C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.08

Current through 2024-51, December 18, 2024

Subsection 144-101-II-65.08 - POLICIES AND PROCEDURES

65.08-1Clinicians and Other Qualified Staff

Clinicians: There must be written evidence from the appropriate governing body that all Clinicians are conditionally, temporarily, or fully licensed and approved to practice. All Clinicians must provide services only to the extent permitted by licensure. Clinicians are required to follow professional licensing requirements, including documentation of clinical credentials.

Other Qualified Staff: consist of a certified Mental Health Rehabilitation Technician (MHRT), a certified Behavioral Health Professional (BHP), a certified FFT therapist, or a certified MST therapist for the purposes of providing 65.05-9 Children's Home and Community Based Treatment certified by DHHS at the level appropriate for the services being delivered.

A provider may be reimbursed for covered services only if they are provided by Clinicians or other qualified staff.

65.08-2Direct Support Professional (DSP)

A DSP is a person who:

A. Successfully completed the Direct Support Professional curriculum as adopted by DHHS , or demonstrated proficiency through DHHS's approved Assessment of Prior Learning, or has successfully completed the curriculum from the Maine College of Direct Support within six (6) months of date of hire.

Prior to providing services to a member alone, a DSP must have completed the following four modules from the College of Direct Support, including computer based and live sessions:

1. Introduction to Developmental Disabilities

2. Professionalism

3. Individual Rights and Choice

4. Maltreatment

Documentation of completion must be retained in the personnel record.

B. Completed the following Department-approved trainings, within the first six (6) months from date of hire and thereafter every thirty-six (36) months:

1. Reportable Events System (14-197, Ch. 12)

2. Regulations Governing Behavioral Support, Modification and Management for People with Intellectual Disabilities or Autism in Maine (14-197, Ch. 5)

3. Rights and Basic Protections of a Person with an Intellectual Disability or Autism (Title 34-B § 5605)

4. Grievance Training (must be completed before working with members).

C. Has a background check consistent with Section 65.08-7;

D. Has an adult protective and Child protective record check;

E. Is at least eighteen (18) years of age;

F. Graduated from high school or acquired a GED;

G. Has current CPR and First Aid Certification.

H. Prior to administering medication, a DSP is legally authorized to assist with the administration of medication if the DSP is certified as a Certified Nursing Assistant-Medications (CNA-M); as a Certified Residential Medication Aide (CRMA), or a Registered Nurse (RN), or otherwise has been trained to administer medications through a training program specifically for Family-Centered or Shared Living model homes and authorized, certified, or approved by DHHS.

All new staff or subcontractors shall have six (6) months from their date of hire to obtain DSP certification. Evidence of date of hire and enrollment in the training must be documented in writing in the employee's personnel file or a file for the subcontractor.

Services provided during this time are reimbursable as long as the documentation exists in the personnel file.

A person who provides Direct Support must be a DSP regardless of his or her status as an employee or subcontractor of a provider.

A DSP can supervise another DSP.

65.08-3Providers of Behavioral Health Services for Members Who are Deaf or are Hard of Hearing

Services for members who are deaf or hard of hearing must be delivered by a provider or an interpreter who is credentialed in the communication mode of the member, whether that is American Sign Language, Oral Interpreter, Cued Speech, or some other communication mode used by deaf, hard of hearing, or non-verbal member.

65.08-4Member Records

A member's record must contain written documentation of a Comprehensive Assessment, an Individualized Treatment Plan and progress notes. The Comprehensive Assessment process determines the intensity and frequency of Medically Necessary Services and includes utilization of instruments as may be approved or required by DHHS. Individualized Treatment Plans are the plans of care developed by the Clinician or the treatment team with the member and in consultation with the Parent or guardian, if appropriate, based on a Comprehensive Assessment of the member. Individualized plans include the Individualized Treatment Plan, the Crisis

A.Comprehensive Assessment

1. A Clinician must complete a Comprehensive Assessment that integrates co-occurring mental health and substance use issues within thirty (30) days of the day the member begins services. The Comprehensive Assessment must be included in the member's record. The Comprehensive Assessment process must include a direct encounter with the member and if appropriate, Family members, Parents, friends, and guardian. The Comprehensive Assessment must be updated at a minimum, when there is a change in level of care, or when major life events occur, and annually.

The Comprehensive Assessment must contain documentation of the member's current status, history, strengths and needs in the following domains: personal, Family, social, emotional, psychiatric, psychological, medical, drug and alcohol (including screening for Co-occurring Services), legal, housing, financial, vocational, educational, leisure/recreation, potential need for crisis intervention, physical/sexual and emotional abuse.

The Comprehensive Assessment may also contain documentation of developmental history, sources of support that may assist the member to sustain treatment outcomes including natural and community resources and state and federal entitlement programs, physical and environmental barriers to treatment and current medications. Domains addressed must be clinically pertinent to the service being provided.

Additionally, for a Comprehensive Assessment for a member with substance use, the documentation must also contain age of onset of alcohol and drug use, duration, patterns and consequences of use, Family usage, types and response to previous treatment.

2. The Comprehensive Assessment must be summarized and include a diagnosis in accordance with the current version of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-5), as appropriate. The Comprehensive Assessment must be signed, credentialed, and dated by the Clinician conducting the Comprehensive Assessment. A Comprehensive Assessment for a member with a substance use diagnosis must also contain ASAM level of care criteria. If the Comprehensive Assessments for a member receiving integrated treatment for Co-occurring Disorders, the Comprehensive Assessment must contain both the DSM and ASAM Criteria.

3. If a provisional diagnosis is made by an MHRT or CADC providing the direct service, the diagnosis will be reviewed within five (5) working days by the supervising licensed Clinician and documented in the record.

4. Historical data may be limited in crisis services. The Comprehensive Assessment must contain documentation if information is missing and the reason the information cannot be obtained or is not clinically applicable to the service being provided.

5. For members receiving Family Psychoeducation, Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments, no Comprehensive Assessment is required.

B.Individualized Treatment Plan (ITP)

1. The Clinician, member and other participants (service providers, Parents or guardian) must develop an ITP, based on the Comprehensive Assessment that is appropriate to the developmental level of the member. 2. When an ITP is required it must contain the following, unless there is an exception:

a. The member's diagnosis and reason for receiving the service;

b. Measurable long-term goals with target dates for achieving the goals;

c. Measurable short-term goals with target dates for achieving the goals, objectives that allow for measurement of progress, and the tasks the member must perform to complete goals;

d. Specific services to be provided with amount, frequency, duration and Practice Methods of services, and designation of who will provide the service, including documentation of Co-occurring Services and Natural Supports, when applicable;

e. Measurable Discharge criteria;

f. Special accommodations needed to address physical or other disabilities to provide the service;

g. For OTP services, the dosage plan, as documented by a physician or physician extender advanced practice professional in the member's record;

h. Participant signatures, credential (if applicable) and date for the initial ITP. For OTP services, the initial ITP must also be signed by the medical director. The first thirty (30) or ninety (90) day period begins with date of the initial signed ITP.

i. The Clinician, member and other participants if indicated (service providers, Parent(s) or Guardian(s)) must review the ITP at all major decision points but no less frequently than ninety (90) days, or as described in 65.08-4(B)(3). If clinically indicated, the member's needs may be reassessed, and the ITP may be reviewed and amended more frequently than described in 65.08-4(B)(3). Changes to the ITP are in effect as of the date it is signed by the Clinician and member or, when appropriate, the Parent or Guardian. All participants must sign, credential (if applicable) and date the reviewed ITP.

3. The ITP must be completed and reviewed within the following schedule as applicable:

a.Crisis Resolution - as clinically indicated. For members receiving Crisis Resolution Services, a written plan of care is substituted for the ITP.

b.Crisis Residential - completed within twenty-four (24) hours from admission and reviewed on the seventh (7^th) day of service and every two (2) days thereafter if DHHS or an Authorized Entity approves continued stay.

c.Outpatient Services - Mental Health, Co-occurring, and Medication Management Services completed within thirty (30) days from admission and reviewed every twelve (12) visits or annually, whichever comes first.

d.Outpatient - Substance Use completed within three (3) outpatient sessions and reviewed every ninety (90) days.

e.Intensive Outpatient Program Services completed within three (3) outpatient sessions from admission and reviewed every thirty (30) days.

f.Children's Assertive Community Treatment, Children's Home and Community Based Treatment completed within thirty (30) days from admission and reviewed every ninety (90) days.

g.Opioid Treatment Program Services with Methadone completed within seven (7) calendar days from admission and reviewed every ninety (90) days.

4. For members receiving Family Psychoeducation, Neurobehavioral Status Exam, Neuropsychological Testing, Psychological Testing, and Adaptive Assessments, no ITP is required.

5. If a member receives covered "Case Management Services" under MaineCare Benefits Manual, to include Section 13, Section 17, Section 92, Section 93, or any similar case management services, the member's mental health provider's ITP will coordinate with the appropriate portion of the member's ITP described in the MaineCare Benefits Manual to include, but not limited to, Section 13, Section 17, Section 92, or Section 93.

6. MaineCare will reimburse for covered services provided before the ITP is approved as long as the ITP is completed within prescribed time frames from the day the member begins treatment.

7. If a member is assessed by appropriate staff, but an ITP is not developed because there is at least a sixty (60) day waiting list to enter into treatment, reimbursement may be made for the assessment only.

Comprehensive Assessments must be updated before treatment begins if, in the opinion of the professional staff assigned to the case, this would result in more effective treatment. If an update is necessary, additional units for the Comprehensive Assessment may be authorized by DHHS or an Authorized Entity.

8. Crisis/Safety Plan

The Crisis/Safety Plan for Children's Home and Community Based Treatment must address the safety of the member and others surrounding a member experiencing a crisis. The plan must:

a. Identify the precursors to the crisis;

b. Identify the strategies and techniques that may be utilized to stabilize the situation;

c. Identify the individuals responsible for the implementation of the plan including any individuals whom the member (or Parents or Guardian, as appropriate) identifies as significant to the member's stability and well-being; and

d. Be reviewed every ninety (90) days or as part of the required review of the ITP.

C.Documentation

Providers must maintain written progress notes for all services, in chronological order.

All entries in the progress note must include the service provided, the provider's signature and credentials, the date on which the service was provided, the duration (including the beginning and end time) of the service, and the progress the member is making toward attaining the goals or outcomes identified in the ITP.

For in-home services, the progress note must also contain the time the provider arrived and left. Additionally, the provider must ask the member or an adult responsible for the member to sign off on a time slip or other documentation documenting the date, time of arrival, and time of departure of the provider.

In the case of co-therapists providing group psychotherapy, the provider who bills for the service for a specific member is responsible for maintaining records and signing entries for that member. Facsimile signatures will be considered valid by DHHS if in accordance with mental health licensing standards.

Separate clinical records must be maintained for all members receiving group psychotherapy services. The records must not identify any other member or confidential information of another member.

For crisis services, the progress note must describe the intervention, the nature of the problem requiring intervention, and how the goal of stabilization will be attempted, in lieu of an ITP.

The clinical record shall also specifically include written information or reports on all medication reviews, medical consultations, psychometric testing, and collateral contacts made on behalf of the member (name, relationship to member, etc.).

Documentation of cases where a member requires more than two (2) hours of outpatient services per week to prevent hospitalization must be included in the file. This documentation must be signed by the supervising Clinician.

D.Discharge/Closing Summary

A closing summary shall be signed, credentialed and dated and included in the clinical record at the time of discharge. This will include a summary of the treatment, to include any after care or support services recommended and outcome in relation to the ITP.

E.Quality Assurance

Periodic review of cases to assure quality and appropriateness of care will be conducted in accordance with the quality assurance (QA) protocols established by DHHS.

Reviews will be in writing, signed and dated by the reviewers, and included in the member's record, or kept in a separate and distinct file parallel to the member's record.

/Safety Plan (as clinically indicated) and the Discharge Plan.

65.08-5Program Integrity (PI) Unit

Program Integrity Unit requirements apply as defined in the MaineCare Benefits Manual, Chapter I, Section 1, "General Administrative Policies and Procedures".

65.08-6Protections for Adults with Serious and Persistent Mental Illness

If the member with a Serious and Persistent Mental Illness is receiving Behavioral Health services reimbursed under Section 65 identified in the member's Individualized Treatment Plan, then the provider must:

A. Obtain written approval from the Director of the Office of Behavioral Health (OBH) or designee prior to terminating services to that Member;

1. Written approval is not required in cases where the terminating provider has successfully facilitated a member's transfer, with the member's consent, to a new provider

B. If approved by OBH, issue a thirty (30) day advanced written termination notice to the member prior to termination of member's services. In cases where the member poses a threat of imminent harm to persons employed or served by the provider, the Director of the Office of Behavioral Health, or designee may approve a shorter notification for termination of services;

C. Assist the member in obtaining clinically necessary services from another provider prior to discharge or termination;

D. Accept Department referrals through the Department-defined referral process within seven calendar days, for members deemed eligible for Medication Management or Crisis Residential Services. Only in cases where providers have received written approval from OBH, may a referral be declined.

65.08-7Background Check Requirements

Behavioral Health Services providers must conduct background checks every five (5) years on all prospective and current employees, persons contracted or hired, consultants, volunteers, students, and other persons who may be providing direct support services under this Section. Background checks on persons professionally licensed by the State of Maine will include a confirmation that the licensee is in good standing with the appropriate licensing board or entity.

The provider shall contact Child and adult protective services (including OADS and the Office of Child and Family Services) units within State government to obtain any record of substantiated allegations of abuse, neglect, or exploitation against an employment applicant before hiring the same. The provider shall follow the requirements set forth in 22 M.R.S. Ch. 1961, The Maine Background Check Center Act, and 10-144 C.M.R. Ch. 60, Maine Background Check Center Rule, for requirements on conducting and evaluating employee background checks.

All background checks must be completed every five (5) years thereafter in accordance with 10-144 C.M.R. Ch. 60. Costs for background checks are the provider's responsibility.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-65, subsec. 144-101-II-65.08