471 NAC 35-010. SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION. secure psychiatric residential rehabilitation facilities are integrated into the community and provide programming in an organized, structured setting, including treatment and rehabilitation services and offer support to beneficiaries with a severe and persistent mental illness or co-occurring substance use disorders, or both

010. SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION. secure psychiatric residential rehabilitation facilities are integrated into the community and provide programming in an organized, structured setting, including treatment and rehabilitation services and offer support to beneficiaries with a severe and persistent mental illness or co-occurring substance use disorders, or both. These beneficiaries demonstrate a moderate to high risk for harm to self or others and are in need of recovery, treatment, and rehabilitation services. The beneficiaries who are in need of this level of care have long standing limitations with limited ability to live independently over an extended period of time. These beneficiaries have needed a high level of psychiatric intervention and have limitations in all three functional areas, vocational and educational, social skills, and activities of daily living as defined in this chapter. The secure psychiatric residential rehabilitation program provides skill building and other related recovery oriented psychiatric rehabilitation services as needed to meet individual beneficiary needs. 010.01 PURPOSE. The secure psychiatric residential rehabilitation program is designed to: (A)Increase the beneficiary's functioning while improving psychiatric stability so that they can eventually live successfully and safely in a less restrictive residential setting of their choice and capabilities; (B) Decrease the frequency and duration of hospitalization; (C)Decrease or eliminate all high risk, unsafe behavior to self or others; and (D)Improve the ability to function independently by improving ability to function. 010.02 PROGRAM COMPONENTS. A secure psychiatric residential rehabilitation program provides a variety of on-site psychosocial rehabilitation and skill acquisition activities and treatment each day. The program must facilitate beneficiary driven skills training and activities as appropriate. A secure psychiatric residential rehabilitation program must provide services identified on the beneficiary specific individual treatment, rehabilitation, and recovery plan, providing culturally-sensitive and trauma-informed care. The activities must include : (A)Ongoing assessment; (B)Arrangement for general medical care including laboratory services, psychopharmacological services, or psychological services, as necessary; (C)Provision of a minimum of 42 hours per week of on-site staff led psychosocial rehabilitation activities and skill acquisition; (D)Programming focused on relapse prevention, recovery, nutrition, daily living skills, social skill building, community living, substance use disorders, education, medication education and self-administration, symptom management, and focus on improving the level of functioning to get to a less restrictive level of care; (E)Educational and vocational focus as appropriate; and (F)Access to community-based rehabilitation and social services to assist in transition to community as symptoms are managed and behaviors are stabilized. 010.03 ASSESSMENTS. The following assessments must be completed: (A)A comprehensive mental health and substance use disorder assessment by an independently licensed mental health practitioner (LMHP) must occur prior to admission. As appropriate, a substance use disorder addendum must be developed to clarify or update the treatment needs and recommendations and gather information that covers the time frame where a beneficiary was not receiving treatment; (B)Following admission and within 24 hours of stay, an assessment by the program's psychiatrist must be completed; (C)A history and physical must be completed by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) within 24 hours of admission and be available in the clinical record; (D)A nursing assessment must be completed by a registered nurse (RN) within 24 hours of admission; and (E)A functional assessment must be completed initially upon admission and annually with continued stay at this level of service. 010.04 INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLANNING. An initial individual treatment, rehabilitation, and recovery plan must be completed within 24 hours of admission. secure psychiatric residential rehabilitation service providers must develop an individual treatment, rehabilitation, and recovery plan with the beneficiary within 30 days following admission to the program. The plan must include treatment protocols for substance use disorder issues. With the beneficiary’s consent, the beneficiary’s family or guardian must be included in all assessment and treatment, rehabilitation, and recovery planning. The provider must make every effort to be available and responsive to the beneficiary’s family or guardian to assist their involvement in the beneficiary’s recovery. The plan must be reviewed and revised with the beneficiary, discussing and documenting the discharge plan a minimum of every 30 days according to the following requirements. 010.04(A) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN. The individual treatment, rehabilitation, and recovery plan must be based upon a comprehensive assessment and completed within 30 days of admission. This plan must: (i)Be oriented to the principles of recovery and meaningful beneficiary participation; (ii)Apply the principles of recovery to include meaningful beneficiary participation, and a life in the community of the beneficiary’s choosing; (iii)Incorporate and be consistent with best practices; (iv)Include the beneficiary’s individualized goals and expected outcomes; (v)Contain prioritized objectives that are measurable and time-limited; (vi)Describe therapeutic interventions to be used in achieving the goals and objectives that are recovery-oriented, trauma-informed, and strength-based; (vii)Identify staff responsible for implementing the therapeutic interventions; (viii)Specify the planned frequency and duration of each therapeutic method; (ix)Delineate the specific behavioral criteria to be met for discharge or transition to a lower level of care and reviewed weekly; (x)Include a plan developed with the beneficiary that includes strategies to avoid crisis or admission to a higher level of care using principles of recovery and wellness; (xi)Include the signature of the beneficiary, parent, or guardian; (xii)Include the health care proxy and trauma safety forms when available and with beneficiary’s consent; (xiii)Include documentation that the initial individual treatment, rehabilitation, and recovery plan has been completed within the timeframe specified in the program’s policies and procedures; (xiv)Document that the plan has been reviewed, updated every 30 days, and revised according to client needs and progress; and (xv)Document that the plan was reviewed by the program's treatment practitioners a minimum of every 30 days and that written revisions were approved, signed, and dated each 30 days by the program psychiatrist. 010.04(B) TREATMENT SERVICES. The program must offer structured, planned treatment and rehabilitation services as prescribed by the individualized treatment, rehabilitation, and recovery plan. The following services must be available and offered to the beneficiary: (i)Individual psychotherapy; (ii)Group psychotherapy; (iii)Family therapy; and (iv)Psychoeducational services. 010.04(C) SUPPORTIVE SERVICES. The program must provide the following supportive services for all active beneficiaries: referrals as necessary, problem identification and solution, and coordination of the secure psychiatric residential rehabilitation program treatment and activities with other services the beneficiary may be receiving. 010.05 STAFFING. The secure psychiatric residential rehabilitation provider must contract with or employ a licensed psychiatrist for the program. The psychiatrist’s hours must be at a sufficient level to provide weekly direct contact with the beneficiary; to provide assessment; to review the individual treatment, rehabilitation, and recovery plan; to evaluate beneficiary’s level of progress; to assist in eliminating barriers to recovery; and to provide psychiatric consultation as necessary 24 hours per day, and seven days per week . Programs must have staff available in skill and numbers to meet the acuity of the beneficiaries being served. Programs must have ability to call staff back when necessary. 010.05(A) STAFFING STANDARDS. Secure psychiatric residential rehabilitation providers must meet the following minimum staffing requirements. The program must employ a: (i)Program director; (ii)Licensed mental health practitioner (LMHP), or licensed alcohol and drug counselor (LADC), or both. ; (iii)Registered nurse (RN); and (iv)Direct care staff. 010.05(A)(1) PROGRAM DIRECTOR REQUIREMENTS. The program director must: (a)Be fully licensed as a mental health practitioner, which could be a psychiatrist, advanced practice registered nurse (APRN), a registered nurse (RN), a licensed mental health practitioner (LMHP), a licensed independent mental health practitioner (LIMHP) or psychologist; and (b)Possess leadership, supervisory, and management skills. 010.05(A)(2) RESPONSIBILITIES OF THE SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION PROGRAM DIRECTOR. The program director must: (a)Complete and sign a comprehensive biopsychosocial assessment for each beneficiary within 14 days of admission or delegate responsibility for the assessment to the program's licensed practitioner who functions as the therapist for the program; (b)Develop, approve, and sign an initial individual treatment, rehabilitation, and recovery plan within the first 24 hours of admission; (c)Supervise and participate in the development of a comprehensive individual treatment, rehabilitation, and recovery plan with the beneficiary and the program staff within 30 days of admission. The program director must approve and sign the plan prior to implementation; (d)Supervise the professional staff and direct care staff by onsite presence during programming; (e)Assure adequate staff training through initial and ongoing training sessions and provide supervision of staff competency checks; (f)Supervise and provide direction regarding all documentation requirements, including organization and completeness of clinical records; and (g)Supervise and direct the development and implementation of the discharge plan. 010.05(A)(3) RESPONSIBILITIES OF THE REGISTERED NURSE (RN). The registered nurse (RN) must: (a)Complete a nursing assessment within 24 hours of admission; (b)Participate in the development of the individual treatment, rehabilitation, and recovery plan and the plan updates; (c)Oversee and monitor daily medication administration; (d)Provide medication education as necessary; (e)Communicate with the psychiatrist and physician consultants as necessary; and (f)Monitor, supervise, and oversee the program’s daily activities in conjunction with and in the absence of the program director. 010.05(A)(4) RESPONSIBILITIES OF THE MENTAL HEALTH PRACTITIONER. The mental health practitioner must: (a)Complete a comprehensive assessment within 14 days of admission when this responsibility is delegated by the program director; (b)Participate in the development of the individual treatment, rehabilitation, and recovery plan and the updates; (c)Provide individual, group, and family psychotherapy according to the beneficiary's individual treatment, rehabilitation, and recovery plan; (d)Communicate with the program director and psychiatrist regarding the clinical needs of the beneficiary as necessary; (e)Monitor, supervise, and oversee the program's daily treatment and activities in the absence of the program director as assigned by the program director; (f) Assist with aggressive discharge planning; and (g)Maintain a maximum staffing ratio of one practitioner to eight beneficiaries. 010.05(A)(5) DIRECT CARE STAFF. Direct care staff to beneficiary ratios must be sufficient to meet beneficiary needs, and ratios must be enhanced to meet beneficiary needs as necessary. The secure psychiatric residential rehabilitation program must employ direct care staff who: (a)Are on site and available to the beneficiaries at a ratio of one staff per four beneficiaries during awake hours and a minimum of one awake direct care per staff per six beneficiaries during overnight hours; and (b) Have a bachelor's degree in psychology, sociology, or related human services field, except that two years of course work in the human services field and two years of experience and training or two years of lived recovery experience is an acceptable substitute. Each staff must have demonstrated skills and competency in treatment with individuals with mental health diagnosis. 010.06 DISCHARGE PLANNING. Discharge and transition planning must begin upon admission. The beneficiary’s family or guardian must be included in discharge planning as authorized by the beneficiary. The plan must be recovery-oriented, trauma-informed, and strength-based. Providers must meet the following standards regarding recovery and discharge planning: (A)Discharge planning must be consistent with the goals and objectives identified in the individual treatment, rehabilitation, and recovery plan and clearly documented in the clinical record; (B)Discharge planning must address the beneficiary’s needs for ongoing services to maintain the gains and to continue as normal functioning as possible following discharge. A crisis, relapse, and safety plan must be in place; (C)Providers must make or facilitate referrals and applications to the next level of care or community support services, or both ; (D)Providers must arrange for the prompt transfer of clinical records and information to ensure continuity of care; and (E)A written discharge summary must be provided as part of the clinical record. It must identify the readiness for discharge and contain the signature of a fully licensed clinician and date of signature and must identify a summary of the services provided. 010.07 CLINICAL DOCUMENTATION. Clinical records must be maintained at the beneficiary’s primary rehabilitation site. 010.08 CLINICAL RECORD REQUIREMENTS. The clinical record must include information required in this chapter and, at a minimum: (A)Assessment and evaluations: (i)Psychiatric assessment, including the name of the clinician and the date of the assessment; (ii) Comprehensive assessment; and (iii) Other assessments completed related to the beneficiary’s behavioral health diagnosis; (B)The beneficiary’s diagnostic formulation, including all five axes; and (C)The individual treatment, rehabilitation, and recovery plan and updates to plans. 010.09 PROVIDER PARTICIPATION. Providers are required to provide annual updates of program information and cost information to determine ongoing compliance with Nebraska Medicaid regulations. Providers must maintain documentation of policies and procedures that meet the standards and regulations described in this chapter. 010.10 BED LIMITATION. The maximum capacity for the provider of secure psychiatric residential rehabilitation services must not exceed 16 beds. 010.11 TREATMENT PRIOR AUTHORIZATION. All secure psychiatric residential rehabilitation services must be prior authorized by Nebraska Medicaid or its designee, including initial admissions and continued stay requests. 010.12 INSPECTIONS OF CARE (IOC). Nebraska Medicaid or its designee can periodically inspect the care which includes the treatment, rehabilitative, and recovery services provided to beneficiaries in each type of service.