Therapeutic group home services and psychiatric residential treatment facility
(PRTF) services for early and periodic screening diagnosis and treatment
(EPSDT) of youth.
1. Definitions. The
following words and terms when used in this subsection shall have the following
meanings:
"Active treatment" means implementation of an initial plan
of care (IPOC) and comprehensive individual plan of care (CIPOC).
"Activities of daily living" or "ADL" means personal care
activities and includes bathing, dressing, transferring, toileting, feeding,
and eating.
"Activities of daily living restoration" or "ADL
restoration" means a face-to-face interaction provided on an individual or
group basis to assist youth in the restoration of lost ADL skills that are
necessary to achieve the goals established in the youth's plan of care.
Services address performance deficits related to a lack of physical, cognitive,
or psychosocial skills which hinder the ability of the youth to complete ADLs.
Services include (i) restoring acceptable habits, behaviors, and attitudes
related to daily health activities and personal care or hygiene and (ii)
assisting the youth restoring and regaining functional ADL skills and
appropriate behavior related to health and safety.
"ADL supervisor" means a child care supervisor with a
baccalaureate degree in social work or psychology and two years of professional
experience working with children one year of which must have been in a
residential facility for children; or a high school diploma or General
Education Development Certificate (GED) and a minimum of five years
professional experience working with children with at least two years in a
residential facility for children.
"ADL technician" means a child care worker at least 21
years of age who has a baccalaureate degree in human services (as defined by
the Department of Health Professions); has an associate's degree and three
months experience working with children; or is a high school graduate or has a
GED and has six months of experience working with children. A trainee with a
high school diploma or a GED may count experience working directly alongside a
staff member who is, at a minimum, an ADL technician with at least one year of
professional experience with children if the trainee is within sight and sound
of the supervising staff member and does not work alone. An individual can only
be classified as an ADL technician if they are supervised by an ADL supervisor,
QMHP-C, LMHP, LMHP-R, LMHP-RP, or LMHP-S.
"Assessment" means the face-to-face interaction by an LMHP,
LMHP-R, LMHP-RP, or LMHP-S to obtain information from the youth and parent,
guardian, or other family member, as appropriate, utilizing a tool or series of
tools to provide a comprehensive evaluation and review of the youth's mental
health status. The assessment shall include a documented history of the
severity, intensity, and duration of mental health problems and behavioral and
emotional issues.
"Certificate of need" or "CON" means a written statement by
an independent certification team that services in a therapeutic group home or
PRTF are or were needed.
"Comprehensive individual plan of care" or "CIPOC" means a
person centered plan of care that meets all of the requirements of this
subsection and is specific to the youth's unique treatment needs and acuity
levels as identified in the clinical assessment and information gathered during
the referral process.
"Crisis" means a deteriorating or unstable situation that
produces an acute, heightened emotional, mental, physical, medical, or
behavioral event.
"Crisis management" means immediately provided activities
and interventions designed to rapidly manage a crisis. The activities and
interventions include behavioral health care to provide immediate assistance to
youth experiencing acute behavioral health problems that require immediate
intervention to stabilize and prevent harm and higher level of acuity.
Activities shall include assessment and short-term counseling designed to
stabilize the youth. Youth are referred to long-term services once the crisis
has been stabilized.
"Daily supervision" means the supervision provided in a
PRTF through a resident-to-staff ratio approved by the Office of Licensure at
the Department of Behavioral Health and Developmental Services with documented
supervision checks every 15 minutes throughout a 24-hour period.
"Discharge planning" means family and locality-based care
coordination that begins upon admission to a PRTF or therapeutic group home
with the goal of transitioning the youth out of the PRTF or therapeutic group
home to a less restrictive care setting with continued, clinically-appropriate
services as soon as possible upon discharge. Discharge plans shall be
recommended by the treating physician, psychiatrist, or treating LMHP
responsible for the overall supervision of the plan of care and shall be
approved by the DMAS contractor.
"DSM-5" means the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric
Association.
"Emergency admissions" means admissions that are made when,
pending a review for the certificate of need, it appears that the youth is in
need of an immediate admission to a therapeutic group home or PRTF and likely
does not meet the medical necessity criteria to receive crisis intervention,
crisis stabilization, or acute psychiatric inpatient services.
"Family engagement" means a family-centered and
strengths-based approach to partnering with families in making decisions,
setting goals, achieving desired outcomes, and promoting safety, permanency,
and well-being for youth and families. Family engagement requires ongoing
opportunities for a youth to build and maintain meaningful relationships with
family members, for example, frequent, unscheduled, and noncontingent telephone
calls and visits between the youth and family members. Family engagement may
also include enhancing or facilitating the development of the youth's
relationship with other family members and supportive adults responsible for
the youth's care and well-being upon discharge.
"Family engagement activity" means an intervention
consisting of family psychoeducational training or coaching, transition
planning with the family, family and independent living skills, and training on
accessing community supports as identified in the plan of care. Family
engagement activity does not include and is not the same as family
therapy.
"Family therapy" means counseling services involving the
youth's family and significant others to advance the treatment goals when (i)
the counseling with the family member and significant others is for the direct
benefit of the youth, (ii) the counseling is not aimed at addressing treatment
needs of the youth's family or significant others, and (iii) the youth is
present except when it is clinically appropriate for the youth to be absent in
order to advance the youth's treatment goals. Family therapy shall be aligned
with the goals of the youth's plan of care. All family therapy services
furnished are for the direct benefit of the youth, in accordance with the
youth's needs and treatment goals identified in the youth's plan of care, and
for the purpose of assisting in the youth's recovery.
"FAPT" means the family assessment and planning
team.
"ICD-10" means International Statistical Classification of
Diseases and Related Health Problems, 10th Revision, published by the World
Health Organization.
"Independent certification team" means a team that has
competence in diagnosis and treatment of mental illness, preferably in child
and adolescent psychiatry; has knowledge of the youth's situation; and is
composed of at least one physician and one LMHP, LMHP-R, LMHP-RP, or LMHP-S.
The independent certification team shall be a DMAS-authorized contractor with
contractual or employment relationships with the required team members.
"Initial plan of care" or "IPOC" means a person centered
plan of care established at admission that meets all of the requirements of
this subsection and is specific to the youth's unique treatment needs and
acuity levels as identified in the clinical assessment and information gathered
during the referral process.
"Intervention" means scheduled therapeutic treatment
included in the individualized plan of care to help the youth achieve the
youth's plan of care goals and objectives. Interventions may include individual
or group psychoeducation; skills restoration; ADL restoration; individual,
group, and family therapy; structured behavior support and training activities;
recreation, art, and music therapies; community integration activities that
promote or assist in the youth's ability to acquire coping and functional or
self-regulating behavior skills; therapeutic passes; and family engagement
activities. Interventions shall not include medical or dental appointments,
physician services, medication evaluation, or management provided by a licensed
clinician or physician and shall not include school attendance. Interventions
are provided in the therapeutic group home or PRTF and, when clinically
necessary, may occur in a community setting or as part of a therapeutic pass if
the setting is documented in the plan of care.
"Plan of care" means the initial plan of care (IPOC) and
the comprehensive individual plan of care (CIPOC).
"Physician" means an individual licensed to practice
medicine or osteopathic medicine in Virginia, as defined in §
54.1-2900 of the Code of
Virginia.
"Psychiatric residential treatment facility" or "PRTF"
means the same as defined in
42
CFR 483.352 and is a 24-hour, supervised,
clinically and medically necessary, out-of-home active treatment program
designed to provide necessary support and address mental health, behavioral,
substance abuse, cognitive, and training needs of a youth in order to prevent
or minimize the need for more intensive treatment.
"Psychotherapy" or "therapy" means the use of psychological
methods in a professional relationship to assist a person to acquire great
human effectiveness or to modify feelings, conditions, attitudes, and behaviors
that are emotionally, intellectually, or socially ineffectual or
maladaptive.
"Recertification" means a certification for each applicant
or recipient for whom therapeutic group home or PRTF services are
needed.
"Room and board" means a component of the total daily cost
for placement in a licensed PRTF. Residential room and board costs are
maintenance costs associated with placement in a licensed PRTF and include a
semi-private room, three meals and two snacks per day, and personal care items.
Room and board costs are reimbursed only for PRTF settings.
"Skills restoration" means a face-to-face service to assist
youth in the restoration of lost skills that are necessary to achieve the goals
established in the youth's plan of care. Services include assisting the youth
in restoring self-management, interpersonal, communication, and problem solving
skills through modeling, coaching, and cueing.
"Therapeutic group home" means a congregate residential
service providing 24-hour supervision in a community-based home having eight or
fewer residents.
"Therapeutic pass" means time at home or time with family
consisting of partial or entire days of time away from the therapeutic group
home or psychiatric residential treatment facility as clinically indicated in
the plan of care and as paired with facility-based and community-based
interventions to promote discharge planning, community integration, and family
engagement activities. Therapeutic passes are not recreational but are a
therapeutic component of the plan of care and are designed for the direct
benefit of the youth.
"Therapeutic services" means the structured therapeutic
program designed to restore appropriate skills necessary to promote prosocial
behavior and healthy living to include: the restoration of coping skills;
family living and health awareness; interpersonal skills; communication skills;
and stress management skills. Therapeutic services also engage families and
reflect family-driven practices that correlate to sustained positive outcomes
post-discharge for youth and their family members. Therapeutic services include
assessment, individualized treatment planning, and interventions.
"Treatment planning" means development, implementing,
monitoring, and updating of a person centered plan of care that is specific to
the individual's unique treatment needs and acuity levels.
"Youth" means an individual younger than 21 years of
age.
2. Therapeutic group
home services pursuant to
42
CFR
440.130(d).
a. Therapeutic group home services for youth
shall provide therapeutic services to restore or maintain appropriate skills
necessary to promote prosocial behavior and healthy living, including skills
restoration, family living and health awareness, interpersonal skills,
communication skills, community integration skills, coping skills, and stress
management skills. Therapeutic services shall also engage families and reflect
family-driven practices that correlate to sustained positive outcomes
post-discharge for youth and their family members. Therapeutic services may
occur in group settings, in one-on-one interactions, or in the home setting
during a therapeutic pass. Each component of therapeutic group home services is
provided for the direct benefit of the youth, in accordance with the youth's
needs and treatment goals identified in the youth's plan of care, and for the
purpose of assisting in the youth's recovery. These services are provided under
42
CFR
440.130(d) in accordance
with the rehabilitative services benefit.
b. Therapeutic group home services providers
shall be licensed by the Department of Behavioral Health and Developmental
Services under the Regulations for Children's Residential Facilities
(12VAC
35-36). Therapeutic group home services may only be rendered by and
within the scope of practice of an LMHP, LMHP-supervisee, LMHP-resident,
LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH as defined in
12VAC35-105-20, an ADL supervisor,
or an ADL technician.
c. Medical
necessity criteria for admission to a therapeutic group home. The following
requirements for severity of need and intensity and quality of service shall be
met to satisfy the medical necessity criteria for admission.
(1) Severity of need required for admission.
All of the following criteria shall be met to satisfy the criteria for severity
of need:
(a) The youth's behavioral health
condition can only be safely and effectively treated in a 24-hour therapeutic
milieu with onsite behavioral health therapy due to significant impairments in
home, school, and community functioning caused by current mental health
symptoms consistent with a DSM-5 diagnosis.
(b) The certificate of need must demonstrate
all of the following:
(i) ambulatory care
resources (all available modalities of treatment less restrictive than
inpatient treatment) available in the community do not meet the treatment needs
of the youth;
(ii) proper treatment
of the youth's psychiatric condition requires services on an inpatient basis
under the direction of a physician; and
(iii) the services can reasonably be expected
to improve the youth's condition or prevent further regression so that the
services will no longer be needed.
(c) The state uniform assessment tool shall
be completed. The assessment shall demonstrate at least two areas of moderate
impairment in major life activities. A moderate impairment is defined as a
major or persistent disruption in major life activities. A moderate impairment
is evidenced by, but not limited to (i) frequent conflict in the family setting
such as credible threats of physical harm, where "frequent" means more than
expected for the youth's age and developmental level; (ii) frequent inability
to accept age-appropriate direction and supervision from caretakers, from
family members, at school, or in the home or community; (iii) severely limited
involvement in social support, which means significant avoidance of appropriate
social interaction, deterioration of existing relationships, or refusal to
participate in therapeutic interventions; (iv) impaired ability to form a
trusting relationship with at least one caretaker in the home, school, or
community; (v) limited ability to consider the effect of one's inappropriate
conduct on others; and (vi) interactions consistently involving conflict, which
may include impulsive or abusive behaviors.
(d) Less restrictive community-based services
have been given a fully adequate trial and were unsuccessful or, if not
attempted, have been considered, but in either situation were determined to be
unable to meet the youth's treatment needs and the reasons for that are
discussed in the certificate of need.
(e) The youth's symptoms, or the need for
treatment in a 24 hours a day, seven days a week level of care (LOC), are not
primarily due to any of the following:
(i)
intellectual disability, developmental disability, or autistic spectrum
disorder;
(ii) organic mental
disorders, traumatic brain injury, or other medical condition; or
(iii) the youth does not require a more
intensive level of care.
(f) The youth does not require primary
medical or surgical treatment.
(2) Intensity and quality of service
necessary for admission. All of the following criteria shall be met to satisfy
the criteria for intensity and quality of service:
(a) The therapeutic group home service has
been prescribed by a psychiatrist, psychologist, or other LMHP, LMHP-R,
LMHP-RP, or LMHP-S who has documented that a residential setting is the least
restrictive clinically appropriate service that can meet the specifically
identified treatment needs of the youth.
(b) The therapeutic group home is not being
used for clinically inappropriate reasons, including (i) an alternative to
incarceration or preventative detention; (ii) an alternative to a parent's,
guardian's, or agency's capacity to provide a place of residence for the youth;
or (iii) a treatment intervention when other less restrictive alternatives are
available.
(c) The youth's
treatment goals are included in the plan of care and include behaviorally
defined objectives that require and can reasonably be achieved within a
therapeutic group home setting.
(d)
The therapeutic group home is required to coordinate with the youth's community
resources, including schools and FAPT as appropriate, with the goal of
transitioning the youth out of the program to a less restrictive care setting
for continued services as soon as possible and appropriate.
(e) The therapeutic group home program must
incorporate nationally established, evidence-based, trauma-informed services
and supports that promote recovery and resiliency.
(3) Continued stay criteria. The following
criteria shall be met in order to satisfy the criteria for continued stay:
(a) All of the admission guidelines continue
to be met and continue to be supported by the written clinical
documentation.
(b) The youth shall
meet one of the following criteria:
(i) the
desired outcome or level of functioning has not been restored or improved in
the timeframe outlined in the youth's plan of care or the youth continues to be
at risk for relapse based on history or
(ii) the nature of the functional gains is
tenuous and use of less intensive services will not achieve
stabilization.
(c) The
youth shall meet one of the following criteria:
(i) the youth has achieved initial plan of
care goals, but additional goals are indicated that cannot be met at a lower
level of care;
(ii) the youth is
making satisfactory progress toward meeting goals but has not attained plan of
care goals, and the goals cannot be addressed at a lower level of care;
(iii) the youth is not making
progress, and the plan of care has been modified to identify more effective
interventions; or
(iv) there are
current indications that the youth requires this level of treatment to maintain
level of functioning as evidenced by failure to achieve goals identified for
therapeutic passes.
(d)
There is a written, up-to-date discharge plan that (i) identifies the custodial
parent or custodial caregiver at discharge; (ii) identifies the school the
youth will attend at discharge, if applicable; (iii) includes individualized
education program (IEP) and FAPT recommendations, if necessary; (iv) outlines
the aftercare treatment plan (discharge to another residential level of care is
not an acceptable discharge goal); and (v) lists barriers to community
reintegration and progress made on resolving these barriers since last
review.
(e) The active plan of care
includes structure for daily therapeutic services and activities to ensure the
attainment of therapeutic mental health goals as identified in the plan of
care.
(f) There is evidence of
intensive family or support system involvement occurring at least once per
week, unless there is an identified or valid reason why it is not clinically
appropriate or feasible.
(g) Less
restrictive treatment options have been considered but cannot yet meet the
youth's treatment needs. There is sufficient current clinical documentation or
evidence to show that therapeutic group home level of care continues to be the
least restrictive level of care that can meet the youth's mental health
treatment needs.
(4)
Discharge shall occur if any of the following applies:
(i) the level of functioning has improved
with respect to the goals outlined in the plan of care, and the youth can
reasonably be expected to maintain these gains at a lower level of treatment;
(ii) the youth no longer benefits
from service as evidenced by absence of progress toward plan of care goals for
a period of 60 days; or
(iii) other
less intensive services may achieve stabilization.
d. The following clinical
activities shall be required for each therapeutic group home resident:
(1) An assessment shall be performed by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S.
(2) A face-to-face evaluation shall be
performed by an LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days prior
to admission with a documented DSM-5 or ICD-10 diagnosis.
(3) A certificate of need shall be completed
by an independent certification team according to the requirements of
subdivision D 4 of this section. Recertification shall occur at least every 60
calendar days by an LMHP, LMHP-R, LMHP-RP, or LMHP-S acting within his scope of
practice.
(4) An IPOC that is
specific to the youth's unique treatment needs and acuity levels. The IPOC
shall be completed on the day of admission by an LMHP, LMHP-R, LMHP-RP, or
LMHP-S and shall be signed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the
youth and a family member or legally authorized representative. The IPOC shall
include all of the following:
(a) Youth and
family strengths and personal traits that would facilitate recovery and
opportunities to develop motivational strategies and treatment
alliance;
(b) Diagnoses, symptoms,
complaints, and complications indicating the need for admission;
(c) A description of the functional level of
the youth;
(d) Treatment objectives
with short-term and long-term goals;
(e) Orders for medications, psychiatric,
medical, dental, and any special health care needs whether or not provided in
the facilities, treatments, restorative and rehabilitative services,
activities, therapies, therapeutic passes, social services, community
integration, diet, and special procedures recommended for the health and safety
of the youth;
(f) Plans for
continuing care, including review and modification to the plan of care;
and
(g) Plans for
discharge.
(5) A CIPOC
shall be completed no later than 14 calendar days after admission. The CIPOC
shall meet all of the following criteria:
(a)
Be based on a diagnostic evaluation that includes examination of the medical,
psychological, social, behavioral, and developmental aspects of the youth's
situation and shall reflect the need for therapeutic group home care;
(b) Be based on input from school, home,
other health care providers, FAPT if necessary, the youth, and the family or
legal guardian;
(c) Shall state
treatment objectives that include measurable short-term and long-term goals and
objectives, with target dates for achievement;
(d) Prescribe an integrated program of
therapies, activities, and experiences designed to meet the treatment
objectives related to the diagnosis; and
(e) Include a comprehensive discharge plan
with clear action steps and target dates, including necessary, clinically
appropriate community services to ensure continuity of care upon discharge with
the youth's family, school, and community.
(6) The CIPOC shall be reviewed, signed, and
dated every 30 calendar days by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the
youth or a family member or primary caregiver. Updates shall be signed and
dated by the LMHP, LMHP-R, LMHP-RP, or LMHP-S and the youth or a family member
or legally authorized representative. The review shall include all of the
following:
(a) The youth's response to the
services provided;
(b) Recommended
changes in the plan as indicated by the youth's overall response to the CIPOC
interventions; and
(c)
Determinations regarding whether the services being provided continue to be
required.
(7) The plan of
care shall include individualized activities, including a minimum of one
intervention per 24-hour period in addition to individual, group, and family
therapies. Daily interventions are not required when there is documentation to
justify clinical or medical reasons for the youth's deviations from the plan of
care. Interventions shall be documented on a progress note and shall be
outlined in and aligned with the treatment goals and objectives in the IPOC and
CIPOC. Any deviation from the plan of care shall be documented along with a
clinical or medical justification for the deviation.
(8) Crisis management, clinical assessment,
and individualized therapy shall be provided to address both mental health and
substance use disorder needs as indicated in the plan of care to address
intermittent crises and challenges within the therapeutic group home setting or
community settings as defined in the plan of care and to avoid a higher level
of care.
(9) Care coordination
shall be provided with medical, educational, and other behavioral health
providers and other entities involved in the care and discharge planning for
the youth as included in the plan of care. Documentation of this care
coordination shall be maintained by the facility or group home in the youth's
record. The documentation shall include who was contacted, when the contact
occurred, what information was transmitted, and recommended next
steps.
(10) Weekly individual
therapy shall be provided in the therapeutic group home, or other settings as
appropriate for the youth's needs, by an LMHP, LMHP-R, LMHP-RP, or LMHP-S,
which shall be documented in progress notes in accordance with the requirements
for progress notes in
12VAC30-60-61 B.
(11) Group therapy shall be
provided at a minimum of weekly and as documented in the plan of care by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S, and shall be documented in progress notes in
accordance with the requirements for progress notes in
12VAC30-60-61 B.
(12) Family involvement begins
immediately upon admission to the therapeutic group home. Family therapy shall
be provided as clinically indicated and as documented in the plan of care and
shall be provided by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, and documented in
progress notes in accordance with the requirements for progress notes in
12VAC30-60-61 B.
(13) Family engagement activities
shall be provided in addition to family therapy. Family engagement activities
shall be provided at least weekly as outlined in the plan of care, and daily
communication with the family or legally authorized representative shall be
part of the family engagement strategies in the plan of care. For each service
authorization period when family engagement is not possible, the therapeutic
group home shall identify and document the specific barriers to the youth's
engagement with the youth's family or legally authorized representatives. The
therapeutic group home shall document on a weekly basis the reasons why family
engagement is not occurring as required. The therapeutic group home shall
document alternative family engagement strategies to be used as part of the
interventions in the plan of care and request approval of the revised plan of
care by DMAS or its contractor. When family engagement is not possible, the
therapeutic group home shall collaborate with DMAS or its contractor on a
weekly basis to develop individualized family engagement strategies and
document the revised strategies in the plan of care.
(14) Therapeutic passes shall be provided as
clinically indicated in the plan of care and as paired with facility-based and
community-based interventions to promote discharge planning, community
integration, and family engagement activities.
(a) The provider shall document how the
family was prepared for the therapeutic pass to include a review of the plan of
care goals and objectives being addressed by the planned interventions and the
safety and crisis plan in effect during the therapeutic pass.
(b) If a facility staff member does not
accompany the youth on the therapeutic pass and the therapeutic pass exceeds 24
hours, the provider shall make daily contacts with the family and be available
24 hours per day to address concerns, incidents, or crises that may arise
during the pass.
(c) Contact with
the family shall occur within seven calendar days of the end date of the
therapeutic pass to discuss the accomplishments and challenges of the
therapeutic pass along with an update on progress toward plan of care goals and
any necessary changes to the plan of care.
(d) Twenty-four therapeutic passes shall be
permitted per youth, per admission, without authorization as approved by the
treating LMHP, LMHP-R, LMHP-RP, and LMHP-S and documented in the plan of care.
Additional therapeutic passes shall require service authorization. Any
unauthorized therapeutic passes shall result in retraction for those days of
service.
(15) Discharge
planning shall begin at admission and continue throughout the youth's stay at
the therapeutic group home. The family or guardian, the community services
board (CSB), the family assessment and planning team (FAPT) case manager, and
the DMAS contracted care manager shall be involved in treatment planning and
shall identify the anticipated needs of the youth and family upon discharge and
available services in the community. Prior to discharge, the therapeutic group
home shall submit a comprehensive discharge plan to the DMAS contractor for
review. Once the DMAS contractor approves the discharge plan, the provider
shall begin actively collaborating with the family or legally authorized
representative and the treatment team to identify behavioral health and medical
providers and schedule appointments for a comprehensive needs assessment as
needed. The therapeutic group home shall request information from
post-discharge providers to establish that the planning of pending services and
transition planning activities has begun, shall establish that the youth has
been enrolled in school, and shall provide individualized education program
recommendations to the school if necessary. The therapeutic group home shall
inform the DMAS contractor of all scheduled appointments within 30 calendar
days of discharge and shall notify the DMAS contractor within one business day
of the youth's discharge date from the therapeutic group home.
(16) Failure to perform any of the items
described in this subsection shall result in a retraction of the per diem for
each day of noncompliance.
e. Service exclusions include the following:
(1) Room and board costs shall not be
reimbursed. Facilities that only provide independent living services or
nonclinical services that do not meet the requirements of this subsection are
not eligible for reimbursement.
(2)
Therapeutic group home services shall not be covered when treatment goals are
met or other less intensive services may achieve stabilization.
(3) Services that are based upon incomplete,
missing, or outdated service-specific provider intakes or plans of care shall
be denied reimbursement.
3. PRTF services are a 24-hour, supervised,
clinically and medically necessary out-of-home program designed to provide
necessary support and address mental health, behavioral, substance use,
cognitive, or other treatment needs of a youth in order to prevent or minimize
the need for more intensive inpatient treatment. Active treatment and
comprehensive discharge planning shall begin prior to admission. In order to be
covered for youth, these services shall (i) meet DMAS-approved psychiatric
medical necessity criteria or be approved as an EPSDT service based upon a
diagnosis made by an LMHP, LMHP-R, LMHP-RP, or LMHP-S who is practicing within
the scope of his license and (ii) be reflected in provider records and on the
provider's claims for services by recognized diagnosis codes that support and
are consistent with the requested professional services.
a. PRTF services shall be covered for the
purpose of diagnosis and treatment of mental health and behavioral disorders
when such services are rendered by a psychiatric facility that is not a
hospital and is accredited by the Joint Commission on Accreditation of
Healthcare Organizations, the Commission on Accreditation of Rehabilitation
Facilities, the Council on Accreditation of Services for Families and Children,
or by any other accrediting organization with comparable standards that is
recognized by the state.
b.
Providers of PRTF services shall be licensed by DBHDS.
c. PRTF services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR Part
441 Subpart
D, specifically
42 CFR
441.151(a) and
(b) and 42 CFR
441.152 through
42 CFR
441.156 and (ii) the Conditions of
Participation in 42 CFR Part
483 Subpart G. Each admission must be service
authorized, and the treatment must meet DMAS requirements for clinical
necessity.
d. The PRTF benefit for
youth shall include services defined at
42 CFR
440.160 that are provided under the direction
of a physician pursuant to a certification of medical necessity and plan of
care developed by an interdisciplinary team of professionals and shall involve
active treatment designed to achieve the youth's discharge from PRTF services
at the earliest possible time.
e.
PRTF services shall include assessment and reassessment; room and board; daily
supervision; therapeutic services; individual, family, and group therapy; care
coordination; interventions; general or special education; medical treatment,
including medication, coordination of necessary medical services, and 24-hour
onsite nursing availability; specialty services; and discharge planning that
meets the medical and clinical needs of the youth.
f. Medical necessity criteria for admission
to a PRTF. The following requirements for severity of need and intensity and
quality of service shall be met to satisfy the medical necessity criteria for
admission:
(1) Severity of need required for
admission. The following criteria shall be met to satisfy the criteria for
severity of need:
(a) There is clinical
evidence that the youth has a DSM-5 disorder that is amenable to active
psychiatric treatment.
(b) There is
a high degree of potential of the condition leading to acute psychiatric
hospitalization in the absence of residential treatment.
(c) Either (i) there is clinical evidence
that the youth would be a risk to self or others if the youth were not in a
PRTF or (ii) as a result of the youth's mental disorder, there is an inability
for the youth to adequately care for his own physical needs, and caretakers,
guardians, or family members are unable to safely fulfill these needs,
representing potential serious harm to self.
(d) The youth requires supervision seven days
per week, 24 hours per day to develop skills necessary for daily living; to
assist with planning and arranging access to a range of educational,
therapeutic, and aftercare services; and to develop the adaptive and functional
behavior that will allow the youth to live outside of a PRTF setting.
(e) The youth's current living environment
does not provide the support and access to therapeutic services
needed.
(f) The youth is medically
stable and does not require the 24-hour medical or nursing monitoring or
procedures provided in a hospital level of care.
(2) Intensity and quality of service
necessary for admission. The following criteria shall be met to satisfy the
criteria for intensity and quality of service:
(a) The evaluation and assignment of a DSM-5
diagnosis must result from a face-to-face psychiatric evaluation.
(b) The program provides supervision seven
days per week, 24 hours per day to assist with the development of skills
necessary for daily living; to assist with planning and arranging access to a
range of educational, therapeutic, and aftercare services; and to assist with
the development of the adaptive and functional behavior that will allow the
youth to live outside of a PRTF setting.
(c) An individualized plan of active
psychiatric treatment and residential living support is provided in a timely
manner. This treatment must be medically monitored, with 24-hour medical
availability and 24-hour nursing services availability. This plan includes (i)
at least once-a-week psychiatric reassessments; (ii) intensive family or
support system involvement occurring at least once per week or valid reasons
identified as to why such a plan is not clinically appropriate or feasible;
(iii) psychotropic medications, when used, are to be used with specific target
symptoms identified; (iv) evaluation for current medical problems; (v)
evaluation for concomitant substance use issues; and (vi) linkage or
coordination with the youth's community resources, including the local school
division and FAPT case manager, as appropriate, with the goal of returning the
youth to his regular social environment as soon as possible, unless
contraindicated.
(3)
Criteria for continued stay. The following criteria shall be met to satisfy the
criteria for continued stay:
(a) Despite
reasonable therapeutic efforts, clinical evidence indicates at least one of the
following:
(i) the persistence of problems
that caused the admission to a degree that continues to meet the admission
criteria (both severity of need and intensity of service needs);
(ii) the emergence of additional problems
that meet the admission criteria (both severity of need and intensity of
service needs); or
(iii) that
disposition planning or attempts at therapeutic reentry into the community have
resulted in or would result in exacerbation of the psychiatric illness to the
degree that would necessitate continued PRTF treatment. Subjective opinions
without objective clinical information or evidence are not sufficient to meet
severity of need based on justifying the expectation that there would be a
decompensation.
(b) There
is evidence of objective, measurable, and time-limited therapeutic clinical
goals that must be met before the youth can return to a new or previous living
situation. There is evidence that attempts are being made to secure timely
access to treatment resources and housing in anticipation of discharge, with
alternative housing contingency plans also being addressed.
(c) There is evidence that the plan of care
is focused on the alleviation of psychiatric symptoms and precipitating
psychosocial stressors that are interfering with the youth's ability to return
to a less-intensive level of care.
(d) The current or revised plan of care can
be reasonably expected to bring about significant improvement in the problems
meeting the criteria in subdivision 3 g (3) (a) of this subsection, and this is
documented in weekly progress notes written and signed by the
provider.
(e) There is evidence of
intensive family or support system involvement occurring at least once per
week, unless there is an identified valid reason why it is not clinically
appropriate or feasible.
(f) A
discharge plan is formulated that is directly linked to the behaviors or
symptoms that resulted in admission and begins to identify appropriate
post-PRTF resources including the local school division and FAPT case manager
as appropriate.
(g) All applicable
elements in admission-intensity and quality of service criteria are applied as
related to assessment and treatment if clinically relevant and
appropriate.
(4)
Discharge criteria. Discharge shall occur if any of the following applies:
(i) the level of functioning has improved
with respect to the goals outlined in the plan of care, and the individual
youth can reasonably be expected to maintain these gains at a lower level of
treatment;
(ii) the youth no longer
benefits from service as evidenced by absence of progress toward plan of care
goals for a period of 30 days; or
(iii) other less intensive services may
achieve stabilization.
g. The following clinical activities shall be
required for each PRTF resident:
(1) A
face-to-face assessment shall be performed by an LMHP, LMHP-R, LMHP-RS, or
LMHP-S within 30 calendar days prior to admission and weekly thereafter and
shall document a DSM-5 or ICD-10 diagnosis.
(2) A certificate of need shall be completed
by an independent certification team according to the requirements of
12VAC30-50-130 D
4. Recertification shall occur at least every
30 calendar days by a physician acting within his scope of practice.
(3) The initial plan of care (IPOC) shall be
completed within 24 hours of admission by the treatment team. The IPOC shall
include:
(a) Individual and family strengths
and personal traits that would facilitate recovery and opportunities to develop
motivational strategies and treatment alliance;
(b) Diagnoses, symptoms, complaints, and
complications indicating the need for admission;
(c) A description of the functional level of
the youth;
(d) Treatment objectives
with short-term and long-term goals;
(e) Any orders for medications, psychiatric,
medical, dental, and any special health care needs, whether or not provided in
the facility; education or special education; treatments; interventions; and
restorative and rehabilitative services, activities, therapies, social
services, diet, and special procedures recommended for the health and safety of
the youth;
(f) Plans for continuing
care, including review and modification to the plan of care;
(g) Plans for discharge; and
(h) Signature and date by the youth, parent,
or legally authorized representative, a physician, and treatment team
members.
(4) The CIPOC
shall be completed and signed no later than 14 calendar days after admission by
the treatment team. This information shall be used when considering changes and
updating the CIPOC. The CIPOC shall meet all of the following criteria:
(a) Be based on a diagnostic evaluation that
includes examination of the medical, psychological, social, behavioral, and
developmental aspects of the youth's situation and must reflect the need for
PRTF care;
(b) Be developed by an
interdisciplinary team of physicians and other personnel specified in
subdivision 3 h of this subsection who are employed by or provide services to
the youth in the facility in consultation with the youth, family member, or
legally authorized representative, or appropriate others into whose care the
youth will be released after discharge;
(c) Shall state treatment objectives that
shall include measurable, evidence-based, and short-term and long-term goals
and objectives; family engagement activities; and the design of community-based
aftercare with target dates for achievement;
(d) Prescribe an integrated program of
therapies, interventions, activities, and experiences designed to meet the
treatment objectives related to the youth and family treatment needs;
and
(e) Describe comprehensive
transition plans and coordination of current care and post-discharge plans with
related community services to ensure continuity of care upon discharge with the
youth's family, school, and community.
(5) The CIPOC shall be reviewed every 30
calendar days by the team specified in subdivision 3 h of this subsection to
determine that services being provided are or were required from a PRTF and to
recommend changes in the plan as indicated by the youth's overall adjustment
during the time away from home. The CIPOC shall include the signature and date
from the youth, parent, or legally authorized representative, a physician, and
treatment team members.
(6)
Individual therapy shall be provided a minimum of three times per week by an
LMHP, LMHP-R, LMHP-RP, or LMHP-S and shall be documented in the plan of care
and progress notes in accordance with the requirements in this subsection and
the requirements for progress notes in
12VAC30-60-61 B.
(7) Group therapy shall be
provided as clinically indicated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and
shall be documented in the plan of care and progress notes in accordance with
the requirements in this subsection and the requirements for progress notes in
12VAC30-60-61 B.
(8) Family therapy shall be
provided as clinically indicated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S and as
documented in the plan of care and progress notes in accordance with the
requirements in this subsection and requirements for progress notes in
12VAC30-60-61 B.
(9) Family engagement shall be
provided in addition to family therapy or counseling. Family engagement shall
be provided at least weekly as outlined in the plan of care and daily
communication with the treatment team representative and the family or legally
authorized representative shall be part of the family engagement strategies in
the plan of care. For each service authorization period when family engagement
is not possible, the PRTF shall identify and document the specific barriers to
the youth's engagement with his family or legally authorized representatives.
The PRTF shall document on a weekly basis the reasons that family engagement is
not occurring as required. The PRTF shall document alternate family engagement
strategies to be used as part of the interventions in the plan of care and
request approval of the revised plan of care by DMAS. When family engagement is
not possible, the PRTF shall collaborate with DMAS on a weekly basis to develop
individualized family engagement strategies and document the revised strategies
in the plan of care.
(10) Three
non-psychotherapy interventions shall be provided per 24-hour period including
nights and weekends. Family engagement activities are considered to be an
intervention and shall occur based on the treatment and visitation goals and
scheduling needs of the family or legally authorized representative.
Interventions shall be documented on a progress note and shall be outlined in
and aligned with the treatment goals and objectives in the plan of care. Any
deviation from the plan of care shall be documented along with a clinical or
medical justification for the deviation based on the needs of the
youth.
(11) Therapeutic passes
shall be provided as clinically indicated in the plan of care and as paired
with community-based and facility-based interventions to promote discharge
planning, community integration, and family engagement. Therapeutic passes
include activities as listed in subdivision 2 d (13) of this section.
Twenty-four therapeutic passes shall be permitted per youth, per admission,
without authorization as approved by the treating physician and documented in
the plan of care. Additional therapeutic passes shall require service
authorization from DMAS or its contractor. Any unauthorized therapeutic passes
not approved by the provider or DMAS or its contractor shall result in
retraction for those days of service.
(12) Discharge planning shall begin at
admission and continue throughout the youth's placement at the PRTF. The parent
or legally authorized representative, the community services board (CSB), the
family assessment planning team (FAPT) case manager, if appropriate, and the
DMAS contracted care manager shall be involved in treatment planning and shall
identify the anticipated needs of the youth and family upon discharge and
identify the available services in the community. Prior to discharge, the PRTF
shall submit a comprehensive discharge plan to the DMAS contractor for review.
Once the DMAS contractor approves the discharge plan, the provider shall begin
collaborating with the parent or legally authorized representative and the
treatment team to identify behavioral health and medical providers and schedule
appointments for comprehensive needs assessments as needed. The PRTF shall
request information from post-discharge providers to establish that the
planning of services and activities has begun, shall establish that the youth
has been enrolled in school, and shall provide individualized education program
recommendations to the school if necessary. The PRTF shall inform the DMAS
contractor of all scheduled appointments within 30 calendar days of discharge
and shall notify the DMAS contractor within one business day of the youth's
discharge date from the PRTF.
(13)
A urine drug screen is considered at the time of admission, when progress is
not occurring, when substance misuse is suspected, or when substance use and
medications may have a potential adverse interaction. After a positive screen,
additional random screens are considered and referral to a substance use
disorder provider is considered.
(14) Failure to perform any of the items as
described in subdivisions 3 g (1) through 3 g (13) of this subsection up until
the discharge of the youth shall result in a retraction of the per diem and all
other contracted and coordinated service payments for each day of
noncompliance.
h. The
team developing the CIPOC shall meet the following requirements:
(1) At least one member of the team must have
expertise in pediatric behavioral health. Based on education and experience,
preferably including competence in child and adolescent psychiatry, the team
must be capable of all of the following: assessing the youth's immediate and
long-range therapeutic needs, developmental priorities, and personal strengths
and liabilities; assessing the potential resources of the youth's family or
legally authorized representative; setting treatment objectives; and
prescribing therapeutic modalities to achieve the CIPOC's objectives.
(2) The team shall include one of the
following:
(a) A board-eligible or
board-certified psychiatrist;
(b) A
licensed clinical 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
clinical psychologist.
(3) The team shall also include one of the
following: an LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
4. Requirements for
independent certification teams applicable to both therapeutic group homes and
PRTFs:
a. The independent certification team
shall certify the need for PRTF or therapeutic group home services and issue a
certificate of need document within the process and timeliness standards as
approved by DMAS under contractual agreement with the DMAS
contractor.
b. The independent
certification team shall be approved by DMAS through a memorandum of
understanding with a locality or be approved under contractual agreement with
the DMAS contractor. The team shall initiate and coordinate referral to the
family assessment and planning team (FAPT) as defined in §§
2.2-5207 and
2.2-5208 of the Code of Virginia
to facilitate care coordination and for consideration of educational coverage
and other supports not covered by DMAS.
c. The independent certification team shall
assess the youth's and family's strengths and needs in addition to diagnoses,
behaviors, and symptoms that indicate the need for behavioral health treatment
and also consider whether local resources and community-based care are
sufficient to meet the youth's treatment needs, as presented within the
previous 30 calendar days, within the least restrictive environment.
d. The LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP, as part of the independent certification team, shall meet with the
youth and the youth's parent or legally authorized representative within two
business days from a request to assess the youth's needs and begin the process
to certify the need for an out-of-home placement.
e. The independent certification team shall
meet with the youth and the youth's parent or legally authorized representative
within 10 business days from a request to certify the need for an out-of-home
placement.
f. The independent
certification team shall assess the treatment needs of the youth to issue a
certificate of need (CON) for the most appropriate medically necessary
services. The certification shall include the dated signature and credentials
for each of the team members who rendered the certification.
g. The CON shall be effective for 30 calendar
days prior to admission.
h. The
independent certification team shall provide the completed CON to the facility
within one calendar day of completing the CON.
i. The youth and the youth's parent or
legally authorized representative shall have the right to freedom of choice of
service providers.
j. If the youth
or the youth's parent or legally authorized representative disagrees with the
independent certification team's recommendation, the parent or legally
authorized representative may appeal the recommendation in accordance with
12VAC
30-110.
k. If the LMHP,
LMHP-R, LMHP-RP, or LMHP-S, as part of the independent certification team,
determines that the youth is in immediate need of treatment, the LMHP, LMHP-R,
LMHP-RP, or LMHP-S shall refer the youth to an appropriate Medicaid-enrolled
crisis intervention provider, crisis stabilization provider, or inpatient
psychiatric provider in accordance with
12VAC30-50-226 or shall refer the
youth for emergency admission to a PRTF or therapeutic group home under
subdivision 4 m of this subsection and shall also alert the youth's managed
care organization.
l. For youth who
are already eligible for Medicaid at the time of admission, the independent
certification team shall be a DMAS-authorized contractor with competence in the
diagnosis and treatment of mental illness, preferably in child and adolescent
psychiatry, and have knowledge of the youth's situation and service
availability in the youth's local service area. The team shall be composed of
at least one physician and one LMHP, including LMHP-S, LMHP-R, or LMHP-RP. The
youth's parent or legally authorized representative shall be included in the
certification process.
m. For
emergency admissions, an assessment must be made by the team responsible for
the comprehensive individual plan of care (CIPOC). Reimbursement shall only
occur when a certificate of need is issued by the team responsible for the
CIPOC within 14 calendar days after admission. The certification shall cover
any period of time after admission and before claims are made for reimbursement
by Medicaid. After processing an emergency admission, the therapeutic group
home, PRTF, or institution for mental diseases (IMD) shall notify the DMAS
contractor within five calendar days of the youth's status as being under the
care of the facility.
n. For youth
who apply and become eligible for Medicaid while an inpatient in the facility
or program, the certification shall be made by the team responsible for the
CIPOC and shall cover any period of time before the application for Medicaid
eligibility for which claims are made for reimbursement by Medicaid. Upon the
youth's enrollment into the Medicaid program, the therapeutic group home, PRTF,
or IMD shall notify the DMAS contractor of the youth's status as being under
the care of the facility within five calendar days of the youth becoming
eligible for Medicaid benefits.
