CLINICAL MANAGEMENT

Current through 2022-14, April 6, 2022

This section of the core standards addresses the clinical management processes deemed to be critical in providing care or services to the client.

Access

AC.1 Each agency facility shall have in effect a transportation plan that assures accessibility to services.

AC. 1. A The agency documents and takes steps to implement a transportation plan that is directed toward assuring reasonable accessibility to all services,

AC.2 Service hours of the agency and the means for accessing services outside of normal business hours are clearly defined at each service site and in literature distributed to the public.

Interpretive Guideline for AC.2

"Normal business hours" are interpreted to mean Monday through Friday for an 8 hour period some time between the hours of 8:00am and 5:00 pm. Agencies that do not provide access to services outside of normal business hours must be able to produce compelling evidence as to why these service hours are not necessary or possible. Agencies that do not provide access to services outside of normal business hours must be able to produce compelling evidence as to shy these service hours are not necessary possible.

AC. 2. A. All substantiated complaints regarding accessibility to services will be assessed for the seriousness of the violation and actions taken to achieve compliance.

AC.3 The agency has a mechanism for providing services in the language chosen by the applicant or client.

AC. 3. A Services will be made available to all potential clients in their language of preference. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.

AC.4 No individual may be denied access to services solely on the basis of having a known substance use/abuse disorder in addition to his/her mental illness.

AC. 4. A. The agency shall develop and maintain a written protocol or policy that describes its service approach to individuals with co-occurring mental illness and substance abuse disorders.

AC.5 Agencies shall insure that clients are not denied access to services based solely upon the clients' refusal of any other service.

Client Rights

CR.1 At the request of the client,, or the legally responsible party, the agency will arrange for a second opinion to be offered by another practitioner from within the agency, who is mutually agreed upon by the client or legally responsible party and the agency.

CR. 1. A. The agency has a documented policy and procedure describing the process for seeking second opinions that minimally addresses who notifies the client of this right and who documents the request and actions taken in the client record.

CR. 1. B Second opinion requests and actions the agency takes as a result are documented in the client's record. Second opinion record entries minimally include:

CR. 1. B.1 the date of the request;

CR. 1. B.2 the reason for the request;

CR. 1. B.3 the actions taken by the agency as a result of the request

CR. 1. C. The practitioner(s) offering the second opinion document in the client record the date they conducted their assessment, their findings, conclusions, and recommendations.

Interpretive Guideline for CR.1.C

It is expected that the practitioner(s) offering the second opinion will minimally see the client in person and review their record.

CR.2 When a client or legally responsible party requests and agrees to pay the cost of a second opinion, the agency does not impede the right to seek a second opinion from a practitioner of his/her choice and does not terminate the client solely because of seeking this second opinion.

CR. 2. A. An agency will not impede the right of, or terminate services to clients seeking a second opinion. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.

CR.4 Only staff who have completed training in physical intervention shall implement physical intervention techniques.

Treatment and Care Processes

Preliminary Screening:

SCR.1 The agency determines an applicant's eligibility for services through a timely preliminary screening process that assesses the applicant's appropriateness for services based on the service's admission or intake criteria.

SCR. 1. A. An eligibility screening is conducted and documented for each applicant.

SCR. 1. B. The documented screening contains a determination of the applicant's appropriateness for services.

SCR. 1. C. Eligibility criteria and screening processes for all programs and services will be in compliance with the requirements of GOV.11.

Interpretive Guideline for SCR.1

Preliminary screening will not trigger the time-limited documentation requirements, e.g., assessment, service plan, that begin with initiation of service, unless otherwise required by agency policy.

SCR.2 The agency has documented admission or intake policies and procedures that assure thorough evaluation of each applicant's eligibility.

SCR. 2. A. There are documented policies and procedures for routine or non-emergency admissions or intakes that minimally include:

SCR. 2. A.1 the procedures for accepting referrals from outside agencies;

SCR. 2. A.2 the information to be obtained on all applicants or referrals for admission or receipt of service;

SCR. 2. A.3 the records to be kept on all applicants and for what length of time the records are kept;

SCR. 2. A.4 the statistical data to be kept on the intake process;

SCR. 2. A.5 the procedures to be Mowed, including alternative referrals, when an applicant is found ineligible or inappropriate for admission or services; and

SCR. 2. A.6 the procedure for aggregating and analyzing collected dam for use in the agency planning process.

SCR.3 The agency has documented policies and procedures for handling emergency intakes or admissions.

Interpretive Guideline for SCR.3

Agencies or serves that do not accept emergency intakes will have a policy stating the justification for refusal or emergency intakes or admissions.

Assessments:

AS.1 Assessments are conducted by qualified staff.

Interpretive Guideline for AS.1

This standard is surveyed following review of the service specific assessment standards. That is, "qualified" is determined by the degree of compliance with assessment standards rather than on other qualifications, e.g., degrees or certifications.

Progress Notes:

PN.1 Progress notes are current and address progress towards service plan goals as well as other interactions that may be pertinent to the service needs of the client.

PN. 1. A. Progress notes are written at least weekly unless services are designed to be offered less frequently.

PN. 1. A.1 For services that are provided on such an intermittent or infrequent basis to make weekly notes inappropriate, the agency shall develop a policy and procedure concerning the frequency with which notes should be written.

PN. 1. B. For services provided on an intensive basis the agency shall develop policies and procedures establishing a frequency of documentation sufficient to reflect the intensity of service delivery.

Discharge Planning and Transfers:

DPT.1 The agency shall develop and implement a discharge plan consistent with the needs and goals of the client.

DPT. 1. A. Upon review, the discharge plan is consistent with the needs and goals identified in the service plan.

DPT. 1. B. Clients are discharged in a manner and to a setting consistent with their discharge plan.

DPT. 1. C. Clinical justification is documented when referring a client to an alternative setting.

DPT. 1. D. Discharge planning in residential settings will be conducted in compliance with the requirements of standards RS.11 through RS.16.

DPT.2 When discharge planning indicates the need for residential services, the agency shall provide clients with information about residential options sufficient for clients to, make informed choices.

DPT.3 Upon the client's or legally responsible party's documented informed consent, the agency transferring or discharging the client will provide a written transfer or discharge summary to the receiving agency.

DPT.4 The agency transferring a client to another service within the organization or to an outside service provider assures that the transfer is completed in a manner that protects the client's safety, comfort, and dignity.

DPT. 4. A. All transfers of clients will be accomplished in a manner that assures the client's safety, comfort, or dignity. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.

Continuity of Care:

CC.1 When an Agency offers services through another provider, a documented affiliated service agreement exists.

CC.2 The agency has a policy and procedure that identifies how service components of their agency and other providers work collaboratively in planning and providing services that are sensitive to client's transition needs.

CC. 2. A. All substantiated complaints regarding transition from one service to another will be assessed for the seriousness of the violation and actions taken to achieve compliance.

CC.3 Clients are referred to contracted service providers only after a determination of need has been documented in the client's service plan.

CC.4 The agency has a policy and procedure concerning the delivery or referral to family support groups, which minimally contains how the determination for family support is made and how delivery or referral is accomplished.

Medications:

MED.1 Where medications are available, administered, or supervised by staff in the agency, the agency shall retain and securely store medications.

MED. 1. A. Medications are kept in original containers in a locked storage cabinet.

MED. 1. B. The storage cabinet shall be equipped with separate cubicles, plainly labeled, and locked when not in use.

MED. 1. C. Medications marked "for external use only" shall be stored separate from other medications.

MED. 1. D. Refrigerated medications shall be kept separate from food by placing them in special trays or containers.

MED.2 Where clients self-administer medications, the agency shall provide to clients the capacity for secure storage.

MED. 2. A. Clients that self-administer medications shall be allowed to keep such medications in a locked storage container in their private living areas.

MED. 2. B. No client shall maintain a private drug supply for which there are no physician's orders or prescription label with the client's name.

MED.3 Agencies retain a professionally qualified individual to provide education and supervision when agency clients self-administer medications and agency staff monitor compliance and observe for side effects.

MED. 3. A Unlicensed personnel shall be trained to observe for side effects and drug reactions to psychotropics; and frequently used medications (such as antibiotics) by a registered nurse consultant, and/or physician, and/or pharmacist.

MED. 3. B. There shall be documentation of the activities of the professionally qualified individual including staff training and review of client records/logs.

MED.4 Where medications are available, administered or supervised by staff in the agency, the agency shall have a procedure for prescribing.

MED. 4. A. Written orders to administer/discontinue medications are generated by a physician, dentist, or physician extender.

MED. 4. B Physicians review medications at least every 30 days in inpatient settings, every 90 days in outpatient settings and, in residential settings, psychotropic medications will be renewed every 90 days and all other medications no less frequently than one year.

MED. 4. C. Telephone orders are accepted by a registered nurse or pharmacist, and only when necessary because of emergency circumstances.

MED. 4. D. Written dated orders taken by agency staff must be signed by the physician within 24 hours.

MED.5 Where medications are available, administered, or supervised by staff in the agency, there is a policy regarding their administration.

MED. 5. A. The agency has policies regarding medication administration that take into account the client's right, to privacy and dignity.

MED.6 No medication is prescribed and administered without the written informed consent of the client or legally responsible party.

MED. 6. A. There is a process by which the prescribing physician informs the client and/or legally responsible party, and when appropriate, the community support worker, of the potential effects and side effects of medications they prescribe, e.g., information sheets.

MED.7 Where medications are available, administered, or supervised by staff in the agency, there is a policy regarding -inventory of medications and paraphernalia.

MED. 7. A. There is documentation that controlled drugs are counted by the incoming and outgoing medication personnel at the change of each shift.

MED.8 Where medications are available, administered, or supervised by staff in the agency, there is it policy regarding reporting and disposing of outdated medications.

MED. 8. A. There is documented monitoring for outdated medications at least quarterly.

MED. 8. A.1 This monitoring shall include documentation of where the outdated drugs are sent and whether they were disposed of according to applicable federal, state and local laws.

MED.9 Where medication is prescribed, administered, or supervised by staff in the agency, a medication record and a record of each occasion of medication administration shall be maintained.

MED. 9. A. A medication record shall be maintained which minimally includes:

MED. 9. A.1 the prescribing physician;

MED. 9. A.2 personnel administering the medication;

MED. 9. A.3 type and frequency of monitoring for effects of the medication.

MED. 9. B. A medication administration record shall be maintained which minimally includes:

MED. 9. B. 1 the type of medication;

MED. 9. B.2 the dosage; and

MED. 9. B.3 the frequency of use.

MED.10 In instances of medication errors, side effects, adverse reactions, client or staff concerns regarding medication, staff inform the prescribing physician and document the problem in an occurrence report.

MED.11 When the agency prescribes, administers, or supervises medications, there is a process for monitoring the effectiveness of medications.

MED. 11. A. Staff members with a minimum of a medication technician certification approved by Maine's Department of Human Services, regularly review and document client response to medication.

MED. 11. B. Side effects, adverse reactions and client concerns are documented, treated in a timely fashion, and corrected.

MED.12 When medications are prescribed by agency staff or consultants prescribing as part of the agency program, the prescribing professional is available to discuss medication issues and concerns between appointments. MED. 12. A. Documented concerns regarding medications are quickly followed by documented consultation with the prescribing physician.

MED. 12. . B. All substantiated complaints regarding the availability or accessibility of the prescribing physician will be assessed for the seriousness of the violation and actions taken to achieve compliance.

MED.13 The agency complies with all federal, state and local laws concerning medication administration.

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MED. 13. A. All substantiated violations of any federal, state or local laws concerning medication administration will be assessed for the seriousness of the violation and actions taken to achieve compliance

SERVICE-SPECIFIC STANDARDS

In addition to the core standards, which all mental health agencies need to comply with, an agency will also be surveyed according to the services they provide. In this way, an agency is given a tailored survey that reviews the full scope of their services. This manual currently addresses the following services:

Community Support

Crisis Residential

Emergency

Inpatient

Outpatient

Residential

Social Clubs'

2Social clubs are the only type of service that are not required to comply with the core standards contained in this manual. Social clubs, due to their unique nature and services, have it separate set of standards used during the licensing process.

The following state regulations pages link to this page.



State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.