C.M.R. 14, 193, ch. 6, COMMUNITY SUPPORT SERVICE STANDARDS
These standards, in addition to the core standards, are applied to agencies providing community support services for clients with severe and disabling mental illness, and include case management, outreach, assistance in meeting basic needs, direct skill teaching (activities of daily living, social skills, etc.), assistance, consultation, education, advocacy, and supportive counseling. Community support functions include: developing service agreements, participation in hospital discharge meetings providing personalized support to clients, and participation in crisis intervention and resolution.
Access
CS.1 The agency has policies and procedures governing the establishment of a waiting list which minimally includes the following: prioritizing clients, selecting clients from the wafting list, and referring to other providers.
CS.2 Eligible individuals are informed of their right to receive an Individualized Support Plan and community support services and, when accepted or requested, receive them in a timely fashion.
CS. 2. A. There is documented evidence that clients living in the community who apply and are eligible for services, are assigned a community support worker within three working days of application.
CS. 2. A.1 When community support services cannot be assigned within three working days, the agency shall immediately notify the Commissioner in writing.
CS. 2. B. There is documented evidence that an Individualized Support Plan is developed within 30 days of application.
CS. 2. C. When a hospitalized client requests a community support worker, a worker will be assigned within one working day of receipt of the request from the hospital.
CS. 2. C.1 The agency documents the date and time of the hospital's request;
CS. 2. C.2 The agency documents the date and time the community support worker was assigned.
CS. 2. D. There is documented evidence that individuals who decline the services of a community support worker or Individualized Support Maine Mental Plan are informed that they may apply for these services at any subsequent time.
CS. 2. E. The agency mill. develop a policy and procedure and be able to demonstrate that he screening process for determination of eligibility for services is completed within 30 days of application.
CS.3 There are regular and scheduled outreach services available in the agency's service area.
CS. 3. A Outreach contacts are documented and attempt to address the following:
CS. 3. A. 1 identifying information;
CS. 3. A.2 an informal assessment of the individual's needs;
CS. 3. A.3 the individual's level of commitment to initiate services; and
CS. 3. A.4 an informal plan for engaging the individual further.
Interpretive Guideline for CS.3 through CS.3.A.4
For outreach services in general, informed consent for service provision should obtained when an individual agrees to initiate services. Initiation of service is defined as the point when an individual agrees to have an outreach worker actively pursue services, other than information and referral, on their behalf.
Assessment
CS.4. A comprehensive assessment is conducted by an individual chosen or agreed to by the client, with the client's participation, within 30 days of the client agreeing to initiate services.
CS. 4. A.. The comprehensive assessment minimally addresses the following:
CS. 4. A..1 the client's strengths and weaknesses;
CS. 4. A..2 the client's perception of his or her needs;
CS. 4. A..3 the family/guardian's input and perception of the client's needs when appropriate, and with the client's consent;
CS. 4. A..4 a personal, family, and social history;
CS. 4. A..5 the emotional, psychiatric and psychological strengths and needs of the client;
CS. 4. A..6 a physical health status and history, including current prescribed and over-the-counter medication use and dental needs;
CS. 4. A..7 past and current drug/alcohol use;
CS. 4. A..8 a developmental history;
CS. 4. A..9 possible sources of assistance and support in meeting the needs expressed by the client or legally responsible party, including state -and federal entitlement programs;
CS. 4. A..10 physical and environmental barriers that may impede the client and family's ability to obtain services;
CS. 4. A..11 history of physical and/or sexual abuse;
CS. 4. A..12 the vocational, educational, social, living, leisure/recreation and medical domains; and
CS. 4. A..13 potential need for crisis intervention services;
CS. 4. A..14 housing and financial needs;
CS.4. A.15 the status of the Individualized Support Plan;
CS. 4. A.15.a. in instances in which the Individualized Support Plan is the only service the client is receiving and there is no evidence of other immediately needed services, the worker will complete a preliminary assessment based upon the information in the workers possession and, every 30 days subsequently, update the status of the ISP in a progress note. For these clients, the comprehensive assessment will be completed within 30 days of the completion of the ISP or the identification of an immediate service need; and
CS. 4. A..16 the signature of the person who performed the assessment.
Interpretive Guideline for CS.4.A.1 thru CS.4.A.16
The Division of Licensing recognizes that in some cases not all of the information requested in these standards will be able to be obtained. The Division also recognizes that the level of detail required will vary given a variety of factors (the client's level of cooperation, the integrity of the information sources, the length of services or treatment, the condition being addressed, the practitioner's training, etc.). Although the Division will attempt to be sensitive to these factors and flexible in surveying this area, the agency should assure that assessments that do not address all these standards have accompanying documentation that justifies abbreviated or absent information.
CS. 4. B. The agency will establish and adhere to policies and procedures establishing criteria for the performance of the following assessments
CS. 4. B.1 a nutritional assessment;
CS. 4. B.2 a cognitive functioning assessment;
Interpretive Guideline for CS.4.B.2
The client's cognitive functioning assessment should include assessment of the following functions: problem solving, decision making, organization, self-direction, system negotiation skills, concentration, and abstract reasoning. For individuals over 60 years of age, this assessment should also include memory, language, orientation, and visuo-spatial abilities.
CS. 4. B.3 an assessment of the client's capacity to make reasoned decisions; and
CS. 4. B.4 a neurological assessment.
Interpretive Guideline for CS.4.B thru CS.4.B.4
These assessments do not necessarily have to be performed in the agency or by agency staff. the intent of these standards are to assure that the agency has mechanisms by which to evaluate the need for these assessments and to perform or refer for assessment those clients whose symptomatology suggests such need.
CS. 4. C The assessment(s) shall be obtained from the client, legally responsible party, community service agencies, and to the extent possible, from other individuals in the community as authorized by the client or legally responsible party.
CS. 4. D The client record contains a summary evaluation of the data collected in the comprehensive assessment.
CS.5 The agency has a documented policy and procedure on updating assessments that assures that assessments are current and in no case exceed annual updates, Service Planning
CS.6 There is documented evidence that the service planning and revision process involves the client, legally responsible party, and other representatives and professionals whom the client designates.
Interpretive Guideline for CS.6
The client and legally designated guardian shall be fully and actively involved in the development or revision of the service plan, if possible. It the client consents, the client's designated representative e, family members or significant others shall be included in the development and revision of the service plan, unless contraindicated. When these individuals do not attend, their absence is noted. Each agency shall document good faith efforts, including at least 10 days notice of any service planning meeting, to involve guardians, representatives or legally responsible parents. In instances in which the agency is unable to provide 10 days notice, a written justification will be entered in the client's record.
CS.7 A service plan is developed for each client within 30 days of initiation of service, with the client and based upon the wants and needs of the client identified in the comprehensive assessment and, if the client has one, the Individualized Support Plan.
CS. 7. A. The service plan minimally contains the following:
CS. 7. A.1 problem statements;
CS. 7. A.2 short- and long-range goals based upon client needs with a projection of when such goals will be attained;
CS. 7. A.3 objectives stated in terms which allow objective measurement of progress;
CS. 7. A.4 multidisciplinary input and specification of treatment responsibilities;
CS. 7. A.5 client input and signature;
CS. 7. A.6 signatures of all people participating in the development of the plan;
CS. 7. A.7 the methods and frequency of treatment, rehabilitation, support;
CS. 7. A.8 a description of any physical handicap and any accommodations necessary to provide the same or equal services and benefits as those afforded non-disabled individuals; and
CS. 7. A.9 criteria for discharge.
CS. 7. B Justification for not addressing problems identified in the assessments is documented in the client record.
Interpretive Guideline for CS.7.B
The intent of this standard is to assure that the clinical staff considers all of the client's identified problems in formulating the service plan. problems that are not reflected on the service plan should have accompanying documentation identifying the rationale for not addressing the problems at this time. This documentation can take many forms including progress notes service plan narratives, etc.
CS.8 The service plait is designed so that the client's progress towards service plan goals can be monitored and evaluated.
Interpretive Guideline for CS.8
Service plans should have measurable goals and some means for reflecting when, or to what degree, a goal has been attained. The organization should also have mechanisms that document monitoring and evaluation of client goals, e.g., quality assessment, treatment plan review documents.
CS.8 The service plan is reviewed at major decision points in each client's treatment course, upon client request, and no less frequently than every 90 days.
Interpretive Guideline for CS.9
Major decision points may include, but are not necessarily limited to the following: when there is a change in the client's condition, when a service appears not to benefit the client, when the client is under- or over- utilizing services.
CS.10 Unmet service needs are documented in the service plan and in Interim plans subsequent to the service planning process.
Interpretive Guideline for CS.10
If at the time of or subsequent to the service planning meeting, team members know, on the basis of reliable information, that the needed services are unavailable, they shall note them as "unmet service needs" on the service plan and develop and interim plan based upon available services that meet, as nearly as possible, the actual needs of the client. The organization should also document notification of the organization's leaders and the commissioner regarding the unavailability of service that is causing the unmet need.
CS.11 The agency has a policy and procedure for providing clients with a copy of their service plan within one week following its formulation, review or revision and notification of client recourse should they disagree with any aspect of the plan.
CS. 11. A. There are no instances in which the agency fails to provide a copy of the client's service plan and/or notify them of recourse should they disagree.
Service Delivery
CS.12 Community support workers assist clients in negotiating linkages with service providers as evidenced by documentation that reflects each contact and the delivery of those services deemed appropriate in the client's service and support plans.
Discharge Planning
CS.13 Each client record contains documentation of current discharge or termination planning.
CS.14 The agency has discharge planning policies and procedures.
CS. 14. A The agency has a policy and procedure for determining when a client is considered 'inactive'.
CS. 14. A.1 The inactive status policy and procedure notes what documentation is kept on the client during inactive status.
CS. 14. A.2 The inactive status policy and procedure notes the duration of inactive status before the case is considered closed.
CS.15 A discharge summary is entered in the client record within 15 days of discharge or on the 90th day of inactive status and includes the client's course of treatment and ongoing needs at discharge.
CS. 15. A. Each discharge summary minimally addresses, WU neat not be limited to the following:
CS. 15. A.1. the reasons for termination of service;
CS. 15. A.2. the final assessment, including die general observations and significant findings of the client's condition initially, while services are being provided and at discharge;
CS. 15. A.3. the course and progress of the client with regard to each identified problem; and
CS. 15. A.4. the recommendations and arrangements for further continued service needs.
Interpretive Guideline for CS.15
For clients on inactive status, a discharge summary should be completed no later that 90 days following placement on inactive status or earlier given the following conditions:
1. another agency submits a request for the client's discharge summary prior to the 90th day of inactive status;
2. agency policy requires that discharge summary be completed earlier than the 90th day of inactive status; and
3. practitioners who are leaving agency employment must complete discharge summaries on all of their inactive status clients regardless of time frame.
CS.16 The agency has policies and procedures that specify under what conditions services may be discontinued or interrupted which minimally include how and when, the client is notified.
CS. 16. A. For agencies serving DMHMR class members, the agency shall first obtain prior written approval for discontinuing or interrupting services from the Department.
CS. 16. B For agencies serving DMHMR class members, the agency shall give thirty days advance written notice to the client and the client's guardian. If the client poses a threat of imminent harm to persons employed or served by the agency, the agency shall give notice that is reasonable under the, circumstances.
CS. 16. C. For agencies serving DMHMR class members, the agency shall give such notice as may be required by law or regulation.
CS. 16. D For agencies serving DMHMR class members, the agency shall assist the client in obtaining the services from another agency.
CS. 16. E For agencies serving DMHMR class members, the agency shall provide documented evidence in the client record of compliance with these standards, through letters, progress notes, phone logs, and/or facsimile.
CS.17 Applicants who are not eligible for services will be referred to appropriate services, if required, available and desired.
CS. 17. A. The agency has a policy and procedure on referral and/or transfers of individuals deemed inappropriate for services offered by the agency that minimally includes communicating the rationale for the referral/transfer to the applicant and providing them with a list of alternative service providers and advocacy services.
CS. 17. B. The agency provides and documents other assistance as required to assist the individual to obtain/access the services to which they are referring him/her.
Health
CS.18 If food services are provided, the facilities for the preparation and serving of food shall be inspected and approved by the Department of Human Services.
CS. 18. A. If food is either prepared or served at the facility, then the agency shall either obtain a DHS Eating Establishment license or show written evidence from DHS indicating that they do not need such a license.
CS. 18. B. When the agency requires a DHS license, the agency's Eating Establishment license is current.
CS.19 The agency shall have methods for obtaining on- or off-site medical services for all clients.
CS. 19. A. The agency defines in policy and procedure those medical services delivered on-site. For those medical services not provided on-site, letters of agreement and/or procedures for accessing medical service provider(s) are in effect.
Human Resource Management
CS.20 There is documented evidence that community support workers are licensed or certified to deliver mental health services as approved by the Division.
CS.21 Community support workers shall have a maximum of 40 clients in their caseload.
CS. 21. A. For purposes of this standard, individual clients who present a multiplicity of needs, who has: recently required aids intervention and resolution services or who have a need for especially intense community support shall, for purposes of computing the above ratio, be counted as 2.5 clients.
CS. 21. 1B. In instances in which the agency has compelling reasons for not meeting this standard, those reasons will be documented as well as efforts being taken to achieve compliance with the standard.
C.M.R. 14, 193, ch. 6, COMMUNITY SUPPORT SERVICE STANDARDS