471 NAC 32-007. THERAPEUTIC GROUP HOME (ThGH) SERVICES

007. THERAPEUTIC GROUP HOME (ThGH) SERVICES. Therapeutic group home (ThGH) services are available to beneficiaries age 20 or younger when the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, the treatment is clinically necessary, and the need for this level of care is identified as part of an initial diagnostic interview, initial diagnostic interview addendum, a substance use disorder assessment, or a substance use disorder addendum. These services are part of a continuum of care designed to prevent hospitalization or to facilitate the movement of the beneficiary in an acute psychiatric setting to a status in which the beneficiary is capable of functioning within the community with less frequent need for clinical contact with the mental health or substance use disorder provider. Therapeutic group home (ThGH) services must be community based, family centered, culturally competent, and developmentally appropriate. Therapeutic group home (ThGH) must meet all requirements in this chapter. 007.01 FAMILY COMPONENT. Providers must encourage 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. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family’s schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. 007.02 MANDATORY SERVICES. The following services must be included in a program for the therapeutic group home (ThGH) to be approved for participation in Nebraska Medicaid. 007.02(A) ACTIVE AND REHABILITATIVE TREATMENT SERVICES. Each beneficiary must be involved in at least 21 hours of active and rehabilitation treatment per week. In addition, the program must provide access to daily recreational activities for all beneficiaries, but these recreational activities are not considered a part of the 21 required treatment hours. 007.02(B) MEDICALLY NECESSARY PSYCHOTHERAPY AND SUBSTANCE USE DISORDER SERVICES. Medically necessary psychotherapy services and substance use disorder services must demonstrate active treatment of a beneficiary with a serious emotional disturbance. Beneficiaries must receive individual psychotherapy, group psychotherapy, or substance use disorder counseling for at least three hours per week, and family psychotherapy or family substance use disorder counseling at least twice monthly. Medically necessary psychotherapy and substance use disorder services include: (i) Individual psychotherapy or substance use disorder counseling; (ii) Group psychotherapy or substance use disorder counseling; (iii) Family psychotherapy or substance use disorder counseling; and (iv) Family assessment. 007.02(C) PSYCHOEDUCATIONAL GROUPS AND INDIVIDUAL PSYCHOEDUCATIONAL THERAPY SERVICES. Psychoeducational services must be available from the therapeutic group home (ThGH) and must be modified to meet the unique treatment needs of the beneficiary as described in the beneficiary’s treatment plan. 007.02(D) MEDICALLY NECESSARY NURSING SERVICES. Medical services provided by an advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN) under registered nurse (RN) supervision, who evaluates the particular medical nursing needs of each beneficiary and provides for the medical care and treatment that is indicated on a Nebraska Medicaid approved treatment planning document and approved by the supervising practitioner. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider. 007.02(E) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the beneficiary. Testing and evaluation services may be performed by a licensed psychologist, specially licensed psychologist or a psychology resident acting within their scope of practice. Clinical necessity must be documented by the program supervising practitioner. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider. 007.02(F) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility or provider. All medications must be stored in a special locked storage space and administered only by a physician, advanced practice registered nurse (APRN), registered nurse (RN), licensed practical nurse (LPN), or a direct care staff person approved by the Nebraska Department of Health and Human Services, Division of Public Health as a medication aide. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider. 007.02(G) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a therapeutic group home (ThGH) program, services must be supervised by a registered dietitian, based on the beneficiary's individualized diet needs. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider. 007.02(H) EDUCATIONAL AND VOCATIONAL ASSISTANCE. The beneficiary must attend a school in the community. In this setting, the beneficiary remains involved in community-based activities and may attend a community educational, vocational program or other treatment setting. The therapeutic group home (ThGH) is required to coordinate with the beneficiary’s community resources, including schools or vocational services, with the goal of transitioning the beneficiary out of the program to a less restrictive care setting for continued, sometimes intensive, services as soon as possible and as appropriate. 007.02(I) TRANSITION AND DISCHARGE. Transition and discharge planning that meets the requirements of this chapter. 007.02(J) SPECIAL TREATMENT PROCEDURES IN THERAPEUTIC GROUP HOMES (ThGH). If a child or adolescent needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in therapeutic group homes (ThGH) are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Parents or legal guardian must approve use of these procedures through informed consent and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures: (i) De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures; (ii) Special treatment procedures may be used only when a child or adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; (iii) The child or adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO), or physical restraints; and (iv) Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner. 007.03 STANDARDS FOR PARTICIPATION. 007.03(A) PROVIDER STANDARDS. Providers of therapeutic group home (ThGH) services must meet the following standards: (i) Be a community-based treatment facility appropriately licensed as determined by the Department of Health and Human Services, Division of Public Health; (ii) Be accredited by the Joint Commission, the Commission on the Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation (COA). Agencies that have applied for accreditation may be enrolled on a provisional status; (iii) To ensure a more home-like setting, each location where beneficiaries live must be in a residential community to facilitate community integration through public education, recreation, and maintenance of family connections; (iv) Therapeutic group home (ThGH) facilities must not have more than eight beds. Existing facilities providing therapeutic group home (ThGH) services may not add beds if the bed total would exceed eight. Facilities exceeding 15 beds may not enroll as a therapeutic group home (ThGH). Facilities enrolled as a therapeutic group home (ThGH) with 9-15 bed capacity on the operative date of these regulations may continue to be operative at that capacity until alterations are made. Any facility alterations must comply with the eight bed limit; and (v) If a provider operates multiple therapeutic group homes (ThGH), they must ensure that they do not meet the definition of an institution of mental disease (IMD). 007.03(B) SERVICE STANDARDS. (i) The program must provide services 24 hours a day, seven days a week, 365 days per year with 24-hour awake staffing; (ii) Staffing: (1) A designated supervising practitioner must be responsible for the care provided in a therapeutic group home (ThGH) program and the clinical supervision of direct care staff. The supervising practitioner must be present on a regularly scheduled basis and must assume responsibility for all beneficiaries. Psychotherapy and substance use disorder counseling services must be provided by clinical staff who are operating within their scope of practice and under the direction of the supervising practitioner. The supervising practitioner's personal involvement must be documented in the beneficiary's clinical record; (2) All treatment must be prescribed and conducted under the direction of the supervising practitioner in charge of the program; (3) A therapeutic group home (ThGH) clinical director may be a physician with a specialty in psychiatry, physician, psychologist, advance practice registered nurse (APRN), physician assistant (PA), licensed independent mental health practitioner (LIMHP), or licensed mental health practitioner (LMHP), who is practicing within their scope of practice. Dual licensure is preferred for therapeutic group home (ThGH) services when co-occurring mental health and substance use diagnoses occur. The clinical director may not also serve in the role of the program’s therapist; (4) A therapeutic group home (ThGH) therapist may be a psychiatrist, physician, psychologist, provisionally licensed psychologist, advanced practice registered nurse (APRN), physician assistant (PA), licensed independent mental health practitioner (LIMHP), licensed mental health practitioner (LMHP), or a provisionally licensed mental health practitioner (LMHP) who is working within their scope of practice; (5) Therapeutic group home (ThGH) direct care staff must be 20 years of age or older and at least two years older than the oldest resident under the age of 20. Direct care staff must have a high school diploma or equivalent, and must have demonstrated skills and competencies in treatment with beneficiaries with a behavioral health diagnosis, demonstrated by at least one of the following: (a) Bachelor's degree or higher in psychology, sociology, or a related field (preferred); (b) One year of coursework in the human services field; or (c) Two years of recovery experience with demonstrated competencies and skills in the treatment of individuals with a behavioral health diagnosis; (6) Staffing ratios must be adequate to meet the individualized treatment needs of the beneficiary and each staff must meet the responsibilities outlined in the staffing requirements. Acceptable hours and ratios include: (a) Direct care staffing ratios must be 1:6 during awake hours and 1:8 during sleep hours. At least one staff member per shift is required to have a current cardiopulmonary (CPR) and first aid certification; (b) A registered nurse (RN) or advanced practice registered nurse (APRN) must be available in person or on-call 24 hours a day, seven days a week, 365 days per year; and (c) The ratio of therapeutic group home (ThGH) therapists to beneficiaries served must be no greater than 1:12; (iii) The following criteria must be met for a beneficiary's admission to a therapeutic group home (ThGH) program: (1) The beneficiary must have sufficient need for active treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and (2) Of all reasonable options for active treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's condition; (iv) Before the beneficiary is admitted to the program, a licensed provider must complete an initial diagnostic interview to validate the appropriateness of care; (v) The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner, and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary's response to the treatment interventions based on the recommendations, goals, and objectives: (1) The multi-disciplinary team must complete the treatment plan within the first seven days after the beneficiary's admission to the program. The plan must be reviewed and revised by the multi-disciplinary team, including the supervising practitioner, at least every 14 days or more often if necessary; and (2) Changes in the treatment plan must be noted on the treatment planning document. An updated treatment plan must be completed every 14 days, or more frequently, if necessary, to reflect changes in treatment needs. The treatment plan must be signed by the beneficiary and their parent or guardian, and the supervising practitioner for therapeutic group home (ThGH) services. The treatment plan review must be documented on the treatment plan, if required, and in the clinical records; (vi) The supervising practitioner must meet personally with the beneficiary for evaluation every 30 days, or more often, as clinically necessary. Reimbursement for the 30-day update visit is not included in the therapeutic group home (ThGH) per diem and can be reimbursed separately as an individual psychotherapy service; (vii) Every 30 days a utilization review must be conducted per this chapter. This review must be documented on the treatment plan, and the facility's treatment plan review form. Utilization review is not required for the calendar month in which the beneficiary was admitted; (viii) The program must have written documentation of each of the services and treatment modalities available. This includes psychotherapy services, substance use disorder counseling, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other therapeutic group home (ThGH) services: (1) The program must have written documentation of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family services; (2) The program must have written documentation of how the community-based requirement in this chapter will be met; and (3) The program must state the qualifications, education, and experience of each staff member and the therapy services each provides; (ix) When brief crisis stabilization is clinically necessary, outpatient observation up to 23 hours 59 minutes in an emergency department or acute hospital may be used as follows: (1) In accordance with the definition of outpatient in this chapter; and (x) The program must have a written policy for immediate admission or readmission for appropriate inpatient services when it is clinically necessary. The policy must include a cooperative agreement with a psychiatric or substance use disorder hospital or distinct part of a hospital, as outlined in this chapter. A copy of the cooperative agreement must accompany the provider application and provider agreement. 007.04 COVERAGE CRITERIA FOR THERAPEUTIC GROUP HOMES (ThGH). Nebraska Medicaid covers therapeutic group home (ThGH) services for beneficiaries age 20 and younger when the services meet the requirements in this chapter and the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen. Therapeutic group home (ThGH) services must be prior authorized by Nebraska Medicaid or its designee. The beneficiary must be observed and interviewed by the supervising practitioner at least once every 30 days, or more frequently if clinically necessary, and the interaction must be documented in the beneficiary 's clinical record. 007.04(A) COSTS NOT INCLUDED IN THE THERAPEUTIC GROUP HOME (ThGH) FEE. Therapeutic group home (ThGH) services are reimbursed for the treatment of unlicensed direct care staff who are supervised by a licensed practitioner and work in the therapeutic group home (ThGH) milieu. The following charges may be reimbursed separately from the therapeutic group home (ThGH) fee when the services are medically necessary, part of the beneficiary’s overall treatment plan, and are in compliance with other state and federal regulations: (i) Direct psychotherapy services provided by the supervising practitioner; (ii) Prescription drugs including injectable medications; (iii) Direct services performed by a physician, advanced practice registered nurse (APRN), or physician assistant (PA), other than the physician directing the program; (iv) All laboratory or physical health diagnostic procedures prescribed by a physician, advanced practice registered nurse (APRN), or physician assistant (PA); (v) Treatment services for physical injury or illness provided by non-mental health practitioners operating within their scope of practice; and (vi) Individual psychotherapy services provided by licensed clinicians. 007.04(B) SERVICES NOT COVERED. Payment is not available for therapeutic group home (ThGH) services for beneficiaries: (i) Receiving services in an out-of-state facility, except as outlined in these regulations; (ii) In long-term care facilities (LTC); (iii) Whose needs are social or educational and may be met through a less structured program; (iv) Whose primary diagnosis and functional impairment is acutely psychiatric in nature and whose condition is not stable enough to allow them to participate in and benefit from the program; and (v) Whose primary diagnosis and functional impairment is due to a developmental disability. 007.05 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification of the beneficiary. In addition to the requirements of this chapter, each beneficiary's medical record must contain the following documentation: (A) The supervising practitioner's orders; (B) The treatment plan; (C) The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least daily. The 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, and discharge planning; (D) Documentation indicating compliance with all requirements in this chapter; (E) Records of the treatment plan review by the multi-disciplinary team including attendees and decisions; (F) The program's utilization review committee's abstract or summary; and (G) The discharge summary. 007.06 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning. 007.07 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following guidelines. A site visit by Nebraska Medicaid staff for purposes of utilization review may be required for further clarification. 007.07(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide: (i) Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment; (ii) Utilization of professional services provided; (iii) High quality patient care; and (iv) Effective and efficient utilization of available health facilities and services. 007.07(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and provider agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include: (i) The organization and composition of the utilization review committee which is responsible for the utilization review function; (ii) The frequency of meetings, which must be not less than once a month; (iii) The type of documentation to be kept; and (iv) The arrangement for committee reports and their dissemination, including how the program and supervising practitioner is informed of the findings. 007.07(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must contain a licensed provider who is able to diagnose and treat major mental illness within their scope of practice and at least two clinical staff professionals, as defined in this chapter. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the beneficiary whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved. 007.07(D) BASIS OF REVIEW. The review must be based on: (i) The identification of the beneficiary by appropriate means to ensure confidentiality; (ii) The identification of the supervising practitioner; (iii) The date of admission; (iv) The diagnosis and symptoms; (v) The supervising practitioner's plan of treatment; and (vi) Other supporting materials the group may deem appropriate. 007.07(E) CONTENTS OF REPORT. The written report must contain: (i) An evaluation of treatment, progress, and prognosis based on: (1) Appropriateness of the current level of care and treatment; (2) Alternate levels of care and treatment available; and (3) The effective and efficient utilization of services provided; (ii) Verification that: (1) Treatment provided is documented in the beneficiary's record; (2) All entries in the beneficiary's record are signed by the person responsible for entry and dated. The supervising practitioner must sign and date all of their orders; and (3) All entries in the beneficiary's record are dated; (iii) Recommendations for: (1) Continued treatment; (2) Alternate treatment or level of care, or both; and (3) Disapproval of continued treatment; (iv) The date of the review; (v) The names of the program utilization review committee members; (vi) The date of the next review if continued treatment is recommended; and (vii) A copy of the admission review and the extended stay review must be attached to all claims for mental health services submitted to Nebraska Medicaid for payment. 007.08 DOCUMENTATION FOR CLAIMS. The following documentation is required for all claims for therapeutic group homes (ThGH) and claims must be kept in the beneficiary’s record. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment. (A) A psychiatric assessment with mental status exam and diagnosis; (B) The treatment plan for admission and every 30 days thereafter; (C) Orders by the supervising practitioner; (D) A complete family assessment; (E) Nurse's notes; (F) Progress notes for all disciplines; and (G) All claims are subject to utilization review by Nebraska Medicaid prior to payment. 007.09 PROCEDURE CODES AND DESCRIPTIONS FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER THERAPEUTIC GROUP HOMES (ThGH). Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT); procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.