DMAS-CMHRS Manual

• “Services based upon incomplete, missing, or outdated (more than a year old or not reflective of the individuals current level of need) intakes/re-assessments and ISPs shall be denied reimbursement.”- CMHRS Manual

CMHRS Manual (DMAS) Required Activities- The following services and activities must be provided: • A comprehensive service specific provider assessment

must be completed by a qualified mental health case manager to determine the need for services.

• The CM service specific provider assessment is part of the first month of CM service and requires no service authorization.

• Service specific provider assessment and planning services, to include developing an ISP (does not include performing medical and psychiatric assessment, but does include referral for such).

Required Activities (continued) • This service specific provider assessment then serves as the basis

for the ISP. • The service provider must notify or document the attempts to

notify the primary care provider or pediatrician of the individual’s receipt of community mental health rehabilitative services, specifically mental health case management.

• The ISP must document the need for case management and be fully completed within 30 days of initiation of the service, and the case manager shall review the ISP every three months.

• The review will be due by the last day of the third month following the month in which the last review was completed. A grace period will be granted up to the last day of the fourth month following the month of the last review.

Required Activities (continued) • Mandatory monthly case management contact, activity, or

communication relevant to the ISP. • Written plan development, review, or other written work is

excluded. • Linking the individual to needed services and supports specified in

the ISP. • Provide services in accordance with the ISP. • Coordinating services and treatment planning with other agencies

and providers. • Enhancing community integration through increased opportunities

for community access and involvement and creating opportunities to enhance community living skills to promote community adjustment.

• Making collateral contacts with significant others to promote implementation of the service plan and community adjustment.

Required Activities (continued) • Monitoring service delivery as needed through

contacts with service providers as well as periodic site visits and home visits.

• Education and counseling, which guide the individual and develop a supportive relationship that promotes the service plan. Counseling, in this context, is not psychological counseling, examination, or therapy. The case management counseling is defined as problem-solving activities designed to promote community adjustment and to enhance an individual’s functional capacity in the community. These activities must be linked to the goals and objectives on the Case Management ISP.

Required Activities (continued) • A face-to-face contact must be made at least once

every 90-day period. The purpose of the face-to-face contact is for the case manager to observe the individual’s condition, to verify that services which the case manager is monitoring are in fact being provided, to assess the individual’s satisfaction with services, to determine any unmet needs, and to generally evaluate the member’s status.

• Case Management services are intended to be an individualized client-specific activity between the case manager and the member.

• The ISP shall be updated at least annually.

Service Limitations (DMAS)

• Billing can be submitted for case management only for months in which direct or client-related contacts, activity, or communications occur. These activities must be documented in the clinical record.

• The provider should bill for the specific date of the face to face visit, or the date the monthly summary note has been documented, or a specific date service was provided.

Service Limitations (DMAS)

• Reimbursement shall be provided only for "active" case management clients, as defined. An active client for case management shall mean an individual for whom there is a plan of care in effect which requires regular direct or client related contacts or activity or communication with the client or families, significant others, service providers, and others including a minimum of one face-to-face client contact within a 90-day period.

Service Limitations (DMAS)

• Federal regulation 42CFR441.18 prohibits providers from using case management services to restrict access to other services.

• An individual cannot be compelled to receive case management if he or she is receiving another service, nor can an individual be required to receive another service if they are receiving case management.

Documentation Requirements

• A SSPI (service specific provider intake) shall be required prior to developing an Individual Services Plan (ISP) and shall be required as a reference point for the ISP during the entire duration of services. Services based upon incomplete, missing, or outdated (more than a year old or not reflective of the individual’s current level of need) intakes/re- assessments and ISPs shall be denied reimbursement.

Documentation (DMAS)

• Case management records must include the individual’s name, dates of service, name of the provider, nature of the services provided, achievement of stated goals, if the individual declined services, and a timeline for reevaluation of the plan.

• There must be documentation that notes all contacts made by the case manager related to the ISP and the individual’s needs

Documentation

• The case manager must have monthly activity regarding the individual and a face-to-face contact with the individual at least once every 90 days.

* If there was no monthly CM activity, there must be documentation explaining “why not”.

Documentation

• The provider shall determine who the primary care provider is and inform him or her of the individual's receipt of Case Management Services.

• The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

Documentation

• An individualized and individual specific ISP must be part of the record. The ISP must address the issues as documented in the SSPI.

• There must be documentation indicating that the individual was included in the development of the ISP and the ISP shall be signed by the individual. If the individual is a child, the ISP shall also be signed by the individual's parent/legal guardian. Documentation shall be provided if the individual, who is a child or an adult who lacks legal competency, is unable or unwilling to sign the ISP.

Documentation

• The ISP contains his treatment or training needs, his goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, the estimated timetable for achieving the goals and objectives, and an individualized discharge plan that describes transition to other appropriate services.

ISP Requirements

Goals: • Should reflect an individualized specific overview

of the objectives and will address the larger presenting needs. Goals are longer term than objectives

Objectives: • Should demonstrate shorter term, measurable,

achievable, action-oriented, strength based activities that the individual/family will engage in toward completion of the goal.

ISP Requirements Intervention/Strategies: • Should define specific steps that the provider and

individual will engage in toward the attainment/achievement of each objective.

• Interventions are developed based on the individual’s specific strengths and needs (i.e. developmental level, level of functioning, academic/literacy ability, interests, etc.).

• Interventions should clearly reflect service coordination.

• purpose of the goals to be achieved within the authorized time period;

ISP Requirements Frequency: • The ISPs must include the recommended service frequency needed

to accomplish the goals and objectives that will meet the needs identified in the SSPI.

• The ISP must be reviewed, at a minimum, every 3 months to determine if the goals and objectives meet the needs of the individual.

• The ISP shall be updated annually and as the needs, goals and progress of the individual changes.

Discharge Goal: • All ISPs shall include an individualized discharge plan. Describe the

discharge planning to summarize an estimated timetable to achieving the goals and objectives in the service plan, include discharge plans that are specific to need of the individual at the time the service needs are reviewed.

Documentation

• Service coordination between all health care service providers who are involved in the individual’s care is required and must be documented in the ISP and Progress Notes.

• DMAS shall not reimburse for dates of services in which the progress notes are not individualized and case-specific. Duplicated progress notes shall not constitute the required case-specific individualized progress notes.

Documentation

• Individualized and case-specific progress notes are part of the minimum documentation requirements and shall convey the individual's status, staff interventions, and, as appropriate, the individual's progress, or lack of progress, toward goals and objectives in the ISP.

• Documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered.

12VAC30-50-226 Individual Services Plan (ISP) Requirements: If one of these elements are missing, the ISP will be considered incomplete and not meeting the reimbursement requirements. • The ISP is a comprehensive and regularly updated document that integrates both physical and behavioral health,

service coordination, and integrated care goals specific to the needs of the individual being treated and meeting the defined specific service requirements.

• The "Individual Service Plan" or "ISP" means a comprehensive and regularly updated treatment plan specific to

the individual's unique treatment needs as identified in the clinical assessment. A comprehensive ISP is person-centered, includes all planned interventions, aligns with the member’s identified needs, care coordination needs, is regularly updated as the member’s needs and progress change, and shows progress throughout the course of treatment.

• The ISP contains, but is not limited to, the individual’s treatment or training needs, the individual’s goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, the estimated timetable for achieving the goals and objectives, and an individualized discharge plan that describes transition to other appropriate services.

• The individual shall be included in the development of the ISP and the ISP shall be signed by the individual. If

the individual is a minor child, the ISP shall also be signed by the individual's parent/legal guardian. Documentation shall be provided if the individual, who is a minor child or an adult who lacks legal capacity, is unable or unwilling to sign the ISP

12VAC35-105-665 - ISP requirements

• A. The comprehensive ISP shall be based on the individual's needs, strengths, abilities, personal preferences, goals, and natural supports identified in the assessment. The ISP shall include:

• Relevant and attainable goals, measurable objectives, and specific strategies for addressing each need;

• Services and supports and frequency of services required to accomplish the goals including relevant psychological, mental health, substance abuse, behavioral, medical, rehabilitation, training, and nursing needs and supports;

• The role of the individual and others in implementing the service plan; • A communication plan for individuals with communication barriers, including language barriers; • A behavioral support or treatment plan, if applicable; • A safety plan that addresses identified risks to the individual or to others, including a fall risk plan; • A crisis or relapse plan, if applicable; • Target dates for accomplishment of goals and objectives; • Identification of employees or contractors responsible for coordination and integration of services,

including employees of other agencies; and • Recovery plans, if applicable.

DBHDS Regulation

• 880.C - Entries in record shall be current, dated and authenticated by staff making entries.

• 660.B - The ISP shall be signed and dated at a minimum by the person responsible for implementing the plan and the individual receiving services or the authorized representative. If the signature of the individual receiving services or the authorized representative cannot be obtained, the provider shall document his attempt to obtain the necessary signature and the reason why he was unable to obtain it.

DBHDS definitions: • "Person-centered" means focusing on the needs and preferences of the

individual; empowering and supporting the individual in defining the direction for his life; and promoting self-determination, community involvement, and recovery.

• "Case management service" means services that can include assistance to

individuals and their family members in assessing needed services that are responsive to the person's individual needs. Case management services include: identifying potential users of the service; assessing needs and planning services; linking the individual to services and supports; assisting the individual directly to locate, develop, or obtain needed services and resources; coordinating services with other providers; enhancing community integration; making collateral contacts; monitoring service delivery; discharge planning; and advocating for individuals in response to their changing needs. "Case management service" does not include maintaining service waiting lists or periodically contacting or tracking individuals to determine potential service needs.

DBHDS Definitions • "Serious incident" means any incident or injury

resulting in bodily damage, harm, or loss that requires medical attention by a licensed physician, doctor of osteopathic medicine, physician assistant, or nurse practitioner while the individual is supervised by or involved in services, such as attempted suicides, medication overdoses, or reactions from medications administered or prescribed by the service.

• "Corrective action plan" (CAP) means the provider's pledged corrective action in response to cited areas of noncompliance documented by the regulatory authority. A corrective action plan must be completed within a specified time.

DBHDS Definitions • "Individualized services plan" or "ISP" means a

comprehensive and regularly updated written plan that describes the individual's needs, the measurable goals and objectives to address those needs, and strategies to reach the individual's goals. An ISP is person-centered, empowers the individual, and is designed to meet the needs and preferences of the individual. The ISP is developed through a partnership between the individual and the provider and includes an individual's treatment plan, habilitation plan, person-centered plan, or plan of care, which are all considered individualized service plans.

D19 required forms • Screening Form (must be kept in active chart- do not purge) • Admission Assessment/Service Specific Provider Intake. Do

not purge original. • Program Orientation checklist- do not purge • Face Sheet • Human Rights • Consent to Services • Receipt of Notice of Privacy • Authorization/Releases of Confidential Information • Fall Risk Assessment • Release of Liability of Transportation

D19 Forms- continued

• Individualized Service Plan • Quarterly Progress Reviews • Consumer Responsibilities • Medical Consultation/Contact with Primary Care

Physician • Financial documents • Referral forms if applicable • Transfer Summary if applicable • Discharge Summary if applicable

Resources • This presentation is a brief overview of the requirements. • Refer to D19 program policies and procedures • Refer to DMAS- CMHRS Manual (Community Mental Health

Rehabilitative Services) https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual

• Refer to DBHDS CHAPTER 105 RULES AND REGULATIONS

FOR LICENSING PROVIDERS BY THE DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES- http://www.dbhds.virginia.gov/library/licensing/ol-12vac35-105dec2011.pdf