Department of Medical Assistance Services
Residential Treatment Services (RTC)
Level C
DMAS Office of Behavioral Health
2013
www.dmas.virginia.gov
1
Department of Medical Assistance Services
Disclaimer
These slides contain only highlights of the Virginia
Medicaid Psychiatric Services Manual (PSM) and is not
meant to substitute for the comprehensive information
available in the manual or state and federal regulations.
*Please refer to the manual, available on the DMAS website portal, for
in-depth information on Psychiatric Services criteria. Providers are
responsible for adhering to related state and federal regulations.
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Department of Medical Assistance Services
Training Objectives
• To define the criteria needed to establish a Level C Residential Treatment
Center (RTC) and licensing requirements;
• To identify staff qualifications;
• To identify required activities;
• To clarify the expectations for Seclusion & Restraint Reporting;
• To clarify eligibility criteria;
• To review the Medicaid Required Documentation for CSA and Non-CSA
Admissions and Plans of Care;
• To review limitations of the service; and
• To review service authorization requirements.
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Department of Medical Assistance Services
Service Definition
“Residential inpatient care” means a 24-hour-per-day
specialized form of highly organized, intensive, and planned
therapeutic interventions, which shall be utilized to treat severe
mental, emotional, and behavioral disorders. It is a definitive
therapeutic modality designed to deliver specified results for a
defined group of problems for children or adolescents for
whom outpatient day treatment or other less intrusive levels of
care are not appropriate, and for whom a protected, structured
milieu is medically necessary for an extended period of time.
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Department of Medical Assistance Services
Service Definition
• A program for children and youth under age 21 to treat severe mental,
emotional and behavioral disorders;
• Is designed to meet the needs when outpatient and day treatment fails;
• Provides inpatient psychiatric treatment;
• Is a 24-hour per day program;
• Provides child-specific care and treatment planning;
• Provides highly organized and intensive services;
• Provides planned therapeutic interventions;
• Required services are provided on-site, including academic programming;
AND
• Is physician-directed mental health treatment.
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Department of Medical Assistance Services
Licensing
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Department of Medical Assistance Services
Licensing Requirements
Individuals under the age of 21 may receive residential psychiatric care in:
1. A residential treatment program for children and adolescents licensed by
the Department of Behavioral Health Developmental Services (DBHDS)
that is located in a psychiatric hospital accredited by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO).
2. A residential treatment program for children and adolescents licensed by
DBHDS that is located in a psychiatric unit of an acute general hospital
accredited by the JCAHO; or
3. A psychiatric facility that is (i) accredited by JCAHO, the Commission
on Accreditation of Rehabilitation Facilities, the Council on Quality and
Leadership in Support for People with Disabilities, or the Council on
Accreditation Services for Families and Children and (ii) licensed by
DBHDS as a residential treatment program for children and adolescents.
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Department of Medical Assistance Services
Staff Qualifications
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Department of Medical Assistance Services
Staff Qualifications
Psychiatric Services and Substance Abuse Services may be provided by:
• A psychiatrist who is a licensed physician who has completed at least three years of
postgraduate residency training in psychiatry;
• A licensed clinical psychologist licensed by the Department of Health Professions, Board of
Psychology;
• A licensed clinical social worker (LCSW) licensed by the Department of Health
Professions, Board of Social Work;
• A licensed professional counselor (LPC) licensed by the Virginia Board of Counseling;
• A psychiatric clinical nurse specialist - psychiatric (CNS) licensed by the Virginia Board of
Nursing and certified by the American Nurses Credentialing Center;
• A psychiatric nurse practitioner, licensed by the Virginia Board of Nursing;
• A marriage and family therapist/counselor licensed by the Virginia Board of Counseling;
• A school psychologist licensed by the Virginia Department of Health Profession’s Board of
Psychology; and
•
An individual who has completed his or her graduate degree and is under the direct personal
supervision of an individual licensed under Virginia state law. The individual must be
working towards licensure and supervised by the appropriate licensed professional in
accordance with the requirements of the individual profession.
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Department of Medical Assistance Services
Staff Qualifications
Substance Abuse Services:
• In addition to the previous listed licensure requirements, substance abuse
treatment providers must also be qualified by training and experience in all
of the following areas of substance abuse/addiction counseling:
• clinical evaluation;
• treatment planning;
• referral;
• service
• coordination;
• counseling;
• client, family, and community education;
• documentation; and
• professional and ethical responsibilities.
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Department of Medical Assistance Services
Facility Reporting
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Department of Medical Assistance Services
Provider Requirement-Attestation
A Restraint & Seclusion (R&S) attestation letter must be submitted to
DMAS for initial enrollment and no later than July 1st annually
thereafter; or if there is a change in Facility Director.
*There is a sample attestation letter in the Psychiatric Services manual at the
end of chapter II.
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Department of Medical Assistance Services
Facility Reporting
Federal Regulation § 483.374
• (a) Attestation of facility compliance. Each psychiatric residential treatment
facility that provides inpatient psychiatric services to individuals under age
21 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 director.
– (1) A facility with a current provider agreement with the Medicaid
agency must provide its attestation to the State Medicaid agency by
July 1.
– (2) A facility enrolling as a Medicaid provider must meet this
requirement at the time it executes a provider agreement with the
Medicaid agency.
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Department of Medical Assistance Services
Facility Reporting
Federal Regulation § 483.374
(b) Reporting of serious occurrences. The facility must report each
serious occurrence to both the State Medicaid agency and, unless
prohibited by State law, the State-designated Protection and Advocacy
system. Serious occurrences that must be reported include a resident's
death, a serious injury to a resident, and a resident's suicide attempt.
– (1) Staff must report any serious occurrence involving a resident to
both the State Medicaid agency and the State-designated Protection and
Advocacy system by no later than close of business the next business
day after a serious occurrence. The report must include the name of the
resident involved in the serious occurrence, a description of the
occurrence, and the name, street address, and telephone number of the
facility.
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Department of Medical Assistance Services
Facility Reporting
Federal Regulation § 483.374
(b. continued)
– (2) In the case of a minor, the facility must notify the resident's
parent(s) or legal guardian(s) as soon as possible, and in no case later
than 24 hours after the serious occurrence.
– (3) Staff must document in the resident's record that the serious
occurrence was reported to both the State Medicaid agency and the
State-designated Protection and Advocacy system, including the name
of the person to whom the incident was reported. A copy of the report
must be maintained in the resident's record, as well as in the incident
and accident report logs kept by the facility.
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Department of Medical Assistance Services
Facility Reporting
Federal Regulation § 483.374
(c) Reporting of deaths. In addition to the reporting requirements contained
in paragraph (b) of this section, facilities must report the death of any
resident to the Centers for Medicare & Medicaid Services (CMS) regional
office.
– (1) Staff must report the death of any resident to the CMS regional
office no later than close of business the next business day after the
resident's death.
– (2) Staff must document in the resident's record that the death was
reported to the CMS regional office.
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Department of Medical Assistance Services
Facility Reporting
§ 483.352 Definitions
• Psychiatric Residential Treatment Facility means a facility other than a hospital,
that provides psychiatric services, to individuals under age 21, in an inpatient
setting.
•
Restraint means a “personal restraint,” “mechanical restraint,” or “drug used as a
restraint” as defined in this section.
•
Seclusion means the involuntary confinement of a resident alone in a room or an
area from which the resident is physically prevented from leaving.
•
Serious injury means any significant impairment of the physical condition of the
resident as determined by qualified medical personnel. This includes, but is not
limited to, burns, lacerations, bone fractures, substantial hematoma, and injuries to
internal organs, whether self-inflicted or inflicted by someone else.
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Department of Medical Assistance Services
Facility Reporting
• Remain in compliance with signed agreement regarding seclusion and
restraint
• In case of injury requiring medical attention off-site or a suicide attempt,
DMAS must be notified by fax within one business day of occurrence:
–
–
–
–
–
–
–
child’s name, Medicaid number
facility name & address of incident, facility’s NPI number
location & date of incident
names of staff involved
description of incident
outcome, including persons notified
current location of child
Fax Reports to The DMAS Office of Behavioral Health
(804) 612-0045
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Department of Medical Assistance Services
Facility Reporting
For additional information regarding the Centers for Medicare & Medicaid
Services (CMS):
www.cms.gov
Or
7500 Security Boulevard, Baltimore, MD 21244
•
•
•
•
Toll-Free: 877-267-2323 (Employee directory available)
Local: 410-786-3000
TTY Toll-Free: 866-226-1819
TTY Local: 410-786-0727
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Department of Medical Assistance Services
CSA or Non-CSA Determination
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Department of Medical Assistance Services
CSA or Non-CSA
• If the case is an Adoption Subsidy case, it is NON-CSA
– The education payment source is not considered;
• If the education is paid for by the Dept. of Education/CSA funded, it is a
CSA case;
• If a child has been receiving CSA funding for other services, it is a CSA
case;
• If the child is in foster care, it is a CSA case.
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Department of Medical Assistance Services
CSA or Non-CSA
• The following slides describe the required documentation for CSA and
Non-CSA admissions;
• All documentation whether CSA or Non-CSA must be complete, timely
and include all required dated signatures;
• All Sample forms are available in the manual;
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Department of Medical Assistance Services
Eligibility Criteria
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Department of Medical Assistance Services
Eligibility
Severity of Illness (both 1 and 2 must be met):
1. Care and treatment shall be provided in the least restrictive treatment environment
possible. The following shall be reviewed by DMAS to determine whether a lower
level of care or ambulatory care was considered and found inappropriate to meet the
needs of the individual.
One or more must be present:
– The individual is currently receiving community-based care with evidence of
failure at a less restrictive level of care;
– The individual’s identified condition is escalating; or
– The individual’s condition is a reoccurrence of a previous acute psychiatric
condition.
2. Individuals admitted for inpatient residential level of care must have been diagnosed
with a psychiatric disorder.
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Department of Medical Assistance Services
Eligibility
There must be documented evidence of recent onset of one or more of the
following conditions:
• The individual is unable to function in a less restrictive environment
evidenced by dysfunction in interpersonal, family, education, or
development;
• The individual has had a history of acute psychiatric episodes and currently
is not making progress or cooperating with the treatment plan in a less
restrictive level of care;
• There are recent increased threats of harm or aggression towards self or
others;
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Department of Medical Assistance Services
Eligibility
There must be documented evidence of recent onset of one or more of the
following conditions (cont’d):
• The individual is unable to function safely in the community without
jeopardizing the safety of self or others;
• There has been recent stabilization of symptoms during a psychiatric
hospitalization but the individual needs a structured 24-hour therapeutic
environment to prevent regression, solidify gains, and/or further resolve
complex psychiatric symptoms; or
• Recent outpatient treatment has failed. Ambulatory care resources available
in the community do not meet treatment needs because the individual
suffers one or more complicating concurrent medical disorders which the
family is not effectively addressing (e.g., conduct disorder with seizures,
depression with insulin-dependent diabetes mellitus).
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Department of Medical Assistance Services
Certificate of Need
(CON)
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Department of Medical Assistance Services
Certification of Need (CON)
For both CSA and NON-CSA:
• The CON should reflect the child’s current condition and must be
completed within 30 days of admission;
• The CON is required to be completed prior to admission with all necessary
dated signatures;
• If the child is discharged and readmitted, a new CON is required; and
• If the child transfers to an acute psychiatric facility, the acute care team can
do the new CON.
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Department of Medical Assistance Services
Certification of Need (CON)
CSA Cases:
• CON must be completed by both the physician and at least 3 members
of the FAPT;
• Must include dated signatures of the physician and FAPT;
• Authorization can begin no earlier than the date of the latest signature;
• Must be child-specific and relate to the need for an RTC (level C) level
of care; and
• Must be available in the medical record.
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Department of Medical Assistance Services
Certification of Need (CON)
Certification of Need
(Independent Team Certification)
NON-CSA Cases:
– The CSB is responsible for completing the Independent Team
Certification; and
– The CSB completes the DMH224 and must include a physician’s dated
signature, as well as the screener’s dated signature.
(The CSB may use the sample CON in the manual in place of the
DMH224)
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Department of Medical Assistance Services
Required Uniform Assessment
(UAI) - CANS
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Department of Medical Assistance Services
Required Uniform Assessment (UAI) - CANS
The State Uniform Assessment Instrument (CANS) is required for CSA Cases
• CSA Cases Only:
– The CANS is the only uniform assessment instrument that is accepted.
– For admission, the CANS should reflect the requested level of care and
must be current.
– It must be completed at least every 90 days.
and must be in the medical record.
– It should be updated by the fiscally responsible locality when the
child’s level of impairment changes significantly.
– Completion information must be submitted to KePRO for SA.
– Scoring notes the level of impairment that supports the need for the
level of care.
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Department of Medical Assistance Services
Required Uniform Assessment (UAI) - CANS
At a minimum:
• The CANS summary sheet should indicate the child’s behavioral and
emotional needs, and risk behaviors; and
• The CANS must also be available in the medical record and current within
90 days throughout the stay.
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Department of Medical Assistance Services
Initial Plan of Care
(IPOC)
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Department of Medical Assistance Services
IPOC
IPOC MUST:
•
Be completed at admission
•
Include diagnoses, symptoms, complaints, and complications indicating need for
admission;
•
Include a description of the functional level of the individual;
•
Include treatment objectives (short-term and long-term goals);
•
Include ANY orders for medications, treatments, restorative and rehabilitative
services, activities, therapies, social services, diet, and special procedures (health &
safety recommendations);
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Department of Medical Assistance Services
IPOC – cont’d
IPOC MUST:
•
Include plans for continuing care, including review and modification to the plan of
care;
•
Prognosis;
•
Include plans for discharge; and
•
Signature and date by the physician
(i.e. Name, title, handwritten date)
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Department of Medical Assistance Services
Comprehensive Individual Plan of Care
(CIPOC)
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Department of Medical Assistance Services
CIPOC
CIPOC MUST:
• Be completed within 14 days after admission;
•
Include the dated signatures of the team members (including physician) specified
in the federal requirements (42 CFR 441.156);
i.e. Name, title, handwritten date
•
Be based on a diagnostic evaluation that includes examination of the medical,
psychological, social, behavioral, and developmental aspects of the recipient's
situation and must reflect the need for inpatient psychiatric care;
•
Be developed by an interdisciplinary team of physicians and other personnel, who
are employed by, or provide services to, patients in the facility in consultation with
the recipient and his parents, legal guardians, or appropriate others in whose care he
will be released after discharge;
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Department of Medical Assistance Services
CIPOC – cont’d
CIPOC MUST:
• State treatment objectives that must include measurable short-term and long-term goals and
objectives, with target dates for achievement;
•
Prescribe an integrated program of therapies, activities, and experiences designed to meet the
treatment objectives related to the diagnosis;
•
Describe comprehensive discharge plans and coordination of inpatient services and postdischarge plans with related community services to ensure continuity of care upon discharge
with the recipient's family, school, and community.
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Department of Medical Assistance Services
Reviews of CIPOC
The CIPOC MUST:
•
Be reviewed every 30 days by the team ;
• Include the dated signatures of the team members (including physician)
specified in the federal requirements (42 CFR 441.156);
i.e. Name, title, handwritten date
• Determine that services are being provided are/were required on an
inpatient basis; and
• Recommend changes in the plan as indicated by the recipients overall
adjustment as a resident.
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Department of Medical Assistance Services
Required Activities
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41
Department of Medical Assistance Services
Required Activities
Treatment must relate to the severity of illness with the goal of improving
the individual’s condition so services will no longer be needed, or
preventing progression to an acute stage.
The active treatment plan must relate to the admission diagnosis and reflect
all of the following:
A licensed professional (psychiatrist, clinical psychologist, licensed clinical
social worker, licensed professional counselor, clinical nurse specialist
psychiatric, school psychologist, psychiatric nurse practitioner, or marriage
and family therapist with education and experience with children and
adolescents) provides individual therapy three out of seven days. No more
than one session per day is billable.
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Department of Medical Assistance Services
Required Activities
The active treatment plan must relate to the admission diagnosis and reflect
all of the following (cont’d):
A minimum of 21 distinct sessions (excluding individual treatment, school
attendance, and family therapy) of appropriate treatment interventions are
provided each week (i.e., group therapy with specific topics focused to
patient needs; insight-oriented and/or behavior modifying). (Group medical
psychotherapy coverage is limited to once per day. Services for sensory
stimulation, recreational activities, art classes, excursions, or eating
together are not included as separately billable group psychotherapy
sessions. There is a maximum of ten individuals per group psychotherapy
session). Play/art/music therapy, occupational therapy, and physical therapy
may be included; however, these modalities of treatment must not be the
major treatment modality.
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Department of Medical Assistance Services
Required Activities
The active treatment plan must relate to the admission diagnosis and reflect
all of the following (cont’d):
The family, guardian, caretaker, or case manager is involved on an ongoing
basis with treatment planning. The family, guardian, or caretaker participates in
family therapy at a minimum of twice monthly except when the family
dysfunction is a reason for admission, then family therapy should be at least
once per week. At least one of these family therapy sessions must be face-to
face each month. Family therapy is limited to one unit per day, regardless of
the number of participants or family members in the session. If the family,
guardian, or caretaker is not involved as required, documentation must
demonstrate why it is not feasible or not in the best interest of the child for the
family to participate. Alternatives for treatment due to the lack of a family’s
involvement should be addressed (telephonic therapy is a non-reimbursable
service) and the discharge plan revised to address the lack of family
involvement.
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Department of Medical Assistance Services
Required Activities
Active treatment and comprehensive discharge planning for aftercare
placement and treatment must begin at admission.
• The discharge planning MUST start at admission.
• Both of the Initial Plan of Care (IPOC) and Comprehensive Individual Plan
of Care (CIPOC) require a discharge plan to be completed.
• The discharge plan identifies the needed services to assist the youth to
maintain stability within the community.
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Department of Medical Assistance Services
Limitations
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Department of Medical Assistance Services
Limitations
The Comprehensive Individual Plan of Care (CIPOC) is a written plan
developed for each individual. The CIPOC must be completed no later than
14 days after admission for residential treatment and must include the dated
signatures of the team members specified in the federal requirements (42
CFR 441.156). The CIPOC must be completed before requesting continued
stay.
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Department of Medical Assistance Services
Limitations
Continued residential level of care is not appropriate and will not be covered
when one or more of the following exist (severity of illness and intensity of
treatment should be reviewed):
• The stabilization of presenting symptoms with demonstrated ability to
perform ADLs appropriate for age and to function appropriately within
residential environment and a community setting;
• The required treatment can be provided in a less restrictive environment;
• There is documented evidence, from the use of day and an overnight pass,
that the recipient has been able to function safely and satisfactorily within
the community;
• There has been no documented evidence of a change in treatment plan
when the individual has not responded for a 20-day period; or
• The individual refuses to cooperate with the treatment plan.
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Department of Medical Assistance Services
Reimbursement Rate
CSA or Non-CSA
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Department of Medical Assistance Services
Reimbursement Rate Certification
For CSA Cases Only:
• Negotiated rate between locality and facility;
• Total rate can be no more than the Medicaid maximum;
• Payment from any other source such as Title IV-E, must be deducted prior
to establishing the rate.
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Department of Medical Assistance Services
Reimbursement Rate Certification
• Identify the responsible locality
– Locality code must be sent in for Service Authorization (SA)
– If the rate is revised by the locality, it must be sent in to KePRO within
1 week to update the SA
• Payment is based on the rate on the certification which is entered by
KePRO into the MMIS.
• All versions of the rate certification must be available at the facility for
review.
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Department of Medical Assistance Services
Reimbursement Rate Certification
NON-CSA Cases:
• Must have a NON-CSA rate established by DMAS in order to request SA
from KePRO.
• Contact Provider Reimbursement at 804-686-7931 to establish a rate. This
should be done at the time of enrollment as a provider.
• If no rate has been established, the request for SA will be rejected by
KePRO.
– If a rate is later established, the request will not be retroactive.
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Department of Medical Assistance Services
Service Authorization
(SA)
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53
Department of Medical Assistance Services
Service Authorization Contractor
KePRO is the DMAS contractor for Service Authorization (SA).
For questions go to the SA website:
DMAS.KePRO.org and click on Virginia Medicaid
Phone: 1-888-VAPAUTH or 1-888-827-2884
Fax: 1-877-OKBYFAX or 1-877-652-9329
Web:
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[email protected]
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Department of Medical Assistance Services
Service Authorization Contractor
Submitting a request
• The preferred method is through the Atrezzo® web-based program
• Registration is required
• Information on Atrezzo is available on the KePRO website, or call 1-888827-2884 or (804) 622-8900 or mail to:
» KePro
» 2810 North Parham Rd, Suite 305
» Henrico, Virginia 23294
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Department of Medical Assistance Services
Service Authorization Contractor
Submitting a request continued…
Continued Stay Requests:
• Continued Stay Requests may be faxed or submitted through Atrezzo and
questions #1-#16 AND questions #20-#26 MUST be completed.
• If utilizing the Atrezzo Service Authorization Checklist complete the
Continued Stay Request Service Authorization sheet.
Retro Requests:
• For a Retro-authorization request, complete ALL questions.
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Department of Medical Assistance Services
Service Authorization Contractor
Submitting a request continued…
• For a CSA case, there must be 4 signatures on the CON including the
physician and 3 FAPT members.
• For Non CSA cases, the CON must be completed by the CSB and signed
by a physician and the CSB screener.
• All signatures must be individually dated and the last signature date is the
date of completion.
• The CANS must be completed and current within 90 days prior to the start
date being requested.
• The Initial Plan of Care must be signed within 24 hours of admission.
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Department of Medical Assistance Services
Reminders
• When documenting that the failed placements were unsuccessful, provide
information regarding why the placements were not successful.
• Treatment failures refers to the lack of improvement of an individual’s
symptoms and behaviors in previous treatment.
• Documentation should reflect that the behaviors have been present for at
least 6 months and that they will persist for longer than 1 year without
treatment.
• Documentation should support that the individual would be unable to be
treated safely at a less intensive level of care.
• Documentation should reflect the individual’s inability or unwillingness to
follow instructions, perform ADLs or maintain behavioral control.
• Information should be submitted as it relates to the individual’s formal and
informal support systems.
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Department of Medical Assistance Services
Contacts
Helpful Resources:
• Virginia Medicaid Web Portal link
www.virginiamedicaid.dmas.virginia.gov
• DMAS Office of Behavioral Health:
– Email Address [email protected]
• DMAS Helpline:
www.dmas.virginia.gov
www.vita.virginia.gov
804-786-6273
1-800-552-8627
Richmond Area
All other
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