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Substance Use Disorder Treatment Provider Manual September 2015 0 Substance Use Disorder Treatment Provider Manual This page intentionally left blank. 1 Contents SUBSTANCE USE DISORDER TREATMENT PROVIDER MANUAL INTRODUCTION ............................................................................................................................ 6 SFHN PHILOSOPHY OF CARE ................................................................................................. 6 SUBSTANCE USE DISORDER TREATMENT SERVICES PROGRAM OVERSIGHT..................................................................................................................................... 6 Substance Use Disorder Treatment Provider Manual DHCS VOLUNTARY TREATMENT CERTIFICATION & DMC CERTIFICATION 6 NEW TITLE 22: DRUG MEDI-CAL PROGRAM INTEGRITY REGULATIONS....... 7 AFFORDABLE CARE ACT OF 2010 AND DRUG MEDI-CAL CERTIFICATION .... 8 DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM WAIVER & SFHN-BHS REQUIREMENTS ........................................................................................................................... 8 MODALITIES COVERED BY PROVIDER MANUAL ........................................................ 9 ROLE OF THE MEDICAL DIRECTOR................................................................................... 9 THE SUD TREATMENT PROCESS ........................................................................................ 10 Client Engagement ...................................................................................................................................... 10 Key SUD Intake, Admission and Treatment Process Milestones ............................................................... 11 Intake, Assessment and Admission Requirements ...................................................................................... 12 Physical Examinations .....................................................................................................................................12 Naltrexone Treatment Admission Requirements .............................................................................................13 Narcotic Treatment Program Admission Requirements ...................................................................................13 Perinatal Treatment Admission Requirements .................................................................................................14 Non-DMC Residential Treatment Admission Requirements ...........................................................................14 Initial Treatment Plan ................................................................................................................................. 14 Updated Treatment Plans ............................................................................................................................ 15 Non-DMC Residential Updated Treatment Plan Requirements .......................................................................16 2 Client Contacts ............................................................................................................................................ 16 Table of Client Contact Requirements ........................................................................................................ 18 Day Care Habilitative .......................................................................................................................................18 Collateral Services............................................................................................................................................19 Individual Counseling ..................................................................................................................................... 19 Crisis Intervention Counseling ........................................................................................................................ 19 Progress Notes ................................................................................................................................................. 19 Table of Progress Note Timelines ................................................................................................................... 20 Day Care Habilitative ...................................................................................................................................... 20 Continuing Services ..................................................................................................................................... 20 Discharge Plan ............................................................................................................................................. 21 Discharge Summary ........................................................................................................................................ 22 AVATAR AND CALOMS TREATMENT DATA ENTRY REQUIREMENTS ........... 22 CLIENT RECORD AND RETENTION REQUIREMENTS ............................................. 23 BILLING .......................................................................................................................................... 24 SFHN Services Code Project ....................................................................................................................... 24 DMC Multiple Same Day Services .............................................................................................................. 24 DMC Client Share of Cost........................................................................................................................... 25 Good Cause Codes ....................................................................................................................................... 25 PROGRAM COMPLIANCE ...................................................................................................... 25 GLOSSARY OF TERMS ............................................................................................................. 27 ABOUT THE CONTRIBUTORS .............................................................................................. 32 APPENDIX A – SFHN-BHS PHILOSOPHY OF CARE ..................................................... 34 Substance Use Disorder Treatment Provider Manual CLIENT FAIR HEARING RIGHTS ........................................................................................ 22 APPENDIX B – DPH DRUG MEDI-CAL CERTIFICATION REQUIREMENT CHECKLIST................................................................................................................................... 38 APPENDIX C – DHCS SUBSTANCE USE DISORDER MODALITY MATRIX ........ 39 APPENDIX D – SUBSTANCE USE DISORDER TREATMENT SERVICES BY MODALITY .................................................................................................................................... 41 Outpatient Drug Free Treatment ................................................................................................................ 41 Day Care Habilitative .................................................................................................................................. 41 3 Narcotic Treatment Program ...................................................................................................................... 41 Naltrexone Treatment ................................................................................................................................. 42 Residentially Based Substance Use Disorder Treatment ............................................................................ 42 APPENDIX E - INDIVIDUAL CLIENT RECORD DATA SET LIST............................. 43 Substance Use Disorder Treatment Provider Manual APPENDIX F – SAMPLE COMPLIANCE AUDIT TOOL ................................................ 45 4 Substance Use Disorder Treatment Provider Manual This page intentionally left blank. 5 Substance Use Disorder Treatment Provider Manual Introduction The SFHN Substance Use Disorder (SUD) Treatment Provider Manual (“Provider Manual”) offers user friendly guidance to all City and County of San Francisco contracted and civil service SUD treatment providers, including Drug Medi-Cal (DMC) certified providers, in complying with State and San Francisco Health Network – Behavioral Health Services (SFHN-BHS) SUD treatment requirements and standards. The Provider Manual reflects the best possible quality client care standards and seeks to prevent program deficiencies that can lead to the assessment of recoupments. It has been developed in partnership with SUD treatment providers in the spirit of collaboration and transparency. Substance Use Disorder Treatment Provider Manual SFHN Philosophy of Care 6 The SFHN-BHS supports a philosophy of care that embraces the “Quadruple Aim” approach to optimizing health care system performance by improving the patient experience of care (including quality and satisfaction), improving the health of populations, reducing the per capita cost of health care, and striving for workforce excellence. Treatment is delivered through the lens of cultural humility and using a Wellness and Recovery Model that is infused with hope and a belief that all clients can achieve their life goals (Appendix A). Consistent with the philosophy of care for the SFHN-BHS, substance use disorder treatment services reflect harm reduction, a public health philosophy that promotes reducing the physical, social, emotional, and economic harm associated with drug and alcohol use, along with other harmful behaviors on individuals and their community. Harm reduction is free of judgment or blame and actively engages clients in setting their own treatment goals and their recovery. Please visit Harm Reduction Policy and Guiding Principles. Substance Use Disorder Treatment Services Program Oversight The Department of Health Care Services (DHCS) is responsible for administering SUD treatment in California (DHCS Substance Use Disorder Services). The San Francisco Department of Public Health SFHN-BHS contracts with DHCS to fund local SUD treatment services. As part of the contract with DHCS, SFHN-BHS ensures that state SUD treatment requirements and standards are met by maintaining fiscal management systems, monitoring provider billing, conducting compliance site visits, processing claims for reimbursement, and offering training and technical assistance to SUD treatment providers. DHCS Voluntary Treatment Certification & DMC Certification The Department of Health Care Services offers voluntary facility certification to programs providing outpatient, intensive outpatient, and nonresidential detoxification treatment. This voluntary certification is granted to programs that exceed minimum levels of service quality and are in substantial compliance with State program standards, specifically the Alcohol and/or Other Drug Certification Standards. In addition, DHCS provides Drug Medi-Cal Certification to SUD treatment providers that meet requirements found under Title 22 of the California Code of Regulations (CCR): 1) Section 51431.1 – Program Administration; 2) Section 51490.1 – Claim Submissions Requirements; and 3) Section 51561.1 – Reimbursement Rates and Requirements. Title 22 refers and ties to Title 9 of the CCR which governs requirements for Narcotic Treatment Programs. Providers are encouraged to learn more about state licensing and certification requirements by visiting the DHCS website. New Title 22: Drug Medi-Cal Program Integrity Regulations New DMC regulations cover documentation requirements for DHCS reviews, clarify existing regulations, and make programmatic changes to DMC regulations that impact individual and group counseling sessions, physical examination requirements, physician review requirements, client treatment plans, progress notes, and discharge planning. Following is a summary of DMC regulatory changes: Strengthening physical examination requirements during the intake process (physical examination waivers are no longer allowed); Requiring licensed physicians to review client personal, medical and substance use histories during the intake process; Allowing therapists, physician assistants, or nurse practitioners to evaluate clients to diagnose whether a client has a DSM 5 Substance Use Disorder, subject to a physician’s review and written approval; Requiring face-to-face contact occur in person at a certified facility (telephone contacts, home visits, and hospital visits are not considered face-to-face); Prohibiting minors from participating in group counseling sessions with adults except at certified school sites; Establishing a group counseling size of two to twelve participants (with at least one Medi-Cal eligible participant) for Outpatient Drug-Free, Narcotic Treatment Program, and Day Care Habilitative services; Revising requirements for group counseling session sign-in sheets; Requiring individual and group counseling sessions be conducted in confidential settings; Requiring clients, counselors, therapists and physicians to type or legibly print their name and date treatment plans, progress notes and discharge plans; Requiring client treatment plans to include client diagnoses and goals related to physical exams and medical illnesses; Requiring clients to participant in the preparation and review of their treatment plans and sign their treatment plans; Specifying when counselors and therapists must prepare progress notes; Requiring a licensed physician to review additional documents in determining whether continued services are medically necessary for a client; and Establishing a requirement for providers to prepare client discharge plans including plan content and documentation requirements. Substance Use Disorder Treatment Provider Manual As a result of the findings of targeted field reviews of DMC providers suspected of committing fraud and abuse within the State, the DHCS has promulgated new regulations under CCR, Title 22, Section 51341.1 in the form of a California State Plan Amendment. The DHCS DMC Program Integrity regulations address abusive and fraudulent practices, promote treatment practices that are based sound medical practice, and provide DHCS with increased regulatory authority to ensure both program integrity and that providers meet performance expectations. The Provider Manual incorporates the DHCS DMC Program Integrity Regulations which have been approved by the federal government and became effective July 1, 2015. 7 Affordable Care Act of 2010 and Drug Medi-Cal Certification Currently, the Substance Abuse Prevention and Treatment (SAPT) Block Grant is a primary source of support for SUD treatment programs in San Francisco. SAPT funding requirements do not allow grant funds to be used for services that have become an entitlement under Medicaid (Medi-Cal in California). Substance Use Disorder Treatment Provider Manual Under the federal Affordable Care Act (ACA) of 2010, drug rehabilitation is a new essential benefit (entitlement) that must be provided by health insurance sold on health insurance exchanges or provided by Medicaid to certain newly eligible adults. In other words, substance use disorder treatment services have become an entitlement under Medi-Cal. While the ACA offers an important new opportunity to leverage Medi-Cal funding to support increased local access to SUD treatment, it also will significantly impact local SUD treatment programs funded through SAPT. 8 Given the expected increase in the number of individuals who will be eligible to receive SUD treatment under the ACA, the SFHN-BHS will encourage SUD treatment providers to begin the process of obtaining DMC certification. It is expected that in the future, SFHN-BHS will require all funded SUD treatment providers to be DMC certified to continue to receive SFHN-BHS funding for SUD treatment services. The SFHN-BHS is committed to supporting SUD treatment providers in obtaining DMC certification. A DMC certification requirement checklist has been developed as a guide (Appendix B). For more information regarding DMC certification, please contact the DPH Business Contract Compliance Office at (415) 255-3400. Drug Medi-Cal Organized Delivery System Waiver & SFHN-BHS Requirements The “Drug Medi-Cal Organized Delivery System (DMC-ODS)” is a State Pilot to test a new paradigm for the organized delivery of health care services for Medicaid eligible individuals with substance use disorders. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs. Critical elements of the DMC-ODS Pilot include providing a continuum of care modeled after the American Society of Addiction Medicine (ASAM) Criteria for substance use disorder treatment services, increased local control and accountability, greater administrative oversight, new utilization controls to improve care and efficient use of resources, evidence-based practices in substance abuse treatment, and increased coordination with other systems of care. The DMC-ODS Pilot approach is expected to provide Medi-Cal clients with improved access to care and to support the level of system interaction needed to achieve sustainable recovery. The City and County of San Francisco will participate as a Phase I county under the DMC-ODS, effectively beginning in Fiscal Year 2015-16. Not only do DMC treatment standards and requirements reflect good clinical practice, but also they offer San Francisco the opportunity to improve access to high quality care under the DMCODS Pilot program. In an effort to encourage SFHN-BHS funded SUD treatment providers to obtain DMC certification and align SFHN-BHS SUD treatment requirements under the DMCODS Pilot, beginning in Fiscal Year 2015-16 and beyond, all SUD treatment providers will be required to adhere to DMC treatment standards and requirements regardless of their DMC certification status, unless otherwise stated in the Provider Manual. Modalities Covered by Provider Manual The SFHN-BHS Provider Manual covers the following SUD treatment modalities1: Outpatient Drug Free (ODF) Narcotic Treatment Program (NTP) Naltrexone Treatment Day Care Habilitative Services (see note below re: Intensive Outpatient Services)2 Residentially Based Substance Use Disorder Services (incorporates Perinatal Residential Substance Use Disorder Services) Role of the Medical Director While SUD treatment providers may have more than one physician or medical director on staff, the medical director has medical responsibility for all clients and must be available on a regularly scheduled basis. Duties of a medical director may vary, but at a minimum, DMC certified treatment provider medical directors must be responsible for: Establishing, reviewing, maintaining medical policies and standards; Ensuring the quality of medical services provided to all clients; Ensuring that at least one physician providing services for the provider has admitting privileges to a general acute hospital; and Ensuring that a physician has assumed medical responsibility for all clients treated by the provider. Medical Necessity All SUD treatment providers must ensure that treatment services are medically necessary. Medical necessity is established when a client is diagnosed with a substance use disorder based on the Diagnostic and Statistical Manual (DSM) of Mental Health Disorders 5, and the DSM diagnosis is documented in the individual client record within 30 calendar days of the client’s admission to treatment date, no sooner than 5 months and no later than 6 months after a client’s admission to treatment, or the completion of the most recent justification for services. DSM codes that may be used include mental, emotional, psychological, behavioral and substance use codes. Medical necessity also may include a physical examination and laboratory testing by staff lawfully authorized to provide such services. Substance Use Disorder Treatment Provider Manual While intake/assessment and treatment plans are standardized across SUD treatment modalities, there are some differences in the type and frequency of required client services by modality. Please see Appendix C & Appendix D for modality service descriptions and a DHCS matrix depicting substance use disorder services by treatment modality. Physicians, therapists, physician assistants, or nurse practitioners acting within the scope of their respective practices may evaluate whether a client has a substance use disorder at intake. Where a therapist, physician assistant or nurse practitioner performs a client diagnosis, a physician must review each client’s diagnosis and document his or her approval of the diagnosis by signing legibly and dating the client’s treatment plan. 9 1 The DHCS has proposed medically necessary Intensive Inpatient Detoxification as a new substance use disorder treatment service for the general treatment population. The DPH DMC Provider Manual will be revised to cover this new service when additional information is available from DHCS regarding specific regulatory requirements. 2 The DMC-ODS Organized Delivery Pilot requires counties to provide Intensive Outpatient Services which are similar in scope to day care habilitative services. For all DMC certified providers, medical necessity must be established by the Medical Director who must be a physician licensed by the Medical Board of California or the Osteopathic Medical Board of California. Throughout the treatment process, client records must document and demonstrate that a physician directed the provision of treatment including the establishment of medical necessity at admission and for continuing services, the development and review of client treatment plans, and medical consultation and evaluation. Substance Use Disorder Treatment Provider Manual The SUD Treatment Process 10 The SUD treatment process reflects a logical approach that can be applied to solving challenges in any area. Solving a challenge begins with the preliminary identification of the general nature of the challenge, followed by a more detailed determination of the specifics of the challenge. For substance use disorder treatment providers, this preliminary step is the intake process of admission (identifying the challenges faced by a client and establishing how a provider can help) and assessment (determining the various issues that make up the challenge). As a next step in the process, a treatment plan is developed in partnership with clients to address issues identified during the assessment process, followed by the implementation of the treatment plan (clients receiving treatment and referrals). The treatment plan is continually updated and changed to reflect any changes in problems or a new treatment focus. When SUD treatment services are completed and a program determines that the client has made sufficient progress to be discharged, providers discharge a client, prepare a discharge plan, and close the client record. If any of the SUD treatment process steps are not completed, the chances for positive client and program compliance outcomes are greatly reduced. Please see the table on the next page which summarizes major treatment milestones. Client Engagement All SUD provider must have a treatment planning process that meaningfully engages clients in the development of initial treatment plans and any updates to the treatment plan. Each client must review, approve, type or legibly print their name, sign and date his or her treatment plans and indicate whether he or she was involved in the plan’s development. If a client refuses to sign his or her treatment plan, providers must indicate the reason for refusal and document strategies that will be taken to engage the client in treatment. Intake and Admission Initial Treatment Plan Treatment Plan Update(s) Medical Necessity for Continued Services Discharge Plan Discharge Summary Must complete a personal, medical, and substance use history for each client that evaluates the cause or nature of each client’s mental, emotional, psychological, behavioral and substance use disorders. Must complete DPH Health Questionnaire for each client. Must assess each client for whether he/she had physical examination within last 12 months; if none, then physician, registered nurse practitioner, or physician’s assistant must conduct an exam within 30 calendar days of the client’s admission to treatment date OR must include a goal within the client’s initial and updated treatment plans to obtain a physical examination until completed. Must evaluate each client to diagnose DSM 5 substance use disorder within 30 calendar days of the client’s admission to treatment date; must be completed by a physician OR can be done by therapist, physician assistant, or nurse practitioner (with review/approval of a physician). Must determine medical necessity within 30 calendar days of a client’s admission to treatment date (must be determined by physician). Must conduct laboratory tests (Naltrexone and NTP clients) and certify fitness for treatment (Naltrexone clients). Must be completed, signed and dated within 30 calendar days of a client’s admission to treatment date and signed by the therapist or counselor and the client (28 calendar days for NTP clients). Must be reviewed for medical necessity by physician, signed and dated 15 calendar days of the signature of the therapist or counselor. Must be completed, signed and dated by a therapist or counselor no later than 90 calendar days after signing the initial treatment plan, and no later than 90 days calendar days thereafter or when a change in problem identification or focus of treatment occurs. Must be reviewed, approved, signed and dated by client indicating whether client participated in the preparation of the plan within 30 calendar days of the signature of the therapist or counselor. Must be reviewed for medical necessity by physician, signed and dated 15 calendar days of the signature of the therapist or counselor. Must determine need for continued treatment no sooner than 5 months and no later than 6 months after client admission to treatment date or date of completion of most recent justification for continuing services. Must be determined and documented by a physician. Substance Use Disorder Treatment Provider Manual Key SUD Intake, Admission and Treatment Process Milestones Must be completed for all discharged clients by the therapist or counselor within 30 calendar days prior to the last face-to-face treatment with the client. Must be signed by the therapist or counselor and the client with a copy provided to the client and placed in the client record. Must be completed by the provider within 30 calendar days of the last face-to-face contact for each client with whom the provider has lost contact and for all involuntary discharges. 11 Intake, Assessment and Admission Requirements3 The first step in the treatment process is client intake and assessment. Drug Medi-Cal requires all providers to have written documentation on procedures for client admission to SUD treatment. The SFHN-BHS is adopting this standard for all SUD treatment providers regardless of their DMC certification status. Substance Use Disorder Treatment Provider Manual A client admission to treatment date is the date on which any face-to-face treatment service is provided to a client. Once an individual has completed the intake and assessment process, the individual becomes a client of the program. 12 All SUD treatment providers, regardless of DMC certification status, must complete a personal, medical and substance use history4 for each client upon admission to treatment to support the treatment plan for each client. In addition, all providers must complete a SFHN Health Questionnaire for each client and enter the required information into Avatar, the SFHN-BHS electronic behavioral health record system. For DMC certified programs, a licensed physician must review each client’s history within 30 calendar days of each client’s admission to treatment date. Physical Examinations5 Substance use can complicate and lead to serious health conditions making it important to assess medical illnesses that clients may face. If left untreated, significant medical illnesses may lead to poor treatment outcomes and years of life lost. Additionally, a central element of the San Francisco Health Network’s philosophy of care is to provide “whole person care” that meets a client’s behavioral health and primary care needs wherever a client accesses services. All SUD treatment providers, regardless of DMC certification status, must consider client physical health information when developing SUD treatment plan goals. For DMC certified programs, all clients must be assessed for whether they have had a physical examination within the twelve-month period prior to admission to treatment. Physical examination waivers are no longer allowable for DMC certified providers. Consistent with the SFHN-BHS philosophy of care, the SFHN-BHS is adopting this DMC physical examination standard for all SUD treatment providers regardless of their DMC certification status. If documentation of a physical examination cannot be obtained, providers must describe in the client record efforts taken to obtain documentation. For all clients in DMC certified programs that had physical exams within the twelve months prior to treatment admission, a physician must review the exam within 30 calendar days of the treatment admission date to determine whether the client has any significant medical illnesses. A copy of the physical exam must be included in the client record. For any significant medical illnesses, the client’s initial and updated treatment plans must incorporate a goal to obtain appropriate treatment for the illnesses. For non-DMC certified providers, program staff must consider client physical health information in developing and updating client treatment plans. When there is no documentation of a client physical exam within the last twelve months from the admission to treatment date, DMC certified providers must either incorporate a physical 3 Section 51341.1(h), Title 22, CCR 4 Section 51341.1(b)(13), Title 22, CCR 5 Section 51341.1(h)(1)(A)(iv)(a)(b)&(c), Title 22, CCR exam as a client goal in the initial and updated treatment plans or conduct a physical exam of the client within 30 calendar days of the admission to treatment date. A physician, registered nurse practitioner or physician’s assistant may conduct the exam. A copy of the exam must be included in each client record. It is not sufficient to include a progress note alone that the exam was completed. The SFHN-BHS is adopting this DMC standard for all SUD treatment providers regardless of their DMC certification status. Has a documented history of opiate addiction; Is at least 18 years of age; Has been opiate free for a period of time to be determined by a licensed physician based on the physician’s clinical judgment (this includes the administration of a body specimen test to confirm the opiate free status of the client); and Is not pregnant (a client must be discharged from treatment if she becomes pregnant during treatment). In addition, a licensed physician must certify each client’s fitness for treatment based on the client’s physical examination, medical history, and laboratory results. The physician also must advise each client of the overdose risk should he or she return to opiate use while taking Naltrexone and the ineffectiveness of pain relievers while on Naltrexone. Narcotic Treatment Program Admission Requirements6 For DMC certified programs providing Narcotic Treatment Program services, the following DMC regulations must be met before an individual may be admitted into detoxification or maintenance treatment. The medical director (licensed physician) must conduct a medical evaluation or document the review and concurrence of a medical evaluation for each client which includes at a minimum: 1. A medical history, including the individual’s history of illicit drug use; 2. Laboratory tests for determination of narcotic drug use, tuberculosis and syphilis (unless the medical director has determined the individual’s subcutaneous veins are severely damaged to the extent that a blood specimen cannot be obtained); and Substance Use Disorder Treatment Provider Manual Naltrexone Treatment Admission Requirements All Naltrexone treatment providers must comply with the following requirements in addition to client intake and admission requirements listed in the prior section above. Naltrexone providers must confirm that each client meets all of the following requirements: 3. A physical examination including, at minimum, the following: a. An evaluation of the individual’s organ systems for possibility of infectious diseases; pulmonary, liver or cardiac abnormalities; and negative dermatologic impacts of addiction; b. A record of the individual’s vital signs (temperature, pulse, blood pressure and respiratory rate); c. An examination of the individual’s head, ears, eyes, nose, throat (including thyroid), chest (including heart, lungs, and breasts), abdomen, extremities, skin and general appearance; 6 Section 10270, Title 9, CCR 13 d. An assessment of the individual’s neurological system; and e. A record of the physician’s overall impression which identifies any medical condition or health problem for which treatment is warranted. In addition, before a client can be admitted to detoxification or to maintenance treatment, the medical director (licensed physician) must: Substance Use Disorder Treatment Provider Manual 1. Document the evidence or review and concur with the documentation of evidence used from the medical evaluation to determine physical dependence and addiction to opiates; and 2. Document the final determination concerning physical dependence and addiction to opiates. Perinatal Treatment Admission Requirements7 SUD treatment providers serving pregnant and postpartum women must meet additional admission criteria that include: Confirming that a client is eligible for and received Medi-Cal during the last month of pregnancy; Having medical documentation that substantiates the client’s pregnancy and last day of pregnancy; Receiving enhanced reimbursement rate only during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy; Terminating eligibility for perinatal treatment services on the last day of the month in which the 60th day occurs. Non-DMC Residential Treatment Admission Requirements8 For non-DMC residential treatment providers, initial client treatment plan requirements include: For short-term residential programs (a program duration of 30 days or less), the initial treatment plan must be developed within 10 days from the client’s admission to treatment date; For long-term residential programs (a program duration of 31 days or more), the initial treatment plan must be developed within 14 days of the client’s admission to treatment date. Initial Treatment Plan The SFHN-BHS is adopting DMC initial treatment plan requirements for all SUD treatment providers regardless of their DMC certification status. An initial treatment plan must be completed, signed and dated for each client within 30 calendar days of a client’s treatment admission date by a therapist or counselor and the client. If a client refuses to sign the treatment plan, providers must document in the client record the reason for refusal and the strategy to engage the client to participate in treatment. 14 For Narcotic Treatment Program clients, the initial treatment plan must be completed within 28 days after the initiation of maintenance treatment.9 7 Sections 50260, 51303, 51341.1(c)(1), 51341.1(g)(1)(A)(iii), Title 22, CCR Section 12070, Alcohol and/or Other Drug Certification Standards 9 Section 10305, Title 9, CCR 8 Each treatment plan must be documented, individualized, and based on information obtained during the intake and assessment. There also must be clear and documented links between client needs, treatment goals and provided services. In addition, the rationale and justification for the content of each of client treatment plan components must be well documented. In assessing treatment needs, all SUD treatment providers must consider, at a minimum, client needs in the following areas: 1) educational opportunity/attainment; 2) vocational counseling and training; 3) job referral and placement; 4) legal services; 5) medical and dental services; 6) social/recreational services; and 7) individual and group counseling. A statement of challenges to be addressed; Goals to be reached which address each challenge identified; Action steps which will be taken by the provider and/or client to accomplish identified goals; Target dates for the accomplishment of action steps and goals; A description of the services including type and frequency of counseling to be provided; Client diagnosis; A physical examination goal if the client has not had a physical exam within the twelve months prior to the client’s admission to treatment date; A goal that the client obtain appropriate treatment for any significant medical illness indicated/documented by a physical examination which occurred within the twelve months prior to treatment admission; Include the names of the assigned primary therapist or counselor and physician. For DMC certified providers, all initial treatment plans must be reviewed for medical necessity by a licensed physician and signed and dated by the physician within 15 calendar days of the date of the signature of the therapist or counselor. For NTP providers, all initial maintenance treatment plans must include: Short-term goals tied to client needs based on intake and admission data (specific time 90 days or less for the client to achieve); Long-term goals tied to client needs based on intake and admission data (specified time in excess of 90 days for the client to achieve); Specific behavioral tasks the client must accomplish to complete each short-term and long-term goal; A description of the type and frequency of counseling services to be provided; An effective date based on the day the primary counselor signed the initial treatment plan. Updated Treatment Plans10 All client treatment plans must be updated, signed and dated by a therapist or counselor no later than 90 calendar days after signing the initial treatment plan, and no later than 90 calendar days thereafter, or when a change in problem identification or focus of treatment occurs. 10 Section 51341.1(h)(2), Title 22, CCR Substance Use Disorder Treatment Provider Manual Each client treatment plan must be legible and include: 15 Substance Use Disorder Treatment Provider Manual Each updated treatment plan must include all of the components included in the initial treatment plan and be reviewed, approved, signed and dated by client within 30 calendar days of the signature of the therapist or counselor. The treatment plan also must indicate whether the client participated in the preparation of the plan. If a client refuses to sign the treatment plan, providers must document in the client record the reason for refusal and the strategy to engage the client to participate in treatment. 16 Narcotic Treatment Program Updated Treatment Plan Requirements11 For NTP providers, updated treatment plans must be reviewed and signed within 14 calendar days from the effective date and reviewed and signed by the medical director within 14 calendar days form the effective date. Client updated treatment plans also must include: 1) a summary of the client’s progress or lack of progress toward each goal identified on the previous treatment plan; and 2) new goals and behavioral tasks for any newly identified needs or related changes in the type and frequency of counseling services to be provided to the client; and 3) an effective date based on the day the primary counselor signed the updated treatment plan. Non-DMC Residential Updated Treatment Plan Requirements12 Residential treatment programs must meet the following updated treatment plan requirements: For short-term residential programs (a program duration of 30 days or less), the initial treatment plan must be updated within 10 days after signing the initial treatment plan and not later than every 10 days thereafter; For long-term residential programs (a program duration of 31 days or more), the initial treatment plan must be updated within 14 days of after signing the initial treatment plan and not later than every 14 days thereafter. Client Contacts All SUD treatment providers must meet a set of treatment plan implementation requirements governing client contact, including the type, number and length of counseling sessions, and client participation in treatment. These requirements may vary depending upon the SUD modality of service and DMC requirements. The table on the next page provides a summary of client contact requirements by modality along with documentation and group size requirements. Note that the frequency of counseling sessions may occur more often depending on the client’s need and recovery or treatment plan. For SUD providers other than NTP providers, client contact requirements can be waived if a physician determines either that fewer contacts are clinically appropriate or the client is making progress toward treatment plan goals. Any exceptions must be noted in the individual client record by a physician, and the physician must type or print legibly his or her name, sign and date the record. For Narcotic Treatment Programs, the medical director (physician) may adjust or waive this minimum number of minutes of counseling services per calendar month by medical order. The medical director also must document his or her rationale for the medical order within the individual client record. Group Counseling Confidentiality Group counseling sessions must be face-to-face and conducted in a confidential setting where individuals not participating in the counseling session cannot hear the comments of the client or therapist/counselor. 11 12 Section 10270, Title 9, CCR Section 12070, Alcohol and/or Other Drug Certification Standards Group Counseling Age Requirements SFHN is adopting the DMC standard for age considerations for all SUD treatment providers, regardless of DMC certification status. A client who is seventeen years of age or younger cannot participate in group counseling with clients who are eighteen years of age or older unless the counseling occurs at a DMC certified program’s school site. 1. The name and signature of the therapist and/or counselor conducting the counseling session; 2. The date of the counseling session; 3. The topic of the counseling sessions. 4. The start and end time of the counseling session; and 5. Each participant’s name and signature of each participant that attended the counseling session. The sign-in sheet must be signed at the start of or during the counseling session. By signing the sign-in sheet, therapists and counselors are certifying that the sign-in sheet is accurate and complete. Substance Use Disorder Treatment Provider Manual Group Counseling Sign-In Requirements All SUD treatment providers, regardless of DMC certification status, must document the focus of group counseling sessions and must have a sign-in sheet, which includes all of the following: 17 Table of Client Contact Requirements SUD Modality Substance Use Disorder Treatment Provider Manual ODF NTP Minimum Contact Requirements Minimum # of Clients for Groups Maximum # of Clients for Groups # of DMC Beneficiaries Required per Group Sessions must focus on short-term personal, family, employment, educational and other client needs and their relationship to substance use or a return to substance use. Sessions must focus on short-term personal, family, employment, educational and other client needs and their relationship to substance use or a return to substance use. Each client must receive at least two group counseling sessions per month. No less than 2 clients No more than 12 clients Only one client needs to be a Medi-Cal beneficiary Each client must receive a minimum of 50 minutes of counseling per calendar month. No less than 2 clients No more than 12 clients Only one client needs to be a Medi-Cal beneficiary Each client must receive counseling sessions and/or structured therapeutic activities a minimum of three hours per day for three days per week. Each client must receive counseling sessions and/or structured activities a minimum of 20 hours per week. No less than 2 clients No more than 12 clients Only one client needs to be a Medi-Cal beneficiary Day Care Habilitative Residential 18 Notes about the Group & Progress Note Structured activities must meet treatment goals and objectives for increased social responsibility, selfmotivation and integration into the community. These activities may include employment, educational or volunteer hours outside the program site. Narcotic Treatment Program - Medical Psychotherapy Sessions For clients in NTP programs, medical psychotherapy sessions are defined as face-to-face discussions between the medical director and/or physician and the client on issues identified in the client treatment plan. Individual Counseling Individual counseling sessions between a therapist or counselor and a client must be face-toface and be conducted in a confidential setting where individuals not participating in the counseling session cannot hear the comments of the client, therapist or counselor. Individual counseling sessions cannot be provided via telephone, home visits or hospital visits and are limited for ODF clients to intake, crisis intervention, collateral services and discharge planning. Crisis Intervention Counseling Crisis intervention counseling must be provided face-to-face between a therapist or a counselor and a client in crisis. A crisis must be an actual relapse or an unforeseen event or circumstance causing imminent threat of relapse. Crisis intervention services must include a focus on alleviating crisis challenges and must be limited to stabilization of the client’s emergency situation. Progress Notes The SFHN-BHS is adopting the DMC standards for progress notes for all SUD treatment providers regardless of DMC certification status. Progress notes tell a client’s treatment story. While progress note requirements vary depending on the treatment modality, a client’s therapist or counselor must document, sign and date each progress note. For ODF and Naltrexone treatment, each progress note must include the following elements: Substance Use Disorder Treatment Provider Manual Collateral Services For all SUD treatment providers, regardless of DMC certification status, collateral services must be provided by therapists and counselors. Collateral services are defined as face-to-face contact with significant persons in the life of the client. Significant persons are defined as individuals that have a personal, not official or professional, relationship with the client. For example, a client’s social worker would not meet the “significant persons” criteria. Each collateral service must focus on the treatment needs of the client to support the achievement of treatment plan goals. A client does not need to be present at the collateral service for the service to billable to DMC. 1. The topic of the session; 2. A description of the client’s progress on treatment plan challenges, goals, action steps, objectives and/or referrals; 3. Information on the client’s attendance including the date, start and end times of each individual and group counseling session. For Narcotic Treatment Programs, the counselor conducting the counseling session must document for each client participating in the counseling session the: 1. Date of counseling session; 2. Type of counseling format (e.g. individual or group); 19 3. Duration of counseling session in ten-minute intervals excluding the time required to document the session; 4. Summary of the session including one or more of the following: a) client progress toward one or more treatment plan goals; b) response to a drug-screening specimen which is positive for illicit drugs or negative for the replacement narcotic therapy medication dispensed under the program; c) new issue or challenge that affects the client’s treatment; d) nature of prenatal support provided by the program or other appropriate health care providers; and e) goal and/or purpose of the group session, the subjects discussed, and a brief summary of the client’s participation. Please see the table below for progress note timeline and content requirements. Substance Use Disorder Treatment Provider Manual Table of Progress Note Timelines Program Type ODF/Naltrexone NTP When to Record Progress Note For each individual and group counseling session, the therapist or counselor who conducted the session must record a progress note for each participating client and type or legibly print his or her name, and sign and date the progress note within seven calendar days of the counseling session. The counselor must record a progress note for each participating client within fourteen calendar days of the counseling session. Day Care Habilitative The therapist or counselor must record a minimum of one progress note per calendar week for each client participating in structured activities including counseling sessions. Residential The therapist or counselor must record a minimum of one progress note per calendar week for each client participating in structured activities including counseling sessions. Continuing Services13 The SFHN-BHS is adopting DMC standards for continuing service for all SUD treatment providers, regardless of DMC certification status. No sooner than five months and no later than six months after treatment admission or the date of completion of the most recent justification for continuing services, the need for continued treatment must be determined. A client’s therapist or counselor must review the client’s progress and eligibility to continue to receive SUD treatment and recommend whether the client should continue to receive treatment services. All of the following continuing service justification areas must be considered in making a recommendation for continuing services: 20 13 A client’s personal, medical and substance use history; Documentation of a client’s most recent physical examination; A client’s progress notes and treatment plan goals; and Section 51341.1(h)(5)(A)(i), Title 22, CCR A client’s prognosis. For DMC certified sites, a physician must determine whether continued services are medically necessary. The determination of medical necessity must be documented the physician in the client record and shall include all of the above continuing service justification areas in addition to the therapist’s or counselor’s recommendation for continuing services. A physician signed updated treatment plan at the six month point of treatment services does not meet the continuing service requirement. There must be an actual determination by a physician of the need for continued treatment based on medical necessity. For all SUD treatment providers, regardless of DMC certification status, all billings submitted after the date that the justification is due may be disallowed if the justification to continue services is missing from a client record. Narcotic Treatment Program Continuing Service Requirements For NTP programs, the medical director and/or physician must discontinue a client’s maintenance treatment within two consecutive years after treatment began unless the medical director and/or physician complete the following: Evaluates client progress or lack of progress in achieving treatment goals in the progress notes; and Determines through clinical judgment that the client status indicates that such treatment should be continued for a longer period of time as discontinuance from treatment would lead to a return to opiate addiction. Client status in treatment must be re-evaluated at least annually after two consecutive years of maintenance treatment. The medical director and/or physician must document the facts justifying the decision to continue client treatment in the client record. Discharge Plan The SFHN-BHS is adopting the DMC standards for discharge for all SUD treatment providers, regardless of DMC certification status. Substance Use Disorder Treatment Provider Manual The therapist or counselor must discharge the client from treatment if the physician determines that continuing treatment for the client is not medically necessary. Clients may be discharged voluntarily or involuntarily from SUD treatment. When SUD treatment is completed and the therapist or counselor determines that the client has made sufficient progress toward or accomplished treatment plan goals, the counselor/therapist may discharge the client. As part of discharge, the therapist or counselor works with the client to develop a discharge plan that must include at a minimum: A description of the client’s relapse triggers14 and a plan to assist the client to avoid relapse when confronted with each relapse trigger; and A support plan.15 14 A relapse trigger is defined as event(s), circumstance(s), place(s), or person(s) that puts a client at risk of relapse (single instance substance use or pattern of substance use). 15 A support plan is a list of individuals and/or organizations that can provide support and assistance to a client to maintain sobriety. 21 For DMC certified providers, when a physician determines that continuing treatment services is not medically necessary, a client discharge plan must be completed by the assigned therapist or counselor within 30 calendar days prior to the date of the last face-to-face treatment with the client. During the last face-to-face treatment, the therapist/counselor and the client must document their names legibly, sign and date the discharge plan. A copy of the discharge plan must be provided to the client and must become part of the client record. Substance Use Disorder Treatment Provider Manual Discharge Summary For a client with whom a provider has lost contact or who does not attend treatment for more than 30 days, providers must discharge the client and complete a discharge summary within 30 calendar days of the date of the provider’s last face-to-face treatment contact with the client. The discharge summary must include: 1) the duration of the client’s treatment, as determined by the dates of admission to and discharge from treatment; 2) the reason for discharge; 3) a narrative summary of the treatment episode; and 4) the client’s prognosis. Narcotic Treatment Program Discharge Requirements NTP counselors must develop a discharge summary for each client who is voluntarily or involuntarily discharged from the program that includes at a minimum: 1) client name; 2) date of discharge; 3) reason for discharge, and 4) summary of the client’s progress during treatment. Client Fair Hearing Rights16 In addition to other appeal processes that may be required, DMC providers must advise clients of their Medi-Cal fair hearing rights upon the denial, reduction or termination of DMC services as these relate to their eligibility or benefits. This requirement applies to all clients who discharge involuntarily as well. This notification must be in writing at least 10 calendar days prior to the effective date of the intended action to terminate or reduce services. The written notification must include: 1. 2. 3. 4. A statement of the action the provide intends to take; The reason for the intended action; A citation of the specific regulation(s) supporting the intended action; An explanation of a client’s right to a fair hearing for the purpose of appealing the intended action; 5. A statement that the provider must continue treatment services pending a fair hearing decision only if the client appeals in writing within 10 calendar days of the mailing or personal delivery of the notice of intended action to the Department of Social Services; 6. The address where the client must submit his or her request for a fair hearing: Department of Social Services State Hearing Division P.O. Box 944243, MS 9-17-37 Sacramento, California 94244-2430 1 (800) 952-5253 TDD 1 (800) 952-8349 22 Avatar and CalOMS Treatment Data Entry Requirements California Outcomes Measurement System (CalOMS) Treatment (Tx) is California's data collection and reporting system for SUD treatment. By entering SUD and recovery data in 16 Section 51341.1(p), Title 22, CCR California, CalOMS Tx provides information for improving treatment client outcomes, supporting cost effective services and meeting legally mandated federal and state reporting requirements. Regardless of DMC certification status, all SUD treatment providers must input client treatment data which is sent to DHCS each month. Summary reports created from CalOMS Tx outcome data contributes to the understanding of treatment and the improvement of substance use disorder treatment programs in the continuum of prevention, treatment and recovery services. Client Record and Retention Requirements All SUD provider regardless of DMC certification status must establish, maintain, and update as necessary an individual client record for each client admitted to treatment and receiving services. This includes, but is not limited to: A client identifier Client date of birth Client gender Client race/ethnicity Client address and telephone number Client’s next of kin or emergency contact; Client consent to treatment; Referral source and reason for referral; Date of admission; and Type of admission. In addition, providers are required to include in each client’s individual patient record treatment episode information that includes all activities, services, sessions, and assessments including but not limited to: Intake and admission data, including a physical examination if applicable; Treatment plans; Evidence of compliance with minimum client contact requirements; Progress notes; Continuing services justifications; Laboratory test orders and results; Referrals; Counseling notes; Discharge plan; Discharge summary; Substance Use Disorder Treatment Provider Manual All SFHN SUD treatment providers, regardless of DMC certification status, must enter required CalOMS Tx data in Avatar. In addition to client demographic data, data entered into Avatar builds a comprehensive picture of client behavior including alcohol and drug use data, employment and education data, criminal justice data, medical and physical health data, mental health data and family and social life data. In addition, Avatar captures client discharge data. 23 Evidence of compliance with multiple billing requirements;17 Evidence of compliance with specific treatment modality requirements;18 and Any other information relating to the treatment services provided to the client. For pregnant and postpartum women, medical documentation also must substantiate a client’s pregnancy and the last day of pregnancy19. Substance Use Disorder Treatment Provider Manual All SUD providers regardless of DMC certification status must maintain the following documentation in the individual client record for a minimum of seven (7) years from the date of the last face-to-face contact with the client.20 If an audit takes place during the seven year period, the provider must maintain records until the audit is completed: Evidence that the client met admission criteria; Treatment plan(s); Progress notes; Evidence that the client received counseling with any exceptions or waivers noted, signed and dates by the physical in the client’s treatment plan; Justification for continuing services; Discharge summary; Evidence of compliance with specific treatment service requirements; Evidence that the provider complied with multiple same day service billing requirements. A client record checklist is included under Appendix E. Billing SFHN Services Code Project The SFHN-BHS has facilitated a Substance Use Disorder Treatment Services Code Project to develop a matrix of provider service codes that incorporates definitions of service codes, DMC units to be billed, allowable service staff, allowable location of services, advanced billing rules and units, and EPSDT eligible services. These new services codes will be implemented as part of the California Drug Medi-Cal Organized Delivery System Pilot program in compliance with instructions from DHCS. For more information about the Substance Use Disorder Treatment Services Code Project or matrix, please contact the SFHN-BHS Billing, SFMHP Claims, and Fiscal Office at (415) 255-3536. DMC Multiple Same Day Services21 In general, DMC will pay for only one service on a calendar day for Outpatient Drug Free and Intensive Outpatient Treatment services. However, there are limited circumstance under which a provider may submit a claim and be paid for a second service on a single calendar day. For Outpatient Drug Free treatment clients, return (multiple) visits by a client on the same calendar day must not create a hardship on a client. A statement should be included in a 24 17 Section 51490.1(b), Title 22, CCR Section 51431.1(d), Title 22, CCR 19 Section 51431.1(g)(1)(A)(iii), Title 22, CCR 20 The Health Insurance Portability and Accountability Act, or HIPAA, requires individual client records be retained for seven (7) years. 21 Section 51341.1(p), Title 22, CCR 18 client’s chart that multiple same day services were not a hardship on the client with stated reasons. Where multiple visits are made to the provider by a client on the same day, the DMC provider must meet the following requirements: Document the time of day of each visit; Progress notes must clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable; The return visit must clearly document a crisis or collateral services; The provider must complete the DHSC MC 7700 form and place it in the individual client record. Where an Outpatient Drug Free second service is a group counseling session, an intake session, a treatment planning session or a discharge planning session, the provider must document in the progress note that an effort was made to provide all services during a single visit and that the return visit was unavoidable. For Intensive Outpatient Treatment clients making multiple visits to the provider on the same calendar day, the only second service that can be billed is a crisis counseling session. DMC certified SUD providers must meet all of the following requirements: The return visit must clearly document a crisis service; Crisis services must be documented in the progress notes; and The provider must complete the DHCS MC 6700 form and place it in the individual client record. DMC Client Share of Cost22 All DMC clients cannot be charged any fees for treatment services except where a share of cost requirement exists (Section 50090). All DMC providers must accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services provided. DMC providers cannot charge fees to a client for access to DMC substance use disorder treatment services or for admission to a DMC treatment program. Good Cause Codes All DMC-funded claims are supposed to be submitted within 30 days of the end of the month that a service was provided. There are limited reasons that are considered “good cause to submit late claims. Substance Use Disorder Treatment Provider Manual Program Compliance To comply with DMC and SUD treatment and documentation requirements and to ensure access to high quality and cost effective treatment services, the San Francisco Department of Public Health Office of Compliance conducts annual site visits at SUD provider sites. The Department reserves the right to broaden or narrow the scope of any compliance audit but generally the audit will consist of a site visit to review a sampling of client charts at a provider’s site and billing claims. Client charts will be reviewed for compliance with treatment program standards requirements found in Title 22 and Title 9 (Narcotic Treatment Program) of the California Code of Regulations. 22 Section 51341.1(h)(7), Title 22, CCR 25 The compliance review will verify at a minimum: Substance Use Disorder Treatment Provider Manual 26 Client records are maintained for a minimum of 3 years for DMC certified providers; Each client meets admission criteria including documentation of the client’s DSM 5 substance use disorder diagnosis and medical necessity; Each client for which reimbursement was claimed has a treatment plan documenting services claimed for reimbursement; Services claimed for reimbursement were provided; For DMC certified providers, services were provided at a certified location; SUD treatment requirements were met that are contained in Section 51341.1 (b), Section 51341.1(c), Section 51341.1(d), Section 51341.1(g), Section 51341.1(h), and Section 51341.1(i) of Title 22, CCR; Good cause codes and procedures that were used were not erroneous, incorrect or fraudulent; Multiple billing codes and certification processes that were used were not erroneous, incorrect or fraudulent; Reimbursement was not received in excess of daily limits; Individual counseling sessions met confidentiality requirements, and for ODF, individual counseling limitations to intake, crisis intervention, collateral services and treatment and discharge planning were met; Group counseling sessions met group size requirements (2 to 12 with at least one MediCal eligible client for DMC providers), confidentiality requirements, and age restrictions for clients 17 and under; Day care habilitative services were not less than three hours of services on calendar days billed or provided to a non-pregnant, non-postpartum or non-EPSDT eligible client. Additionally for narcotic treatment programs, the following requirements under Title 9, CCR, will be reviewed, at a minimum: Section 10270 (admission criteria time frames); Section 10305 (treatment plan completion and review time frames); Section 10410 (continuing treatment plan time frames); Section 10345 (minimum counseling session requirements); and Section 10305 (counseling session type and frequency). A sample compliance audit tool can be found under Appendix F. Admission to Treatment Date Calendar Week Collateral Services Counselor Crisis Intervention Detoxification Treatment Face-to-Face Group Counseling Illicit Drug Individual Counseling Intake The date of the first face-to-face treatment service provided by the provider to the client. Seven (7) day period from Sunday through Saturday. Face-to-face sessions with therapists or counselors and significant persons in the life of a beneficiary, focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary's treatment goals. Significant persons are individuals that have a personal, not official or professional, relationship with the beneficiary. A Certified AOD Counselor as defined in Section 13005(a)(2) of Title 9, CCR or a Registrant as defined in Section 13005(a)(8) of Title 9, CCR. A face-to-face contact between a therapist or counselor and a beneficiary in crisis. Services shall focus on alleviating crisis problems. “Crisis” means an actual relapse or an unforeseen event or circumstance which presents to the beneficiary an imminent threat of relapse. Crisis intervention services shall be limited to stabilization of the beneficiary's emergency situation. The treatment modality whereby replacement narcotic therapy is used in decreasing, medically determined dosage levels for a period not more than 21 days, to reduce or eliminate opiate addiction, while the patient is provided treatment services. Occurring in person at a certified facility. Telephone contacts, home visits, and hospital visits are not considered face-to-face. Face-to-face contacts in which one of more therapists or counselors treat two or more clients at the same time, focusing on the needs of the individuals served. Any substance defined as a drug in Section 11014, Chapter 1, Division 10 of the Health and Safety Code, except: (A) Drugs or medications prescribed by a physician or other person authorized to prescribe drugs, pursuant to Section 4040, Chapter 9, Division 2 of the Business and Professions Code, and used in the dosage and frequency prescribed; or (B) Over-the-counter drugs or medications used in the dosage and frequency described on the box, bottle, or package insert. Face-to-face contacts between a beneficiary and a therapist or counselor. The process of admitting a client into a substance use disorder treatment program and includes the evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral or substance use disorders; the diagnosis of substance use disorders using the DSM-5; and the assessment of treatment needs to provide medically necessary treatment services by a physician. May include a physical examination and laboratory testing. Substance Use Disorder Treatment Provider Manual Glossary of Terms 27 Substance Use Disorder Treatment Provider Manual 28 Outpatient counseling and rehabilitation services provided at least three (3) hours per day, three (3) days per week to persons with substance use disorder diagnoses, who are pregnant or Day Care Habilitative postpartum, and/or to Early and Periodic Screening Diagnosis, and Treatment (EPSDT)-eligible beneficiaries. A drug analysis laboratory approved and licensed by the State Department of Health Services to test or analyze samples of Laboratory patient body specimens for the substances named in Section 10315 for a narcotic treatment program. Also known as Levo-Alpha-Acetyl-Methadol or levomethadyl acetate hydrochloride - the substance that can be described Levoalphacetylmethadol chemically as levo-alpha-6-dimethylamino-4, 4-diphenyl-3heptyl acetate hydrochloride. Treatment modality whereby replacement narcotic therapy is used in sustained, stable, medically determined dosage levels for Maintenance Treatment a period in excess of 21 days, to reduce or eliminate chronic opiate addiction, while the patient is provided a comprehensive range of treatment services. The physician licensed to practice medicine in California who is Medical Director responsible for medical services provided by the program. A type of counseling services defined in Section 10345 of Title Medical Psychotherapy 9, CCR. Any opiate agonist medications that have been approved for use in replacement narcotic therapy, including: Medication (A) Methadone, and (B) Levoalphacetylmethadol (LAAM). The prescription or administration of medication related to substance use disorder treatment services or the assessment of the side effects or results of that medication conducted by staff Medication Services lawfully authorized to provide such services and/or laboratory testing within the scope of their practice or licensure. A narcotic treatment facility, established by a program sponsor as part of a maintenance treatment program, from which licensed private practitioners and community pharmacists are permitted to administer and dispense medications used in replacement Medication Unit narcotic therapy. These medication units may also collect patient body specimens for testing or analysis of samples for illicit drug use. The substance that can be described as 6-dimenthylamino-4, 4diphenyl-3-heptanone. Methadone doses are usually administered Methadone as methadone hydrochloride. An outpatient treatment services directed at serving detoxified Naltrexone Treatment opiate addicts who have substance use disorder diagnosis by Services using the drug Naltrexone which prevents relapse. Any controlled substance which produces insensibility or stupor Narcotic Drug and applies especially to opium or any of its natural derivatives or synthetic substitutes. Opiate Opiate Addiction Outpatient Drug Free Treatment Services Perinatal Certified Substance Use Disorder Program Perinatal Residential Substance Use Disorder Services Program Physical Dependence Physician Relapse Relapse Trigger Replacement Narcotic Therapy Substance Use Disorder Diagnoses Support Plan An outpatient service using methadone and/or levoalphacetylmethadol (LAAM), directed at stabilization and rehabilitation of persons who are opiate addicted and have a substance use disorder diagnoses. Narcotic drug substances having an addiction-forming or addiction-sustaining liability similar to morphine or being capable of conversion into a drug having addiction-forming or addiction-sustaining liability; including heroin, morphine, methadone, or any natural or synthetic opiate as set forth in the California Uniform Controlled Substances Act (Health and Safety Code sections 11000, et seq.). A condition characterized by compulsion and lack of control that lead to illicit or inappropriate opiate-seeking behavior, including an opiate addiction that was acquired or supported by the misuse of a physician's legally prescribed narcotic medication. An outpatient service directed at stabilizing and rehabilitating persons with substance use disorder diagnoses. A Medi-Cal certified program which provides substance use disorder services to pregnant and postpartum women with substance use disorder diagnoses for up to 60 days after pregnancy ends. A non-institutional, non-medical, residential program which provides rehabilitation services to pregnant and postpartum women with substance use disorder diagnoses. A condition resulting from repeated administration of a drug that necessitates its continued use to prevent withdrawal syndrome that occurs when the drug is abruptly discontinued. A person licensed by the Medical Board of California or the Osteopathic Medical Board of California. A single instance of a client’s substance use or a client’s return to a pattern of substance use. An event, circumstance, place or person that puts a beneficiary at risk of relapse. The medically supervised use of an opiate agonist medication that mimics the effects of endorphin, a naturally occurring compound, thus producing an opiate effect by interaction with the opioid receptor. Those set forth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition, published by the American Psychiatric Association. A list of individuals and/or organizations that can provide support and assistance to a beneficiary to maintain sobriety. Substance Use Disorder Treatment Provider Manual Narcotic Treatment Program 29 Therapist Substance Use Disorder Treatment Provider Manual Unit of Service 30 Any of the following: 1) a psychologist licensed by the California Board of Psychology; 2) a clinical social worker or marriage and family therapist licensed by the California Board of Behavioral Sciences; 3) an intern registered with the California Board of Psychology or the California Board of Behavioral Sciences; or 4) a physician. For outpatient drug free, day care habilitative services, perinatal residential, and Naltrexone treatment services, a face-to-face contact on a calendar day. For narcotic treatment program services, a calendar month of treatment services provided pursuant to this section and Chapter 4 commencing with Section 10000 of Title 9, CCR. Substance Use Disorder Treatment Provider Manual This page intentionally left blank. 31 ABOUT THE CONTRIBUTORS The Substance Use Disorder Treatment Program Provider Manual was produced through a partnership between the San Francisco Department of Public Health, substance use disorder treatment providers, and Golden Bear Associates, a Bay Area management consulting firm. Thank you to the following individuals for their contributions to the manual (in alphabetical order): Substance Use Disorder Treatment Provider Manual Alice Gleghorn, Ph.D., Deputy Director & County Alcohol and Drug Administrator SF Health Network – Behavioral Health Services, S.F. Department of Public Health Valerie Gruber, Ph.D./MPH, Clinical Professor University of California, San Francisco/San Francisco General Hospital Department of Psychiatry Kellee Hom, Ph.D., IS Project Director SF Health Network – Behavioral Health Services, S.F. Department of Public Health Chona Peralta, LCSW, DPH Compliance Officer S.F. Department of Public Health Judith Martin, M.D., Deputy Medical Director, Substance Use Services SF Health Network – Behavioral Health Services, S.F. Department of Public Health Ravi Mehta, PsyD, DPH Compliance Manager S.F. Department of Public Health Gilda Mansour, MSW, Compliance Manager S.F. Department of Public Health James Stillwell, Consultant Karen Strickland, Principal Golden Bear Associates/Provider Manual Producer Denise Williams, Vice President of Compliance HealthRIGHT 360 32 Substance Use Disorder Treatment Provider Manual This page intentionally left blank. 33 Substance Use Disorder Treatment Provider Manual Appendix A – SFHN-BHS Philosophy of Care 34 Substance Use Disorder Treatment Provider Manual This page intentionally left blank. 35 San Francisco Health Network - Behavioral Health Alignment Philosophy of Care Substance Use Disorder Treatment Provider Manual June 2015 Our Purpose: As members of the San Francisco Health Network (SFHN) deepen integration efforts, its behavioral health leaders will work together to build a comprehensive behavioral health system of care for the patients of SFHN. This includes community, urgent, emergency, acute, long-term, and ambulatory care. By applying “Quadruple Aim”23 through the lenses of cultural humility, wellness and recovery, we will work to meet the behavioral health needs of San Franciscans who access care through the SFHN. Our Philosophy of Care: Throughout the SFHN, we envision a system of care that promotes wellness and recovery by supporting clients with mental health and substance use disorders to pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources. In support of our vision, we value the following aspects of care: 1. A trauma-informed system of care that fosters wellness and resilience for everyone in the system, from our clients to the staff who serve them; 2. The practice of cultural humility where we make a consistent commitment to understanding different cultures and focusing on self-humility, maintaining an openness to someone else's cultural identity, and acknowledging that each of us brings our own belief/value systems, biases, and privileges to our work; 3. Whole Person Care that integrates both behavioral and physical care of a client including assessing the needs of a client’s identified family and other significant relationships; 4. Colleagues who have experienced behavioral health challenges and bring their empathy and empowerment to recovery in others, as well as inspire and share their experience to create a truly recovery-oriented system; 5. Valuing all clients that seek our services; 6. Shared decision making in providing the best possible coordinated care, where clients and their providers collaborate as part of a team to make care decisions together; 7. Integration of prevention, early intervention, education, outreach, and engagement within the continuum of care. Our Commitments: As behavioral health leaders, we will… 36 1. Share the S.F. Department of Public Health vision as we implement change within our organizations; 2. Promote collaboration across the SFHN in finding solutions for our common clients; 3. Designate a single point of responsibility (case coordinator) within a client’s care team to 23 The “Quadruple Aim” is based on the IHI Triple Aim framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; and 3) reducing the per capita cost of health care. The SFHN-BHS has added a fourth aim for San Francisco, improving the workforce. Our Alignment Opportunities: We acknowledge that integration offers the SFHN opportunities for alignment including: Philosophy of care (wellness and recovery, team-based care); Communication/Electronic Health Record; Evaluation of program and staff performance and staff competency; Single point of responsibility for high need clients (care coordination); Utilization of local experts; Patient flow and transitions of care; Shared knowledge of systems; Standardization of practice; Productivity standards; Standardized definitions and meaning; Philosophy of collaboration at line staff level across system; Appropriate level of care – commitment to stretch services to fill gaps and meet needs; Shared accountability for all aspects of the system of care from client engagement to regulatory compliance; Any door is the right door to receive seamless, coordinated, quality and appropriate care. Substance Use Disorder Treatment Provider Manual support client needs and preferences when a client cannot be responsible for his or her care due to health and/or behavioral health challenges; 4. Communicate at all levels to empower our staff to communicate and find common ground; 5. Articulate within our organizations that we are part of a larger system; 6. Create a workforce that strives for excellence and commit the resources needed to achieve excellence; 7. Implement a trauma informed system of care; 8. Provide services with cultural humility with a priority focus on Black/African American health disparities; 9. Address all health disparities, as well as the needs of underserved populations; 10. Promote fiscal responsibility; 11. Convene regularly to share best practices, solve challenges, and foster open lines of communication among each other. 37 Substance Use Disorder Treatment Provider Manual Appendix B – DPH Drug Medi-Cal Certification Requirement Checklist 38 DRUG MEDI-CAL REQUIREMENT CHECKLIST – Is a drug and alcohol treatment program funded through the federal Medicaid program. The primary regulations that govern DMC are contained in Title 22, Sections 51341.1 (program requirements), 51490.1 (claim submission requirements) and 51516.1 (reimbursement rates and requirements) Program Integrity emergency regulations for Section 51341.1 became effective on 6/25/14 This checklist is meant to help you prepare for State certification. The services provided must be contained in an approved State Medicaid Plan (approved by CMS) 1. Agency Name (Must match Appendix A, database and ITWS) 1 5. Program Name (Must match Appendix A, database and ITWS) 8. Program Site Service Delivery Address & Satellite3, if any (Must match Appendix A, database and ITWS) 10. DPH Staff 1 2. Agency No 3. NPI No2 (Each program site location must have its own NPI number. One address equals one NPI number.) 4. Program Code(s) 6. Agency Representative(s) 7. Phone No. (If Different than Provider No.) 9. Mailing Address (If Different Than Delivery Address) Attn: 11. Date of Review Note that changing an Agency’s name may necessitate a change in the NPPES system and other changes. 2 If moving, agencies must update the NPI number to exactly match the new address. Please provide a copy of the NPI number documentation to the Certifier. https://nppes.cms.hhs.gov/NPPES/Welcome.do 3 Satellite site means a clinic based at a specific building, place or premises that is at a separate location from a DHCS certified substance abuse clinic or OBOT that is: Licensed as a Narcotic Treatment Program; OR Affiliated and associated with a licensed narcotic treatment program or licensed OBOT. 12. Contracted Services4(Must match Attachment A, database, ITWS and/or procurement) ☐ Substance Abuse Clinic or Clinic5 ☐ Office-Based Opiate Treatment6 ☐ Narcotic Treatment Program7 ☐ Naltrexone Treatment8 4 CCR, Title 9, Section 1840.366. Lockouts for Crisis Intervention include: (a) Crisis Intervention is not reimbursable on days when Crisis Residential Treatment Services, Psychiatric Health Facility Services, Psychiatric Nursing Facility Services, or Psychiatric Inpatient Hospital Services are reimbursed, except for the day of admission to those services. (b) The maximum amount claimable for Crisis Intervention in a 24-hour period is 8 hours. 5 Substance Abuse Clinic or Clinic is a Nonresidential Substance Abuse Treatment program that provides services to individuals who remain less than 24 -hours or a perinatal residential substance abuse services program. Services include evaluation, assessment, education, individual and group counseling, replacement narcotic therapy using the medications methadone and/or levoalphacetymethadol (LAAM), naltrexone treatment, treatment planning, treatment outcome goals, and objectives. A Substance Abuse Clinic shall provide substance abuse services more than 20 hours a week. DHCS shall conduct an on-site inspection prior to DHCS certification. 6 Office-Based Opiate Treatment is an office-based opiate treatment program that is: Licensed as a Narcotic Treatment Program, pursuant to Section 11877.2(a) (1), Chapter 1, Part 3, Division 10.5, Health and Safety Code; or Affiliated and associated with a licensed Narcotic Treatment Program or licensed OBOT, pursuant to Section 11877.2(a)(2), Chapter 1, Part 3, Division 10.5, Health and Safety Code. An OBOT shall submit proof of authorization by the Narcotic Treatment Program Licensing Branch to provide services and a copy of the physician and/or pharmacy license with the application for DMC certification. 7 Narcotic Treatment Program is an outpatient service using methadone and/or levoalphacetylmethadol (LAAM), directed at stabilization and rehabilitation of persons who are opiate addicted and have a substance use disorder diagnoses. For the purposes of this section, Narcotic Treatment Program does not include detoxification treatment. 8 Naltrexone Treatment includes intake, admission physical examinations, treatment planning, provision of medication services, medical direction, physician and nursing services related to substance use, body specimen screens, individual and group counseling, collateral services, and crisis intervention services, provided by staff that are lawfully authorized to provide, prescribe and/or order these services within the scope of their practice or licensure. Naltrexone Treatment services shall only be provided to a beneficiary who meets all of the following conditions: has a confirmed documented history of opiate addiction; is at least 18 year or over; is opiate free; is not pregnant. Medication Services" means the prescription or administration of medication related to substance use disorder treatment services, or the assessment of the side effects or results of that medication conducted by staff lawfully authorized to provide such services and/or order laboratory testing within the scope of their practice or licensure. Page 2 of 28 Last updated: 8/28/2015 ☐ Outpatient Drug Free Treatment9 ☐ Regular ☐ Perinatal ☐ Residential12 ☐ Day Care Habilitative (DHC)10 ☐ EPSDT & Perinatal ☐ Perinatal Residential Substance Abuse Services11 License # 9 Outpatient Drug Free Treatment means an outpatient service directed at stabilizing and rehabilitating persons with substance use disorder diagnoses. Multiple visits on the same day must adhere to the below and shall not create a hardship on beneficiary Document time of day of each visit Progress note shall clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable; The return visit shall clearly document a crisis or collateral service The provider must complete the DHCS MC 7700 form and place in Beneficiary record 10 Day Care Habilitative (also known as Intensive Outpatient) is outpatient counseling and rehabilitation services provided at least three hours per day, three days per week to persons with substance use disorder diagnoses, who are pregnant postpartum period, and/or to Early and Periodic Screening Diagnosis, and Treatment (EPSDT)-eligible beneficiaries, as otherwise authorized. Multiple visits on the same day must adhere to the below and shall not create a hardship on beneficiary The return visit shall clearly document a crisis service Crisis services shall be documented in the progress notes Provider must complete the DHCS MC 7700 form and place in Beneficiary record 11 Perinatal Residential Substance Abuse Services is a 24-hour freestanding residential program, which is licensed for a treatment capacity of sixteen beds or less. Beds occupied by children who stay in the facility with their mothers are not counted in the 16-bed limit. Reimbursable services are limited to pregnant and postpartum women with substance abuse impairments. Services include intake, assessments, diagnosis, evaluation and individual and group counseling ad well as the perinatal program elements listed in Title 22, CCR, Section 51341.1. "Perinatal residential substance use disorder services program" means a non-institutional, non-medical, residential program which provides rehabilitation services to pregnant and postpartum women with substance use disorder diagnoses. Each beneficiary shall live on the premises and shall be supported in her efforts to restore, maintain, and apply interpersonal and independent living skills and access community support systems. Programs shall provide a range of activities and services for pregnant and postpartum women. Supervision and treatment services shall be available day and night, seven days a week. 12 In order to participate in the DMC Program for substance abuse treatment services provided within a residential setting, a licensed residential alcoholism or drug abuse recovery or treatment facility shall be DMC certified to provide perinatal residential substance abuse services. DMC certified perinatal residential substance abuse service programs shall be limited to billing DMC for treatment services as described in Title 22, CCR, Section 51341.1. Page 3 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A I. General Management A. Governing Body – Each program shall have a governing body, which has legal authority for ☐ ☐ ☐ operating the program. Each program must have: Meeting minutes available to the public Bylaws and rules of program shall follow applicable legal requirements Documentation of legal authority for the formation of the agency15 B. Chief Executive Officer – The governing body shall appoint a chief officer and list major duties, ☐ ☐ ☐ authority and qualifications. C. Personnel Policies ☐ ☐ ☐ 1. Shall be: ☐ ☐ ☐ Written and revised as needed and approved by the governing body Applicable to all employees and reviewed with new employees; Comply with applicable local, state and federal employment practice laws; Contain information about the following: o Recruitment, hiring, evaluation, promotion, disciplinary action & termination o Equal employment opportunity, non-discrimination and affirmative action policies o Employee benefits, training development & grievance procedures o Salary schedule, merit adjustment, severance pay, rules of conduct; o Employee safety and injuries o Physical health status, as required 2. Personnel files shall be maintained on all employees and shall contain: ☐ ☐ ☐ Application for employment and resume 13 The standards included in this document identify minimal requirements for Drug Treatment Programs within the State of California. They apply to all programs designated as treatment services in each County Plan and funded wholly or in part through the DHCS. Only those policies and procedures considered absolutely essential are specifically identified in these minimal standards. Requirements identified elsewhere - such as Confidentiality Regulations (42 CFR Part 2), Methadone Regulations (Title 9), "Proposed Short-Doyle Medi-Cal Certification Standards", and Short-Doyle Community Services Systems Manual are not repeated in this document. In case of conflicts the most restrictive requirement shall apply. 14 Request for exceptions to the standards shall be submitted to the appropriate funding source(s) with a full explanation and justification. These exceptions shall be granted only if the quality of treatment is not significantly reduced or when application of these standards makes the program cost ineffective. 15 Public organizations shall provide an organization chart which reflects the program's placement within a government agency. Page 4 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A Employment confirmation statement Salary schedule and adjustment Employee’s evaluation Health records, as required Other personnel actions 3. Procedures shall be established for access to and confidentiality of personnel records. ☐ ☐ ☐ 4. Job descriptions shall be developed, revised as needed and approved by the governing body. ☐ ☐ ☐ These shall include: Position title and classification Duties and responsibilities Lines of supervision Education, training, work experience and other qualifications for the position 5. A written code of conduct for employees and volunteers shall be established which address ☐ ☐ ☐ at least the following: Use of drug and/or alcohol Relationship between staff and clients Prohibition of sexual contact with clients Conflict of interest D. Fiscal Management ☐ ☐ ☐ 1. Each program shall have an annual written budget, which includes income and expenses ☐ ☐ ☐ and: Lists all income by source Lists all expenses by program component or service type 2. Each program shall use the Uniform Method of Determining Ability to Pay (UMDAP) as the ☐ ☐ ☐ fee schedule for collecting fees. 3. Each program shall develop a reporting mechanism, which indicates the relation of the ☐ ☐ ☐ budget to actual income expenses to date. 4. Each program shall maintain written policies and procedures that govern fiscal management ☐ ☐ ☐ systems (e.g. purchasing authority, accounts receivable, cash, billings and cost allocation) 5. Program personnel responsible for signing checks and performing other accounting activities ☐ ☐ ☐ shall be bonded. 6. The fiscal management system shall provide for an audit of the financial operations of the ☐ ☐ ☐ program at least every two years by either a public accountant who is not a staff or Board member or by the funding agency. Page 5 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A E. Volunteer Services – if a program utilizes the services of volunteers, it shall develop and ☐ ☐ ☐ implement policies and procedures that address: Recruitment Screening Selection Training and orientation Duties and assignments Supervision Evaluation Protection of client confidentiality II. Program Management A. Admission or Readmission 1. Criteria – Each program shall include a written admission and readmission criteria for Beneficiary and program ☐ ☐ ☐ determining client eligibility16 and suitability for treatment. These shall include: staff must not sign blank or incomplete documents. Identification of drug abuse Documentation of social, psychological, physical and/or behavioral problems related to drug abuse Statement of nondiscrimination 2. Intake17 – Each program shall have a written intake procedure with accompanying The Intake/Assessment is ☐ ☐ ☐ documents, which shall include: the basis for establishing Medical Necessity. The An initial interview to determine whether or not a client meets the admission criteria 16 Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to beneficiary for access to Drug Medi-Cal substance use disorder services or for admission to a Drug Medi-Cal treatment slot. 17 Intake means the process of admitting a beneficiary into a substance use disorder treatment program. Intake includes the evaluation or analysis of the cause or nature of mental, emotional, psychological, behavioral, and substance use disorders; the diagnosis of substance use disorders utilizing the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition, published by the American Psychiatric Association; and the assessment of treatment needs to provide medically necessary treatment services by a physician licensed to practice medicine in the State of California. Intake may include a physical examination and laboratory testing (e.g., body specimen screening) necessary for substance use disorder treatment and evaluation conducted by staff lawfully authorized to provide such services and/or order laboratory testing within the scope of their practice or licensure. Page 6 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A If a client does not meet the admission criteria, the client shall be referred elsewhere for evaluation or analysis of the cause or nature of the treatment All clients admission shall meet the admission criteria and this shall be documented in disorders listed below using DSM codes: Mental, the client file If a client is appropriate for treatment, the following information shall be gathered, at Emotional, Psychological, Behavioral, Substance Use minimum: o Social economic and family background Intake/Assessment may o Education also include a physical o Vocational achievements examination and laboratory o Criminal history, legal status testing by staff lawfully o Medical history authorized to provide such o Drug history services o Previous treatment Only upon completion of this process and signing of the consent form shall the client be For each beneficiary, the admitted to treatment. provider shall complete: Personal history Medical history Substance use history Assessment of the physical condition 3. Medical Assessment – A complete medical and drug history shall be taken. The program A physical examination can ☐ ☐ ☐ shall take reasonable steps to protect clients form the spread of infectious diseases. An be conducted by the assessment of physical conditions shall be made within 30 days of admission and program’s physician, documented in the client file in one of the following ways: registered nurse practitioner or physician’s assistant, within thirty (30) days of admission OR Physician can review documentation of most recent (within 12 months) physical examination OR Page 7 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A A physical examination18 by a physician19, registered nurse practitioner or physician’s Include obtaining a physical examination as a assistant Upon review of the medical history and other appropriate material a determination shall treatment plan goal. be made by a licensed physical of the need for physical and laboratory examinations. Any Physical Examination recommended examination shall be made available either directly or by referral. Waivers are no longer an option for Drug Medi-Cal Programs B. Services 1. Staffing – Each program shall be staffed to ensure adequate delivery of required and provided ☐ ☐ ☐ services as approved. 2. Hours of Operation – Each program shall provide sufficient scheduled hours or service to ☐ ☐ ☐ meet the needs of clients. The hours shall be set so that clients may utilize services without undue inconvenience. When not open, the program shall provide information concerning availability of short-term emergency or referrals. 18 If a beneficiary had a physical examination within the twelve month period prior to the beneficiary's admission to treatment date the physician shall review documentation of the beneficiary's most recent physical examination within thirty calendar days of the beneficiary's admission to treatment date. If a provider is unable to obtain documentation of a beneficiary's most recent physical examination, the provider shall describe the efforts made to obtain this documentation in the beneficiary's individual patient record. As an alternative to or in addition to complying with above, the physician, a registered nurse practitioner or a physician's assistant may perform a physical examination of the beneficiary within thirty calendar days of the beneficiary's admission to treatment date. If the physician has not reviewed the documentation of the beneficiary's physical examination as described above or the provider does not perform a physical examination of the beneficiary as provided for above, then the provider shall include in the beneficiary's initial and updated treatment plans the goal of obtaining a physical examination, until this goal has been met. 19 Physician means a person licensed as a physician by the Medical Board of California or the Osteopathic Medical Board of California Page 8 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A 3. Counseling and Other Therapeutic Services Group Counseling must be ☐ ☐ ☐ a. Frequency of Services – Program shall have written protocols and implement the conducted in a confidential following, respective to the service offered20: setting and have a group Outpatient – Each client shall be seen weekly or more often, as indicated by the sign-in sheet that includes: treatment plan. At minimum all clients shall receive two counseling sessions per 30 A typed or printed list of day period or be subject to discharge. the beneficiary’s names and the signature of Residential – Each client shall receive a minimum of twenty hours per week of each beneficiary that counseling and/or structured therapeutic activities attended the counseling Day Treatment – Each client shall receive a minimum of ten hours per week of session. Provider staff counseling and/or structured therapeutic activities may not sign beneficiary b. Type of Services - The need for the following minimum services must be assessed and names onto any when needed, shall be provided directly or by referral to an ancillary service. These document or sign-in services include, but are not limited to: sheet. Educational opportunities A typed or printed name Vocational counseling and training and signature of Job referral and placement counselor(s) facilitating Medical and dental services session (certifying Social/recreational services accuracy and completeness) The date of the counseling session The start and end times of the counseling session o The topic of the counseling session 20 Exceptions to above frequency of services may be made for individual clients where it is determined by program staff that fewer contacts are clinically appropriate and that progress toward treatment goals is being maintained. Such exceptions shall be noted in the client file. Page 9 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A Providers may not sign Individual21 and group counseling22 for clients and significant persons23 o Group counseling sign-in sheets shall be maintained, which shall include the beneficiary names to any document or sign-in sheet. following: , name, date, start and end time, signature 21 Individual Counseling is face-to-face contacts between a beneficiary and a therapist or counselor at a DMC certified location. Individual counseling shall be conducted in a confidential setting, so that individuals not participating in the counseling session cannot hear the comments of the beneficiary, therapist or counselor. Individual counseling shall be limited to intake crisis intervention, collateral services, and treatment and discharge planning. For ODF, Individual Counseling is limited to: Intake/Assessment; Treatment Planning; Discharge Planning; Collateral; and Crisis. 22 Group Counseling is face-to-face contacts in which one or more therapists or counselors treat two or more clients at the same time, focusing on the needs of the individuals served. Group counseling sessions shall focus on short-term personal, family, job/school, and other problems and their relationship to substance use or a return to substance use. Services shall be provided by appointment. Each beneficiary shall receive at least two group counseling sessions per month. Group counseling shall be conducted in a confidential setting, so that individuals not participating in the group cannot hear the comments of the group participants, therapist or counselor. Page 10 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A 4. Referral Services - If during the course of treatment it is judged that a client is not appropriate ☐ ☐ ☐ for treatment, or is in need of other services, the program shall provide the client with a referral to appropriate alternative services. Program policies and procedures shall identify the conditions under which referrals are made, the procedures for making and following-up the referrals, and the agencies to which referrals may be made. 5. Medical Services – Each program shall have policies and procedures for: ☐ ☐ ☐ Emergency Consulting Medical Detoxification C. File Management 1. Programs shall establish and control all client records: ☐ ☐ ☐ A client file shall be established for each client admitted to the program All client files shall be maintained. Information shall only be released in accordance with 42 CFR Part 2. 2. Content of Records – All client files shall be signed, dated, legible, have a standard format Program staff may not back ☐ ☐ ☐ and easily accessible to staff providing services, and contain the following, at minimum: or forward date any signatures. Demographic and identifying data o Client identifier (i.e. name, number, etc.) Beneficiary and program o Date of birth staff must not sign blank or o Sex incomplete documents. o Race/ethnicity o Address o Phone number Modality Outpatient Drug-Free (ODF) Minimum Maximum 2 12 Day Care Habilitative 2 (DCH) 23 12 Group Counseling Billing In order to bill DMC, at least one of the two to twelve participants must be a DMC Beneficiary In order to bill DMC, at least one of the two to twelve participants must be a DMC beneficiary Age Limits A beneficiary that is under the age of 18 years cannot participate in group counseling sessions with any participants that are 18 years or older UNLESS the group counseling sessions are held at a provider’s certified school site Significant persons are individuals that have a personal, not official or professional, relationship with the beneficiary. Page 11 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A Next of kin, emergency contact with phone number All Treatment Plans must Consent to treat have: Referral source and reason for referral 1. A statement of the Date of admission problems to be address; Type of admission (i.e. new) 2. Goals to be reached, All information gathered during intake shall also be included in the client file which address each Treatment Plan – Each client shall have an individual treatment plan, which is based upon stated problem; the information obtained during the intake and assessment process. The treatment plan shall be developed within 30 days from the client’s admission. The treatment plan shall 3. Action steps, which will be taken by the provider be updated at least every 90 days and shall include the following: and/or Beneficiary to o Statement of problem(s) to be addressed in treatment accomplish each goal; o Statement of goals to be reached which address the problem(s) 4. Targeted dates for o Action steps which will be taken by program and/or client to accomplish goal(s) accomplishments of o Target dates for accomplishments of action steps, goals and resolution of steps for each goal; problem(s) 5. Description of the Urine Surveillance – When drug screening by urinalysis is deemed appropriate by the services, including type program director or supervising physician, the program shall: and frequency (Group o Established written procedures which protect against the falsification and/or counseling must be a contamination of any urine sample specific number of o Document urinalysis results in client files sessions over a specific Other information required period of time. If o The documentation of all services which show the relationship of services to Individual Counseling is treatment plans planned, it must be on o The documentation of quality assurance procedures the Treatment Plan. o Progress notes which state clients' progress toward reaching goal(s). 6. Assignment of a primary therapist or counselor 7. The beneficiary’s DSM code diagnosis 8. Physical Examination. 3. Disposal and Maintenance of Files ☐ ☐ ☐ Closed programs – In the case of a program closing, all client records shall be stored in an appropriate confidential manner by the County for no less than four years Page 12 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A Closed cases – There shall be a written policy in all programs regarding the maintenance and disposal of client records. All records shall be stored in an appropriate confidential manner for no less than four years from the date they are officially closed. D. Quality Assurance – Each program shall have written policies and procedures for quality ☐ ☐ ☐ assurance. These shall include the following: Continuity of Care – the program shall provide for a staff person for the clients’ continuity of care that at least the following take place: o A treatment plan is developed at the earliest practical time after admission, but not to exceed 30 days o Services required are provided and documented in the client file o Failure of client to keep scheduled appointments is discussed with client and documented o Progress in achieving goals and objectives identified in the treatment plan are assessed and documented on a continuous basis o The treatment plan is periodically reviewed and updated, at least every 90 days o The client file contains all required documents (e.g. correspondence, authorization to release information, consent for treatment, etc.) o If feasible, the client is followed up with after treatment as scheduled in the discharge summary Case and Treatment Plan Reviews - The treatment review plan shall: o Assess progress to date o Reassess needs and services o Identify additional problem areas and formulate new goals, when appropriate Program Evaluation – each program shall have written self-evaluation procedures for management decision making, which shall be included in the program’s policies and procedures. Follow-up – Each program shall have follow-up procedures for clients who remain the community after discharge. Staff Development – each program shall have a written plan for training needs for all staff and document such training/events. Utilization Review – Each program shall have written procedures for utilization review Facility Management – Each program’s facility shall comply with all applicable local, state and federal laws and regulations. Procedures shall be developed to ensure the facility will be maintained in a clean, safe and sanitary and drug-free condition. E. Client Rights Page 13 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A 1. A document shall be prepared and provided to each client upon admission or posted in a ☐ ☐ ☐ prominent place, accessible to clients, which shall include the following: A statement of nondiscrimination by race, religion, sex, ethnicity, age, disability, sexual preference and ability to pay Client rights Grievance procedures Appeal process for denial or discharge24 Program rules and regulations Client fees Access to treatment files in accordance with Executive Order #B-22/76 2. Confidentiality – All programs shall comply with 42 CFR, Part 2 and Article 7 (commencing Beneficiary and program ☐ ☐ ☐ with Section 5325) of Subchapter 2, Part 1 of Division 5 of the Welfare and Institution Code. staff must not sign blank or In addition, all methadone programs shall comply with Sections 11875-11882 of the Health incomplete documents. and Safety Code. 3. Consent to Treatment - Each program shall develop a consent to treatment Beneficiary and program ☐ ☐ ☐ (or admission agreement) form, which shall be read and signed by client upon admission. staff must not sign blank or This form shall advise clients of his/her obligations as well as those of the program. incomplete documents. 4. Consent for Follow-Up - The follow-up after discharge cannot occur without a written consent Beneficiary and program ☐ ☐ ☐ from the client. staff must not sign blank or incomplete documents. 5. Research - Any program conducting research using clients s subjects shall ☐ ☐ ☐ 24 Per Section 51341.1 (p) Providers shall inform beneficiaries of their right to a fair hearing related to: Denial; Involuntary discharge; or Reduction in DMC services. At least ten calendar days prior to the effective date of the intended action the provider must give the beneficiary a written notice that includes: A statement of the action the provider intends to take The reason for the intended action A citation of the specific regulation(s) supporting the intended action Informing the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended action Informing the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the notice Must include the address where the request for a fair hearing must be submitted Page 14 of 28 Last updated: 8/28/2015 TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained herein which shall be approved by the appropriate funding source(s).14 Criteria & What the Agency Must Do Yes No N/A comply with all standards of the California Research Advisory Panel and the federal regulations for protection of human subjects (45 CFR 46). F. Discharge – Each program shall have written procedures regarding client discharge, which shall ☐ ☐ ☐ contain the following: 1. Written criteria, which defines: Successful completion of the program Unsuccessful discharge Involuntary discharge Transfers and referrals 2. A discharge summary, which includes: ☐ ☐ ☐ Description of treatment episode Current drug usage Vocational/educational achievements Criminal activity Reason for discharge Client’s discharge plan25 Referrals CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits GENERAL REQUIREMENTS A. Fire Clearance Completed? Yes No N/A ☐ ☐ ☐ Notes Each clinic shall conform with the rules and regulations adopted by the State Fire Marshal and the requirements of the local fire authority. Each clinic shall have a copy of the valid fire clearance.26 26 In lieu of a fire clearance, a clinic that is located at a public school site may provide a letter from the school principal that certifies that all services provided at the public school site meet fire safety rules and regulations. Page 15 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits Completed? B. Use Permits Yes ☐ No ☐ N/A ☐ Approval shall be secured by the local agency authorized to provide building use permit. If the local agency authorized to provide a building use permit does not require a use permit, the clinic shall obtain a letter from the local agency attesting to the circumstances.27 C. Accessibility of Service ☐ ☐ ☐ Services shall be accessible to the disabled. D. Physical Plant ☐ ☐ ☐ The clinic shall be clean, sanitary, and in good repair at all times. Maintenance shall include provisions and surveillance of maintenance services and procedures for the safety and well-being of patients, personnel, and visitors.28 E. Utilization Review ☐ ☐ ☐ ☐ ☐ ☐ The provider shall establish, implement, and maintain procedures.29 F. Client Health Records 1. Each provider shall establish and maintain a patient health record on every patient admitted for care at the clinic 27 Notes In lieu of a local use permit, a clinic or satellite site that operates on a public school campus shall obtain a letter authorizing the provision of services at the public school from the school principal. 28 Health and Safety Code, Sections 208(a) and 1275 29 Title 22, CCR, Section 51341.1 Page 16 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits 2. All health records of discharged patients shall be completed and filed in a secure and confidential location within 30 days after discharge, and such records shall be kept for a minimum of three years30 3. Information contained in health records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state, and local laws31. G. Administrative Policies 1. Written administrative policies and procedures regarding patient health records implemented, maintained, reviewed annually and revised as necessary 2. Written administrative policies and procedures regarding personnel files implemented, maintained, reviewed annually and revised as necessary and include: a) Application for employment and/or resume b) Employment confirmation statement c) Salary schedule and salary adjustment information d) Evaluations e) Health records, as required f) Other personnel actions (e.g. commendations, discipline, status change, employment incident and/or injuries) 3. Procedures for access to and confidentiality of personnel records. 30 Title 22, CCR, Section 51341.1 (i) 31 Title 9, CCR, Section 10155 Page 17 of 28 Last updated: 8/28/2015 Completed? Yes ☐ No ☐ N/A ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Notes CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits 4. Job descriptions shall be developed, revised as needed, and approved annually by the governing body. The job descriptions shall include: a) Position title and classification; b) Duties and responsibilities; c) Lines of supervision, (if applicable); d) Education, training, work experience and other qualifications for the position. 5. A written code of conduct for employees and volunteers shall be established, which addresses at least the following: a) Use of drugs and/or alcohol; b) Prohibition of sexual contact with clients; and c) Conflict of interest H. Health Records 1. All persons working in the clinic, including volunteers, shall have a health screening within six months prior to employment or within 15 days after employment. 2. The provider shall maintain a health record for each employee, which includes reports of all employment related health examinations. These should be kept for a minimum of three years following termination of employment. 3. All persons working in the clinic shall have been screened and those who are found to have symptoms of infectious disease shall be removed from contact with clients. I. Basic Services 1. A DSM diagnosis32 and evaluation toward formulation of a continuing treatment plan is provided. 32 Completed? Yes ☐ No ☐ N/A ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Notes Substance use disorder diagnoses are those set forth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition, published by the American Psychiatric Association. The physician shall document the basis for the diagnosis in the beneficiary's individual patient record. Page 18 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits 2. A medication maintenance program is provided, if appropriate. 3. Individual and/or group therapy or counseling is provided. G. Perinatal Services – An enhanced type of certification for a clinic that provides additional services for pregnant and postpartum women Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy. Must have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy. Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy Eligibility ends on the last day of the month in which the 60th day occurs 1. Mother/Child Habilitative and Rehabilitative Services – Perinatal clinics provide habilitative services that include interactive parenting skills building and child development training. The provider may hire staff specifically for these duties, or they may be incorporated into the duties of other positions (e.g., counselor). Parenting skills building and child development staff shall provide the mothers with positive role modeling, education, instruction and structured activities. At no time shall staff provide child care. Page 19 of 28 Last updated: 8/28/2015 Completed? Yes ☐ No ☐ N/A ☐ ☐ ☐ ☐ Notes CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits Completed? Yes No N/A Notes The interactive skills building and child development training can be provided through the program’s on-site cooperative child care component. On-site cooperative child care is defined by the following elements: a) Child development staff provide the mothers with parenting skills training, child development education, and supportive role modeling; b) The mothers are on-site and the children are under their care and supervision; and c) The number of children is limited to 12 or less at any one time33. 2. Service Access - Perinatal clinics shall provide or arrange for transportation to and from medically necessary treatment and other Medi-Cal covered services, such as primary medical care and pediatric care, for pregnant and postpartum women who do not have their own transportation. 3. Education - Pregnant and postpartum women require medically necessary prevention and education intervention to reduce harmful effects of alcohol and drugs on mother and fetus or mother and infant. Perinatal clinics shall provide education and training on: a) The impact of substance abuse during pregnancy; b) The impact of substance abuse while breast feeding; c) Environmental impact of substance abuse on infant; 33 For more information on cooperative child care, refer to the California Health and Safety Code, Section 15986.792. Child care also may be provided through on-site licensed child care or offsite licensed child care for the children of clients receiving treatment, however, Perinatal DMC will not reimburse clinics for the cost of licensed child care whether it is provided on or off-site. Page 20 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits d) HIV/AIDS transmission and access to testing; and e) Tuberculosis and access to testing. 4. Coordination of Ancillary Services - Pregnant an postpartum women shall receive medically necessary assistance to access and complete required appointments to ancillary services, such as other medical services, dental services, necessary social services, community services, and educational/vocational training. STAFF A. Medical Director/Medical Responsibility 1. Each clinic shall have a licensed physician designated as the medical director. All medical services provided by the clinic shall be under the direction of a physician, who shall be available on a regularly scheduled basis and otherwise on call. The medical director shall assume medical responsibility for all clients. The medical director shall direct medical services, either by acting alone or through an organized medical staff. 2. The medical director’s responsibilities, acting alone or through an organized medical staff, shall include: No signature stamps are allowed. a) Establishing, reviewing, and maintaining medical policies and standards. b) Assuring the quality of medical services given to all patients. c) Assuring that at least one physician practicing at the clinic shall have admitting privileges to a general acute care hospital or a plan, as approved by ADP, f or ensuring needed hospital services. For narcotic treatment programs, this requirement is the responsibility of the program sponsor and shall be met by the program sponsor entering into an Page 21 of 28 Last updated: 8/28/2015 Completed? Yes No N/A ☐ ☐ ☐ ☐ ☐ ☐ Notes CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits agreement with a hospital official to provide general medical care34 d) Assuring that a physician has assumed medical responsibility for all patients treated by the clinic35 3. Documentation of assumption of medical responsibility shall include, but not be limited to, written approval of the treatment plan36 B. Clinic Director Completed? Yes No N/A ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Notes The clinic staff, professional and nonprofessional, shall be under the administration of the clinic director C. Substance Abuse Professional 1. Each substance abuse clinic shall have one or more substance abuse professionals 2. A substance abuse professional is defined as a person who has completed an Associate of Arts degree and one year of experience, or has three years’ experience in a mental health or substance abuse setting. Experience in a mental health or substance abuse field may be substituted for the degree requirement on a year-for-year basis provided that the experience includes clinical evaluation, treatment planning, and individual and group counseling. 34 Title 9, CCR, Section 10340 35 Title 9, CCR, Section 10110 36 Title 22, CCR, Section 51341.1 (h)(2)(A), or for narcotic treatment programs, Title 9, CCR, Section 10305, as specified in Title 22, CCR, Section 51341.1(h)(2)(B) Page 22 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits 3. A substance abuse professional shall provide the following medically necessary, clinical services prescribed for patients admitted, registered, or accepted for care by the clinic: a) Individual and group counseling b) Crisis intervention37 c) Collateral services38 C. Substance Abuse Professional 4. A substance abuse professional shall document and review client progress, prepare treatment and discharge plans and discharge summaries C. Minimum Staff Requirements Completed? Yes ☐ No ☐ N/A ☐ ☐ ☐ ☐ ☐ ☐ ☐ Notes Each clinic shall be staffed by a medical director, clinic director, and substance abuse professional. If qualified, one person may serve in all three positions--medical director, clinic director, and substance abuse professional. The staff may also include other qualified professionals and counselors39 which may include 37 Crisis Intervention is a face-to-face contact with a beneficiary in crisis. Services shall focus on alleviating crisis problems, not those already in the Treatment Plan of Care, such as a an actual relapse or an unforeseen event or circumstance, which presents to the beneficiary an imminent threat of relapse. Crisis intervention services shall be limited to stabilization of the beneficiary's emergency situation. A therapist means a psychologist licensed by the California Board of Psychology; a clinical social worker or marriage and family therapist licensed by the California Board of Behavioral Sciences; an intern registered with the California Board of Behavioral Sciences or the California Board of Psychology; a physician. 38 Collateral Services is a face-to-face session with therapists or counselors and significant persons in the life of a beneficiary, personal, not professional relationships focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary's treatment goals. Per Section 51341.1(b)(4). The beneficiary does not have to attend. 39 Counselor may mean any of the following: A Certified AOD Counselor as defined in Section 13005(a)(2) of Title 9 CCR. A Registrant as defined in 13005(a)(8) of Title 9 CCR. Page 23 of 28 Last updated: 8/28/2015 CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits Completed? Yes No N/A psychiatric technicians, registered nurses, licensed vocational nurses, nurse practitioners, physician's assistants, or other non-physician practitioners. Narcotic treatment programs shall be staffed by a licensed nurse or other individual lawfully authorized to administer medication. D. Clinic Staff ☐ ☐ ☐ Clinic staff shall furnish the services prescribed for patients admitted for care by the clinic. The clinic staff shall be qualified in accordance these standards and current legal, professional, and technical standards, and appropriately licensed, registered, or certified where required PHARMACEUTICAL SERVICE REQUIREMENTS A. Orders for Drugs ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ No drugs shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. All such orders shall be in writing and signed by the person giving the order. The name, quantity or duration of therapy, dosage, and time of administration of the drug, the route of administration if other than oral, and the site of injection when indicated shall be specified. Prescription orders may be given by telephone to a licensed pharmacist, licensed nurse, registered nurse, or licensed psychiatric technician and shall be immediately recorded in the patient's health record. The prescription order shall be signed by the prescriber within 72 hours. B. Labeling and Storage 1. Containers with are cracked, soiled or without secure closures shall not be used. Drug labels must be legible. 2. All drugs obtained by prescription shall be labeled in compliance with state and federal laws governing Page 24 of 28 Last updated: 8/28/2015 Notes CERTIFICATION STANDARDS Federal and State Criteria & What the Agency Must Do Guideline for Certification Reviews/Visits prescription dispensing. No person other than a pharmacists or physician shall alter any prescription label. 3. Non-legend drugs shall be labeled in conformance with state and federal food and drug laws. 4. Test reagents, germicides, disinfectants and other household substances shall be stored separately from drugs. 5. External use drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use. 6. Drugs shall be stored at appropriate temperatures based on the manufacturer’s product insert. When drugs are stored in the same refrigerator with food, the drugs shall be kept in a closed, properly labeled container clearly labeled "DRUGS." 7. Drugs shall be stored in an orderly manner in cabinets, drawers, or cards of sufficient size to prevent crowding. 8. Drugs shall be accessible only to personnel designated in writing by the clinic director. 9. Drugs shall not be kept in stock after expiration date on the labels and no contaminated or deteriorated drugs shall be available for use. 10. The drug of each client shall be kept and stored in their original individual received containers. No drug shall be transferred between containers, with the exception of take-home bottles. C. Disposal of Drugs Disposal of drugs shall meet all applicable state and federal requirements. 1. Drugs shall be administered as prescribed and shall be recorded in the client’s health record 2. Drugs shall be administered only by those persons lawfully authorized to do so. Page 25 of 28 Last updated: 8/28/2015 Completed? Yes No N/A ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Notes Milestone Activity Assessment Activities and Timing Assessments shall be completed and signed by Contractor’s staff within 30 days from the date of client’s entry into the program. Evaluation or analysis of the cause or nature of the disorder(s) listed using DSM codes: Mental, Emotional, Psychological, Behavioral and Substance Abuse. Perinatal Assessment These also include a physical examination and laboratory testing by staff lawfully authorized to provide such services. Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy Must have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy. Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy Admission Medical Necessity Treatment Plan Development* Eligibility ends on the last day of the month in which the 60th day occurs Admission to treatment date means the first date of the first face-to-face treatment service rendered by the provider to the beneficiary. The physician shall document the basis for the DSM code diagnosis indicating medical necessity in the beneficiary’s record within 30 calendar days of the beneficiary’s date of admission to treatment. The therapist/counselor shall complete, sign and date the initial treatment plan within 30 calendar days of the admission to treatment date. The beneficiary shall review, approve, sign and date the initial treatment plan, indicating whether the beneficiary participated in preparation of the plan, within 30 calendar days of the admission to treatment date. Physical Examination ODF Intervention The physician shall review the initial treatment plan to determine whether the services are medically necessary, sign, and date the initial treatment plan within fifteen calendar days of signature by the therapist or counselor. If the Beneficiary has not had a physical examination within the twelve month period prior to the date of admission, a goal that the Beneficiary have a physical examination must be added to the treatment plan. If documentation of a Beneficiary’s physical examination, which was performed during the prior twelve months, indicates a significant medical illness, a goal that the Beneficiary obtain appropriate treatment for the illness must be added to the treatment plan. Interventions, including a minimum of two provider/beneficiary contacts per 30 day period and two group counseling sessions40 shall be provided ongoing between plan development and discharge. 40 This requirement may be waived by the physician if: Fewer contacts are clinically appropriate; or the Beneficiary is making progress towards treatment plan goals. Exceptions must be noted, signed and dated by the physician in the Beneficiary’s record Page 26 of 28 Last updated: 8/28/2015 ODF Progress Notes DCH/Perinatal Residential Progress Notes Individual Counseling limits exist for ODF are as follows: Intake/Assessment; Treatment Planning; Discharge Planning; Collateral and Crisis. Counselor/therapist must legibly print, sign and date the progress notes. Provider may not pre-date any documents. For each Individual and Group Counseling session the therapist or counselor who conducted the counseling session shall record a progress note for each beneficiary who participated within seven calendar days of the session that includes the following: The topic of the session A description of the beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals Information on the beneficiary's attendance, including the date, start and end times of each individual and group counseling session. o Provider staff may not sign beneficiary names onto any document or sign-in sheet. Counselor/therapist must legibly print, sign and date the progress notes. Provider may not pre-date any documents. At minimum, one progress note, per calendar week, should be recorded for each beneficiary and should include: A description of the beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals A record of the beneficiary's attendance at each counseling session including the date, start and end times and topic of the counseling session o Provider staff may not sign beneficiary names onto any document or sign-in sheet. Update of Treatment The therapist/counselor shall complete, sign and date the updated treatment plan no later than 90 calendar days after signing Plan and Intervention the initial treatment plan, and no later than every 90 calendar days thereafter (unless a change in problem identification or focus of treatment occurs) The beneficiary shall review, approve, sign and date the updated treatment plan, indicating whether the beneficiary participated in preparation of the plan within 30 calendar days of signature by the therapist or counselor. ODF, DCH, Perinatal Residential & Naltrexone Continued Treatment The physician shall review each updated treatment plan to determine whether the services are medically necessary and sign and date the updated treatment plan within fifteen calendar days of signature by the therapist or counselor. No sooner than five months and no later than six months after admission, or the completion of the most recent justification, the need for continued treatment must be determined by the physician. The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s: Personal, medical and substance use history Most recent physical exam Treatment plan goals Progress in treatment (progress notes) Therapist/counselor recommendations Page 27 of 28 Last updated: 8/28/2015 Discharge Plan Prognosis Discharge Plans must be completed in the 30 calendar days prior to the last face-to-face treatment session on all beneficiaries by the therapist/counselor. Discharge of a beneficiary from treatment may occur on Voluntary or Involuntary Bases. An Involuntary Discharge is subject to the requirements as follows: A therapist or counselor shall complete a Discharge Plan for each beneficiary, except for a beneficiary with whom the provider loses contact. The Discharge Plan shall include, but not be limited to the following: A description of each of the beneficiary's relapse triggers and a plan to assist the beneficiary to avoid relapse when confronted with each trigger. A Support Plan - A list of individuals and/or organizations and activities that can provide support and assistance to a Beneficiary to maintain sobriety. Discharge/Discharge Summary The Discharge Plan shall be prepared within 30 calendar days prior to the date of the last face-to-face treatment with the beneficiary. During the therapist or counselor's last face-to-face treatment with the beneficiary, the therapist or counselor and the beneficiary shall type or legibly print their names, sign and date the Discharge Plan. If the beneficiary does not attend treatment for more than 30 days, the provider must discharge the beneficiary. The provider shall complete a Discharge Summary for all beneficiaries with whom the provider has lost contact, in accordance with all of the following requirements: For Outpatient Drug Free, Day Care Habilitative, Perinatal Residential, and Naltrexone Treatment, the provider shall complete the Discharge Summary within 30 calendar days of the date of the provider's last face-to-face treatment contact with the beneficiary. The Discharge Summary shall include all of the following: The duration of the beneficiary's treatment as determined by the dates of admission to and discharge from treatment; The reason for discharge; A narrative summary of the treatment episode; The beneficiary's prognosis. * Treatment Plan Development shall be individualized, based on information obtained during the intake and assessment process. Treatment Planning shall engage the beneficiary to meaningfully participate in the preparation of the initial treatment and updated treatment plans. Beneficiaries must sign. If the beneficiary refuses to sign, staff must document the strategy used to engage beneficiary. The Treatment Plan shall be legible, include staff names, names of counselors, therapists, physicians and be signed and dated. Page 28 of 28 Last updated: 8/28/2015 Substance Use Disorder Treatment Provider Manual Appendix C – DHCS Substance Use Disorder Modality Matrix 39 Service Component Provider Type Intensive Outpatient Treatment Naltrexone Treatment Narcotic Treatment Program Outpatient Drug Free Treatment Residentially Based Substance Use Disorder Services Intake (Admission & Assessment) 3 Diagnosis of substance use disorders utilizing the current DSM and assessment of treatment needs for medically necessary treatment services. Approval of a treatment plan by a physician licensed in the State of California. This may include a physical examination and laboratory testing (e.g., body specimen screening) necessary for treatment and evaluation conducted by staff lawfully authorized to provide such services and/or order laboratory. Collection of information for assessment used in the evaluation and analysis of the cause or nature of the substance use disorder which includes exploration of relevant mental, emotional, psychological and behavioral problems that may be contributing to the substance use disorder. L1 C2 Group Counseling Individual Counseling Face-to-face Face-to-face contacts in contacts between which one or more therapists or counselors a beneficiary and a therapist or treat two or more clients at the same counselor. time, focusing on the Telephone needs of the individuals contacts, home served. visits, and For outpatient drug hospital visits free treatment services shall not qualify and narcotic treatment as Medi-Cal programs, group reimbursable counseling shall be units of service. conducted with no less than four and no more than 10 clients at the same time, only one of whom needs to be a Medi-Cal beneficiary. Patient Education A learning experience using a combination of methods such as teaching, counseling, and behavior modification techniques which influence patients' knowledge and health and illness behavior. Medical Psychotherapy Medication Services Type of The prescription counseling service or administration consisting of a of medication face-to-face related to discussion substance use conducted by the treatment medical director services, or the of the Narcotic assessment of the Treatment side effects or Program on a results of that one-to-one basis medication with the patient. conducted by staff lawfully authorized to provide such services and/or order laboratory testing within the scope of their practice or licensure. Transportation Services Provision of or arrangement for transportation to and from medically necessary treatment. This may also include health questionnaires. L1 C2 L1 C2 L1 C2 L1 L1 C2 X X X X X X X X X X X X X X X X X X X X X Collateral Services Crisis Intervention Services Face-to-face Face-to-face contact sessions with between a therapist or therapists or counselor and a counselors and beneficiary in crisis. significant Services shall focus persons in the life on alleviating crisis of a beneficiary, problems. “Crisis” focusing on the means an actual treatment needs relapse or an of the beneficiary unforeseen event or in terms of circumstance which supporting the presents to the achievement of beneficiary an the beneficiary's imminent threat of treatment goals. relapse. Crisis Significant intervention services persons are shall be limited to individuals that stabilization of the have a personal, beneficiary's not official or emergency situation. professional, relationship with the beneficiary. L1 C2 L1 C2 Treatment Planning* The provider shall prepare an individualized written treatment plan, based upon information obtained in the intake and assessment process. The treatment plan includes: problems to be addressed, goals to be reached which address each problem, action steps which will be taken by the provider and/or beneficiary to accomplish identified goals, target dates for accomplishment of action steps and goals, and a description of services, including the type of counseling to be provided and the frequency thereof. The treatment plan may also include medical. L1 C2* Discharge Services* The process to prepare a person for the post treatment return or reentry into the community, and the linkage of the individual to essential community treatment, housing and human services. L1 C2* X X X X X X X X X X X X X X X X X X X X X X S X X X X X X SOURCE: DHCS SUD Services Chart – California State Plan, Attachment 3 – Services, Supplement 3 to Attachment 3. 1-B 1 Licensed providers must meet the following qualifications: MD, PA, NP, RN, Psy. D, LCSW, MFT or Intern registered by Board of Psychology or Behavioral Science Board and supervised by a mental health professional. 2 Certified providers must meet the following qualifications: Counselors or registrants certified by an organization who will have 155 hours of formal Education; 160 hours of supervised AOD training; 2,080 hours of work experience in AOD counseling; obtain at least 70% score on a written or oral examination approved by the certifying organization and complete 40 hours of continuing education every two years in order to retain certification. 3 The process of admitting a beneficiary into a Substance Use Disorder Treatment Program. Intake includes the evaluation or analysis of substance use disorders; the diagnosis of substance use disorders; the assessment of treatment needs to provide and assistance with accessing community and human services networks. Intake may include a physical examination and laboratory testing necessary for substance use disorder treatment. * Certified personnel may assist with some aspects of this service, however, a licensed provider is responsible for this service component. S - Safeguarding Medication; assistance with resident's self-administration of medication 40 medically necessary services; Appendix D – Substance Use Disorder Treatment Services by Modality Outpatient Drug Free Treatment Outpatient Drug Free (ODF) Treatment is provided to clients who have a substance use disorder diagnosis prescribed by a physician as medically necessary. These services are offered in a community outpatient setting and include: Intake Individual and Group Counseling Patient Education Medication Services Collateral Services Crisis Intervention Treatment Planning and Discharge Services Individual counseling is provided only for the purposes of intake, crisis intervention, collateral services, and treatment and discharge planning. Each ODF clients must receive at least two group face-to-face counseling sessions every thirty days. Groups may range in size from 4 to 10 participants, at least one of which must be a Medi-Cal beneficiary. Group sessions focus on shortterm personal, family, job/school and other challenges and their relationship to substance use. Reimbursable group sessions may last up to 90 minutes. Day Care Habilitative Day Care Habilitative treatment counseling services must be provided to clients for a minimum of three hours per day, three days a week and include: Intake Individual and Group Counseling Patient Education Medication Services Collateral Services Crisis Intervention Services Treatment Planning and Discharge Services Narcotic Treatment Program The Narcotic Treatment Program uses methadone (or levoalphacetylmethadol if available and prescribed) as a narcotic replacement drug to alleviate the symptoms of withdrawal from opioids. Each client must receive a minimum of fifty minutes of face-to-face counseling sessions with a therapist or counselor for up to 200 minutes per calendar month. Additional services may be provided based on medical necessity. Components of the Narcotic Treatment Program include: Intake Individual and Group Counseling Patient Education Medical Psychotherapy Medication Services Collateral Services Crisis Intervention Treatment Planning and Discharge Services 41 Naltrexone Treatment Naltrexone is a medication provided as an outpatient treatment service to serve clients who have detoxified after using opioids. Naltrexone clients must receive at least two face-to-face counseling sessions with a therapist or counselor every 30-day period. The intake assessment to admit a patient into the program is the same as for the Narcotic Treatment Program. Service components include: Intake Individual and Group Counseling Patient Education Medication Services Collateral Services Crisis Intervention Services Treatment Planning and Discharge Services Residentially Based Substance Use Disorder Treatment Residentially Based Substance Use Disorder Treatment is a non-institutional, non-medical, residential program that provides rehabilitation services to clients, including pregnant and postpartum women, with a substance use disorder diagnosis. Services must include womenspecific treatment and recovery services for pregnant and postpartum women. Each client shall live on the premises and shall be supported in their efforts to restore, maintain, and apply interpersonal and independent living skills and access community support systems. Services are provided in a 24-hour structured environment and covered under the Drug Medi-Cal program when medically necessary. Medically necessary rehabilitative services are provided in accordance with an individualized client plan prescribed by a licensed physician. The cost of room and board are not reimbursable under the Medi-Cal program. Components of Perinatal Residential Substance Use Disorder Treatment include: Intake (once per admission) Individual and Group Counseling (a minimum of two sessions per 30-day period) Patient Education (varies according to the needs of the client) Collateral Services (as needed) Crisis Intervention Services (as needed) Treatment Planning (upon admission and every 90 days thereafter) Discharge Services (once per admission) In addition, services must include transportation to and from medically necessary treatment. Facilities also must safeguard medication by storing all resident medication and facility staff members assisting residents with self-administration of medication. 42 Appendix E - Individual Client Record Data Set List Following is a list of the minimum data sets that must be entered, maintained, and updated as necessary for each client admitted to treatment and receiving services. Each client record must be maintained for at least three years following the last face-to-face contact with the client, or if an audit is in progress, until the audit is completed. Note that these required data sets reflect DMC requirements; your program may have additional documentation and retention requirements. I. Demographic of Personal Information: Client Identifier (i.e. name, number) Client Date of Birth Client Gender Client Race/Ethnicity Client Address Client Telephone Number Client Next of Kin or Emergency Contact (include phone number) Medical Documentation Substantiating Client Pregnancy and Last Day of Pregnancy (for pregnant and postpartum women clients only) II. Treatment Episode Information (all activities, services, sessions, and assessments) Intake and Admission Data (including Health Questionnaire, and, if applicable, Physical Examination) Treatment Plan (see Narcotic Treatment Program note on next page): 1. Statement of problem(s) to be addressed in treatment; 2. Goal(s) to be reached addressing each problem(s); 3. Action steps which will be taken by provider and/or client to accomplish identified goal(s); 4. Target date(s) for accomplishment of action step(s) and goal(s); 5. Description of services including the type and frequency of counseling to be provided including a specific number of sessions over a specific period of time for group counseling and for individual counseling, it must be on the treatment plan; 6. Assignment of a primary therapist or counselor; 7. DSM-5 code diagnosis; and 8. Physical examination goal (for clients with no physical exam in 12 months prior to admission) and treatment goal for clients with significant medical illness(es) as documented by physical examination in 12 months prior to admission or within 30 calendar days of treatment admission date. Client Contacts Client Services (services tied to client treatment plan) Progress Notes (notes directly linked to client progress toward treatment goals) Continuing Services Justification Laboratory Test Orders and Results (i.e. urine surveillance) Referrals (referrals tied to client treatment plans) Counseling Notes Discharge Plan Discharge Summary Evidence of Compliance with Requirements for Specific Treatment Services Evidence of Compliance with Multiple DMC Billing Requirements Other Information Relating to Treatment Services Provided to Client Narcotic Treatment Programs Narcotic Treatment Programs must comply with treatment plan documentation requirements that are similar to those for other treatment modalities. Current DHCS regulations require NTP providers to comply with requirements for initial and updated treatment plans that are found in Section 10305, Title 9, CCR including: A statement of client needs to be addressed including a summary of client’s initial psychological and sociological background including education and vocational experience, health care, employment, education, psychosocial, vocational rehabilitation, economic, and legal services; Short-term goals (less than 90 days to achieve) and long-term goals (specified time of greater than 90 days to achieve) to be achieved by the client based on needs identified; Target dates for the accomplishment of short-term and long-term goals; Specific behavioral tasks that will be taken by the client to complete each short-term and long-term goal; A description of the type and frequency of counseling services to be provided to the client; and An effective date based on the day the primary counselor signed the initial treatment plan. Given the SFHN-BHS goal to create a seamless treatment system for all clients regardless of where they seek treatment services, DPH DMC NTP providers will be required to document all treatment plan elements required of other treatment modality providers in addition to Section 10305, Title 9, CCR requirements. 44 Appendix F – Sample Compliance Audit Tool 1 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004); DPH = S.F. Department of Public Health; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal Compliance Ratings Y = Yes; N I=ofNeeds Improvement; = Immediate Action; NA = Not Applicable S.F.Key: Department Public Health * IA Office of Compliance Substance Use Disorder Treatment Provider Compliance Audit Date of Review: _______________________________________ Review for County Fiscal Year: 20___ - ___ Provider Name: __________________________________________ Provider DMC Certified? □ Yes □ No Modality of Service (check all that apply): □ Day Care Habilitative □ Narcotic Treatment Program □ Residential - Perinatal?: □ Yes □ Outpatient Drug Free □ Naltrexone □ No DPH Compliance Officer(s): __________________________________________________________________________________________ Contact Information: Email: _______________________________________________________________________ Phone: _______________________________________________________________________ DPH Compliance Officer(s): ____________________________________ _____________________________________ Signature _____________________________________ Print Name Provider Representative(s): ____________________________________ _____________________________________ Print Name _____________________________________ Signature ____________________________________ Print Name ____________________________________ _____________________________________ Print Name _____________________________________ Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable Compliance Review Section 1. Client Individual Patient Records - The provider establishes an individual client record for each client admitted to the program? - All client individual records include all of the following client personal information: Client identifier (e.g. name, number); Client date of birth, gender, and race and/or ethnicity; Client address and telephone number; and Client next of kin or emergency contact; plus For pregnant and postpartum women, medical documentation substantiating client’s pregnancy and last day of pregnancy. - All client individual records include all of the following client treatment episode info & documentation of reimbursed services? Regulatory Authority Y NI IA NA DTS II.C.1 Title 9 §10160 Title 22 §51341.1(g)(1)(A) □ □ □ □ DTS II.C.2.a Title 9 §10165 Title 22 §51341.1(g)(1)(A) □ □ □ □ DTS II.C.2.b thru f Title 9 §10165, 10310, 10360 Title 22 §51341.1(g)(1)(B) □ □ □ □ Compliance Findings/Notes Intake and admission data (including, if applicable, a physical examination); Completed DPH Health Questionnaire; Initial and updated treatment plans with required review, approvals, type/legibly printed names, signatures, and dates; Evidence of compliance with provider and client contact requirements for treatment modalities or a written and signed determination by a licensed physician that fewer client contacts are appropriate and the client is progressing toward treatment plan goals; Progress notes; Continuing services justifications; Laboratory test orders and results; Referrals; Counseling notes; Discharge plan; Discharge summary (for lost contacts/involuntary discharges); Evidence of compliance with multiple billing requirements; Evidence of compliance with specific treatment modality service requirements (Title 22 §51341.1(d)); and Any other information relating to services claimed for reimbursement. Prepared by Golden Bear Associates for SFHN-BHS * June 2015 2 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 1. Client Individual Patient Records continued Regulatory Authority Y NI IA NA - All client records are written legibly in ink or typed? DTS II.C.2 f Title 22§51341.1(g)(1) □ □ □ □ - All client record entries are signed and dated? DTS II.C.2.bf Title 22 §51341.1(g)(1) □ □ □ □ DPH/HIPAA Requirement □ □ □ □ Title 22 §51341.1(h)(1)(A)(v) □ □ □ □ Title 22 §51341.1(h)(1)(A)(v) □ □ □ □ Title 22 §51341.1(h)(1)(A)(v) □ □ □ □ Title 22 §51341.1(h)(1)(A)(vi) □ □ □ □ 2. Client Individual Patient Record Retention - All of the documentation in the client’s individual client record is maintained for a minimum of 7 years from the date of the last faceto-face contact between the client and provider? 3. Intake & Admission: DSM 5 Diagnosis - All clients meet admission criteria as evidenced by a client DSM 5 substance use disorder diagnosis written in the client record? - A licensed physician, therapist, physician assistant or nurse practitioner has evaluated each client to diagnose whether clients have a substance use disorder within 30 calendar days of the client’s admission to treatment date as evidenced by a written basis for the diagnosis in the client’s individual patient record that is legible, signed and dated? - Where a licensed physician did not determine the client DSM 5 substance use disorder diagnosis, a licensed physician has reviewed and approved each client’s diagnosis as evidenced by a physician’s legibly printed or typed name, signature and date in a client’s treatment plan? 4. Intake & Admission: Medical Necessity - All clients meet medical necessity requirements as evidenced by a written and dated justification by a licensed physician in the client’s individual patient record within 30 calendar days of a client’s admission/readmission to treatment date? Compliance Findings/Notes 2 3 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 3 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 4 5. Intake & Admission: Additional Requirements Regulatory Authority Y NI IA NA DTS II.A.2 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ - Conducts initial interview with client to determine whether admission eligibility criteria are met? Title 22§51341.1 (h) - Documents how client meets admission criteria in client record? Title 22 §51341.1 (h) - Documents personal, medical and substance us history at intake including, at a minimum: Title 22§51341.1 (h) DTS II.A.2.c DTS II.A.2.d DTS II.A.2.d Social, economic, and family background? Title 22§51341.1 (h) Education? Title 22 §51341.1 (h) Vocational achievements? Title 22 §51341.1 (h) Criminal history and legal status? Title 22 §51341.1 (h) Medical history? Title 22 §51341.1 (h) Drug history? Title 22 §51341.1 (h) Previous treatment? Title 22 §51341.1 (h) DTS II.A.2.d DTS II.A.2.d DTS II.A.2.d DTS II.A.2.d DTS II.A.2.d DTS II.A.2.d DTS II.A.2.e - Obtains client consent after completion of intake/admission process? Title 22 §51341.1 (h) - Completes DPH Health Questionnaire for all clients? DPH Requirement - Conducts a health assessment within 30 calendar days from admission to treatment date that includes a physical examination by a physician, nurse practitioner, or physician’s assistant? Title 22 §51341.1 (h) - Documents health assessment in client record? Title 22 §51341.1 (h) - Determines client need for physical or laboratory examinations (by a licensed physician)? Title 22 §51341.1 (h) DTS II.A.3.a DTS II.A.3 DTS II.A.3.b Compliance Findings/Notes 5 6 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 4 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 5. Intake and Admission: Additional Requirements continued For DMC Programs: Licensed Physician Review of Client History - A physician reviews each client’s personal, medical and substance use history within 30 calendar days of the client’s admission to treatment date as evidenced by documentation in the client individual patient record and the legibly printed or typed name, date and signature of a physician? Physical Examination Requirements - A licensed physician reviews the client’s most recent physical examination within 30 calendar days of client’s admission to treatment date for clients who have had a physical examination within the twelve-month period prior to admission to treatment date as evidenced by documentation in the client’s individual patient record? - When the provider has not been able to obtain documentation of a client’s most recent physical examination, there is written documentation in the client’s individual patient record of efforts made to obtain the documentation on the client’s behalf? - Where a physician, registered nurse practitioner, or physician’s assistant performs a physical examination of the client within 30 calendar days of the client’s admission to treatment date, there is written documentation of findings within the client’s individual patient record? - Where there is no physical examination documentation or an examination performed by a physician, registered nurse practitioner or physician’s assistant, there is a goal incorporated within the initial and updated treatment plans of obtaining a physical examination until the exam goal has been met? - Where a client’s physical examination in the past 12 months indicates a client has a significant medical illness, there is evidence of a goal in the treatment plan that the client obtain appropriate treatment for the illness? Regulatory Authority Y NI IA NA Title 22 §51341.1(h)(1)(A)(iii) □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Title 22 §51341.1(h)(1)(A)(iv)(a) through (c) Title 22 §51341.1(h)(2)(A)(i)(h)(i) Compliance Findings/Notes 7 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 5 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable Regulatory Authority Y NI IA NA For Naltrexone Treatment Services: - Provider documents client has a documented history of opiate addiction as evidenced by documentation in client individual patient record? Title 22 §51341.1(h)(1)(B)(i)(a) □ □ □ □ - Provider confirms client is at least 18 years of age as evidenced by documentation in client individual patient record? Title 22 §51341.1(h)(1)(B)(i)(b) □ □ □ □ - Provider confirms client has been opiate free for a period of time to be determined by a physician based on the physician’s clinical judgement as evidenced by documentation in client individual patient record? - Provider administers a body specimen to confirm opiate free state of each client as evidenced by documentation in client individual patient record? Title 22 §51341.1(h)(1)(B)(i)(c) □ □ □ □ Title 22 §51341.1(h)(1)(B)(i)(d) □ □ □ □ Title 9 §10270 Title 9 §10305 □ □ □ □ DMC Organized Delivery System Waiver □ □ □ □ 5. Intake and Admission: Additional Requirements continued - Provider confirms client is not pregnant and is discharged from the treatment if client becomes pregnant as evidenced by documentation in client individual patient record? For Narcotic Treatment Programs: - Initial treatment plan includes strategies to assist clients in understanding substance use and how to reduce harm associated with substance use? - Medical director has conducted a medical evaluation consisting of at a minimum a medical history that includes a history of client’s illicit drug use; lab tests for determination of narcotic drug use, tuberculosis, infectious diseases, and syphilis; and a physical examination as specified under Title 9 §10270 as evidenced by written documentation in the client’s individual patient record? - Medical director has documented the evidence used in the medical evaluation to determine physical dependence and addition to opiates? For Residential: - Program administers the American Society for Addiction Medicine (ASAM) Multidimensional Assessment as evidenced by written documentation in individual patient record? Compliance Findings/Notes 8 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 6 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 6. Initial Treatment Plan For nonresidential programs: - Develops initial individual treatment plan for each client within 30 calendar days from the client’s admission to treatment date which includes all of the following at minimum: Regulatory Authority Y NI IA NA DTS II.C.2.c □ □ □ □ □ □ □ □ □ □ Statement of challenge(s) to be addressed in treatment? DTS II.C.2.c Statement of goal(s) to be reached which address the challenge(s)? DTS II.C.2.c □ □ Action steps which will be taken by the program and/or client to accomplish goal(s)? DTS II.C.2.c □ □ □ □ DTS II.C.2.c □ □ □ □ DTS II.C.2.f □ □ □ □ Title 22 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Target date(s) for accomplishment of action step(s), goal(s), and when possible, resolution of challenge(s)? - Initial treatment plan signed and dated by staff? For DMC Programs: - A description of services including the types of counseling to be provided and the frequency thereof? § 51341.1(h)(2)(A)(i) Title 22 - Assignment of a primary therapist or counselor? § 51341.1(h)(2)(A)(i) - Client’s diagnosis? § 51341.1(h)(2)(A)(i) - Goal to have a physical examination if client has not had a physical exam within the 12-month period prior to the admission to treatment date? - Goal to obtain appropriate treatment for significant medical illness documented on a physical examination of the client that was performed during the 12 months prior to the admission to treatment date? - Therapist or counselor completes, types or legibly prints name, and signs and dates the initial treatment plan within 30 calendar days of the admission to treatment date? Title 22 Title 22 § 51341.1(h)(2)(A)(i) Title 22 § 51341.1(h)(2)(A)(i) Title 22 §51341.1(h)(2)(A)(ii) Compliance Findings/Notes 9 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 7 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 6. Initial Treatment Plan continued - Client review and approval of initial treatment plan with typed or legibly printed name, signature and date within 30 calendar days of the admission to treatment date? - If client refuses, documentation of reason for refusal to sign the treatment plan and strategy to engage the client to participate in treatment? - Physician reviews initial treatment plan for medical necessity and type or legibly print their name, and sign and date the treatment plan within 15 calendar days of the signature by the therapist or counselor? For short-term residential (program duration 30 days or less): - Develops individual treatment plan for each client within 14 calendar days from the client’s admission to treatment date with required elements? - Uses ASAM Multidimensional Assessment in developing treatment plan as evidenced by ASAM findings in client individual patient record? For long-term residential (program duration 31 days or more): - Develops individual treatment plan for each client within 14 calendar days from the client’s admission to treatment date with required elements? - Uses ASAM Multidimensional Assessment in developed treatment plan? For Narcotic Treatment Programs: - Develops an individualized initial maintenance treatment plan within 28 calendar days after the initiation of maintenance treatment? - Includes short-term goals (those requiring 90 days or less for client to achieve); long-term goals (those exceeding 90 days for client to achieve); specific behavioral tasks clients must accomplish to compete each goals; a description go the type an frequency of counseling services to be provided; and an effective date based on the day the primary counselor signs the initial treatment plan? - Supervising counselor reviews and signs initial maintenance treatment plan within 14 calendar days from effective date? Prepared by Golden Bear Associates for SFHN-BHS * June 2015 Regulatory Authority Y NI IA NA Title 22 □ □ □ □ □ □ □ □ □ □ □ □ DMC Organized Delivery System Waiver □ □ □ □ AOD Cert. Stds. 12070 □ □ □ □ DMC Organized Delivery System Waiver □ □ □ □ Title 9 §10270 □ □ □ □ Title 9 §10270 □ □ □ □ Title 9 §10270 □ □ □ □ §51341.1(h)(2)(A)(ii) Title 22 §51341.1(h)(2)(A)(ii) AOD Cert. Stds. 12070 Compliance Findings/Notes 8 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 6. Initial Treatment Plan continued - Medical director reviews initial maintenance treatment plan and needs assessment and signs within 14 calendar days from the effective date and makes amendments to the plan where medically deemed appropriate? Regulatory Authority Y NI IA NA Title 9 § 10270 □ □ □ □ Compliance Findings/Notes 0 1 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 9 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 7. Treatment Plan Review and Updates For nonresidential programs: - Staff reviews and documents client’s progress in achieving treatment plan objectives within 30 days of signing the initial treatment plan and no later than 30 days thereafter? For short-term residential (program duration 30 days or less): - Staff reviews and documents client’s progress in achieving treatment plan objectives within 10 calendar days after signing the initial treatment plan and not later than every 10 days thereafter? - Uses ASAM Multidimensional Assessment in assessing client progress on treatment plan goals? For long-term residential (program duration 31 days or more): - Staff reviews and documents client’s progress in achieving treatment plan objectives within 14 calendar days after signing the initial treatment plan and no later than 14 days thereafter? - Staff and client review and update treatment plan when a change in problem identification or focus of treatment occurs, or no later than 90 days after signing the initial treatment plan and no later than 90 days thereafter, whichever comes first? - Uses ASAM Multidimensional Assessment in assessing client progress on treatment plan goals? - Updated treatment plans signed and dated by staff and client? For DMC Programs: - Therapist or counselor completes, types or legibly prints name, signs and dates updated treatment plan no later than 90 calendar days after signing the initial treatment plan, and no later than every 90 calendar days thereafter, or when a change in problem identification or focus of treatment occurs, whichever comes first? Regulatory Authority Y NI IA NA AOD Cert. Stds. 12070 □ □ □ □ AOD Cert. Stds. 12070 □ □ □ □ DMC Organized Delivery System Waiver □ □ □ □ AOD Cert. Stds. 12070 □ □ □ □ AOD Cert. Stds. 12070 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ DMC Organized Delivery System Waiver AOD Cert. Stds. 12070 Title 22 §51341.1(h)(2)(A)(iii) Compliance Findings/Notes 2 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 10 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 7. Treatment Plan Updates continued - Clients review, approve, type or legibly print their name and sign and date updated treatment plans within 30 calendar days of the signature by the therapist or counselor? - If client refuses to sign updated treatment plan, provider documents reason for refusal and strategy for to engage client to participate in treatment? - Physicians review each updated treatment plan to determine whether services are medically necessary? - Physicians type or legibly print their name and sign and date updated treatment plans within 15 calendar days of the signature of the therapist or counselor when they determine services in updated treatment plan are medically necessary? For Narcotic Treatment Programs: - Primary counselor evaluates and updates client’s maintenance treatment plan whenever necessary or at least once every three months from the date of admission? - Supervising counselor reviews and signs updated client maintenance treatment plans within 14 calendar days from the effective date? - Medical director reviews updated client maintenance treatment plans and signs within 14 calendar days from the effective date and makes amendments to the plan where medically deemed appropriate (a licensed psychologist may review for medical necessity, type or legibly print their name and sign and date an updated treatment plan where a physician has not prescribed medication)? Regulatory Authority Y NI IA NA Title 22 □ □ □ □ Title 9 § 10270 □ □ □ □ Title 9 § 10270 □ □ □ □ Title 9 § 10270 □ □ □ □ §51341.1(h)(2)(A)(iii) Compliance Findings/Notes Title 22 §51341.1(h)(2)(A)(iii) 3 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 11 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 8. Progress Notes For Outpatient Drug Free and Naltrexone Treatment: - Therapists or counselors record a progress note for each individual or group counseling session for each client who participates in the session and type or legibly print their name and sign and date the progress note within 7 calendar days of the counseling session? - Progress notes include all of the following? Topic of the session? Type of counseling format (e.g. individual, group or medical psychotherapy)? Description of client’s progress on the treatment plan challenges, goals, action steps, objectives and/or referrals? Information on the client’s attendance, including the date, start and end times of each individual and group counseling session? For Intensive Outpatient and Perinatal Residential: - Therapists or counselors record a minimum of one progress note per calendar week for each client participating in structured activities including counseling sessions and type or legibly print their name and sign and date the progress note within the following calendar week - Progress notes include: description of client’s progress on the treatment plan challenges, goals, action steps, objectives, and/or referrals; record of the client’s attendance at each counseling session including the date, start and end times and topic of the counseling session. Regulatory Authority Y NI IA NA Title 22 §51341.1(h)(3) □ □ □ □ Title 22 §51341.1(h)(3) □ □ □ □ □ □ □ □ □ □ □ □ Title 22§51341.1(h)(3) □ □ □ □ Title 22 §51341.1(h)(3) □ □ □ □ Title 22 §51341.1(h)(3) □ □ □ □ Title 22 §51341.1(h)(3) Title 22§51341.1(h)(3) Compliance Findings/Notes 4 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 12 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 8. Progress Notes continued For Narcotic Treatment Programs: - Counselors conducting the counseling sessions document within 14 calendar days of the session including all of the following: Date of session? Type of counseling format (e.g. individual, group or medical psychotherapy)? Duration of session in 10-minute intervals? Summary of session including one or more of the following: Regulatory Authority Y NI IA NA Title 9 §10345 □ □ □ □ Title 9 §10345 □ □ □ □ Title 9 §10345 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Title 9 §10345 □ □ □ □ AOD. Cert. Stds. 13000 □ □ □ □ Title 9 §10345 Title 9 §0345 Title 9 §10345 o Patient’s progress toward goals in treatment plan? Title 9 §10345 o Response to a drug screening specimen? Title 9 §10345 o New issues or challenges that affect the client’s treatment? Title 9 §10345 o Nature of prenatal support provided by the program or other health care providers? o Goal and/or purpose of the group session, the subjects discussed, and a brief summary of client’s participation? For Residential Treatment: - Documents progress notes on a weekly basis? Compliance Findings/Notes 5 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 13 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 9. Frequency of Services, Services Referrals and Group Counseling Requirements Regulatory Authority - Meets frequency of service requirements? For Outpatient Drug Free, sees clients weekly or more often depending on his/her need and treatment plan? For Outpatient Drug Free, all clients participate in at least two counseling sessions per 30-day period? For Day Care Habilitative, all clients provided a minimum of three hours per day for three days per week of individual or group sessions and/or structured therapeutic activities. For Residential, all clients receive minimum of 20 hours per week of counseling and/or structured therapeutic activities? For Day Treatment, all clients receive a minimum of 10 hours per week of counseling and/or structured therapeutic activities? Documents in client records exceptions to frequency of services for clients where program staff have determined that fewer client contracts are clinically appropriate and progress toward treatment goals is being maintained? - Assesses need for the following minimum services and provides or makes referrals directly to an ancillary service to meet service needs: Education opportunity? DTS II.B.3.a Y NI IA NA DTS II.B.3.a □ □ □ □ □ □ □ □ DTS II.B.3.a □ □ □ □ AOD Cert. Stds. 13000 e □ □ □ □ DTS II.B.3.a □ □ □ □ DTS II.B.3.a □ □ □ □ DTS II.B.3.a □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ DTS II.B.3.b DTS II.B.3.b Vocational counseling and training? DTS II.B.3.b Job referral and placement? DTS II.B.3.b Legal services? DTS II.B.3.b Medical services and dental services? DTS II.B.3.b Social/recreational services? Individual counseling and group counseling for clients, spouses, domestic partners, parents and other significant people? - Documents service referrals in client records? DTS II.B.3.b DTS II.B.3.b DTS II.B.3.b Compliance Findings/Notes 6 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 14 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 9. Frequency of Services, Services Referrals and Group Counseling Requirements continued - Provides or refers clients to the following services: Regulatory Authority Y NI IA NA □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Title 22 §51341.1 1(h)(5) □ □ □ □ Title 22 §51341.1 1(h)(5) □ □ □ □ Title 22 §51341. (b)(11) □ □ □ □ Title 9 §10345 □ □ □ □ DTS II.B.4 Emergency? DTS II.B.4.a Medical consulting? DTS II.B.4.b Medical detoxification when deemed appropriate? DTS II.B.4.c - Meets group size requirements for group counseling (two or more participants)? - Meets group counseling documentation requirements? For DMC Programs: - For Outpatient Drug Free clients are provided a minimum of 2 counseling sessions per 30 day period except when physician determines fewer client contacts are clinically appropriate or the client is progressing toward treatment plan goals? - For Intensive Outpatient clients are provided a minimum of 3 hours of counseling session 3 days a week except when physician determines fewer client contacts are clinically appropriate or the client is progressing toward treatment plan goals? - Meets group size requirements for counseling sessions? No less than 2, no more than 12 clients at the same time. - Meets confidential session setting requirements? - Ensures client’s age 17 or younger do not participate with clients age 18 and older except at school sites? For Narcotic Treatment Programs: - Clients receive a minimum of 50 minutes of counseling per calendar month except where the medical director adjusts or waives at any time after admission by medical order the minimum number of minutes of counseling services per calendar month along with rationale for adjusting or waiving counseling services? AOD Cert. Stds. 13000 AOD Cert. Stds. 13000 Compliance Findings/Notes 7 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 15 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable Regulatory Authority Y NI IA NA - Clients administered monthly urinalysis test/weekly for clients who are pregnant Title 9 § 10310 Title 9 § 10360 □ □ □ □ - Complies with multiple registration at time of admission requirements including physician documentation of dosage? Title 9 § 10210 □ □ □ □ - Complies with medication dosage level requirements including clients who are pregnant? Title 9 § 10355 Title 9 § 10360 □ □ □ □ - Complies with tuberculosis testing requirements? Title 9 § 10567 □ □ □ □ 9. Frequency of Services, Services Referrals and Group Counseling Requirements continued Compliance Findings/Notes 8 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 16 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 10. Continuing Services - Therapist or counselor no sooner than 5 months and no later than 6 months after client admission to treatment dates or the date of completion of the most recent justification for continuing services, reviews the client’s progress and eligibility to continue to receive treatment services and recommends whether the client should or should not continue to receive treatment services? For DMC Providers: - Physician determines whether continued services are medically necessary and documents determination in client record including consideration of all of the following: client’s personal, medical, and substance use history; documentation of the client’s most recent physical examination; client’s progress notes and treatment plan goals; and client’s prognosis? - Client discharged when physician determined continuing treatment services not medically necessary? Regulatory Authority Y NI IA NA Title 22 □ □ □ □ □ □ □ □ §51341.1(h)(5)(A)(i) Title 22 §51341.1(h)(5)(A)(ii) Compliance Findings/Notes 9 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 17 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 11. Discharge Plan and Discharge Summary - Staff completes discharge summaries for each client that include: Description of treatment episodes or recovery services? Current alcohol and/or other drug usage? Vocational and educational achievements? Legal status? Reason for discharge and whether the discharge was involuntary or a successful completion? Client’s continuing recovery or treatment exit plan? Transfers and referrals? Client’s comments? For DMC Programs: - Therapists or counselors complete a discharge plan for each client except for clients with whom the provider loses contact? - Discharge plan prepared within 30 calendar days prior to the date of the last face-to-face treatment with the client that includes all of the following at a minimum: Description of each of the client’s relapse triggers and a plan to assist the client to avoid relapse when confronted with triggers? A support plan? - Therapists or counselors and clients type or print legibly their names, sign and date the discharge plans? - Clients provided a copy of discharge plan by therapist or counselors at last face-to-face treatment with client? Regulatory Authority Y NI IA NA AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 AOD Cert. Stds. 12085 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Title 22 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ §51341.1(h)(6)(A) Title 22 §51341.1(h)(6)(A) Title 22 §51341.1(h)(6)(A) Title 22 §51341.1(h)(6)(A) Title 22 §51341.1(h)(6)(A) Compliance Findings/Notes 0 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 18 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 11. Discharge Plan and Discharge Summary continued - Providers complete a discharge summary for clients with whom contact has been lost within 30 calendar days of the date of the provider’s last face-to-face treatment contact with the client that includes all of the following: duration of client’s treatment; reason for discharge; narrative summary of treatment episode; and client’s prognosis. For Narcotic Treatment Programs: - Program completes a discharge summary for each client who is terminated from treatment either voluntarily or involuntarily that includes at a minimum: client’s name and discharge date; reason for discharge; and summary of client’s progress during treatment. For Residential Programs: - Links clients to medically necessary recovery services, using results of the ASAM Criteria Multidimensional Assessment, Dimension 6, Recovery Environment, that may include the following: Recovery Monitoring: Recovery coaching, monitoring via telephone and internet; Substance Abuse Assistance: Outreach, peer-to-peer services, relapse prevention, and substance abuse education; Education and Job Skills: Linkages to life skills, employment services, job training, and education services; Family Support: Linkages to childcare, parent education, child development support services, family/marriage education; Support Groups: Linkages to self-help and support, spiritual and faith-based support; Ancillary Services: Linkages to housing assistance, transportation, case management, individual services coordination. Prepared by Golden Bear Associates for SFHN-BHS * June 2015 Regulatory Authority Y NI IA NA Title 22 §51341.1(h)(6)(B) □ □ □ □ Title 9 §10415 □ □ □ □ DMC Organized Delivery system Waiver □ □ □ □ Compliance Findings/Notes 19 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 12. Client Fair Hearing Rights - Providers comply with client notification of fair hearing requirements that involve the denial, involuntary discharge, or reduction in DMC substance use disorder services as it relates to their eligibility for benefits by providing written notification at least 10 calendar days prior to the effective date of the intended action to terminate or reduce services that includes: Statement of action to be taken; Reason for intended action; Citation of the specific regulations supporting intended action; Explanation of client’s right to fair hearing for purpose of appealing the intended action; Explanation that client may request a fair hearing by submitting a written request to the Department of Social Services; and Explanation that provider will continue treatment services pending a fair hearing decision? Regulatory Authority Y NI IA NA Title 22 □ □ □ □ §51341.1(h)(7) Compliance Findings/Notes - Copy of written notification in client individual patient record? 1 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 20 Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations) Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable 2 3 Number of Charts Reviewed: _______ 4 Findings 5 Number of Yes: _______ 6 Number of Needs Improvement: ________ 7 Number of Immediate Action: ________ 8 Program meets contractual requirements and goals? _______ 9 Plan of Correction? ______ Yes ______ No 0 1 PROVIDER EVALUATION SUMMARY: 2 __________________________________________________________________________________________________________________ 3 __________________________________________________________________________________________________________________ 4 __________________________________________________________________________________________________________________ 5 __________________________________________________________________________________________________________________ 6 __________________________________________________________________________________________________________________ 7 8 9 ________________________________ ____________________________________ __________________________________ 0 Compliance Officer Printed Name Signature Date 2 ________________________________ ____________________________________ __________________________________ 3 Provider Representative Printed Name Signature Date 1 Prepared by Golden Bear Associates for SFHN-BHS * June 2015 21