471 NAC 32-008. INPATIENT PSYCHIATRIC SERVICES FOR BENEFICIARIES UNDER AGE 19 IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF)

008. INPATIENT PSYCHIATRIC SERVICES FOR BENEFICIARIES UNDER AGE 19 IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF). 008.01 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF) FOR CHILDREN AND ADOLESCENTS. A Psychiatric Residential Treatment Facility (PRTF) is a facility that provides inpatient psychiatric services to beneficiaries under the age of 19. A Psychiatric Residential Treatment Facility (PRTF) must provide the inpatient psychiatric services under the direction of a physician or advanced practice registered nurse (APRN), must be accredited, and must comply with all the requirements of applicable state and federal regulations. 008.02 PRIOR AUTHORIZATION. In order for an admission to a Psychiatric Residential Treatment Facility (PRTF) to be reimbursed by Nebraska Medicaid, the beneficiary must have a certification of need for services as set forth in this chapter and be prior authorized by Nebraska Medicaid or its designee. Prior authorization applies to all admissions described in this chapter. 008.03 CERTIFICATION OF NEED FOR SERVICES. A team certifying need for services must certify, prior to admission, that: (A)Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary; (B)Proper treatment of the beneficiary’s psychiatric condition requires services on an inpatient basis under the direction of a physician or advanced practice registered nurse (APRN); and (C)The services can reasonably be expected to improve the beneficiary’s condition or prevent further regression so that the services will no longer be needed. 008.04 TEAM CERTIFYING NEED FOR SERVICES. Certification of need for services must be made by an independent team which includes a physician or advanced practice registered nurse (APRN); has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and has knowledge of the beneficiary’s situation. 008.04(A) INDIVIDUALS WHO BECOME ELIGIBLE FOR NEBRASKA MEDICAID WHILE IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). For an individual who applies for Nebraska Medicaid while in the Psychiatric Residential Treatment Facility (PRTF), the certification must be made by the team responsible for the plan of care as specified in this chapter and cover any period before application for which claims are made. 008.04(B) EMERGENCY ADMISSIONS. For emergency admissions, the certification must be made by the team responsible for the plan of care within 14 days after admission. 008.05 ACTIVE TREATMENT. Inpatient psychiatric service must involve active treatment which means implementation of a professionally developed and supervised individual plan of care, as described in this section, which is developed and implemented no later than 14 days after admission and is designed to achieve the beneficiary’s discharge from inpatient status at the earliest possible time. 008.06 INDIVIDUAL PLAN OF CARE. The plan of care means a written plan developed for each beneficiary to improve their condition to the extent that inpatient care is no longer necessary. The plan of care must: (A)Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the beneficiary’s situation and reflects the need for inpatient psychiatric care; (B)Be developed by a team of professionals specified in this section, in consultation with the beneficiary and their parents, legal guardian, or others in whose care the beneficiary will be released after discharge; (C)State treatment objectives; (D)Prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; and (E)Include post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the beneficiary’s family, school, and community upon discharge. The discharge plan must: (i)Identify the custodial parent or custodial caregiver anticipated at discharge; (ii)Identify the school the beneficiary will attend; (iii)Include individualized educational program (IEP) recommendations as necessary; (iv)Outline the aftercare treatment plan; and (v) List barriers to community reintegration, including barriers for the custodial parent or custodial caregiver, and progress toward resolving these barriers since the last review. 008.07 TEAM DEVELOPING INDIVIDUAL PLAN OF CARE. (A)The individual plan of care must be developed by an interdisciplinary team of physicians or advanced practice registered nurses (APRN) and other personnel who are employed by, or provide services to beneficiaries in the facility; (B)Based on education and experience, the team must be capable of: (i)Assessing the beneficiary’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; (ii)Assessing the potential resources of the beneficiary’s family; (iii)Setting treatment objectives; and (iv)Prescribing therapeutic modalities to achieve the plan’s objectives; (C)The team must include, as a minimum, either: (i)A board-eligible or board-certified psychiatrist; (ii)A licensed psychologist and a physician or advanced practice registered nurse (APRN) ; or (iii)A physician or advanced practice registered nurse (APRN) with specialized training and experience in the diagnosis and treatment of mental diseases and a licensed psychologist; and (D)The team must also include one of the following: (i)A psychiatric social worker; (ii)A licensed registered nurse (RN) with specialized training or one year’s experience in treating mentally ill individuals; (iii) A licensed occupational therapist (OT) who has specialized training or one year of experience in treating mentally ill individuals; or (iv)A licensed psychologist. 008.08 REPORTS OF EVALUATION AND PLANS OF CARE. A written report of each evaluation and plan of care must be entered in the beneficiary’s record: (A)At the time of admission; or (B)If the beneficiary is already in the Psychiatric Residential Treatment Facility (PRTF), immediately upon completion of the evaluation or plan. 008.09 REVIEW OF PLAN OF CARE. The plan of care must be reviewed every 30 days by the team as specified in this section, to: (A)Determine that services being provided continue to be required on an inpatient basis; and (B)Recommend changes in the plan as indicated by the beneficiary’s overall progress from the treatment provided at this level of care. 008.10 TREATMENT SERVICES PROVIDED BY THE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). Providers of Psychiatric Residential Treatment Facility (PRTF) services must provide 40 hours of psychotherapy and other treatment interventions per week. The following services and frequency of services are included in the Psychiatric Residential Treatment Facility (PRTF) rate and must be available to the beneficiary unless clinically contraindicated: (A)Twice weekly individual psychotherapy or substance use disorder counseling, or both; (B)Minimum three times a week group psychotherapy or substance use disorder counseling, or both; (C) Weekly family mental health or substance abuse disorder counseling, or both. A family therapy session is provided on the day of admission and the day prior to discharge; (D)Occupational therapy (OT) as clinically indicated; (E)Physical therapy (PT) as clinically indicated; (F)Speech therapy as clinically indicated; (G)Laboratory services; (H)Transportation; (I)Medical services, as necessary; and (J)Nursing service availability seven days a week, 365 days a year by an onsite nurse during awake hours and by an on-call availability during sleep hours. 008.11 PSYCHOEDUCATION SERVICES PROVIDED IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). Psychoeducational services must be available from the Psychiatric Residential Treatment Facility (PRTF) and must be modified to meet the unique treatment needs of the beneficiary as described in the individual’s plan of care: (A)Crisis intervention and aftercare planning; (B)Life survival skills as clinically indicated; (C)Social skills building; (D)Substance use prevention interventions; (E)Self-care services as clinically indicated; (F)Medication education, compliance, and information regarding the effectiveness of medication; (G)Health care issues which may include nutrition, hygiene, and personal wellness; (H)Vocational and career planning as clinically indicated; and (I)Recreational activity, which is not considered in 40 hours per week of therapy but healthful outcomes of recreation and exercise may be a part of a psycho-educational group service. 008.12 INDIVIDUAL PARTICIPATION IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES. Every beneficiary need not partake in all treatment services that are available in the Psychiatric Residential Treatment Facility (PRTF) if such services are clinically contraindicated. If individual, group, or family psychotherapy services are not appropriately beneficial to the beneficiary’s need and plan of care, the plan of care must identify the rationale for this omission. However, in no case should a child or adolescent receive less than 40 hours of Psychiatric Residential Treatment Facility (PRTF) services each week. 008.13 STAFFING STANDARDS FOR PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF). A Psychiatric Residential Treatment Facility (PRTF) must operate 24 hours a day, seven days a week, and 365 days per year with 24-hour awake staffing. Staffing ratios should be 1:4 during awake hours and 1:6 during sleep hours. The following positions are required to be staffed, with a minimum of the stated qualifications. 008.13(A) SUPERVISING PRACTITIONER. The Psychiatric Residential Treatment Facility (PRTF) Supervising Practitioner must be a licensed physician. 008.13(B) PROGRAM OR CLINICAL DIRECTOR. A program or clinical director must be a licensed mental health practitioner (LMHP), licensed registered nurse (RN), licensed advanced practice registered nurse (APRN), licensed independent mental health practitioner (LIMHP), licensed physician with a specialty in psychiatry, or licensed psychologist. Dual-credentialing is required for Psychiatric Residential Treatment Facility (PRTF) services when co-occurring conditions occur. The program or clinical director must have two years professional experience in a treatment setting similar to a Psychiatric Residential Treatment Facility (PRTF). The program or clinical director may not also serve in the role of the program’s therapist. 008.13(C) THERAPIST. A Psychiatric Residential Treatment Facility (PRTF) therapist must be a licensed practitioner whose scope of practice includes mental health or substance use disorder services or both, including a licensed mental health practitioner (LMHP), licensed independent mental health practitioner (LIMHP), provisionally licensed mental health practitioner (LMHP), licensed alcohol and drug counselor (LADC), licensed psychologist, provisionally licensed psychologist, licensed advanced practice registered nurse (APRN), or licensed physician with a specialty in psychiatry. 008.13(D) REGISTERED NURSE (RN) OR ADVANCED PRACTICING REGISTERED NURSE (APRN). Nursing services must be provided by a registered nurse (RN), or Advanced Practice Registered Nurse (APRN) licensed by the state in which they practice. 008.13(E) DIRECT CARE STAFF. Direct care staff must meet the following requirements: Be 20 years of age or older and at least two years older than the oldest resident and have a high school diploma or its equivalent. Direct care staff must be appropriately trained and responsible for basic interaction care as well as assisting in the implementation of the plan of care that is within their scope of practice. 008.14 RESTRAINT AND SECLUSION. Restraint and seclusion activities utilized by the Psychiatric Residential Treatment Facility (PRTF) must be in compliance with federal standards for restraint and seclusion. 008.15 MEDICALLY NECESSARY SERVICES AND SUPPLIES. The following services must be available to the beneficiary and may be billed separately to Nebraska Medicaid: (A)Medically necessary services and supplies not otherwise included in the Psychiatric Residential Treatment Facility (PRTF) rate when that care is reflected in the plan of care; and (B)The Psychiatric Residential Treatment Facility (PRTF) must : (i)Arrange for and oversee the provision of such services and supplies; (ii)Maintain all medical records of care furnished to the beneficiary; and (iii)Ensure that all services and supplies are furnished under the direction of a physician or advanced practice registered nurse (APRN).