471 Neb. Admin. Code, ch. 32, § 008

Current through September 17, 2024

Section 471-32-008 - Inpatient Psychiatric Services for Individuals Under Age 19 in Psychiatric Residential Treatment Facilities

008.01 Psychiatric Residential Treatment Facilities (PRTFs) for Children/Adolescents

A Psychiatric Residential Treatment Facility (PRTF) is a facility, other than a hospital, that provides inpatient psychiatric services to individuals under the age of 19. A PRTF must provide the inpatient psychiatric services under the direction of a physician, must be accredited and must comply with all the requirements of applicable state and federal regulations.

008.02 Prior Authorization

In order for an admission to a PRTF to be reimbursed by Medicaid, the individual must meet the Certification of Need for Services requirements set forth in 32-008.03 and be prior authorized by Medicaid or its designee. Prior authorization applies to all admissions described in 32-008.04.

008.03 Certification of Need for Services

A team specified in Section 32-008.04 must certify, prior to admission, that:

1. Ambulatory care resources available in the community do not meet the treatment needs of the individual;

2. Proper treatment of the individual's psychiatric condition requires services on an inpatient basis under the direction of a physician; and

3. The services can reasonably be expected to improve the individual's condition or prevent further regression so that the services will no longer be needed.

008.04 Team Certifying Need for Services

Certification of the need for services specified in 32-008.03 must be made by an independent team that:

1. Includes a physician;

2. Has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and

3. Has knowledge of the individual's situation.

32-008.04AIndividuals Who Become Eligible for Medicaid While in PRTF: For an individual who applies for Medicaid while in the PRTF, the certification must be:

1. Made by the team responsible for the Plan of Care as specified in 32-008.07; and

2. Cover any period before application for which claims are made.

32-008.04BEmergency Admissions: For emergency admissions, the certification must be made by the team responsible for the Plan of Care within 14 days after admission.

008.05 Active Treatment

Inpatient psychiatric service must involve "active treatment" which means implementation of a professionally developed and supervised individual plan of care, as described in 32-008.06, that is developed and implemented no later than 14 days after admission and is designed to achieve the individual's discharge from inpatient status at the earliest possible time.

008.06 Individual Plan of Care

The plan of care means a written plan developed for each individual to improve his/her condition to the extent that inpatient care is no longer necessary. The plan of care must:

1. Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the individual's situation and reflects the need for inpatient psychiatric care;

2. Be developed by a team of professionals specified in 32-008.07 in consultation with the individual and the parents, legal guardian or others in whose care the individual will be released after discharge;

3. State treatment objectives;

4. Prescribe an integrated program of therapies, activities and experiences designed to meet the objectives; and

5. Include post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the individual's family, school and community upon discharge. The discharge plan must:

a. Identify the custodial parent or custodial caregiver anticipated at discharge;

b. Identify the school the patient will attend;

c. Include individualized educational program (IEP) recommendations as necessary;

d. Outline the aftercare treatment plan; and

e. List barriers to community reintegration and progress toward resolving these barriers since the last review. Include the needs of the custodial parent or custodial caregiver.

008.07 Team Developing Individual Plan of Care

1. The individual plan of care shall be developed by an interdisciplinary team of physicians and other personnel who are employed by, or provide services to individuals in the facility.

2. Based on education and experience, preferably including competence in child psychiatry, the team must be capable of:

a. Assessing the individual's immediate and long-range therapeutic needs, developmental priorities and personal strengths and liabilities;

b. Assessing the potential resources of the individual's family;

c. Setting treatment objectives; and

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

3. The team must include, as a minimum, either:

a. A Board-eligible or Board-certified psychiatrist; or

b. A licensed psychologist and a physician licensed to practice medicine or osteopathy; or

c. A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases and a licensed psychologist.

4. The team must also include one of the following:

a. A psychiatric social worker;

b. A licensed registered nurse with specialized training or one year's experience in treating mentally ill individuals;

c. A licensed occupational therapist who has specialized training or one year of experience in treating mentally ill individuals.

d. A licensed psychologist.

008.08 Reports of Evaluations and Plans of Care

A written report of each evaluation and plan of care must be entered in the individual's record:

1. At the time of admission; or

2. If the individual is already in the PRTF, immediately upon completion of the evaluation or plan.

008.09 Review of Plan of Care

The Plan of Care must be reviewed every 30 days by the team specified in 32-008.07, to:

1. Determine that services being provided continue to be required on an inpatient basis, and

2. Recommend changes in the plan as indicated by the individual's overall progress from the treatment provided at this level of care.

008.10 Treatment Services Provided by the PRTF

Providers of PRTF services shall provide 40 hours of psychotherapy and other treatment interventions per week. The following services and frequency of services are included in the PRTF rate and must be available to the individual unless clinically contraindicated:

1. Twice weekly individual psychotherapy and/or substance abuse counseling;

2. Minimum three times a week group psychotherapy and/or substance abuse counseling;

3. Weekly family psychotherapy and/or family substance abuse counseling. A family therapy session is provided on the day of admission and the day prior to discharge;

4. Occupational therapy as clinically indicated;

5. Physical therapy as clinically indicated;

6. Speech therapy as clinically indicated;

7. Laboratory services;

8. Transportation; and

9. Medical Services, as necessary; and

10. Nursing service availability 7 days a week, 365 days a year by an onsite nurse during awake hours and by an on-call availability during sleep hours.

008.11 Psychoeducation Services Provided in PRTF

Psychoeducational services must be available from the PRTF and must be modified to meet the unique treatment needs of the individual as described in the individual's Plan of Care:

1. Crisis intervention and aftercare planning;

2. Life survival skills as clinically indicated;

3. Social skills building;

4. Substance abuse prevention interventions;

5. Self-care services as clinically indicated;

6. Medication education, compliance and information regarding the effectiveness of medication;

7. Health care issues which may include nutrition, hygiene and personal wellness;

8. Vocational/career planning as clinically indicated; and

9. Recreational activity (recreational activity is not considered in 40 hours per week of therapy but healthful outcomes of recreation and exercise may be a part of a psycho-educational group service).

008.12 Individual Participation in PRTF Services

Every individual need not partake in all treatment services that are available in the PRTF if such services are clinically contraindicated. If individual, group or family psychotherapy services are not appropriately beneficial to the individual's need and Plan of Care, the Plan of Care shall identify the rationale for this omission. However, in no case should a child/adolescent receive less than 40 hours of PRTF services each week.

008.13 Staffing Standards for PRTFs

A PRTF shall be available 24 hours a day, 7 days a week, 365 days per year with 24-hour awake staffing. Staffing ratios should be 1:4 during awake hours and 1:6 during sleep hours. The following positions are required to be staffed, with a minimum of the stated qualifications.

32-008.13ASupervising Practitioner: The PRTF Supervising Practitioner shall be a licensed physician.

32-008.13BProgram/Clinical Director: A program/clinical director shall be a LMHP, licensed RN, licensed APRN, LIMHP, licensed physician with a specialty in psychiatry, or licensed psychologist. Dual-credentialing (e.g., LMHP/LADC or LMHP/PLADC) is required for PRTF services when co-occurring conditions (e.g. mental health and substance abuse) occur. The Program/Clinical Director shall have two years professional experience in a treatment setting similar to a PRTF. The Program/Clinical Director may not also serve in the role of the program's therapist.

32-008.13CPRTF Therapist: A PRTF therapist shall be a licensed practitioner whose scope of practice includes mental health and/or substance abuse services, including a LMHP, LIMHP, PLMHP, LADC, licensed psychologist, provisionally licensed psychologist, licensed APRN, or licensed physician with a specialty in psychiatry.

32-008.13DRegistered Nurse or Advanced Practicing Registered Nurse (RN or APRN): Nursing services shall be provided by a Registered Nurse or APRN licensed by the State in which she or he practices.

32-008.13EDirect Care Staff: Direct care staff shall meet the following requirements: Be 21 years of age or older and at least three years older than the oldest resident and have a high school diploma or its equivalent. Direct care staff shall be appropriately trained and responsible for basic interaction care such as supervision, daily living care and mentoring of the residents as well as assisting in the implementation of the plan of care that is within their scope of practice.

008.14 Restraint and Seclusion

Restraint and seclusion activities utilized by the PRTF shall be in compliance with federal standards for restraint and seclusion.

008.15 Services Provided Outside the PRTF

The following services must be available to the individual and may be billed separately to Medicaid:

1. Medically necessary services and/or supplies, including dental, vision, diagnostic/radiology and prescribed medications, not otherwise included in the PRTF rate when that care is reflected in the plan of care.

2. The PRTF shall:

a. Arrange for and oversee the provision of such services and/or supplies;

b. Maintain all medical records of care furnished to the individual; and

c. Ensure that all services and/or supplies are furnished under the direction of a physician.

471 Neb. Admin. Code, ch. 32, § 008