N.Y. Comp. Codes R. & Regs. tit. 14 § 512.4

Current through Register Vol. 46, No. 43, October 23, 2024

Section 512.4 - Definitions

(a) Admission date is the day that the PROS program completes and submits a PROS registration form on behalf of a PROS participant, using the registration system approved by the office.

(b) Adult means an individual 18 years of age or older.

(c) Behavioral health organization or BHO means an entity selected by the Commissioner of the Office of Mental Health and the Commissioner of the Office of Alcoholism and Substance Abuse Services pursuant to section 365-m of the New York State Social Services Law to provide administrative and management services for the purposes of conducting concurrent review of behavioral health admissions to inpatient treatment settings, assisting in the coordination of behavioral health services, and facilitating the integration of such services with physical health care.

(d) Capacity means the maximum number of people to whom a PROS program can provide services at any given time.

(e) Carved-out services means those special care services that are not included in the benefit package of a managed care provider, for all managed care enrollees, regardless of aid category.

(f) Clinical staff means all staff members, including any recipient employees, who provide services directly to individuals admitted to PROS programs or their collaterals. Students and trainees may qualify if they are participating in a program leading to a degree or certificate appropriate to the goals, objectives and services of the PROS program, are supervised in accordance with the policies governing the training program, and are approved as part of the staffing plan by the Office of Mental Health.

(g) Collateral means a person who is:

(1) a significant other or member of the PROS participant's family or household, academic, workplace or residential setting, who regularly interacts with the individual and is directly affected by, or has the capability of affecting, his or her condition; and

(2) identified in the individualized recovery plan, and approved by the individual, as having a role in services and/or is identified in the pre-admission notes as being necessary for participation in the evaluation and assessment of the individual prior to admission; and

(3) not a staff member of the PROS program or any other mental health service provider except when the staff member is participating in services in his or her role as the recipient's collateral, and not in his or her staff member role.

(h) Commissioner means the Commissioner of the New York State Office of Mental Health.

(i) Comprehensive PROS program, unless otherwise specified, means a comprehensive PROS program with clinical treatment or a comprehensive PROS program without clinical treatment.

(j) Comprehensive psychiatric rehabilitation assessment means the process of identifying the skills and supports necessary for an individual to be successful in his or her chosen life roles. Such assessment is intended to focus on the individual's living, learning, working, parenting and social goals, and to identify barriers, due to the individual's mental illness, that are preventing achievement of the individual's recovery goals. The assessment should also identify the individual's strengths that can be utilized in the achievement of his or her recovery goals.

(k) Concurrent review means the review of the clinical necessity for continued inpatient behavioral health services, resulting in a non-binding recommendation regarding the need for such continued inpatient services.

(l) Designated mental illness diagnosis means a DSM-IV diagnosis (or ICD-9-CM equivalent) other than:

(1) alcohol or drug disorders;

(2) developmental disabilities;

(3) organic brain syndromes; or

(4) social conditions (V-codes).

ICD-9-CM categories and codes that do not have an equivalent in DSM-IV are not included as designated mental illness diagnoses.

(m) Due diligence means the exercise of reasonable and appropriate efforts to comply with the standards set forth in this Part.

(n) Evidence-based practice means an intervention for which there is consistent, scientific evidence showing that it improves recipient outcomes. Those services identified in section 512.5 of this Part that are most closely associated with evidence-based practices, as of the effective date of this Part, include the following: family psychoeducation/intensive family support; integrated treatment for dual disorders (IDDT); medication management; ongoing rehabilitation and support (related to the evidence based practice of supported employment); and wellness self-management.

(o) Face-to-face means contact between a PROS participant, or his or her collateral, and a member of the PROS clinical staff, at a specific location, for the purpose of providing a medically necessary service for the PROS participant's benefit.

(p) Functional disability means a deficit that rises to the level of impairment in one or more of the following areas: self-care; activities of daily living; interpersonal relations; or adaptation to change or task performance in work or work-like settings.

(q) Licensed practitioner of the healing arts (LPHA) means the following professional staff, as defined in this Part:

(1) nurse practitioner;

(2) physician;

(3) physician assistant;

(4) psychiatric nurse practitioner;

(5) psychiatrist;

(6) psychologist;

(7) registered professional nurse;

(8) licensed clinical social worker (LCSW); and

(9) licensed master social worker (LMSW) if supervised by an LCSW, licensed psychologist, or psychiatrist employed by the agency.

(r) Local governmental unit (LGU) means the unit of government given the authority in accordance with article 41 of the Mental Hygiene Law to plan and provide for local or unified services.

(s) Month means any time between and including the first and last days of any calendar month in a given year.

(t) Monthly caseload means the maximum number of individuals who can be registered to receive services from the PROS program in any given month.

(u) New York Employment Support System (NYESS) is a secure computer-based case management tool developed by OMH and New York State Department of Labor used by PROS providers to provide employment services and as a data-reporting instrument.

(v) Office means the New York State Office of Mental Health (OMH).

(w) Off-site, for purposes of providing PROS services, means any clinically appropriate location in the community, other than a licensed PROS site, where an individual may receive services.

(x) Off-site program participation means the duration of time spent in the delivery of face-to-face services to a PROS participant or collateral at an off-site location.

(y) On-site program participation means the duration of time that a PROS participant or collateral is in attendance at the PROS program on a given day.

(1) Scheduled meal periods or planned recreational activities that are not specifically designated as medically necessary in the individual's individualized recovery plan shall be excluded from the calculation of program participation.

(2) Time spent in the program by a collateral shall not be considered on-site program participation if the PROS participant is simultaneously being credited with program participation on a given day.

(z) Pre-admission status means the time period that begins when an individual first receives a PROS pre-admission service, and ends on the individual's PROS admission date.

(aa) Professional staff means members of the clinical staff who are qualified by credentials, training and experience to provide supervision and direct service related to the care or treatment of persons with a designated mental illness diagnosis, and shall include the following:

(1) creative arts therapist, which means an individual who is currently licensed as a creative arts therapist by the New York State Education Department, or who has a master's degree in a mental health field from a program approved by the New York State Education Department, and registration or certification by the American Art Therapy Association, American Dance Therapy Association, National Association of Music Therapy or American Association for Music Therapy;

(2) credentialed alcoholism and substance abuse counselor, which means an individual who is currently credentialed by the New York State Office of Alcoholism and Substance Abuse Services in accordance with Part 853 of this Title;

(3) marriage and family therapist, which means an individual who is currently licensed as a marriage and family therapist by the New York State Education Department;

(4) mental health counselor, which means an individual who is currently licensed as a mental health counselor by the New York State Education Department;

(5) nurse practitioner, which means an individual who is currently certified as a nurse practitioner by the New York State Education Department;

(6) nurse practitioner in psychiatry, which means an individual who is currently certified as a nurse practitioner in psychiatry by the New York State Education Department. For purposes of this Part, nurse practitioner in psychiatry shall have the same meaning as psychiatric nurse practitioner, as defined by the New York State Education Department;

(7) occupational therapist, which means an individual who is currently licensed as an occupational therapist by the New York State Education Department;

(8) pastoral counselor, which means an individual who has a master's degree or equivalent in pastoral counseling or is a Fellow of the American Association of Pastoral Counselors;

(9) physician, which means an individual who is currently licensed as a physician by the New York State Education Department;

(10) physician assistant, which means an individual who is currently registered as a physician assistant or a specialist's assistant by the New York State Education Department;

(11) psychiatrist, which means an individual who is currently licensed as a physician by the New York State Education Department and who is certified by, or eligible to be certified by, the American Board of Psychiatry and Neurology;

(12) psychoanalyst, which means an individual who is currently licensed as a psychoanalyst by the New York State Education Department;

(13) psychologist, which means an individual who is currently licensed as a psychologist by the New York State Education Department. Individuals with at least a master's degree in psychology who do not meet this definition may not be considered licensed practitioners of the healing arts, and may not be assigned supervisory responsibility. However, individuals who have obtained at least a master's degree in psychology may be considered professional staff for the purposes of calculating professional staff and full time equivalent professional staff;

(14) registered professional nurse, which means an individual who is currently licensed as a registered professional nurse by the New York State Education Department;

(15) rehabilitation counselor, which means an individual who has either a master's degree in rehabilitation counseling from a program approved by the New York State Education Department or current certification by the Commission on Rehabilitation Counselor Certification;

(16) social worker, which means an individual who is currently licensed as a master social worker (LMSW) or clinical social worker (LCSW) by the New York State Education Department. LMSWs must be supervised by a LCSW, licensed psychologist, or psychiatrist employed by the agency. Social workers who do not meet this criteria may not be considered licensed practitioners of the healing arts. However, social workers who have obtained at least a master's degree in social work from a program approved by the New York State Education Department may be considered professional staff for the purposes of calculating professional staff and full-time equivalent professional staff;

(17) therapeutic recreation specialist, which means an individual who has either a master's degree in therapeutic recreation from a program approved by the New York State Education Department or registration as a therapeutic recreation specialist by the National Therapeutic Recreation Society; and

(18) other staff may be included as professional staff with the prior written approval of the office, when such individuals have specified training or experience in the care or treatment of individuals diagnosed with mental illness. Such staff may include, but are not limited to, persons who are registered or certified by the United States Psychiatric Rehabilitation Association (USPRA).

(ab) Program participation means a combination of on-site program participation and off-site program participation for a specific individual on a given day.

(ac) PROS program or PROS provider, unless otherwise specified, means a comprehensive PROS program or a limited license PROS program.

(ad) PROS unit is determined by a combination of on-site and off-site program participation and service frequency.

(ae) Provider of service means the entity that is legally responsible for the operation of a PROS program. Such entity may be an individual, partnership, association, limited liability corporation, or corporation.

(af) Recipient attestation form is a form provided to a recipient by a PROS program for him or her to sign when he or she has chosen to participate in one or more components of the PROS program.

(ag) Recipient employee means an individual who is financially compensated by a provider for providing clinical or non-clinical PROS services in the same program where the individual also receives PROS services.

(ah) Registration is the process by which individuals are assigned to PROS programs and specific PROS components. The programs with which individuals are registered are recognized by the office as authorized providers of PROS services for those individuals.

(ai) Registration date means the first calendar month for which all PROS components and monthly base rate levels can be billed for Medicaid-eligible individuals.

(aj) Relapse prevention plan means a collaboratively developed document, required as part of individualized recovery planning and included in the individualized recovery plan, that identifies a series of actions to be taken by the individual, the program, and/or a collateral identified by the individual to avoid worsening of an individual's mental health symptoms and prevent hospitalization.

(ak) Service frequency means the number of medically necessary PROS services delivered to an individual or collateral during the course of a program day.

(al) Site means a location where PROS services are provided on a regular and routine basis, and which is authorized by a PROS operating certificate.

(am) Sponsor means the provider of service or an entity that substantially controls or has the ability to substantially control the provider of service. For the purpose of this Part, factors used to determine whether there is substantial control shall include, but are not limited to, the following:

(1) the right to appoint and remove directors or officers;

(2) the right to approve bylaws or articles of incorporation;

(3) the right to approve strategic or financial plans for a provider of service; or

(4) the right to approve operating or capital budgets for a provider of service.

(an) Target population member means an individual who has received long-term supports and services for at least six (6) months while living in an adult home, nursing home as defined in Section 2801 of the Public Health Law, State-operated community residence, or as an inpatient in a State psychiatric center, and is currently living in a more independent, integrated community setting, provided, however, that an individual shall be a considered a target population member for no longer than 12 consecutive calendar months following discharge from one of the aforementioned settings.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 512.4

Amended, New York State Register November 12, 2014/Volume XXXVI, Issue 45, eff.11/12/2014