471 NAC 20-027. ADULT SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES

027. ADULT SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES. The care and treatment of a subacute inpatient with a primary psychiatric diagnosis must be under the direction of a Nebraska licensed psychiatrist who meets the state's licensing criteria and is enrolled as a Nebraska Medicaid provider . Subacute inpatient hospital psychiatric services must be prior-authorized by Nebraska Medicaid contracted peer review organization or management designee. In addition, out-of-state subacute hospitalizations must be approved by Nebraska Medicaid . 027.01 PROVIDER AGREEMENT. A hospital that provides subacute inpatient psychiatric services must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval and enrollment as a Nebraska Medicaid provider of subacute inpatient hospital psychiatric services. The hospital must submit with the provider agreement: (A)A complete description of the psychiatric program and the elements of the program ; (B)A statement of the total number of licensed inpatient psychiatric beds, designated as subacute psychiatric beds that are approved by the Nebraska Department of Health and Human Services, Division of Public Health or agency in the state in which the facility is located; a listing of the bed numbers for those licensed psychiatric beds; and the size of the proposed subacute inpatient psychiatric unit; (C)Documentation that the subacute inpatient program meets the family-centered, community-based requirements in this chapter; (D)A description of how beneficiary, group, and family psychotherapy services as well as other psycho-educational and rehabilitation services will be provided; (E)A description of how the subacute inpatient hospital psychiatric services will interface with community services for discharge planning and service provision after discharge; (F)A copy of the most recent Joint Commission ) or the American Osteopathic Association (AOA) accreditation survey; and (G)Any other information requested. 027.01(i) ON-SITE REVIEW. Any facility requesting a provider agreement must make the facility available for an on-site review before issuance of a provider agreement. 027.02 STANDARDS FOR PARTICIPATION FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICE PROVIDERS. A hospital that provides subacute inpatient hospital psychiatric services must meet the following standards for participation to ensure that payment is made only for subacute inpatient psychiatric treatment. The hospital or unit of an acute care hospital: (A)Is maintained for the care and treatment of beneficiaries with primary psychiatric disorders; (B)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard-setting in that state; (C)Is accredited by the Joint Commission or by the American Osteopathic Association (AOA); (D)Meets the requirements for participation in Medicare for psychiatric hospitals; (E)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries ; (F)Must have medical records that are sufficient to permit Nebraska Medicaid to determine the degree and intensity of treatment furnished to the beneficiary; (G)Must meet staffing requirements Nebraska Medicaid finds necessary to carry out an active treatment program as described in this chapter; (H)Must encourage the beneficiary and family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws; (I)Must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family, guardian, or caretaker schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings; and (J)Must document their attempts to involve the beneficiary and the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered to involve family. . 027.03 STANDARDS FOR PARTICIPATION FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICE PROVIDERS. Subacute inpatient psychiatric hospital must have staff adequate in number and qualified to carry out a subacute psychiatric program for treatment for beneficiaries who are in need of further psychiatric stabilization, treatment, rehabilitation, and recovery activities. The hospital must meet the following standards. 027.03(A) HOSPITAL PERSONNEL. Hospitals that provide subacute inpatient psychiatric services must be staffed with the number of qualified professional, technical, and supporting personnel, and consultants required to carry out an intensive and comprehensive treatment program that includes evaluation of beneficiary and family needs; establishment of beneficiary and family treatment goals; and implementation, directly or by arrangement, of a broad-range psychiatric treatment program including, at least, professional psychiatric, medical, nursing, social services, psychological, psychotherapy, psychiatric rehabilitation, and recovery therapies required to carry out an individual treatment plan for each patient and their family. The following standards must be met: (i)Qualified professional psychiatric staff must be available to evaluate each beneficiary at the time of admission, including diagnosis of any intercurrent disease. Services necessary for the evaluation include: (1) Initial diagnostic interview; (2) Nursing assessment by a licensed registered nurse (RN); (3) Substance use disorder assessment and development of a substance use disorder addendum as appropriate; (4) Laboratory, radiological, and other diagnostic tests as necessary; and (5) A physical examination including a complete neurological examination when indicated within 24 hours after admission by a licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN); (ii)The number of qualified professional personnel and paraprofessionals, including licensed professional staff and technical and supporting personnel, must be adequate to ensure representation of the disciplines necessary to establish short-range and long-term goals; and to plan, carry out, and periodically revise a treatment plan for each client; (1) Qualified staff must be available to provide treatment intervention, social interaction and experiences, education regarding psychiatric issues , appropriate nursing interventions and structured milieu therapy. Available services must include beneficiary, group, and family therapy, group living experiences, occupational and recreational therapy and other prescribed activities to maintain or increase the beneficiary’s capacity to manage their psychiatric condition and activities of daily living. A minimum of 42 structured, scheduled, and documented treatment hours are required per week; and (2) The program must provide environmental and physical limitations required to protect the beneficiary's health and safety with a plan to develop the beneficiary's potential for return to their home, supervised adult living, or skilled nursing facility (NF). The treatment milieu must be a safe, organized, structured environment at the least restrictive level of care to meet the individualized treatment needs of the beneficiary. 027.03(B) MEDICAL DIRECTOR OF SUBACUTE INPATIENT SERVICES. Subacute inpatient psychiatric services must be under the supervision of a psychiatrist who is identified as the medical director and is qualified to provide the clinical direction and the leadership required for an intensive psychiatric subacute inpatient treatment program. The number and qualifications of additional psychiatrists must be adequate to provide essential psychiatric services. The medical director may also serve as the attending psychiatrist for each beneficiary depending on the size of the program. The following standards must be met: (i)The medical director and any attending psychiatrists must meet the training and experience requirements for a psychiatrist licensed to practice in the state where services are provided; (ii)The program must identify a covering or alternative psychiatrist when the medical director is not available to provide direction and supervision of the direct care of the beneficiary and the treatment program; (iii)The psychiatrist's personal involvement in all aspects of the beneficiary's psychiatric care must be documented in the beneficiary's medical record, consisting of the physician's orders, the progress notes, and the nurse’s notes; and (iv)The medical director or attending psychiatrist must be available, in person or by telephone, to provide assistance and direction to the treatment team as needed. 027.03(C) AVAILABILITY OF PHYSICIANS AND OTHER MEDICAL CONSULTATION. Physicians and other appropriate professional consultants must be available to provide medical, surgical, diagnostic, and treatment services, including specialized services. If medical, surgical, diagnostic, and treatment services are not available within the hospital, qualified physician consultants or attending physicians must be immediately available, or a satisfactory arrangement must be established for transferring patients to a general hospital certified for Medicare. 027.04 PROGRAM STANDARDS FOR PARTICIPATION. Subacute inpatient psychiatric services must have available licensed professionals and paraprofessionals with specific, identified duties and responsibilities to meet the acute and rehabilitative psychiatric needs of the beneficiaries being served. The following positions and services are required. 027.04(A) PROGRAM AND CLINICAL DIRECTOR. Must be a fully licensed clinician who is skilled and knowledgeable to provide leadership and clinical direction to the treatment team. The duties and responsibilities of a program or clinical director are: (i)Oversee, implement, and coordinate all treatment services and activities provided within the program 24 hours a day; (ii)Incorporate new clinical information and best practices into the program to assure effectiveness, viability and safety; (iii)Oversee the process to identify, respond to and report crisis situations on a 24-hour per day, seven day per week basis; (iv)Be responsible, in conjunction with the medical director or attending psychiatrist, for the program’s clinical management by representation in the multidisciplinary treatment team meetings providing supervision to all program professionals and paraprofessional staff; (v)Communicate with the attending psychiatrist regarding individual treatment needs of the beneficiary; (vi)Assure quality organization and management of clinical record documentation and confidentiality; and (vii)Oversee and be responsible for the safety of beneficiaries and staff. 027.04(B) NURSING SERVICES. All nursing services must be under the supervision of a registered professional nurse who is qualified by education and experience for the supervisory role. The number of registered professional nurses and other nursing personnel must be adequate to formulate and carry out the nursing components of a treatment plan for each beneficiary. The following standards must be met: (i)The registered professional nurse supervising the nursing program must have a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or must be qualified by education and experience in the care of the beneficiary with mental illness, and have demonstrated competence to: (1) Provide a comprehensive nursing assessment; (2) Participate in interdisciplinary formulation of treatment plans; (3) Provide skilled nursing care and therapy; and (4) Direct, supervise, and train others who assist in implementing and carrying out the nursing components of each beneficiary's treatment plan; (ii)The staffing pattern must ensure the direct nursing coverage by a registered professional nurse 24 hours each day for: (1) Direct care; and (2) Supervising care performed by other nursing personnel; (iii)The number of registered professional nurses must be adequate to formulate a nursing care plan in writing for each beneficiary and to ensure that the plan is carried out; and (iv)Registered professional nurses and other nursing personnel must be prepared by continuing in-service and staff development programs for active participation in interdisciplinary meetings affecting the planning or implementation of nursing care plans for beneficiaries. The meetings include diagnostic conferences, treatment planning sessions, and meetings held to consider alternative services and transitioning to the most appropriate treatment service and community resources. 027.04(C) PSYCHOLOGICAL SERVICES. Psychological services must be available through employment or contractual arrangement with a licensed psychologist. Psychological consultation must be available by a qualified licensed psychologist capable of providing diagnostic and treatment services. The following standards must be met: (i)Psychologists, consultants, and supporting personnel must be adequate in number and be qualified to assist in essential diagnostic formulations, and to participate in: (1) Program development and evaluation of program effectiveness; (2) Training and research activities; (3) Therapeutic interventions ; and (4) Interdisciplinary conferences and meetings held to establish diagnoses, goals, and treatment programs; and (ii)Psychological testing must be ordered and directed by a psychiatrist. 027.04(D) PSYCHOTHERAPY SERVICES. Licensed clinicians must be employed in the facility to provide psychotherapy services according to the therapist's scope of practice and according to the individualized treatment plan for the beneficiary. Licensed clinicians may include psychologists (Psy.D.), licensed independent mental health practitioners (LIMHP), licensed mental health practitioners (LMHP), licensed alcohol and drug counselors (LADC), and advanced practice registered nurses (APRN). Individual, group, and family psychotherapy must be available to each beneficiary and provided according to the beneficiary’s individual treatment plan. Services must be able to meet the unique needs of each beneficiary. Minimum requirements for psychotherapy offered and available to the beneficiary are: (i)Individual therapy minimum two times weekly; (ii)Group therapy minimum three times weekly; and (iii)Family therapy and intervention as appropriate and consented to by the beneficiary. With consent of the beneficiary, family therapy must be provided at the frequency and intensity to meet the unique needs of beneficiary and the family. 027.04(E) LICENSED ADDICTION AND DRUG ABUSE SERVICES. Substance use disorder assessment, development of a substance use disorder addendum as needed, and treatment must be available to beneficiaries whose problems and symptoms indicate the possibility of or an established substance abuse problem, in addition to the primary psychiatric diagnosis. Licensed clinicians able to provide assessment, develop a substance use disorder addendum, and provide treatment of substance use disorder problems must provide services according to and within their scope of practice. Usually, services are provided by a licensed alcohol and drug counselor (LADC). 027.04(F) PSYCHOEDUCATIONAL SERVICES. Psychoeducational services must be offered in the program, and providers must have psychoeducational services available to beneficiaries on a daily basis. Services may include education for diagnosis, treatment and relapse, life skills, medication management and symptom management. Services must be provided by a qualified professional or paraprofessional staff. Medication education must be provided by a registered nurse (RN). Other psychoeducational services may be provided by a paraprofessional whose education and training provides competency to provide the service. 027.04(G) CASE MANAGEMENT SERVICES AND SOCIAL SERVICES STAFF. Case Management and social services staff must be under the supervision of the program or clinical director. The case management and social service staff must be adequate in numbers and be qualified to fulfill responsibilities related to the specific needs of individual beneficiaries and their families. The role and responsibility of case management and social services staff is to: (i) Assist the beneficiary with accessing community resources and services; (ii) Consult with other staff and community agencies to coordinate beneficiary care; (iii) Assist the beneficiary with accessing alternative services and maintaining a safe living environment according to the treatment plan; and (iv) Perform daily case management services and maintain a summary of services in the beneficiary’s clinical record. : 027.04(H) ANCILLARY SERVICES. Recreational or activity therapy services must be available and offered to the beneficiary daily and directly supervised by the program or clinical director who has supervisory responsibility to the entire treatment team and the services they provide. 027.04(I) PSYCHIATRIC TECHNICIANS. The program must have available paraprofessional staff who are members of the multi-disciplinary team. The role and responsibility of the psychiatric technician is to: (i)Intervene in the treatment milieu; (ii)Provide treatment interventions to the beneficiary which meet the specific psychiatric needs of the beneficiary as identified in the treatment plan; (iii)Demonstrate competency in applying the learned treatment interventions; and (iv)Have direct knowledge of policies and procedures of the agency. 027.04(I)(1) PSYCHIATRIC TECHNICIANS. Psychiatric technicians must have completed the program’s initial training program and continued ongoing training requirements. 75 percent of the psychiatric technician staff must have completed a Bachelor of Science (BS) or Bachelor of Arts (BA) degree in the human services field or have five years’ experience providing health care services. 027.05 COVERAGE CRITERIA FOR SUBACUTE INPATIENT PSYCHIATRIC HOSPITAL SERVICES. Nebraska Medicaid covers subacute inpatient hospital psychiatric services for beneficiaries age 21 and over when the services meet the criteria in this chapter and when the following requirements are met: (A)The attending psychiatrist must personally and face-to-face evaluate the beneficiary and document the psychiatric evaluation and diagnosis formulation within 24 hours of admission; (B)The attending psychiatrist assumes accountability to direct the care of the beneficiary at the time of admission; (C)The beneficiary must be treated by a psychiatrist personally and face-to-face a minimum of three times per week or more often, if medically necessary and the interaction must be documented in the beneficiary's clinical record; (D)The attending psychiatrist describes the medical necessity and active treatment requirements for the beneficiary; (E)The attending psychiatrist provides certification and recertification of the beneficiary's need for subacute inpatient psychiatric services; and (F)Clinical supervision of the multi-disciplinary treatment team and treatment team planning meetings as necessary to meet the individualized treatment needs of the beneficiary. 027.06 TREATMENT PLANNING. An initial treatment plan must be implemented upon admission. The master or comprehensive treatment plan must be developed within 72 hours and reviewed by the treatment team a minimum of three times weekly. The master or comprehensive treatment plan must be developed from the recommendations made by the attending psychiatrist who has provided evaluation of the beneficiary and the input from all other assessments completed following admission to subacute inpatient treatment services. Comprehensive treatment plans must meet medical necessity requirements. 027.06(A) DISCHARGE PLANNING. Discharge planning must be a part of the comprehensive treatment plan. Discharge planning must be specific, realistic and individualized for the beneficiary from the time of admission and revised as medically necessary with treatment planning reviews. 027.07 CRITERIA FOR SUBACUTE INPATIENT PSYCHIATRIC HOSPITAL SERVICES. One or more of the following criteria must be present: (A)The beneficiary can benefit from longer-term evaluation, stabilization, and treatment services; (B)The beneficiary is at moderate to high risk to harm self or others; (C)The beneficiary has active symptomatology ; (D)The beneficiary has the ability to respond to intensive structured intervention services; (E)The beneficiary is at moderate to high risk of relapse or symptom reoccurrence; (F)The beneficiary has high need of professional structure and intervention services; or (G)The beneficiary can be treated with short term intensive intervention services. 027.08 PRIOR AUTHORIZATION. All subacute inpatient psychiatric admissions must be prior-authorized by Nebraska Medicaid’s contracted peer review organization or management designee. If the admission is approved, the Nebraska Medicaid’s contracted peer review organization or management designee must assign a specific prior-authorization number. Providers must follow the Nebraska Medicaid’s contracted peer review organization or management designee requirements for facilitating prior authorization and continued stay review. Continued stay authorization is provided at a frequency appropriate for this short-term subacute program by the Nebraska Medicaid’s contracted peer review organization or management designee. 027.09 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. The medical records maintained by a hospital permit determination of the degree and intensity of the treatment provided to beneficiaries who receive services in a subacute inpatient psychiatric program. Clinical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the beneficiary is hospitalized. The clinical record must include: (A)The identification data, including the beneficiary's name, date of service, provider's name, and beneficiary's legal status, whether the admission is voluntary , by the Board of Mental Health , or court mandated; (B)A provisional or admitting diagnosis which is made on every beneficiary at the time of admission and includes the diagnoses of intercurrent diseases as well as the psychiatric diagnoses; (C)The complaint of others regarding the beneficiary, as well as the beneficiary's comments; (D)The psychiatric evaluation, including a medical history, which contains a record of mental status and notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the beneficiary's strengths in a descriptive, not interpretative, fashion; (E)A complete neurological examination, when indicated, recorded at the time of the admitting physical examination; (F)Reports of consultations, psychological evaluations, electroencephalograms, dental records, and special studies; (G)The beneficiary's treatment plan and treatment plan reviews; (H)The treatment received by the beneficiary, which is documented in a manner and with a frequency to ensure that all active therapeutic efforts are included; (I)Progress notes which are recorded by the psychiatrist or physician, nurse, social worker, and, when appropriate, others significantly involved in active treatment modalities. The frequency is determined by the condition of the beneficiary, but progress notes must be recorded daily by nursing staff, and at each contact by psychiatrist or physician and by all other treatment staff. Progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan as indicated by the beneficiary's condition; (J)The psychiatric diagnosis contained in the final diagnosis (K)Transition and discharge planning documentation including relapse and crisis prevention planning; (L)Proof of family and community involvement; and (M)The discharge summary, including a recapitulation of the beneficiary's hospitalization, recommendations for appropriate services concerning follow-up, and a brief summary of the beneficiary's condition on discharge. 027.10 CERTIFICATION AND RECERTIFICATION BY PSYCHIATRISTS FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES. Nebraska Medicaid pays for covered subacute inpatient hospital psychiatric services only if a psychiatrist certifies, and recertifies at designated intervals, the medical necessity for the admission to and continued hospitalization for subacute inpatient psychiatric treatment services. Appropriate supporting material may be required. The psychiatrist's certification or recertification statement must document the medical necessity for the admission to and continued hospitalization for short-term inpatient psychiatric treatment, based on a current evaluation of the beneficiary's condition. 027.10(A) CERTIFICATION OR WRITTEN ORDER REQUIRED. For beneficiaries admitted to a subacute program, a psychiatrist's certification by written order for admission is required at the time of admission. 027.10(B) FAILURE TO CERTIFY. If a hospital fails to obtain the required certification and recertification statements for the beneficiary’s stay, Nebraska Medicaid will not make payment for the services that are not certified. 027.11 HOSPITAL UTILIZATION REVIEW. A site visit by Nebraska Medicaid staff for purposes of utilization review may be required for further clarification. 027.12 BILLING. Providers must submit claims for subacute inpatient hospital psychiatric services on the appropriate Nebraska Medicaid approved health care claim form. Providers must enter the prior authorization number as required for subacute inpatient services. 027.13 LIMITATIONS. For subacute inpatient hospital psychiatric services, the following limitations apply: (A)Care must be provided by and directly supervised by a licensed psychiatrist. The psychiatrist must be licensed in the state where the service is being delivered; (B)All subacute inpatient hospital psychiatric services must be prior-authorized; and (C)Payment for subacute inpatient hospital services is made according to this title . 027.14 DOCUMENTATION. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment of subacute inpatient psychiatric care. 027.15 EMERGENCY PROTECTIVE CUSTODY (EPC). A hospital may be reimbursed for beneficiaries under an emergency protective custody (EPC) order in an acute care hospital without designated psychiatric beds for an average of three to five days, up to seven days under the following conditions: (A)The hospital is licensed by the Nebraska Department of Health and Human Services Division of Public Health; (B)The hospital is accredited by the Joint Commission or the American Osteopathic Association (AOA); (C)The admitting and attending physician is a psychiatrist; (D)The hospital provides a setting that is separate from the rest of the hospital activities and is a safe, therapeutic environment; (E)The hospital provides an active treatment program in the form of assessment and diagnostic interventions; (F)The hospital emergency protective custody (EPC) program is approved by Nebraska Medicaid ; and (G)The hospital emergency protective custody (EPC) program meets all other standards for inpatient hospital psychiatric care.