Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES
Section 40-7 - Admission
Universal Citation: WY Code of Rules 40-7
Current through September 21, 2024
(a) Before admission to a facility, an interdisciplinary team shall complete a certification of need for services in accordance with 42 CFR § 441.154.
(b) Admission Certification. Admissions to PRTFs are subject to the prior authorization procedures outlined in Section 8 of this Chapter. The Department shall determine the medical necessity of admission to an PRTF using the following criteria:
(i) The client presents with a
longstanding (at least six months) psychiatric diagnosis characterized by
severely distressing, disruptive or immobilizing symptoms that are persistent
and pervasive, and which cannot be reversed with treatment in an outpatient
treatment setting, or is being stepped down in intensity from an acute
psychiatric facility. The diagnosis shall meet the criteria for an Axis 1 as
defined by the current edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM);
(ii) There
are documented attempts to treat the client with the maximum intensity of
services available at a less intensive level of care that cannot meet or has
failed to meet the needs of the client within the past six (6) months. The
client shall have failed to respond to outpatient interventions. Six (6) months
of alternative, less restrictive levels of care shall have been tried and have
failed, or are not psychiatrically indicated;
(iii) At least one of the patterns of
behavior listed below must be present:
(A)
Persistent, pervasive and frequently occurring oppositional/defiant
behavior;
(B) Reckless or impulsive
behavior, which represents a disregard for the well-being or safety of
self/others;
(C) Aggressiveness or
explosive behavior;
(D) Gestures
with intent to injure self/others, which have not resulted in serious injury,
without evidence that such gestures are immediately progressing to life
threatening behavior;
(E)
Self-induced vomiting, use of laxatives/diuretics, strict dieting, fasting
and/or vigorous exercise;
(F)
Extreme phobic/avoidant behavior;
(G) Extreme social isolation; or
(H) History of repeated life threatening
injury to self/others, resulting in acute care admissions within the past
twelve (12) months. The client is not currently considered at risk to inflict
life-threatening injury to self/others in the residential treatment
setting.
(iv) Without
intervention, there is clear evidence that the client will likely decompensate
and present a risk of serious harm to self or others; or
(v) A psychiatric evaluation by a board
certified child/adolescent psychiatrist. The child/adolescent psychiatrist must
be licensed, board certified, and in good standing. The child/adolescent
psychiatrist must be independent of the PRTF being considered for admission. If
the child/adolescent psychiatrist works for the PRTF being considered for
admission, a second opinion must be obtained from the agency contracted by the
Division for such services. The evaluation must take place no more than
forty-five (45) days prior to PRTF Admission.
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