C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.07

Current through 2024-44, October 30, 2024

Subsection 144-101-II-107.07 - POLICIES AND PROCEDURES

107.07-01Licensing, Certification, and Accreditation

A. All PRTFs must maintain current CMS certification and state licensure as administered by the Department of Health and Human Services.

B. All PRTFs must maintain current accreditation by one of the following entities:

1. The Joint Commission on Accreditation of Healthcare Organizations, or

2. The Commission on Accreditation of Rehabilitation Facilities, or

3. The Council on Accreditation

C. All accreditation reports, with findings & remediation, must be submitted to the Maine Center for Disease Control and Prevention (CDC).

107.07-02Enrollment

A. All PRTFs must maintain enrollment with MaineCare according to the terms of Chapter I Section 1 of the MaineCare Benefits Manual.

B. All PRTFs, upon enrollment with MaineCare, must attest, in writing, that the facility is in compliance with CMS's standards governing the use of restraint and seclusion. This attestation must be signed by the facility medical director.

107.07-03Qualified Providers

PRTF Programs must have appropriately credentialed staff, as described in the roles below, to satisfy the minimum staffing requirement for covered services described in Appendix D. Roles and qualified providers are described as follows:

A. Medical Director - is responsible for overall program implementation, individualized treatment planning, interventions, and key decision-making regarding an individual's treatment. The medical director must be licensed to practice in the State of Maine and be held by at least one of the following:

1. Board-eligible or board-certified psychiatrist, or

2. Licensed Psychologist AND a physician licensed to practice medicine or osteopathy practicing as co-directors to fulfill the above medical director duties.

B. Administrator- is responsible for business oriented decisions regarding the PRTF. The Program Administrator must be at least 21 years of age, have a Bachelor's Degree from an accredited school and two years of experience in the management and supervision of personnel and children's care facilities, or comparable training or experience. Duties include, but are not limited to: oversight of day-to-day operations, scheduling, ensuring staff training, and maintaining the physical plant.

C. Clinical Coordinator - is responsible for the oversight of the implementation of a member's clinical interventions. The Clinical Coordinator will provide supervision, training, and clinical support staff clinician(s). Additionally, the Clinical Coordinator must serve on the member's team to develop the ITP and must facilitate the member's discharge and transition to aid in ensuring a successful transition from the PRTF. A clinical coordinator must be held by one of the following:

1. A LCSW with at least two years of experience in the diagnosis and treatment of children with serious behavioral health conditions (experience may include experience gained while obtaining clinical licensure status as an LMSW-CC), or

2. A Licensed Psychologist by the State of Maine.

D. Staff Clinician - is responsible for the implementation of the clinical services offered by the PRTF. The clinical services include at minimum a mixture of individual, group, and family therapy provided at the levels outlined in Section.

A Staff Clinician may be any of the following:

1. A fully Licensed Clinical Social Worker (LCSW);

2. A fully Licensed Clinical Professional Counselor (LCPC); or

3. A fully Licensed Marriage and Family Therapist (LMFT).

E. Nurse - is responsible for the support of the behavioral health, wellness, and medical needs of a member receiving PRTF services. There must be a nurse present in the PRTF 24 hours per day, 365 days per year. The Nurse must be either:

1. A psychiatric mental health nurse practitioner or

2. A registered nurse with at least two years' experience in the treatment of children with serious behavioral health conditions.

F. Nurse Support - is responsible for supporting the Nurse in duties allowable by the scope of their licensure including the administration of medications as well as assistance with personal care activities. The Nurse Support must be either:

1. A Certified Nursing Assistant-Medication Aide (C.N.A.-M) listed on the Maine C.N.A. Registry with no disqualifying annotations and two years of experience as a C.N.A.-M. responsible for the administration of medications as well as assistance with personal care activities; or

2. A Licensed Practical Nurse (LPN) with at least two years' experience in the treatment of children with serious behavioral health conditions.

G. Direct Care Staff - is responsible for the daily implementation of the direct program. Direct support staff must be present 24 hours per day, 365 days per year. Direct care staff are critical staff required to maintain structure and safety within the program, and to implement a member's individualized programming. A Direct Care Staff must hold current Behavioral Health Professional certification (BHPs) with at least two years' experience working as a BHP with a related population.

107.07-04Treatment Planning Team

The Treatment Plan must be developed by an interdisciplinary team within the PRTF. This team may also include any Ancillary service providers as medically indicated.

The member must be involved in the planning process to the greatest degree possible. The member's parent or guardian (when applicable) must be involved in the planning process. The team, based on education and experience (including competence in child psychiatry) must be capable of:

A. Assessing the member's immediate and long-term therapeutic needs, developmental priorities, and personal strengths and liabilities;

B. Assessing the potential resources of the member's family;

C. Setting treatment objectives; and

D. Prescribing therapeutic modalities to achieve the plan's objectives.

E. The team must include:

1. The Medical Director;

2. Clinical Coordinator; and

3. One of the following:

a. Registered Nurse with specialized training or one year's experience in treating mentally ill individuals; OR

b. A psychologist who has a master's degree in clinical psychology or who has been certified by the State or by the State psychological association.

107.07-05Supervision Requirements

A. The facility must assign a supervisor to each staff member based on the staff member's roles and responsibilities.

1. BHPs must be supervised by a Staff Clinician (LCSW, LCPC or LMFT) for the purposes of treatment plan implementation.

2. RNs must be supervised by a physician or nurse practitioner.

3. LPNs and CNA-Ms must be supervised by RNs or nurse practitioners.

4. Staff Clinicians will be supervised by the Clinical Coordinator.

5. The facility Administrator will provide supervision regarding any administrative or operational issues.

B. Supervisors must meet with assigned staff at least one hour per week, either individually or in a group format. The supervisory sessions must be documented. At least one hour per month must be individual supervision.

107.07-06Required Disclosures and Informed Consents

A. At the time of admission, the facility must:

1. Inform the incoming member and, in the case of a minor, the member's parents or legal guardians, of the facility's policy regarding the use of restraint or seclusion during an emergency safety situation that may occur while the member is in the program;

2. Communicate its restraint and seclusion policy in a language that the member and his or her parents or legal guardians understand and when necessary, the facility must provide interpreters or translators;

3. Obtain an acknowledgement, in writing, from the member, or in the case of a minor, from the parent or legal guardian that he or she (or they) have been informed of and have received the facility's policy on the use of restraint or seclusion during an emergency safety situation. Staff must file this acknowledgement in the member's record;

4. Provide a copy of the facility policy on the use of restraint or seclusion during an emergency situation to the member and in the case of a minor, to the member's parents or legal guardians; and

5. Provide contact information, including the phone number and mailing address, for the State Protection and Advocacy Organization.

6. Advise the member and the member's parent or legal guardians (as applicable) in understandable terms of the member's rights pursuant to the Rights of Recipients of Mental Health Services Who are Children in Need of Treatment, 14-172 C.M.R. ch. 1, and provide a copy of these rights to the member and the member's parents or legal guardians (as applicable). For members 18 years of age and older or who are emancipated minors, also advise the member and the member's legal guardian (as applicable) in understandable terms of the member's rights pursuant to the Rights of Recipients of Mental Health Services, 14-193 C.M.R. ch. 1, and provide a copy of these rights to the member and the member's legal guardian (as applicable). The member's parent/guardian must sign acknowledgement that the member's rights have been reviewed and the publication has been received.

7. Acquire informed consent for services from the member and his or her parent/guardian, when applicable. Informed consent means sharing, in writing, a description of the services being provided, service goals, service expectations, disclosure of risks and benefits and the roles and the responsibilities of the Provider and the family toward meeting service goals and expectations. Proof of Informed Consent will be documented, and signed by the Provider and the parent/guardian. Additional requirements are as follows:

a. The Provider shall document in the member's plan the treatment or service delivery method or model for each service provided to a client, indicating full disclosure to the child, youth, parent and guardian of the risks and benefits of the method or model and alternative methods or models.

b. The Provider shall review with the member and his or her parent/guardian, when applicable upon intake, its role and responsibility as a mandated reporter of abuse and/or neglect pursuant to 22 M.R.S. §3477 and 22 M.R.S. §4011-A and document this disclosure within the client record.

c. The Provider shall secure consent from the member and his or her parent/guardian, when applicable, to use the disclosed methods of intervention to treat the identified areas of need in the member's Individualized Treatment Plan. The Provider shall document the consent within the member's service record.

d. The Provider shall consider available Evidence-Based Practices and consider using such practices when clinically appropriate for the member's condition. Provider staff shall understand and consider empirical evidence, clinical expertise, and the values and preferences of families and youth in implementing treatments.

e. The Provider shall clearly document the target symptoms of the treatment, how they will be measured and improvement determined.

107.07-07Provider Documentation Requirements and Member Record

A. Assessment and Evaluation

1. The Provider shall conduct an initial assessment and evaluation in accordance with §107.5-1.A within seventy-two (72) hours of admission, with a full comprehensive assessment and evaluation completed within fourteen (14) days of admission to the facility.

2. The assessment and evaluation must consist of direct and indirect encounters. Direct encounter shall include a psychological assessment and medical evaluation (to include medication review) directly with the member. Indirect encounters consist of record review and may include conversations with the member's parent/guardian (as applicable), teachers, other professionals involved, and natural supports (as applicable). Direct and indirect encounters must inform the medical, psychological, social, behavioral and developmental aspects of the member's situation, and reflects the need for inpatient psychiatric care. Assessment and evaluation will be conducted to the extent necessary to determine the member's current disposition and treatment recommendations.

3. Documents submitted to the PRTF by the CCON team in accordance with 107.04-02.B may be used to satisfy parts of the documentation requirements for the initial and/or full comprehensive assessment.

4. The assessment must contain documentation of the member's current status, the reason for referral to the service, 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, permanency/housing, financial, vocational, educational, leisure/recreation, transition needs (when applicable), potential need for crisis intervention, physical/sexual and emotional abuse (including trauma history). The assessment must review cultural needs including issues of literacy and English and language barriers, and the need for interpretation and other needed services. The assessment should also take into consideration the member's expressed desires.

5. The assessment shall 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. The assessment shall address physical and environmental barriers to treatment and current medications. Domains addressed must be clinically pertinent to the service being provided.

6. For a member with substance abuse, 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.

7. The provider will review the member's CANS assessment as a part of the full comprehensive assessment and will review the CANS ongoing in coordination with the member's treatment plan intervals described below in 107.07-07.B.2.

8. The assessment must be summarized to include a clinical formulation that summarizes the strengths and needs of the member and family (when applicable) that informs treatment, service intensity, and recommendations for service. The formulation will include intended intervention modalities. The assessment must include a diagnosis using the most recent version of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) or the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (DC 0-5), as appropriate. The assessment must be signed, credentialed and dated by the appropriate personnel conducting the assessment.

B. Treatment Plan

1. All members must have an active Treatment Plan, which must:

a. Be developed and implemented in a timely manner; an initial treatment plan must be developed and implemented within 72 hours of admission while a more comprehensive treatment plan must be developed and implemented within 14 days of admission.

b. Be developed by the Treatment Planning Team as described in Section 107.07-04 of this policy;

c. Be developed based on the Assessment completed in accordance with Section 107.07-07.A;

d. Reflect the needs and strengths identified in the member's CANS assessment;

e. Be designed to achieve the member's discharge from inpatient status at the earliest possible time;

f. Describe the functional level of the member;

g. Prescribe an integrated program of therapies, activities, and experiences designed to meet the member's treatment objectives, and include any orders for:

i. Medications; and

ii. Treatments and Therapy; and

iii. Social services; and

iv. Special procedures recommended for the health and safety of the member.

h. Include plans for continuing care, including review and modification of the Treatment Plan;

i. Include clear short and long-term goals and treatment objectives that are specific, measurable and are time limited to include target dates, and include the frequency, intensity, and duration of each described intervention;

j. Describe the rationale for utilizing the prescribed treatment and services;

k. Specify treatment and service responsibility, including both staff and member responsibilities in meeting the member's treatment objectives;

l. Be developed in consultation with the member, the member's parents or legal guardians (where appropriate), or others who will be caring for the member following discharge from the PRTF, including but not limited to family, school officials, and community service providers; and

m. Include a list of needs identified in the assessment process that are not addressed in the Treatment Plan and an explanation of why the identified needs are not addressed;

n. Include a discharge plan which must:

i. Identify individualized discharge criteria that are related to the goals and objectives described in the Treatment Plan;

ii. Identify the individuals responsible for implementing the plan, including staff who can assist the member in making referrals for other resources;

iii. Identify natural and other supports necessary for the member and family to maintain the safety and well-being of the member, and to sustain progress made during the course of treatment;

iv. Be reviewed by the treatment planning team every review meeting and no less than every thirty (30) days;

v. Identify any service recommendations and reasons for recommending that service;

vi. Address behavior planning, including interventions and resources necessary to carry out the plan without supports; and

vii. Contain a list of resources tailored to the member's individualized needs and situation necessary for parents, guardians, and natural supports to increase the likelihood of a successful and sustainable discharge.

2. The Treatment Plan must:

a. Be entered in the member's medical record upon initial completion and upon any alteration;

b. Consider any additional assessments in the development of the Treatment Plan;

c. Be reviewed every 30 days, or sooner as clinically indicated by the treatment planning team to:

i. Determine that services being provided are required on an inpatient basis and

ii. Recommend changes in the plan as indicated by the member's overall adjustment as an inpatient;

d. Document plan approval as shown by the signature of the member (when applicable), parent/guardian (when applicable), any staff with credential(s) involved in creating the treatment plan, and the medical director with credential(s). All signatures will be dated at the time of signature. In extenuating circumstances, verbal approval by the parent/guardian may be obtained in lieu of signature which must be documented in the member record with the staff member who received the approval (and signature/date), and the reason why signature could not be obtained;

e. Be provided to the member and the member's parent/guardian (if applicable) within five (5) working days from the date of final plan approval.

C. Results of any assessments conducted must be included in the member record.

D. Progress Notes:

1. Providers must maintain written progress notes for each service discipline provided by the PRTF, in chronological order. There must be one milieu note per shift and all medication/therapy services (as defined under covered services Section 107.05-01.D) must be documented individually. 2. 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 of the service, and the progress the member is making toward attaining the goals or outcomes identified in the Treatment Plan.

107.07-08Additional Treatment Standards

In addition to the requirements detailed above, providers must follow all the Treatment Standards described below:

A. Family Centered Practice

1. The treatment shall be tailored to return the member to a family when possible and to a community. The Provider shall include and support family members as extensively as possible from the beginning of the admissions process through discharge, transition and aftercare. Families shall be full partners in all aspects of the member's treatment, barring any limitations on participation. The focus of treatment shall be on helping families acquire the skills necessary to solve problems, meet needs, and attain desired goals. Individualized Family Therapy goals shall be included in the Treatment Plan.

2. It is the responsibility of the PRTF Provider to work with the member and his or her family to continually pursue effective levels of engagement with families, which include extended family members and natural/informal supports.

3. Planning with families shall make every effort to mobilize both informal and formal resources in support of families.Informal/natural supports include identification of the member and family's personal resources including their specific skills, capacities or attributes. The PRTF staff shall work as a part of the team in exploring these resources for families.

4. The Treatment Planning Team shall address family readiness and the specific supports needed to ensure placement stability and success.

5. The PRTF Provider will have a family-centered policy including the following components, and will maintain records documenting training of all staff in the policy. The family-centered policy shall:

a. Ensure family involvement in all aspects of the program (medical appointments, school communication, daily living, daily programming, etc.);

b. Illustrate family's right to visitation and treatment participation in the PRTF setting;

c. Expectations of family treatment & daily living participation; and

d. Define exceptions when limits are placed on family participation, including but not limited to protect the member's welfare, as a result of a protection from abuse or other court order, or a member age 18 years and older or an emancipated minor who does not consent to family participation.

6. The PRTF Provider will provide parent with supports and treatment interventions including psycho-educational, preventive, and supportive services as indicated by assessments. The focus will be on enhancing the parents' coping mechanisms and providing them with the tools to move towards self-sufficiency through involvement in normal parenting activities and participating in positive behavioral supports and management techniques. The program will actively engage parental involvement and provide ongoing opportunities for parent to engage within the daily life activities of the member in the PRTF setting. Sibling involvement in treatment, visitation, and shared activities should be a part of the family treatment.

7. Documentation of parental presence and participation in treatment and typical daily parenting activities, as well as sibling involvement shall be maintained in the member's record. It is the responsibility of the PRTF Provider to document its attempts and strategies for family engagement and to overcome barriers to family participation in treatment.

B. Behavioral Support and Management Standards

The PRTF shall practice positive behavior support strategies. Interventions are designed to modify member behavior should be individualized, respectful, developmentally appropriate, related to the issue at hand, flexibly applied, and designed to help the child master age and developmentally appropriate skills.

1. All individualized positive behavior support plans shall be based on a Functional Behavioral Assessment (FBA) by a qualified clinician or Board Certified Behavioral Analyst, with specific training in FBAs.

2. All individual positive behavioral support plans shall be monitored, reviewed, and adjusted on an ongoing basis based on the member's behavior and response to treatment. Review shall not be limited solely to the required 30-day Treatment Plan review.

a. Each behavioral plan shall include strategies that encourage the use of adaptive and pro-social behaviors with the goal of preventing aggressive behavior and de-escalating behavior before it becomes necessary to use more restrictive measures. The member's trauma history shall be considered in determining the most effective means to de-escalate behavior.

3. Behavioral interventions shall not be used as punishment, a form of discipline, or for the convenience of staff.

4. All staff will be trained in appropriate de-escalation techniques. Staff shall be provided ongoing trainings and supervision around their use to ensure fidelity to the model chosen by the provider.

C. Any use of outside resources to intervene with psychiatric or behavioral occurrences must be reviewed and approved by the Medical Director prior to the intervention. The approval, including rationale, must be documented in the member record. This includes, but is not limited to referring a member to psychiatric hospitalization and requesting police intervention.

107.07-09Education, Training Requirements and Background Checks

A. Required Background checks:

The following is required for all staff working in a PRTF;

1. Background checks must be completed in accordance with the facility's licensing requirement 10-144 C.M.R Ch. 36;

2. Additionally, all background checks must be performed at hire and every two years, at minimum, thereafter;

3. Any potentially adverse findings must be vetted by the provider and documented in the staff's personnel record.

B. The facility must require staff to have initial and ongoing training, education and demonstrated knowledge of:

1. Techniques to identify staff and member behaviors, events, and environmental factors that may trigger emergency safety situations;

2. The use of non-physical intervention skills, such as de-escalation, mediation conflict resolution, active listening, and verbal and observational methods, to prevent emergency safety situations; and

3. The safe use of restraint and the safe use of seclusion, including the ability to recognize and respond to signs of physical distress in members who are restrained or in seclusion.

C. Certification in the use of cardiopulmonary resuscitation (CPR), including periodic recertification, is required. Certification and staff competency in the use of CPR must be reviewed on an annual basis.

D. First aid certification is required. Certification must be reviewed on an annual basis.

E. Staff trainings must be provided by individuals who are qualified by education, training and experience to provide such training.

F. Staff training must include training exercises in which staff members successfully demonstrate, in practice, the techniques they have learned for managing emergency safety situations.

G. Staff must be trained and demonstrate competency before participating in an emergency safety intervention.

H. Staff must demonstrate their competencies and proficiencies in the skills described in subsection (B) above every six months.

I. The facility must document in the staff personnel records that the training and demonstration of competency were successfully completed. Documentation must include the date training was completed and the name of persons certifying the completion of training.

J. All training programs and materials used by the facility must be available for review by CMS, the Office of MaineCare Services, Maine CDC, and the Office for Child and Family Services.

107.07-10Reporting of Serious Occurrences

A. PRTFs must report each Serious Occurrence to:

1. The Office of MaineCare Services;

2. The Office of Child and Family Services (OCFS);

3. Maine CDC; and

4. The Department's State Protection and Advocacy Agency.

B. Reports must be made by the close of business the next business day following a Serious Occurrence.

C. The report must include the name of the member involved in the serious occurrence, a description of the occurrence, and the name, street address, and telephone number of the facility.

D. If the member involved is a minor, the facility must notify the member's parents or legal guardians as soon as possible, and in no case no later than 24 hours after a Serious Occurrence.

E. Staff must document in the member's record that the serious occurrence was reported to the agencies as required in this provision, including the name of the person to whom the incident was reported.

F. A copy of the report must be maintained in the member's record, as well as in the incident and accident report logs maintained by the facility.

G. In the event of a member death, the following additional reporting and documentation must be made:

1. Facilities must report the death of any member to the Centers for Medicare and Medicaid Services (CMS) regional office no later than close of business the next business day after the member's death; and

2. Staff must document in the member's record that the death was reported to the CMS regional office.

H. In certain circumstances, additional reports must be made to Child Protective services for youth under 18 years old per 22 M.R.S. §4011-A, or Adult Protective Services for individuals 18 years and older per 22 M.R.S. §3477.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.07