016.06.13 Ark. Code R. 014

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.13-014 - Rehabilitative Services for Persons with Mental Illness (RSPMI) Update No. 3-13 and Inpatient Psychiatric Services for Under Age 21 Update No. 1-13

Section IIRehabilitative Services for Persons with Mental Illness

228.300Record Reviews

The Division of Medical Services (DMS) of the Arkansas Department of Human Services (DHS) has contracted with ValueOptions to perform on-site inspections of care (IOC) and retrospective reviews of outpatient mental health services provided by RSPMI providers. View or print________

ValueOptions contact information. The reviews are conducted by licensed mental health professionals and are based on applicable federal and state laws, rules and professionally recognized standards of care.

228.311Purpose of the Review

The on-site inspections of care of RSPMI providers are intended to:

A. Promote RSPMI services being provided in compliance with federal and state laws, rules and professionally recognized standards of care;

B. Identify and clearly define areas of deficiency where the provision of services is not in compliance with federal and state laws, rules and professionally recognized standards of care;

C. Require provider facilities to develop and implement appropriate corrective action plans to remediate all deficiencies identified;

D. Provide accountability that corrective action plans are implemented and

E. Determine the effectiveness of implemented corrective action plans.

The review tool, process and procedures are available on the contractor's website at http://arkansas.valueoptions.com/provider/prv_forms.htm. Any amendments to the review tool will be adopted under the Arkansas Administrative Procedures Act.

228.313Information Available Upon Arrival of the IOC Team

The provider shall make the following available upon the IOC Team's arrival at the site:

A. Medical records of Arkansas Medicaid beneficiaries who are identified by the reviewer;

B. One or more knowledgeable administrative staff member(s) to assist the team;

C. The opportunity to assess direct patient care in a manner least disruptive to the actual provision of care;

D. Staff personnel records, complete with hire dates, dates of credentialing and copies of current licenses, credentials, criminal background checks and similar or related records;

E. Written policies, procedures and quality assurance committee minutes;

F. Clinical Administration, Clinical Services, Quality Assurance, Quality improvement, Utilization Review and Credentialing;

G. Program descriptions, manuals, schedules, staffing plans and evaluation studies;

H. YOQ documentation and

I. If identified as necessary and as requested, additional documents required by a provider's individual licensing board, child maltreatment checks and adult maltreatment checks.

228.314Cases Chosen for Review

The contractor will review twenty (20) randomly selected cases during the IOC review. If a provider has fewer than 20 open cases, all cases shall be reviewed.

The review period shall be specified in the provider notification letter. The list of cases to be reviewed shall be given to the provider upon arrival or chosen by the IOC Team from a list for the provider site. The components of the records required for review include:

1. All required assessments, including SED/SMI Certifications where applicable;

2. Master treatment plan and periodic reviews of master treatment plan;

3. Progress notes, including physician notes;

4. Physician orders and lab results and

5. Copies of records. The reviewer shall retain a copy of any record reviewed.

228.316Beneficiary/Family Interviews

The provider is required to arrange interviews of Medicaid beneficiaries and family members as requested by the IOC team, preferably with the beneficiaries whose records are selected for review. If a beneficiary whose records are chosen for review is not available, then the interviews shall be conducted with a beneficiary on-site whose records are not scheduled for review. Beneficiaries and family members may be interviewed on-site, by telephone conference or both.

228.318Written Reports and Follow-Up Procedures

The contractor shall provide a written report of the IOC team's findings to the provider, DMS Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within 14 calendar days from the last day of on-site inspection. The written report shall clearly identify any area of deficiency and required submission of a corrective action plan.

The contractor shall provide a notification of either acceptance or requirement of directed correction to the provider, DMS Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within 14 calendar days of receiving a proposed corrective action plan and shall monitor corrective actions to ensure the plan is implemented and results in compliance.

All IOC reviews are subject to policy regarding Administrative Remedies and Sanctions (Section 150.000), Administrative Reconsideration and Appeals (Section 160.000) and Provider Due Process (Section 190.000). DMS will not voluntarily publish the results of the IOC review until the provider has exhausted all administrative remedies. Administrative remedies are exhausted if the provider does not seek a review or appeal within the time period permitted by law or rule.

228.320DMS/DBHS Work Group Reports and Recommendations

The DMS/DBHS Work Group (comprised of representatives from the Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the Division of Behavioral Health Services, the Office of Quality Assurance, the utilization review agency, as well as other units or divisions as required) will meet monthly to discuss IOC reports. When warranted by IOC results, the DMS/DBHS Work Group shall recommend to the DHS Review Team one or more actions in Section 228.322. Recommendations shall be in writing and shall include supporting documentation.

If a deficiency related to safety or potential risk to the beneficiary or others is found, then the utilization review agency shall immediately report this to the DMS Director (or the Director's designee).

228.321Corrective Action Plans

The provider must submit a Corrective Action Plan designed to correct any deficiency noted in the written report of the IOC. The provider must submit the Corrective Action Plan to the contracted utilization review agency within 30 calendar days of the date of the written report. The contractor shall review the Corrective Action Plan and forward it, with recommendations, to the DMS Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General and Division of Behavioral Health Services.

After acceptance of the Corrective Action Plan, the utilization review agency will monitor the implementation and effectiveness of the Corrective Action Plan via on-site review. DMS, its contractor(s) or both may conduct a desk review of beneficiary records. The desk review will be site-specific and not by organization. If it is determined that the provider has failed to meet the conditions of participation, DMS will determine if sanctions are warranted.

228.322Actions

Actions that may be taken following an inspection of care review include, but are not limited to:

A. Decertification of any beneficiary determined to not meet medical necessity criteria for outpatient mental health services;

B. Decertification of any provider determined to be noncompliant with the Division of Behavioral Health Services provider certification rules;

C. On-site monitoring by the utilization review agency to verify the implementation and effectiveness of corrective actions;

D. The contractor may recommend, and DMS may require, follow-up inspections of care and/or desk reviews. Follow-up inspections may review the issues addressed by the Corrective Action Plans or may be a complete re-inspection of care, at the sole discretion of the Division of Medical Services;

E. Review and revision of the Corrective Action Plan;

F. Review by the Arkansas Office of Medicaid Inspector General;

G. Formulation of an emergency transition plan for beneficiaries including those in custody of DCFS and DYS;

H. Suspension of provider referrals;

I. Placement in high priority monitoring;

J. Mandatory monthly staff training by the utilization review agency;

K. Provider requirement for one of the following staff members to attend a DMS/DBHS monthly work group meeting: Clinical Director/Designee (at least a master's level mental health professional) or Executive Officer;

L. Recoupment for services that are not medically necessary or that fail to meet professionally recognized standards for health care or

M. Any sanction identified in Section 152.000.

Provider Manual Update Transmittal RSPMI-3-13

TOC required

221.600Inspection of Care ( 42 CFR Part 456, Subpart I)

All in-state inpatient psychiatric providers will receive an Inspection of Care (IOC) consistent with the Code of Federal Regulations, 42 CFR §§ 456.600 through 456.614. An IOC will be performed by an independent contractor or team annually, at a minimum. There must be a sufficient number of teams within the State that an on-site IOC can be made at appropriate intervals in each facility.

The inpatient psychiatric provider will be notified of the time of the inspection no more than forty-eight (48) hours before the scheduled arrival of the inspection team. The inspection must include:

A. Personal contact and observation of each Medicaid recipient in the inpatient psychiatric facility and

B. Review of each beneficiary's medical record.

See Section 241.000 for more information regarding inspections of care.

241.000On-Site Inspection of Care (IOC)

The Department of Human Services (DHS) requires the contractor to conduct annual On-Site Inspections of Care for acute inpatient and residential services provided to Medicaid beneficiaries under age 21.

The inpatient psychiatric provider will be notified of the time of the inspection no more than forty-eight (48) hours before the schedule arrival of the inspection team.

241.100Purpose of the Review

The on-site inspections of care of Inpatient Psychiatric Services for Under Age 21 providers are intended to:

A. Promote Inpatient Psychiatric Services for Under Age 21 that are provided in compliance with federal and state laws, rules and professionally recognized standards of care;

B. Identify and clearly define areas of deficiency where the provision of services is not in compliance with federal and state laws, rules and professionally recognized standards of care;

C. Require provider facilities to develop and implement appropriate corrective action plans to remediate all deficiencies identified;

D. Provide accountability that corrective action plans are implemented and

E. Determine the effectiveness of implemented corrective action plans.

241.200Information Available Upon Arrival of the IOC Team

The provider shall make the following available upon the IOC Team's arrival at the site:

A. Medical records of all Arkansas Medicaid beneficiaries;

B. One or more knowledgeable administrative staff member(s) to assist the team;

C. The opportunity to assess direct patient care in a manner least disruptive to the actual provision of care;

D. Staff personnel records, complete with hire dates, dates of credentialing and copies of current licenses, credentials, criminal background checks, and similar or related records;

E. Written policies, procedures and quality assurance committee minutes;

F. Clinical Administrative, Clinical Services, Quality Assurance, Quality improvement, Utilization Review and Credentialing;

G. Program descriptions, manuals, schedules, staffing plans and evaluation studies and

H. If identified as necessary and as requested, additional documents required by a provider's individual licensing board, child maltreatment checks and adult maltreatment checks.

241.300Written Reports and Follow Up Procedures

241.400Resident Interviews

Each resident who is a Medicaid beneficiary under age 21 must be interviewed by the IOC Team. It is the responsibility of the provider to devise a system that allows access to the residents in a way that is minimally disruptive to the treatment process.

If a Medicaid beneficiary will be discharged during the review, the provider is responsible for arranging for the resident to be interviewed prior to discharge.

Interviews should be conducted in a place and manner that respects the resident's right to privacy. The provider must provide private interview space for the interviews.

241.500DMS/DBHS Work Group Reports and Recommendations

The DMS/DBHS Work Group (comprised of representatives from the Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the Division of Behavioral Health Services, the Office of Quality Assurance, the utilization review agency, as well as other units or divisions as required) will meet monthly to discuss IOC reports. When warranted by IOC results, the DMS/DBHS Work Group shall recommend to the DHS Review Team one or more actions in Section 241.700. Recommendations shall be in writing and shall include supporting documentation.

241.600Corrective Action Plans

The provider must submit a Corrective Action Plan designed to correct any deficiency noted in the written report of the IOC. The provider must submit the Corrective Action Plan to the contracted utilization review agency within 14 calendar days of the date of the written report. The contractor shall review the Corrective Action Plan and forward it, with recommendations, to the DMS Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General and Division of Behavioral Health Services.

241.700Actions