ADMISSION THROUGH DISCHARGE
Special Descriptions of Services-Admission Through Discharge
Psychiatric Rehabilitation Program-PRP/Psychosocial Rehabilitation-PSR
Referral is required for all admissions into the program. The ONLY acceptable referral according to COMAR 10.21.29.05.(1) (a), 10.21.29.05.(1). (b) and 10.63 is that provided by the treating Mental Health Professional (MHP) or Court Ordered referral. Any one applying for a PRP service at this agency that has no MHP e. g. a therapist or have not seen one before SHALL be referred to our Out Patient Mental Health Center-OMHC or any other place of their choice for assessment and diagnosis to determine if the person meets the medical necessity and severity of condition/need requiring PRP services. Request for authorization must be submitted to the Administrative Service Organization (ASO), Insurance provider or payer of service for approval and until such authorization is obtained with confirmation authorization number, the individual will not be admitted into the program. Acceptance notification will not be sent out to the individual until such a time authorization for service is obtained. Admission for minor will be based on severity of needs. Individuals with greater needs will take preference over those with less need.
Once a complete and appropriate referral is obtained, the Rehabilitation Coordinator or (Marketing Admission Officer when assigned) shall make face-to-face contact with the individual within 5 working days, 2 hours, or depending on applicability/feasibility/requirement. During such meeting, the assigned staff shall schedule an appointment to conduct a face-to-face screening assessment to determine the Rehabilitation service needs:
a) Willingness to participate in PRP services
b) Our programs ability to address the needs identified in the assessment
c) If the person is not eligible or admitted, notify the person or guardian (if a minor) the reason why and recommendation for alternative services.
d) If the person is eligible or admitted, notify the person or guardian (if a minor) about the status of their eligibility or admission, including but not limited to the responsible staff and start date of service.
Within 5 working days of the screening assessment conducted as in (1) above, notify the person of the status of their application as in (1d) above. Such notice may include informing the individual what he/she need to do to be enrolled, placing the individual on waiting list with option to seek for alternative services available, that the person will be enrolled when he/she is discharged from impatient facility, RTC, Detention center.
In line with COMAR 10.21.29.06, 10.21.29.07, 10.21.21.06 and 10.21.21.07, all evaluation and planning services, rehabilitation assessment, individual rehabilitation plan, rehabilitation plan review, continuing evaluation, rehabilitation and support services provided, rehabilitation activities, medication services, promotion of illness management, on-call and emergency response, emergency care and discharges, SHALL follow procedures, formats, forms, guidelines as set fort in relevant questionnaire, surveys, or methods as approved by the State, laws, rules and regulations and accreditation guidelines; under method of implementation of each program part. Signature must be obtained from both individual and guardian, in case of a minor, where minor signature is not obtained, document the rational for refusing to sign all required forms in their medical records. Where the minor refused to sign any required form, the guardian is required to sign it to continue to participate in our program. Minor 16 years old can sign themselves up without permission of the parent and in such case the 16 years old minor must sign consent for release of information before any staff can disclose any information to his/her parent about our services to the minor.
Additional services SHALL follow the following rules:
i. All evaluation and planning services, rehabilitation assessment shall be completed within 14 working days. Where the individual has been schedule later than 14 days, assigned staff shall document the reason justifying such prolonged process and must be approved by the Program Director. Any applicant whose intake process will be more than 30 working days regardless of the rational must be referred or recommendation be made for alternative services while waiting. The intake staff shall notify the Program Director. The Program Director shall notify the Core Service Agency-CSA and Administrative Service Organization-ASO. Such notification shall be documented in the individual’s medical records.
ii. All individual rehabilitation plans shall be completed by the Rehabilitation Coordinators within 30 working days.
iii. All rehabilitation plan reviews shall be completed by the Rehabilitation Coordinators with the individual and guardian (for a minor) every three months to discuss progress and review medical records. Such review shall be documented.
iv. All rehabilitation coordinator shall complete monthly summaries and submit it to their supervisors for review by the 15th of the month after the month under review unless otherwise included in at least one of the contact progress report.
v. All continuing evaluations and continuing stay authorization requests from the ASO, insurance company or payer shall be completed and submitted by the rehabilitation coordinator 14 working days prior to the end date of the most current authorization for the service.
vi. The Rehabilitation Coordinators shall document all rehabilitation and support services provided, rehabilitation activities, medication services, promotion of illness management, on-call and emergency response, and emergency care which supports individual recovery, independent decision making ability and create opportunities for choices regarding home, school, work, community, promoting use of community resources and good support systems within 24 hours.
vii. All discharges shall be done by the Rehabilitation Coordinator according to the discharge policy after the meeting of the Behavior Management Committee. Every discharged individual shall receive a discharge summary and a letter of discharge and SHALL include the individual and their significant others or representative. Where the individual failed to show up for discharge meetings scheduled, the discharge summary and letter shall be sent to the address on file within 5 working days.
5. Case management
The Case Managers shall document all case management, rehabilitation and support services provided, rehabilitation activities, medication services, promotion of illness management, on-call and emergency response, and emergency care which supports individual recovery, independent decision making ability and create opportunities for choices regarding home, school, work, community promoting use of community resources and good support systems within 24 hours. They shall perform all the duties and responsibilities of Treatment and Rehabilitation Coordinators where and when they fail and/or any lack thereof and SHALL be credentialed and clinically privileged to do so.
The Customer Service Representative for medical records/Custodian shall keep all medical records of individuals in admission process as pending and SHALL NOT accept such records as completed until enrollment, screening, evaluations, plans and authorization is completed. It is the duty of the assigned staff conducting the admission to ensure that this process is completed timely by all team members in line with this protocol. All staff shall follow their respective detailed job description, duties and responsibilities in ensuring that this protocol is not compromised. All Schedules must be coordinated centrally by the Administrative Assistants and support staffs
B. Outpatient Mental Health Center-OMHC
Referral is not required for all admissions into the program. The ONLY required referral is such according to COMAR 10.21.20.05. (B), and any individual could self refer (walk-in) and authorization SHALL be obtained from the State through the ASO, insurance company or payer according to provisions of COMAR 10.21.17.03A, insurance company’s or payer’s guidelines. Face-to-Face screening assessment SHALL be provided by a licensed Mental Health Professional. After initial screening assessment by the licensed Mental Health Professional, a referral is required for psychiatric evaluation and medication services to the Medical Director. The Medical Director can either conduct a face-to-face diagnostic interview or assign another licensed Psychiatrist to conduct such interview. Any one applying for OMHC service at this agency that has no licensed Mental Health Professional and psychiatrist or have not seen one before SHALL be referred to our Out Patient Mental Health Clinic-OMHC or any other place of their choice for assessment and diagnosis to confirm that the person meets the medical necessity and severity of condition/need requiring treatment services. Request for authorization must be submitted to the ASO, insurance company or payer and until such authorization is obtained with confirmation authorization number, the individual will not be admitted into the program, except in case of emergency. Acceptance notification will not be sent out to the individual until such a time authorization for service is obtained from the ASO, insurance company or payer. Admission for minor will be based on severity of needs. Individuals with greater needs will take preference over those with less need. Services for child and adolescent require more evaluations and assessments as indicated in the evaluation forms and systems and according to provisions of COMAR 10.21.20.06.C.
Once a complete and appropriate referral is obtained (where necessary), theTreatment Coordinator must make face-to-face contact with the individual within 5 working days, 2 hours, depending on applicability, feasibility or requirement. During such meeting, the assigned staff shall schedule an appointment to conduct a face-to-face screening assessment to determine the:
Treatment service needs Goals, resources, strengths and contents for recovery services Collaborate with Medical Director in determining our programs ability to address the needs identified in the assessment and the acuity of the diagnosis.
If the person is not eligible or admitted, notify the person or guardian (if a minor) the reason why and recommendation for alternative services. If the person is eligible or admitted, notify the person or guardian (if a minor) about the status of their eligibility or admission, including but not limited to the responsible staff and start date of service.
Within 5 working days of the screening assessment conducted as in (2) above, notify the person of the status of their application as in (2d-e) above. Such notice may include informing the individual what he/she need to do to be enrolled, placing the individual on waiting list with option to seek for alternative services available, that the person will be enrolled when he/she is discharge from impatient facility, RTC, Detention center.
Treatment Coordinator shall initiate services immediately if the person is referred from impatient facility.
In line with COMAR 10.21.20.06, 10.21.20.07, all evaluation and planning services, treatment assessment and documentations, individual treatment plan, treatment plan review, continuing evaluation, treatment and support services provided, coordination of treatment services, medication services, promotion of illness management, on-call and emergency response, emergency care and discharges, SHALL follow procedures, formats, forms, guidelines as set fort in relevant questionnaire, surveys, or methods as approved by the State, laws, rules and regulations and accreditation guidelines; under method of implementation of each program part. Signature shall be obtained from both individual and guardian, in case of a minor, where minor signature is not obtained, document the rational for refusing to sign all required forms in their medical records. Where the minor refused to sign any required form, the guardian is required to sign it to continue to participate in our program. Minor 16 years old can sign themselves up without permission of the parent and in such case the 16 years old minor must sign consent for release of information before any staff can disclose any information to his/her parent about our services to the minor.
This section MUST follow the following rules:
All evaluation and planning services, treatment assessment shall be completed within 14 working days. Where the individual has been schedule later than 14 days, assigned staff shall document the reason justifying such prolonged process and shall be approved by the Program Director. Any applicant whose intake process will be more than 30 working days regardless of the rational shall be referred or recommendation be made for alternative services while waiting. The intake staff shall notify the Program Director. The Program Director shall notify the Core Service Agency-CSA and Administrative Service Organization-ASO. Such notification shall be documented in the individual’s medical records.
All individual treatment plans shall be completed by the Treatment Coordinators before the fifth visit with the individual.
All treatment plan reviews shall be completed by the Treatment Coordinators with the individual and guardian (for a minor) every three months to discuss progress and review medical records. For individual in our intensive treatment every week. Such review shall be documented.
All Treatment Coordinators shall complete monthly summaries and submit it to their supervisors for review by the 15th of the month after the month under review unless that is included in at least one of the contact progress report.
All continuing evaluations and continuing stay authorization requests from the ASO, insurance company or payer shall be completed and submitted by the Treatment Coordinator 14 working days prior to the end date of the most current authorization for the service.
The Treatment Coordinators shall document all treatment and support services provided, treatment services and coordination of services, medication services, promotion of illness management, on-call and emergency response, and emergency care which supports individual recovery, independent decision making ability and create opportunities for choices regarding home, school, work, community promoting use of community resources and good support systems within 24 hours.
All discharges shall be done by the Treatment Coordinator according to the discharge policy after the meeting of the Behavior Management Committee and Medical Director. Every discharged individual shall receive a discharge summary and letter and SHALL include the individual and their significant others or representative. Where the individual failed to show up for discharge meetings scheduled, the discharge summary and letter shall be sent to the address on file within 5 working days.
B-1). Administrative Services
1. The Customer Service Representative for medical records/Custodian shall keep all medical records of individuals in admission process as pending and SHALL NOT accept such records as completed until enrollment, screening, evaluations, plans, authorization etc are completed. It is the duty of the assigned staff conducting the admission to ensure that this process is completed timely by all team members in line with this protocol.
2. All staff shall follow their respective licenses, detailed job description, duties and responsibilities in ensuring that this protocol is not compromised.
3. Treatment Coordinator shall provide psychological testing (if credentialed), case management and co-occurring substance abuse treatment as part of mental health treatment and when clinically appropriate provide referral for psychological testing, PRP, somatic care, speech and language services, vision and hearing services, special instruction, special education or other educational interventions, occupational therapy and substance abuse services.
4. All schedules shall be coordinated centrally by the Administrative Assistants and support staffs
5. This section shall apply to all programs and services owned by Care Solutions Corporation.
C. Outpatient Mental Health Center-OMHC-Medication Services
1. The Medical Director shall ensure that appropriate staff are trained and updated on use, effects, interactions, and potential side effects of medication used by individuals served by the program.
2. Licensed mental health professionals credentialed by the program shall, as appropriate, provide the following services:
a. Prescription
b. Administration
c. Monitoring
d. Education regarding medication; benefits and possible side effects and document it.
e. Evaluate the individual face-to-face initially and at a minimum of every 90 days
f. Assess for any contraindication to specific medications and document it
g. Document the rational for prescribing the medication in the individual’s medical record.
h. With proper consent notify anyone responsible to administer or monitor the medication regimen including the primary care physician.
i. Alter medications and adjust dosage as clinically indicated; documenting rational for such changes or current prescription.
j. Order and monitor tests at medically recommended intervals and document results.
k. Crisis response plan at home, school, work or other settings when clinically appropriate.
D. Residential Group Homes
1. A child is admitted into our home when the local placement agency/worker brings a child in need of a home to our program. Assigned intake staff SHALL ensure that all necessary documentation as well as the intake package is reviewed and authenticated. The admission review is an integral part of the admission process through which we ensure that the needs of the child will be met by our program. All necessary logistics will be provided for a smooth and easy transition of the child into his new home. To reduce initial adjustment effects, his placement worker, parent, parent surrogate or guardian will accompany the child to his new home as the case may be with our program staff escorting them. There will be a formal introduction of the members of the household to the in coming child or vice versa.
2. The assigned admission staff SHALL ensure the child is accompanied by the following:
b. Non Discrimination Policy
c. Admission Evaluation Form
d. Psychosocial History or Predisposition Report
e. Educational History
f. Health Passport
g. Medical Insurance Documentation
h. Clinical Report (if any)
i. Emergency Contact of Guardian and Parents
j. Legal Guardian Documentation
k. The Child’s Permanency Plan
l. Authorization to Provide Care
m. Any applicable court and non court order
3. All staff shall follow their respective licenses, detailed job description, duties and responsibilities in ensuring that this protocol is not compromised.
E. Transportation and Mobility Services
All Mental Health Associate SHALL check their vehicle before embarking and after disembarking for all safety check including maintenance checks and documentation.
All vehicle checklist SHALL be completing in accordance with set guidelines and SHALL be enforced by the Transportation and Mobility Manager.
All requests for use of company vehicle by any staff shall be submitted to the Transportation and Mobility Manager five (5) business days ahead of time in the appropriate forms
All pick up and drop off of individuals by the Mental Health Associate must be accompanied by the Rehabilitation and/or Treatment Coordinators. Behavior of the individuals SHALL be observed to and from accessing needed resources or services and such observations documented and reported in appropriate forms.
All Mental Health Associate shall provide additional support while their individual are being served by the clinicians especially during therapeutic activities.
No individual is allowed on the physical plant without supervision and SHALL not be left unattended.
All Mental Health Associate SHALL wait and observe the individual (if a minor) enter his/her house and shall reiterate to them the importance of going in the house first; before disembarking. Staff must not pull off without the child going into the house. Accompanying staff should walk the individual into the house when defiance is suspected and alert the guardian.
No child is allowed to stay in the vehicle unattended.
All mileage SHALL be approved by the Program Director and shall be submitted to The Transportation and Mobility Manager in the appropriate format. Transportation and Mobility Manager will verify it and turn it in to Administrative Assistant 12.00 noon 2nd of each month. Any mileage not turned in on time will be reimbursed the following month same period. All staff shall follow their respective licenses, detailed job description, duties and responsibilities in ensuring that this protocol is not compromised.
F. Program Administration Services
All supervisors SHALL ensure proper supervision, monitoring and compliance with all policies, procedures, protocols, COMAR regulation and laws, rules and regulations and accreditation guidelines under their authority. Medical records are to be safely stored and controlled by the Customer Service Representative for Medical Records and Custodian.
Under no circumstances should any staff reveal or release any information about any individual in any of our programs to anyone without written authorization from the individual or guardian (in case of a minor). The Administrative Assistant is responsible to provide support to all staff providing products and services to individuals and members for all member organizations.
All initial clerical admission and demographic information SHALL be entered at the front desk before the individual is seen by any direct care staff e.g. Psychiatrist. This will allow them to have the ‘face sheet’ to fill in necessary information in their specialty. All data must be entered in accordance with guidelines set by the Executive Director or his/her designate.
All folders of individuals scheduled to be seen each day must be pulled by the Customer Service Representative for Medical Records/Custodian before 11.00 AM and available for the attending clinicians. Where he/she is unavailable, the Administrative Assistant is responsible to do so.
All folders signed out for any staff as scheduled SHALL be accounted for and returned by the Customer Service Representative for Medical Records/Custodian immediately after services are completed. All relevant documentation accounted for, reviewed and filed immediately.
All individuals scheduled or walking in for appointments or services SHALL sign in at the front desk. The Customer Service Representative for Administration and where unavailable The Administrative Assistant is responsible to ensure that this is implemented.
The productivity Form SHALL be turned in every Monday at 12.00 noon and all supervisors shall ensure that all staff regardless of their employment status (employees, contractors, consultants, volunteers, interns, externs etc) comply with this directive.
No individual other than company personnel will be allowed to have access to any company property especially the computers.
All progress, contact, summaries, reports or documents SHALL be submitted to The Administrative Assistant for onward transmission to the appropriate staff
All documents or item received or sent out SHALL be recorded or logged in with date and time.
Administrative Assistant is the official time keeper. Times approved by any supervisor must be reported to the Administrative Assistant for records purposes.
iv. Universal Transitional Plan
All new members must be served at the highest level of care possible. Where the direct care staff has problem making contact for offsite service (e.g. individual not at home, failed to participate) or the individual failed to make scheduled office visit or keep his/her appointment for onsite/offsite service, the staff shall make the minimum contact required by Public Mental Health System or the individual’s insurance company for that to be billable (e.g. if fee-for-service requires 2 minimum encounter in order for the allowed amount to be billed and paid for, person seen once must not be billed for). If the person sets a pattern over reasonable period of time, the person is presenting lack of interest or participation which will undermine the effectiveness of treatment or rehabilitation and/or an indication that the person may not meet the severity of need piece of the agency and therefore need to be referred or discharged.
If the individual starts to show reasonable improvement with management of symptoms, self-help and attained recovery, in the rehabilitation and/or treatment, the level of care will gradually be reduced to the minimum required for authorized service such that the individual’s functioning is not decreased or affected.
All individuals who have successfully completed their rehabilitation or treatment must be discharged regardless of whether their authorization is still current to encourage independence and create opening for staff to help others in need to benefit from our program. Such decision can only be made by the Behavior Management Committee during their quarterly or emergency meeting and must follow discharge procedure.
Discharge of all individuals must follow discharge plan for individual programs
If any individual discharged relapsed or returns for same or any of our services, the individual shall be connected to the staff who originally worked with the individual with whom he/she had established a trusting relationship.