hospitalized during the course of their participation in the
program. These services shall include, but are not limited to, arranging needed
transportation to the program site, relating to other agencies, and contacting
and visiting consumers who have discontinued participating in the
program;
8. Integrated treatment
for co-occurring mental health and substance use disorders, which is a distinct
clinical approach that combines mental health and addiction into a unified,
comprehensive and blended philosophy that provides prevention, intervention and
treatment techniques that simultaneously address the needs from both disorders.
Service may include, but is not limited to: a "no wrong door" approach to care,
education and life skills management, motivational (staged) treatment, case
coordination across systems, dual focus assessment and interventions, milieu of
recovery, wellness and empowerment, use of recovery oriented tools and models
such as wellness recovery action plan (WRAP), illness management recovery
(IMR), integration of self help and 12-step into clinical technique;
9. Educational services, which may include
basic education courses, special education courses, G.E.D. classes and
pre-college preparation to enter community roles identified in the
IRP;
10. Residential services,
which may include assisting consumers to secure community residences, board and
care homes, private homes or apartments with support, emergency shelters,
cooperative apartments or crisis housing; and
11. Accessing acute care services, which may
include screening, crisis intervention and inpatient services.
(f) The PA shall develop
procedures regarding medications to include:
1. Identification of each consumer's
medication needs;
2. Documentation
of each consumer's current medications;
3. A mechanism for sharing relevant clinical
information with medication providers;
4. Medication education for consumers and
families, where relevant; and
5.
Provisions for education of staff and other involved caregivers regarding
adverse reactions and potential side effects, procedures to respond to such
reactions and the consumer's right to refuse or consent to
medication.
(g) The PA
shall develop written descriptions, outlines and curricula for activities and
interventions of services directly provided or arranged for. Clinical records,
schedules, logs and other documents shall serve as evidence that these services
have been provided.