BPI MEDICAID CertificationReview Process and Federal Requirements

Federal RequirementsBPI is responsible for PRTF MEDICAID CertificationThis Certification ensures that providers are in compliance with Federal RequirementsAlso monitored during site-visits are the state specific requirements and MA General Regulations

Federal RequirementsPRTF physician involvementAll services and treatment must be directed and ordered by the psychiatristPsychiatrist heads treatment team

Federal Requirements42 CFR 441.155(d)(1) and 456.160(b)Physicians Recertification of Need for CareA Physician, Physicians Assistant or Nurse Practioner acting within the scope of their practice, must recertify for each recipient that inpatient RTF level of care is still required. This recertification must be made at least every thirty (30) days and documented in the residents record

Federal Requirements42 CFR 441.155 and 456.180Individual Plan of CareA individual plan of care must be written for each recipient. The plan of care must be based on a diagnostic evaluation and include the diagnosis, symptoms, complications, therapies, treatment objectives, social services and discharge planning.

Federal Requirements42 CFR 441.154Active TreatmentA Initial Psychiatric Evaluation and plan of care must be developed within fourteen (14) days of admission to the RTF.

Federal Requirements42 CFR 441.154, 441.155, 441.156 and 456.180Treatment Team/Plan ReviewsThe plan of care must be reviewed and/or revised by the treatment team, as specified, at least every thirty (30) days.

Federal Requirements42 CFR 441.155(b)(2) and 441.156Treatment Team/Members or Composition The team must include at a minimum: 1) a board certified or board eligible psychiatrist; 2) a clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; 3) a physician with specialized training in the treatment and diagnosis of mental health issues, and a clinical psychologist who has a masters degree in clinical psychology and one of the following: (a) a clinical psychiatric social worker, (b) a registered nurse specialized with training or experience in treating mentally ill individuals, (c) a occupational therapist, (d) a clinical psychologist who has a masters degree.

Federal Requirements 42 CFR 441.155(b)(2), 441.156 and MA Bulletin 1165-95-01All therapeutic leaves must be ordered by the physician and be used as a part of the recipients individual treatment program. Dates and times of the passes must be documented, as well as the therapeutic goals and results of the pass. MA payment for therapeutic passes in an RTF is limited to forty-eight (48) per calendar year.

Federal Requirements42 CFR 441.155, 456.180 and 456.610MedicationsAll medications must be ordered by the attending physician, to include the dosage, route and frequency. Diagnoses, symptoms and complications must be documented to justify the medication ordered, this includes over-the-counter medications. The attending physician must review and reorder the prescribed medications at least every thirty (30) days.

Federal Requirements42 CFR 441.155, 456.180 and 456.610Treatments/TherapiesAll tests and treatments must be ordered by the attending physician. Diagnoses, symptoms and complaints must be documented to justify the orders. The attending physician must review prescribed treatments at least every thirty (30) days. (This can be done via the Treatment Plan Review process)

Federal Requirements42 CFR 441.155, 456.180 and 456.610Dietary NeedsAll dietary needs must be ordered by the attending physician. The attending physician must review and reorder prescribed diet at least every thirty (30) days.

Federal Requirements42 CFR 456.610Progress NotesThe physician, nurse and all other professional progress notes must be consistent with the observed condition and progress of the recipient.

Federal Requirements42 CFR 483 and MA Bulletin 53-01-01Restraint and SeclusionRestraints (holds) must be ordered by the physician or LIP Licensed Independent Practioner)Orders must include the type of hold to be used and the duration of the holdOrders must be signed by the physician, LIPIf LIP is ordering the hold, documentation by the LIP must indicate that the physician was notified of the hold

Federal RequirementsRestraint and Seclusion (Continued)Times must be documented as to when the hold began and endedIf holds last over 10 minutes in duration the 3800 Licensing Regulations must be followed as to documentation that physical assessments and adequate hydration and toileting needs are met

Federal Requirements Restraint and Seclusion (Continued)Within one hour of the duration of the hold, a physical and psychological assessment must be completed by a MD, PA, CRNP or RN and documented in the record. The documentation must include the time the assessment occurred

Federal Requirements Restraint and Seclusion (Continued) A client debriefing must take place with the client and staff involved in the physical hold within 24 hours of the safety intervention. Documentation of this debriefing must included all members who attended and the time and date the debriefing occurred

Federal RequirementsRestraints and Seclusion (Continued)Within 24 hours of the release of the hold a staff debriefing consisting of all staff involved in the hold as well as appropriate treatment team members, and supervisory and administrative staff must occur. Documentation of this debriefing must include all members attending and the date and time of the meeting

Federal RequirementsRestraint and Seclusion (Continued)The parents, guardians or custodians of the resident involved in the hold must be notified as soon as possible. The date, time, name of party contacted and name of staff member providing the notification must be documented in the residents record

Federal Requirements42 CFR 456.180Multi-disciplinary Treatment Team (Inter-agency Team)The attending physician and all other personnel and agencies involved in the recipients immediate care and discharge care must meet to review and/or revise the recipients plan of care at least every ninety (90) days.

Federal Requirements 42 CFR 456.200 and 456.201Utilization ReviewEach mental health facility must have a written utilization review plan.