N.M. Admin. Code § 7.20.11.26

Current through Register Vol. 35, No. 23, December 10, 2024

Section 7.20.11.26 - COMPREHENSIVE COMMUNITY SUPPORT SERVICES

A. Comprehensive community support services (CCSS) shall coordinate and provide necessary services and resources to eligible clients and families to promote recovery, rehabilitation and resiliency.

B. These culturally sensitive services shall identify and address the barriers that impede the development of skills necessary for independent functioning in the community as well as strengths, goals and measurable objectives, which may aid the client or family in the recovery or resiliency process.

C. CCSS shall address goals as identified by the client or family specifically to meet recovery and resilience based outcomes in the areas of independent living, learning, working, socializing and recreation.

D. CCSS shall be provided to children, youth and adults with significant behavioral health disorders and who meet other criteria as identified by the collaborative.

E. CCSS shall be provided in compliance with the medical assistance division (MAD) definition of medical necessity and shall be furnished within the MAD benefits.

F. CCSS shall be furnished within the scope and practice of the provider's respective profession as defined by state law, and in accordance with applicable federal, state and local laws and regulations.

G. An assessment of baseline functioning shall be performed within 10 working days of the client's admission into CCSS services. The assessment shall evaluate and document the client's specific functional effectiveness in multiple skill domains based on the desired outcomes of the client or family.

(1) Functional level determination shall identify domains in which functional limitations precipitated by the behavioral health disorder are present. The diagnoses and assessments shall be the basis for the comprehensive client or family driven goal directed, measurable service plan

(2) CCSS eligible clients shall have one designated agency that will have the primary responsibility of partnering with the client and family for the purpose of implementing the comprehensive service plan.

H. Within the CCSS agency, a primary community support worker (CSW), under the documented supervision of the CCSS supervisor, shall be identified on the comprehensive service plan and shall partner with the client and family for the purpose of coordinating and facilitating recovery and resiliency directed team meetings. The CCSS supervisor shall sign, with name, credentials, and date, the initial service plan indicating that he has reviewed and approved the comprehensive service plan and each revision as it occurs.

I. Community support activities and relevant providers shall be clearly identified in the comprehensive service plan. The primary CSW shall coordinate the service plan without duplication by the other service providers. The CCSS comprehensive service plan shall be completed no later than 30 calendar days of the client's admission into CCSS services and specify recovery and resiliency strategies to include:

(1) the community support(s) and any other rehabilitative and treatment interventions needed for the client to achieve his specified service goals and to meet recovery and resiliency outcomes;

(2) the CCSS staff responsible for each recovery and resiliency intervention and the frequency of the planned interventions;

(3) the client's relevant diagnoses and other risk factors that place him at risk of further diagnoses;

(4) measurable goals and objectives identified by the client and family as their comprehensive service plan priorities to meet desired recovery and resiliency outcomes;

(5) a recovery/ resiliency management plan;

(6) a crisis management plan to address after-hours crisis situations including actions to be taken by client, family and natural supports;

(7) potential service plan barriers and applicable strategies; and

(8) if requested, advanced directives related to client's behavioral healthcare.

J. CCSS shall include the development of crisis plan interventions, as defined in an individual crisis plan, as a component of overall CCSS comprehensive service plan. If the client has or requests an advance directive, the crisis plan may be incorporated into the advance directive. The individualized crisis plan shall support the client and family in the management of crisis situations outside of regular business hours to develop or enhance the client's ability to make informed and independent choices.

(1) the crisis plan shall include the following requirements, which shall be formulated on admission to CCSS by the CCSS team, client, family, legal guardian and other interested parties.

(a) Risk assessment: Specify a process to assess potential risk and specify an algorithm of community resources to address by risk level that ranges from immediate (i.e. 911 or first responders) to intermediate (e.g. call to crisis line) to moderate (call for a clinic appointment). Specify a process to identify benchmarks that indicate when a crisis is appropriate reconciled.

(b) Client/family education: Provide the client and family education on community resources to be accessed during crisis situations. Each family and client shall be provided basic verbal communication techniques to help de-escalate a potential crisis situation.

(c) Internal communication: Crisis events are discussed in the CCSS team meeting to ensure all risk factors are identified and known by all team members.

(d) Face-to-face assessment: CCSS team member shall make a face-to-face visit as soon as possible, but no more than 48 hours after notification of a crisis, and complete an updated assessment for presentation to the team.

(e) Research past crisis situations for antecedent, precipitant, and consequent behaviors and discuss with the client or family to identify strategies or objectives likely to prevent crises.

(f) Identify alternative interventions that may be initiated during crisis situations, including pre-crisis or crisis instructions identified by the client or family.

(g) Incorporate client and family outcomes as benchmarks or measures of when the crisis is over.

(h) Revise crisis plan over time based on newly identified triggers and what is known to be effective.

(i) Document behavioral benchmarks (e.g., number of runs, self-injury, assaults, etc., and what worked).

(2) The negotiated crisis plan shall triage for differing levels of intensity and severity of crisis events and may identify other types of interventions that may include:

(a) residential services for stabilization;

(b) crisis respite services;

(c) wrap around services;

(d) increased family and community support specialist capacity to manage crisis situations;

(e) activation of advance directive instruction; and

(f) utilization of emergency room (ER) and other emergency response supports.

K. Every 90 days after implementation of the comprehensive service plan, the CCSS team, in partnership with the client and family, shall track and provide detailed documentation demonstrating progress made over time relating to the CCSS service goals, objectives and client/family designated recovery or resiliency outcomes. These shall be documented in the service plan updates with modifications made based upon barriers identified or redefined goals and objectives and future needs.

L. The follow up assessment shall document the current status of the client and family designated measurable recovery or resiliency functional outcomes.

M. Individualized CCSS interventions shall address the following objectives, as indicated in the assessment and comprehensive service plan:

(1) community services and resources available to support the client's achievement of his functional CCSS service goals and objectives;

(2) assistance in the development of interpersonal, community coping and functional skills (i.e., adaptation to home, school and work environments), utilizing evidence-based practices to support the skills development in the following domains:

(a) socialization skills;

(b) developmental issues as identified in the assessment;

(c) daily living skills;

(d) school and work readiness activities; and

(e) education and management of co-occurring illness;

(3) facilitating the development and eventual succession of natural supports in the workplace, housing/home, and social and school environments;

(4) provision of client and family education as appropriate regarding:

(a) self-management of symptom monitoring, illness management, and recovery and resiliency skills;

(b) relapse prevention skills;

(c) knowledge of medication and potential side effects;

(d) motivational and skill development in taking medication as prescribed;

(e) ability to identify and minimize the negative effects of symptoms which potentially interfere with the client's activities of daily living; and

(f) as indicated, supports to the client to maintain employment and school or community tenure;

(5) facilitating the client's abilities to obtain and maintain stable housing;

(6) any necessary follow-up by the CSW to determine if the services accessed have adequately met the client's needs.

N. Cultural competence shall be demonstrated by the CCSS provider through the agency's policies, procedures, training, outreach and advocacy efforts, and throughout the array of service delivery framework.

O. The CCSS provider shall demonstrate through a documented internal quality monitoring process that on average (60% or more) of CCSS services are delivered face-to-face and in vivo (where client is in the community).

P. The CSW shall provide routine follow-up to determine if the services accessed have adequately met the client's rehabilitative, recovery, resiliency, and treatment needs and document findings.

Q. CCSS shall be offered at convenient times and locations to meet the needs of the client and family; the CCSS provider will actively work to eliminate language, financial, and other barriers to service.

R. For clients and their families: The CSW shall make every effort to engage and partner with the client and family in achieving rehabilitative, recovery, and resiliency goals. Barriers to engaging the client or achievement of the service goals will be identified and utilized to amend the service plan interventions.

S. When CCSS is provided by a certified peer or family specialist, CCSS functions shall be performed with a special emphasis on recovery and resiliency values and process, such as:

(1) empowering the client to have hope for, and participate in, his own recovery;

(2) assisting the client to identify strengths and needs related to attainment of independence in terms of skills, resources and supports, and to use available strengths, resources and supports to achieve independence;

(3) assisting the client to identify and achieve his personalized recovery and resiliency goals; and

(4) promoting the client's responsibility related to illness self-management.

T. CCSS shall be subject to the limitations and coverage restrictions as defined by 8.315.6 NMAC, Comprehensive Community Support Services.

U. Behavior management skills development service (BMS) interventions are distinct and different from CCSS and shall not be considered to be CCSS.

V.Eligible providers: CCSS shall be delivered by a certified mental health agency.

(1) The agency shall be a legally recognized entity in the United States, qualified to do business in New Mexico, and shall meet standards established by the state of New Mexico or its designee, and requirements of the funding source.

(2) CCSS shall be provided in the following type of entities:

(a) federally qualified health center (FQHC);

(b) Indian health service (IHS) hospital or clinic;

(c) tribal-638 hospital or clinic;

(d) community mental health center

(e) core service agency (CSA); or

(f) an agency otherwise certified as a CCSS agency by New Mexico children, youth and families department (CYFD) or New Mexico department of health (DOH)

(3) Eligible clients who are 18 through 20 years of age may be served by an agency certified for CCSS by CYFD or DOH, as indicated.

W.Staff qualifications: Clinical services and supervision by licensed behavioral health practitioners shall be in accordance with their respective licensing board regulations.

(1) Minimum staff qualifications for the CSW:

(a) shall be a minimum of 18 years of age; and

(b) shall hold a bachelor's degree in a human service field from an accredited university and one (1) year relevant experience working with the target population; or

(c) shall hold an associate's degree in a human service field from an accredited college and have a minimum of two (2) years of experience working with the target population; or

(d) shall be a high school graduate or have a general education development (GED) and shall have a minimum of three years of experience working with the target population; or

(e) shall be certified as a certified peer specialist (CPS) or certified family specialist (CFS).

(2) Minimum staff qualifications for the CCSS program supervisor:

(a) shall hold a bachelor's degree in human services field from an a accredited university;

(b) shall have a four (4) years relevant experience working with the target population; and

(c) shall have one year demonstrated supervisory experience.

(3) Minimum staff qualifications for the clinical supervisor (The clinical supervisor and the CCSS program supervisor may be the same individual):

(a) shall be a licensed independent practitioner (i.e., psychiatrist, psychologist, LISW LPCC, LMFT, psychiatrically certified CNS) practicing within the scope of their New Mexico licensure;

(b) shall have one year documented supervisory experience; and

(c) shall provide documented clinical supervision on a regular basis to the CSW, CPS and CFS.

(4) Minimum staff qualifications for CPS:

(a) shall be a minimum of 18 years of age;

(b) shall have a minimum of high school diploma or GED;

(c) shall be self-identified as a current or former consumer of mental health or substance abuse services and have at least one year of mental health or substance abuse recovery; and

(d) shall have received certification as CPS.

(5) Minimum staff qualifications for CFS:

(a) shall be a minimum of 18 years of age;

(b) shall have a minimum of high school diploma or GED;

(c) shall have personal experience navigating any of the child-family-serving systems or advocating for family members who are involved with the behavioral health systems; shall have an understanding of how these systems operate in New Mexico;

(d) if the individual is a current or former consumer, he shall be well- grounded in his symptom self-management; and

(e) shall have received certification as a CFS.

X.Staff training requirements:

(1) The minimum CCSS staff training completed for all CSWs shall be documented in the personnel record and include:

(a) an initial training comprised of 20 hours of documented training or education drawn from an array of the following areas, to be completed within the first 90 days of employment as a CSW:

(i) clinical and psychosocial needs of the target population, including cultural competency with regard to race, religion, national origin, sex, physical disability and other community- specific characteristics;

(ii) psychotropic medications and possible side effects;

(iii) drugs of abuse and related symptoms;

(iv) crisis management;

(v) principles of recovery, resiliency and empowerment;

(vi) ethical and cultural considerations;

(vii) community resources and services, including pertinent referral criteria;

(viii) client and family support networking;

(ix) mental health or developmental disabilities code;

(x) children's code;

(xi) client and family centered practice;

(xii) behavioral management;

(xiii) treatment and discharge planning with an emphasis on recovery and crisis planning.

(b) documentation of ongoing training is required and maintained in the personnel record and comprised of 20 hours per year, commencing after the first year of hire, with content of the education based upon agency assessment of staff's needs. Such assessment shall be monitored and documented through the agency's continuous quality improvement program and annual plan.

(2) Minimum staff training requirements for supervisors shall be documented in the personnel record and include:

(a) the same 20 hours of documented training or continued education as required for the CCSS CSW;

(b) a minimum of eight hours of training specific to supervisory activities; and

(c) documentation of ongoing training comprised of 20 hours is required of a CCSS supervisor every year, commencing after the first year of hire, with content of the education based upon agency assessment of staff's needs. Such assessment shall be monitored and documented through the agency's continuous quality improvement functions.

Y.Case loads:

(1) Caseloads, on average, shall not exceed a ratio of 1:20 (one CSW to 20 clients receiving CCSS).

(2) Clients participating in medication management as the primary focus of service are not subject to the client- staff ratio.

(3) CSW caseloads, of client to staff ratio of 1:20 on average, shall be monitored and documented through the agency's internal continuous quality improvement program through defined periodic review activities such as peer chart reviews to ensure the agency is in caseload compliance. The agency will implement timely corrective action when it is identified that staff ratio averages are not in compliance.

(4) Detailed case notes document all CCSS service intervention activities and locations of services provided for each service span delivered and include the CCSS worker's name, credential and date of the service delivery.

Z.Documentation requirement:

(1) The CCSS provider shall be responsible for consistent documentation of all service delivery. Each service delivery case note shall include but not be limited to:

(a) date of service;

(b) service location;

(c) duration of service span (e.g., 1:00-2:00pm);

(d) description of the service provided with reference to the comprehensive service plan and related service goal and objective; and

(e) the client's name, and signature and credential of the individual delivering the service.

(i) All CCSS file documentation shall be legible.

(ii) All CCSS service delivery shall be consistent with the service definition requirements.

(2) CCSS comprehensive service plan and service delivery documentation shall be internally monitored through the agency's continuous quality improvement functions at least quarterly to ensure compliance with all of the certification requirements.

N.M. Admin. Code § 7.20.11.26

7.20.11.26 NMAC - Rp 7 NMAC 20.11.25, 03/29/02; A, 12/31/08