007.01 Introduction Residential treatment services are available to clients age 20 or younger when the client participates in a HEALTH CHECK (EPSDT) screen, the treatment is clinically necessary, and the need for care at this level has been identified on the Initial Diagnostic Interview.
Residential treatment services must be family-centered, culturally competent, community based, and developmentally appropriate.
Providers must encourage family members to be involved in the assessment of the client, the development of the treatment plan, and all aspects of the client's treatment unless prohibited by the client, through legal action, or because of federal confidentiality laws.
Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings.
The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends.
Residential treatment services for children covered by Medicaid include residential treatment for children age 20 and younger who are eligible for Medicaid. These regulations also cover children age 18 or younger who are wards of the Department.
Residential treatment services must be provided under the direction of a supervising practitioner as designated in 471 NAC 32-001.06.
007.02 Residential Treatment for Children The Department's philosophy is that all care provided to clients must be provided at the least restrictive and most appropriate level of care. Care must be family-centered, community-based, culturally competent, and developmentally appropriate. Medicaid will cover more restrictive levels of care only when all other resources have been explored and deemed to be inappropriate. If hospital-based inpatient care is deemed appropriate, see 471 NAC 32-008.
Residential treatment center services are clinically necessary services provided to a client who requires professional care and highly structured 24-hour awake care at a greater intensity than that available at the treatment group home and foster home levels.
In keeping with the philosophy that children are better served in more family-like settings, the total number of approved beds for a residential treatment center will not exceed two units of up to 20 beds each, and the center must provide a home-like atmosphere commensurate with the size and scope of the program. Exception: A state owned and operated residential treatment center may exceed two units provided that each unit has no more than 20 beds each. When a state owned and operated residential treatment center exceeds two 20 bed units, children may be placed there for treatment only if all other in state residential treatment center providers have declined to serve the child within a reasonable period of time. This exception shall expire two years after the effective date of the exception.
007.03 Standards for Participation for Residential Treatment Centers 32-007.03AProvider Agreement: A provider of residential treatment center services shall complete Form MC-19 or Form MC-20, "Medical Assistance Provider Agreement," and submit the completed form to the Department for approval. The Department is the sole determiner of which centers are approved for participation in this program. The facility will be advised in writing when its participation is approved. The provider shall submit the following with Form MC-19 or Form MC-20:
1. A written overview of the program's philosophy and objectives of treating children and youth including: a. A description of each available service;b. A list of treatment modalities available and the capacity for individualized treatment planning;c. A statement of the qualification, education, and experience of each staff member providing treatment and the therapy service each provides;d. A schedule covering the total number of hours that the program operates;e. The Department approved cost reporting document; andf. The target population.2. Facility/Program Changes: A residential treatment facility shall report to the HHS Licensing Unit and to the Medicaid Division any major changes in its program and/or facilities, before the change is made. The HHS Licensing Unit will determine whether the license must be modified or reissued. Any change in the capacity of a licensed facility requires that a license be reissued showing the number of youth who can be cared for under the new plan. The Medicaid Division will determine if the facility maintains appropriate therapeutic programming for NMAP.3. Confirmation that the staffing standards in 471 NAC 32-007.04D are met.4. Current licensure as a child caring agency. If the child caring agency license is denied or revoked, this requirement is not met; therefore, the provider is not eligible for participation. Licensure as a child caring agency is not required for hospital-based services.5. Copy of JCAHO, CARF, AOA, or COA accreditation certificate.32-007.03BPlace of Service: Residential treatment services may be provided in the following locations when the requirements listed in 471 NAC 32-007.04B have been met:1. A residential type community-based treatment facility appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health; or2. A hospital that is licensed as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, is accredited by the Joint Commission on Accreditation of Health-Care Organizations (JCAHO) or the American Osteopathic Association (AOA), meets the requirements for participation in Medicare, and has a utilization review plan applicable to all Medicaid clients in effect.32-007.03B1Facility Requirements: In order to be approved as a provider of Residential Treatment Services, the program must insure that the following requirements are met:1. Adequate access to recreational facilities for both indoor and outdoor activities, commensurate with the size and scope of the program. (This may be provided on-site or through contract);2. Separation of the treatment group home program from inpatient hospital operations, including laboratory, radiology, surgery, patient rooms, dining areas, patient lounges, etc.;3. The doors to the unit and to the outside may be locked from the outside to allow for safety, but they must be unlocked or easily unlocked from the inside;4. Kitchen and laundry facilities easily accessible to the unit;5. Staff offices must be located on the unit;6. Secure storage for medications and clinical charts must be on the unit;7. A general living or lounge area must be on the unit;8. A home-like atmosphere;9. Program is staffed by awake personnel 24 hours per day; and10. Other requirements as listed in this chapter. 32-007.03COther Requirements: The residential treatment center must - 1. Be in conformance with all applicable federal, state, and local laws;2. Meet the program and operational definitions and criteria contained in the Nebraska HHS Finance and Support Manual;3. Meet the definition of a residential treatment center as stated in 471 NAC 32007.02;4. Maintain documentation in each client's treatment record that provides a full and complete picture of the nature and quality of all services provided (see 471 NAC 32-007.07);5. Have the capacity to meet the needs of the individual Medicaid client either through employment of or contracts with appropriate staff (see 471 NAC 32-007.04D);6. Be licensed by the Department under the minimum regulations for child caring agencies. If the child caring agency license is denied or revoked, this requirement is not met; therefore, the provider is not eligible for participation (See 474 NAC 6-005, Licensing Group Homes and Child Caring and Placing Agencies and Nebraska State Statute 81-505.01, 1983.) Hospitals are not required to be licensed as a child caring agency. 32-007.03DAccreditation: The residential treatment center must have -1. Be accredited by JCAHO, CARF, COA or AOA; or2. Include a copy of the accreditation certificate with the initial and updated enrollment materials and forward a copy of all survey visit reports and provider responses. If the most recent survey required a plan of corrections, the plan must also be submitted; or
Agencies accredited through these accrediting bodies are eligible for NMAP reimbursement of treatment and maintenance (room and board) costs and must maintain accreditation in order to qualify as a residential treatment services provider. Treatment and maintenance costs are reimbursed as a per diem rate. See NMAP Fee Schedule, (Appendix 471-000-532).
Interpretive Note: Agencies that have applied for accreditation with one of these entities may be enrolled on a provisional status and receive reimbursement for treatment only.
32-007.03EStaffing Standards for Participation: A residential treatment center for children shall meet the following standards to participate in NMAP: 1. The center's staff must include - a. An executive director who has a sufficient background and experience to administered a treatment program;b. A program director who meets the requirements of a clinical staff person in 471 NAC 32-001.04 and is operating within his/her scope of practice, with two years of professional experience in the treatment of children and adolescents with mental illnesses or emotional disturbances;c. Clinical staff professionals (who meet the requirements of a clinical staff person in 471 NAC 32-001.04) who provide psychotherapy and counseling, including face-to-face individual, family, and group counseling, who are directed by the supervising practitioner;d. Child care staff who are age 21 or older and have specialized training and experience sufficient to equip them for their duties and are under the supervision of the program director. 75% of child care staff must have a bachelor's degree or five years of experience in human services field;e. Supervisory staff will meet the standards outlined in 471 NAC 32-001.04 and four years experience in a related field.f. Training must be approved by the Department and must meet the minimum standards for pre-service and on-going training in licensing requirements;g. A supervising practitioner who is a licensed psychologist, physician, or doctor or osteopathy;h. Each facility shall show by employment records or on a contractual basis the ability to provide the needed services as indicated by the scope of the program, including necessary medical/psychiatric evaluations, and access to emergency care. The clinical services of a psychologist, psychiatrist, and physician may be obtained on a consultation basis; andj. Educators, when on-site education is provided. Services must be provided in accordance with applicable state and federal laws. NMAP does not make payment for educational services;2. Volunteer services may be used to augment and assist other staff in carrying out program or treatment plans. Volunteers who work directly with youth must receive orientation training regarding the program, staff, and children of the center and the functions that volunteers can perform. However, the services performed by a volunteer cannot be substituted for necessary medical/psychiatric and therapeutic patient/staff ratios;3. Staff must be mentally and physically capable of performing assigned duties and demonstrate basic professional competencies as required by the job description. Every staff member shall have an annual physical examination and obtain a statement that no medical condition exists that may interfere with his/her ability to perform assigned duties. This is addressed in policy governing licensure regulations. All applicable state, federal, and local laws must be followed.4. All program personnel having access to clients, including full-time, part-time, paid, volunteer or contract, must be checked through the Central Registry, Adult Protective Services Registry, and the motor vehicle records. A criminal check must also be done through a law enforcement agency. A person whose name appears on any of the above registries must not have access to clients.5. The ratio of professional staff to children is dependent on the needs of the children and commensurate with the size and scope of the program, however - a. The minimum ratio of Master's level therapists providing direct face-to-face therapy services to children and families must be 1:10;b. The supervising practitioner must be available to spend approximately 45 minutes (or more often as clinically necessary) per month, per client, in the facility as a minimum. This includes face-to-face time with the client, treatment plan reviews, and supervision;c. There must be sufficient supervising practitioner consultation hours on a regular basis to meet the requirements for active treatment (see 471 NAC 32-007.06) and to properly supervise the Master's level therapists (see 471 NAC 32-007.03F). Youth at this level of care must be seen and interviewed by the supervising practitioner a minimum of once every 30 days.6. The ratio of child care staff to children during prime time hours is dependent on the needs of the children and the requirements of the individualized treatment plans. The ratio of staff to children must be commensurate with the size and scope of the program; however, minimum ratio is 1:4. This may be increased depending on the intensity of the program and the child's needs.7. The ratio of child care awake staff during sleeping and non-prime hours is dependent on the needs of the children and must be commensurate with the size and scope of the program; however, the minimum ratio is 1:6. This may be increased depending on the intensity of the program and the individual child's needs.8. The facility must be able to call back child care staff to provide staff and client safety in crisis situations.9. If the facility has a level program that requires intense observation for admissions, the direct care staff to youth ratio will need to be more intense during that observation period.10. Access to emergency services such as additional supervision and medical/psychiatric care must be available on a 24-hour basis.11. Those facilities providing this service prior to the effective date of this policy may apply to become an approved provider with their current staffing levels provided: a. Any new staff hired must meet the criteria stated in these policies; andb. Staff ratios are upgraded to policy standards within four months of the policy's effective date. 32-007.03FService Standards for Participation for Residential Treatment Centers: Residential treatment centers shall - 1. Make every effort to keep the child in contact, when appropriate and possible, with the child's family and relatives, when reunification or reconciliation is the plan;2. Involve the parents and family, when appropriate and possible, in the treatment planning. For wards of the Department, the case manager must be included in all phases of assessment, treatment planning, evaluation of services, and discharge/after care arrangements;3. Provide a minimum of 42 hours of scheduled treatment intervention per week. These include, but are not limited to: a. Group psychotherapy by a practitioner operating within his/her scope of practice;b. Individual therapy by a practitioner operating within his/her scope of practice;c. Family intervention (one hour per week minimum);d. Face-to-face sessions with the supervising practitioner; ande. Other approved group or individual therapeutic activities.4. Provide or arrange for face-to-face family therapy a minimum of twice a month. Depending on the child's needs, this may include reunification/reconciliation therapy and may also include biological families, foster families, adoptive families, and/or extended family;5. Provide the following mandatory services - a.Clinically Necessary Nursing Services: Medical services directed by a Qualified Registered Nurse who evaluates the particular nursing needs of each client and provides for the medical care and treatment that is indicated on the Department approved treatment planning document approved by the supervising practitioner. Reimbursement for psychological diagnostic services is included in the per diem.b.Clinically Necessary Psychological Diagnostic Services: Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual client. Testing and evaluation services may be performed by a Clinical Psychologist acting within his/her scope of practice. Clinical necessity must be documented by the program supervising practitioner.c.Clinically Necessary Pharmaceutical Services: If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside licensed/certified facility. All medications must be stored in a special locked storage space and administered only by a physician, registered nurse, licensed practical nurse, or a staff person approved by the Nebraska Department of Health and Human Services, Division of Public Health as a Medication Aide.d.Clinically Necessary Dietary Services: The meal services provided must be supervised by a registered dietitian, based on the client's individualized diet needs. Programs may contract for these services through an outside licensed certified facility.e. Transition and discharge planning must meet the requirements of 471 NAC 32-001.07A.6.Optional Services: The program must provide two of the following optional services. The client must have a need for the services, the supervising practitioner must order the services, and the services must be a part of the client's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy: a. Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a licensed/certified professional as listed below: (1) Recreational Therapy;(3) Occupational Therapy;(4) Vocational Skills Therapy;(5) Self-Care Services: Services supervised by a registered nurse or occupational therapist who is oriented toward activities of daily living and personal hygiene. This includes toileting, bathing, grooming, etc.b. Psychoeducational Services: Therapeutic psychoeducational services may be provided as part of a total program. Therapeutic psychoeducational services must be provided by teachers specially trained to work with child and adolescents experiencing mental health or substance abuse problems. These services may meet some strictly educational requirements, but must also include the therapeutic component. Professionals providing these services must be appropriately licensed and certified for the scope of practice.c. Social Work Services by a Bachelor's Level Social Worker: Social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment, i.e., case management type services.d. Crisis Intervention (may be provided in home);e. Social Skills Building;g. Substance abuse prevention, intervention, or treatment by an appropriately licensed alcohol and drug counselor.7. Provide appropriate conferences involving the youth's interdisciplinary treatment team, the parents, the referring agency, and the child, to review the case status and progress at least every month. This does not substitute for documentation requirements. The need for conferences with interested parties is indicated by the individual child's circumstances and needs, which may indicate conferences occurring more frequently. For wards of the Department, this need will be jointly determined with the case manager;8. Allow for more than one type of activity to be scheduled at one time allowing for specialized and individualized treatment planning;9. Provide a progress report to the referring agency, and the parents or legal guardian every month for the purpose of service coordination. For wards of the Department, monthly reports must be provided to the Division of Children and Family Services case manager. The documentation from the Monthly Treatment Plan review may serve this purpose;10. The services of specialists in the fields of medicine, psychiatry, psychology, and education must be used as needed. 32-007.03GAnnual Update/Renewal: The residential treatment center shall submit the following information with the provider application and agreement, and update/renewal the information annually to coincide with submission of the cost report: 1. A written overview of the program's philosophy and objectives of treating children and adolescents including: a. A description of each available service;b. A list of treatment modalities available and the capacity for individualized treatment planning;c. A statement of the qualification, education, and experience of each staff member providing treatment and the therapy service each provides;d. A schedule covering the total number of hours that the program operates;f. The target population.2. Confirmation that the staffing standards in 471 NAC 32-007.03E are met;3. Copy of child caring agency licensure certificate; and4. Copy of accreditation certificate. The Division of Medicaid and Long-Term Care or its designee may request this information on an intermittent basis and the provider must comply by promptly supplying the requested information.
007.04 Covered Services NMAP limits payment for residential treatment services to those services for medically necessary to treat primary diagnoses. NMAP covers residential services as delineated in 471 NAC 32-007 when the services are medically necessary and provide active treatment.
32-007.04APre-Admission Authorization: For residential treatment center services to be covered by NMAP, the need for admission to this level of care must be determined by a supervising practitioner through a thorough pre-treatment assessment (see 471 NAC 32001.01) and prior authorized through the Medicaid Division or its designee. For wards of the Department, consent for treatment for wards of the Department must be obtained from the Department case manager or supervisor. See 471 NAC 32-001.32-007.04BGuidelines for Use of Residential Treatment Services for Children: A youth must have a diagnosable condition listed in the current diagnostic and statistics manual of the American Psychiatric Association (excluding V-codes and developmental disorders) for this level of care. NMAP applies the following guidelines to determine when residential treatment services for children or adolescents are medically necessary for a client:1. The child/adolescent requires 24-hour awake supervision with high staff ratios;2. Utilization of residential treatment services is appropriate for individualized treatment and is expected to improve the client's condition to facilitate moving the client to a less restrictive placement;3. The child/adolescent's problem behaviors are persistent, unpredictable, and may jeopardize the health or safety of the client and/or others;4. The child/adolescent's daily functioning must be significantly impaired in multiple areas, such as family relationships, education, daily living skills, community, health, etc.;5. The child/adolescent has a documented history of previous placement disruptions due to on-going behaviors/psychiatric issues; and6. Less restrictive treatment approaches have not been successful or are deemed inappropriate by the referring supervising practitioner. 32-007.04CTherapeutic Passes for Clients Involved in Residential Treatment Services: Therapeutic passes are an essential part of the treatment for client/families involved in residential treatment services. Documentation of the client's continued need for residential treatment services must follow overnight therapeutic passes. Therapeutic passes must be indicated in the treatment plan as they become appropriate. NMAP reimburses for only 60 therapeutic pass days per client per year. This includes all treatment services in which the client is involved during the year. Therapeutic leave days are counted by the entity reimbursing for the care. Because the NMAP fee-for-service program reimburses for therapeutic leave days on a post-service basis and because providers have one year to bill for services, the Department cannot guarantee that an accurate account of the therapeutic leave days that have been used.
32-007.04DVacations: If a residential treatment program takes the clients on a "vacation," NMAP will reimburse for those days under the following conditions - 1. The trip is prior authorized by the Division of Medicaid and Long-Term Care or its designee;2. There is a clear statement of goals and objectives for the individual client's participation in the trip;3. At least 50% of the scheduled treatment interventions must occur during the "vacation";4. A clinical staff person must accompany the "vacation" trip; and5. The "vacation" must be included in the treatment program. NMAP will reimburse for up to seven "vacation" days per year for clients in residential treatment program.
007.05 Additional Requirements 32-007.05AWork Experience: When a center has a work program, it must - 1. Provide work experience that is appropriate to the developmental age and abilities of the child/adolescent;2. Differentiate between the chores that children/adolescents are expected to perform as their share in the process of living together, specific work assignments available to children/adolescents as a means of earning money, and jobs performed in or out of the center to gain vocational training;3. Give children/adolescents some choice in their work experience and offer change from routine duties to provide a variety of experiences;4. Not interfere with the child/adolescent's time for school, study periods, play, chores, sleep, normal community activities, visits with the family, or individual, group, or family therapy.5. Children/adolescents may not be solely responsible for any major phase of the center's operation or maintenance, such as cooking, laundering, housekeeping, farming, or repairing; and6. Comply with all state and federal labor laws. 32-007.05BSolicitation of Funds: A center may not use a child/adolescent for advertising, soliciting funds, or in any other way that may cause harm or embarrassment to the child/adolescent or the family. Written consent of the parent or guardian must be obtained before the center uses a child's picture, person, or name in any form of written, visual, or verbal communication. Before obtaining consent, the center shall advise the parent or guardian of the purpose for which it intends to use the child's picture, person, or name, and of the times and places when and where this use would occur.32-007.05CSpecial Treatment Procedures: If a youth needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in psychiatric RTC's are limited to physical restraint, locked time out (LTO), and a locked unit. Mechanical restraints and pressure point tactics are not allowed. Parents or legal guardians or the Department case manager must approve use of these procedures through informed consent and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures:
1. De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;2. Special treatment procedures may be used only when a child/adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; and3. The child/adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring LTO, physical restraints, or a locked unit. These standards must be reflected in all aspects of the treatment program. Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.
32-007.05DMedical Care: The center shall ensure that the following medical care is provided for each child/adolescent: 1. Each child/adolescent must receive a medical examination (EPSDT/Health Check exam) before or at the time of admission;2. Each child/adolescent must have current immunizations as required by the Nebraska Department of Health and Human Services;3. The center shall arrange with a physician and a psychiatrist for the medical and psychiatric care of the clients;4. Each child/adolescent must have a medical examination annually as allowed in 471 NAC 33-000 ff.;5. The center shall inform staff members of what medical care, including first aid, may be given by staff without specific physician orders. Staff must be instructed on how to obtain further medical care and how to handle emergency cases. The center shall ensure that - a. Staff members on duty must have satisfactorily completed current first aid and cardiopulmonary resuscitation training and have on file at the center a certificate of satisfactory completion as required by Department of Health and Human Services, Division of Public Health regulations;b. Each staff member must be able to recognize the common symptoms of illnesses in children/adolescents and to note any marked physical defects of children.c. A sterile clinical thermometer, a complete first aid kit, and clearly posted emergency phone numbers must be available, according to Department of Health and Human Services. 32-007.05EHospital Admissions: The center shall make arrangements for the emergency admission of children from the center in case of serious illness, emergency, or psychiatric crisis. Parents, legal guardians, or the Department case manager or the case manager's supervisor must give permission and consent to treat for admission. In the event that a client does require hospitalization while in a residential treatment center, NMAP will reimburse the treatment program for up to 15 days per hospitalization. This reimbursement is only available if the treatment placement is not used by another client.
32-007.05FHospitalization or Death Reports: The center shall report any accident or illness requiring hospitalization to the parents or guardian immediately. The center shall immediately report any death to the parents or guardian, the Division of Medicaid and Long-Term Care, a law enforcement agency, and the county coroner. If the child is a Department ward, see 474 NAC 4-009.28D 8.32-007.05GDental Care: Each child/adolescent must have an annual dental examination. If a child/adolescent has not had a dental exam in the twelve months before admission, an examination must occur within 90 days following admission. See 471 NAC 6-000 and 33-000 and 474 NAC 6-005.26F.32-007.05HGeneral Health: The center shall ensure the following: 1. Each child/adolescent must have enough sleep for the child/adolescent's age and physical and emotional condition at regular and reasonable hours, and under conditions conducive to rest. While clients are asleep, at least one staff member must be within hearing distance;2. Children/adolescents must be encouraged and helped to keep themselves clean;3. Bathing and toilet facilities must be properly maintained and kept clean;4. Each child/adolescent must have a toothbrush, comb, an adequate supply of towels and washcloths, and personal toilet articles;5. Menus must provide for a varied diet that meets a child/adolescent's daily nutritional requirements;6. Each child/adolescent must have clothing for their exclusive use. The clothing must be comfortable and appropriate for the current weather conditions; and7. The center must provide safe, age-appropriate equipment for indoor and outdoor play. See 471 NAC 33-000.
32-007.05JEducation: Educational services, when required by law, must be available. Education services must only be one aspect of the treatment plan, not the primary reason for admission or treatment. Educational services are not eligible for payment by the NMAP.32-007.05KReligious Education: Children/adolescent must be provided with an opportunity to receive instruction in their religion. No child/adolescent may be required to attend religious services or to receive religious instructions if the child/adolescent chooses not to attend the services or receive instruction.32-007.05LDiscipline: Discipline must be diagnostic and remedial rather than punitive. Corporal punishment, verbal abuse, and derogatory remarks about the child/adolescent, the family, religion, or cultural background are prohibited. A child/adolescent may not be slapped, punched, spanked, shaken, pinched, or struck with an object by any staff of the center. Only staff members of the center may discipline children (see 474 NAC 6-005.26K) while in treatment.32-007.05MTransition and Discharge Planning: Whenever a child or adolescent is transferred from one setting to another, discharge planning must be performed and documented, beginning at the time of admission (see 471 NAC 32-001.07A and 474 NAC 6-005.27H ). Facilities must meet the following standards regarding discharge planning:
1. Discharge planning must be based on the multidisciplinary treatment plan designed to achieve the client's discharge from residential treatment status to a less restrictive level of care at the most appropriate time;2. Discharge planning must address the client's need for ongoing treatment, continuing education, and support for normal development following discharge;3. Discharge planning must include identification of and transition into services needed following discharge;4. The residential treatment facility shall arrange for prompt transfer of appropriate records and information to ensure continuity of care following the client's discharge;5. A written discharge summary must be provided as part of the clinical record; and6. The client's family and caseworker must be active participants in discharge planning. This participation must be clearly documented in the client's record. 32-007.05NNotification of Runaway Children: See 390 NAC 7-001.05.32-007.05PInterstate Compact on the Placement of Children: The center shall comply with the interstate compact on the placement of children (see 474 NAC 6-005.27J ).32-007.05QMedications: The center may possess a limited quantity of nonprescription medications and administer them under the supervision of designated staff. The center must follow all applicable regulations through the Department of Health and Human Services, Division of Public Health for storing and administering medications. The center shall have written policies governing the use of psychotropic medications. Parents or the guardian of a client who receives psychotropic medication must be informed of the benefits, risks, side effects, and potential effects of medications. A parent or legal guardian's written informed consent for use of the medication must be obtained before giving the medication and filed in the client's record.
A child/adolescent's medication regime must be reviewed by the attending physician at least every seven days for the first 30 days and at least every 30 days thereafter.
007.06 Individual Treatment To be covered by NMAP, individual treatment services must include -
1.Program philosophy: Residential treatment facilities must provide intensive family-centered, community-based, developmentally appropriate services under the direction of a supervising practitioner. a. These services must be able to meet the special needs of families, including the "identified client" in the treatment facility. Families must be involved in treatment and discharge planning. For wards of the Department, the case manager must also be involved in treatment and discharge planning.b. The program intensity must be such that direct care staff, the client in treatment, and/or the client's family have access to professional staff on an "as needed" basis, determined by the client's condition.2.Active treatment, which must be - a. Treatment provided under a multi-disciplinary treatment plan reviewed and approved by the supervising practitioner. This plan will be developed within 14 days of admission by a multi-disciplinary team of professional staff members. The treatment plan must be for a primary psychiatric diagnosis and must be based on a thorough evaluation of the client's restorative needs and the client's potential. The treatment plan must be reviewed at least every 30 days by the multi-disciplinary team. The goals and objectives documented on the treatment plan must reflect the recommendations from the Initial Diagnostic Interview, the supervising practitioner and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the client's response to the treatment interventions based on the recommendations, goals and objectives.
b. In compliance with 471 NAC 32-001.07, Treatment Planning; andc. In compliance with 471 NAC 32-001.06, Active Treatment.3.Medically necessary services, which must be an appropriate level of care based on documented Initial Diagnostic Interview including a comprehensive diagnostic workup and supervising practitioner-ordered treatment.007.07 Documentation in the Client's Clinical Record The center must maintain accurate clinical records indicating the degree and intensity of the treatment provided to clients who receive services in the residential treatment facility. For residential services, clinical records must stress the treatment intervention components of the clinical record, including history of findings and treatment provided for the psychiatric condition for which the client is in the facility. The clinical record must include the requirements stated in 471 NAC 32-001.05 and -
1. The identification data, including the client's legal status (i.e., voluntary admission, Board of Mental Health commitment, court mandated);2. A provisional or admitting diagnosis which is determined for every client at the time of admission and includes the diagnoses of intercurrent diseases as well as the psychiatric diagnoses;3. The statements of others regarding the client's problems and needs, as well as the client's statement of their problems and needs;4. The pre-treatment assessment, including a medical/psychiatric history, which contains a record of mental status and notes the onset of illness/problems, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the client's strengths in a descriptive, not interpretative, fashion;5. A complete psychological evaluation;6. A complete neurological examination, when indicated;7. A social history sufficient to provide data on the client's relevant past history, present situation, social support system, community resource contacts, and other information relevant to good treatment and discharge planning;8. A thorough family assessment;9. Reports of consultations, psychological evaluations, electroencephalograms, dental records, and special studies;10. The treatment received by the client, which is documented in a manner and with a frequency to ensure that all active therapeutic efforts, such as individual, group, and family psychotherapy, drug therapy, milieu therapy, occupational therapy, recreational therapy, nursing care, and other therapeutic interventions, are included;11. Progress notes must be recorded by all professional staff and, when appropriate, others significantly involved in active treatment modalities, following each contact. The frequency is determined by the individual treatment plan and the condition of the client, but should be recorded at least daily. Progress notes must contain a concise assessment of the client's progress and recommendations for revising the treatment plan as indicated by the client's condition. Child care workers must maintain 24-hour documentation of a client's whereabouts and activities;12. The transition plan and discharge summary, including a summary of the client's and family's treatment, recommendations for appropriate services concerning follow-up, and a brief summary of the client's condition on discharge;13. The psychiatric diagnosis contained in the final diagnosis written in the terminology of the American Psychiatric Association's Diagnostic and Statistical Manual; and14. The client's response to therapeutic leave days prescribed by the supervising practitioner under the treatment plan. The client's, family's, or guardian's response to time spent outside the facility must be entered in the client's clinical record. All documents from the client's medical record submitted to the Division of Medicaid and Long-Term Care must contain sufficient information for identification (i.e., client's name, date of service, provider's name).
007.08 Utilization Review All facilities must have a utilization review protocol for their services.
007.09 Inspection of Care (IOC) The Division of Medicaid and Long-Term Care or its designee's inspection of care team will conduct inspection of care reviews for psychiatric residential treatment facilities. See 471 NAC 32-001.09 and 471 NAC 32-001.10.
007.10 Documentation for Claims The following documentation is required and kept in the client's clinical record for all claims for residential treatment services. The facility will be notified in writing if that occurs:
2. Orders by the supervising practitioner; and3. Progress notes for all disciplines. All claims are subject to utilization review by the Department prior to payment.
32-007.10AException: Additional documentation from the client's clinical record may be requested by the Department prior to considering authorization of payment.007.11 Costs Not Included in the Residential Treatment Per Diem The mandatory and optional services are considered to be part of the per diem for residential treatment services. The following charges can be reimbursed separately from the residential treatment per diem when the services are necessary, part of the client's overall treatment plan, and in compliance with NMAP policy:
1. Direct client services performed by the supervising practitioner;2. Prescription medications (including injectable medications);3. Direct client services performed by a physician other than the supervising practitioner; and4. Treatment services for a physical injury or illness provided by other professionals. If the client is enrolled with another managed care vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity.
007.12 Procedure Code and Description for Residential Treatment Services HCPCS/CPT procedure codes used by NMAP are listed in the Nebraska Medicaid Practitioner Fee Schedule at 471-000-532.
471 Neb. Admin. Code, ch. 32, § 007