St. Peter's Behavioral Health Management Admission Review Team ART. Table of Contents

Transcription

1 St. Peter's Behavioral Health Management Admission Review Team ART PROVIDER MANUAL Table of Contents 1. Introduction 2. Certification 3. Completing the Pre-Admission Review 4. Timeframe for Determinations 5. Second Review 6. Medical Record Documentation 7. Forms

2 St. Peter's Behavioral Health Management Admission Review Team ART INTRODUCTION St. Peter s Hospital began in 1869 as a 22-bed hospital and has evolved into St. Peter s Health Care Services, a comprehensive health care system. With 4,500 employees, St. Peter s is the New York State Capital Region s fourth-largest employer. On any given day, nearly 4,000 persons are helped by St. Peter s Health Care Services. The organization has earned national and state honors for its high-quality, compassionate care. St. Peter's Behavioral Health Management, part of the Behavioral Health Department of St. Peter s Hospital, embraces the Valves In Practice philosophy of St. Peter s Health Care Services with the 7 core values of Compassion, Reverance for each person, Community, Hospitality, Excellence, Integrity, and Courage. The New York State Office of Alcoholism and Substance Abuse Services (OASAS) is implementing Title 14 NYCRR Part 817 regulations for the delivery of quality Chemical Dependence Residential Rehabilitation Services for Youth (RRSY) beginning in the year The development of this service is largely based on Inpatient Psychiatric Facility Services for Individuals under 21 Years of Age, a federal Medicaid service category. A major Federaloperating requirement for this service category is that all Medicaid eligible youth are certified for clinical appropriateness in order to maximize treatment accessibility and effectiveness. OASAS has chosen to meet this requirement with an Admission Review Team (ART), and St. Peter's Behavioral Health Management has contracted with OASAS to develop and administer the ART. The ART consists of a physician, a Certified Social Worker, and a New York State Credentialed Alcoholism and Substance Abuse Counselor (CASAC). These professionals examine Pre-Admission Review forms that are submitted by RRSY providers. The provider, by completing an ART Pre-Admission Review form, attests that the admission criteria has been fulfilled and documentation to substantiate each criteria checked yes has been made in a written record. The ART then completes the process with written certification that the prospective patient can be admitted to the RRSY level of treatment. Thus, the ART certifies that each Medicaid eligible youth admitted to an RRSY meets the admission criteria delineated in Section of Part 817 regulations as attested by the RRSY provider. 6/2007

3 St. Peter's Behavioral Health Management Admission Review Team ART CERTIFICATION A certification by ART is required prior to a prospective patient s admission into a RRSY facility. The pre-admission certification can only be issued by ART. Certification: A certification issued by ART will be valid for the date of admission, or for 30 days from the date the Pre-Admission Review is deemed to have been received by ART if the date of admission is blank on the first page of the Pre-Admission Review. When a prospective patient is certified and admission does not occur within 30 days, which occurs due to any number of reasons, a complete Pre-Admission Review form must be resubmitted. Decertification: The prospective patient could have some factors that change and the certification would be no longer valid. For example, The ART is notified, or independently determines, that the youth has been placed in another appropriate setting and placement in an RRSY is no longer needed. The youth is receiving appropriate clinical services. A parent or legal guardian no longer desires the prospective patient s admission to residential rehabilitation. The clinical condition has deteriorated such that admission to a RRSY within a period of 30 days would not be appropriate. Admission criteria are no longer met. Emergency Admission: Part 817 allows that circumstances may be present which could result in a youth s emergency admission to a RRSY without prior approval from the ART. The prospective patient must meet the first four (4) admission criteria, in addition to the presence of one of the following: 1) The youth has demonstrated an inability to abstain outside of a structured 24-hour setting; or 2) The youth is unable to access transitional services in the community; or 3) The youth is without appropriate housing. Under no circumstances should a youth be admitted on an emergency basis or otherwise if they are in medical or psychiatric crisis, or if in need of medically necessary withdrawal services.

4 Legal Mandates: The ART certification utilizes medical and clinical standards certifying conformity to medical necessity criteria. Civil and court determined status recommendations do not necessarily conform to medical necessity and do not replace ART certification. An emergency admission does not pre-empt certification by ART. The ART process remains unchanged and certification is needed within 2 business days. Providers are cautioned that an ART determination could be made to deny a request for certification. Thus, if the facility chooses to admit a Medicaid eligible youth under an emergency admission or due to a legal mandate and ART denies the request for certification, the facility may not be paid by Medicaid. ART Approvals for Court Ordered Admissions Question: What ART approvals must be received for court ordered admissions? Answer: To ensure compliance with the Federal ART requirement for all active Medicaid admissions, the RRSY must, within 48 hours, submit the court ordered admission to the ART for review and certification. However, the RRSY is not obligated to admit court ordered patients who do not meet the RRSY admission criteria. Therefore, if, during the initial admission process, the RRSY assesses the court ordered patient and determines they are not appropriate for RRSY services, the RRSY should immediately contact the court and discuss alternative treatment arrangements. Backdated Certifications: Providers will need to note on the application if the patient has already been admitted to the RRSY so that the start date on the certification is the same as the date the patient was admitted to the RRSY. Part 817 clearly states that the ART certification process is required prior to admission. Thus, post-admission certifications are not encouraged, but when necessary the certification date can be backdated as much as thirty (30) calendar days. OASAS will be notified regarding RRSY providers who habitually request backdated certifications. The above does not apply to programs within the first month of a program s conversion to RRSY. Newly Converting RRSY Programs: The date of the program s conversion is considered the Date Approved for Admission because Medicaid will pay the RRSY rate from the conversion date and forward. The actual date of an existing patient s admission is not used by the newly converted RRSY. Example: A patient s actual date of admission is 02/15/2008. The program s conversion to an RRSY is officially 03/01/2008. The date of admission for ART s purposes is 03/01/2008 and should be noted as such on page one of the Pre-Admission Review form. Every current patient on active Medicaid on the date of a program s conversion must go through ART.

5 St. Peter's Behavioral Health Management Admission Review Team ART COMPLETING THE ART PRE-ADMISSION REVIEW FOR ADMISSIONS TO RESIDENTIAL REHABILITATION SERVICES FOR YOUTH A prospective patient presenting for admittance to a RRSY facility is assessed by the RRSY facility to determine if the youth is appropriate for chemical dependence services. A qualified health professional or other clinical staff under the supervision of a qualified health professional, conducts the assessment. All Medicaid eligible youth are required to be certified by ART in order to have Medicaid as the payer of RRSY. ART requires a complete Pre-Admission Review form in order to determine that a certification can be issued. The signed ART Pre-Admission Review form is an attestation that information supporting the yes statements has been documented in the prospective patient s medical record. Additional documentation may be requested by ART but should not be included with the initial Pre-Admission Review form. The ART Pre-Admission Review form must be signed and dated by a qualified health professional. The responses shall be based upon documents and information provided by the prospective patient. Information obtained shall also be based on written and verbal reports from other providers and through a face-to-face contact with the prospective patient. A responsible family member or significant other may also provide information. Sources of information must be documented in the individual medical record, which may be subject to an audit by Medicaid at a future date. To assist RRSY facilities in the process of medical record documentation, a detailed presentation of information to be collected by the staff conducting the assessment is provided in this section. Now that your facility has completed the OASAS conversion process to become a RRSY, it may be a good time to review forms and modify the information you have typically collected. A Medical Record Documentation Check List Summary is included in another section of the Provider Information. The Admission Review Team trusts this will be helpful. 02/01/2008 1

6 Page 1, the cover sheet: Pre-Admission Review for Medicaid Eligible Youth Residential Rehabilitation Services for Youth Provider Information Counselor Submitting This Application: Facility: Telephone: Fax: Prospective Patient Information First 2 Letters of Name: Last Name at Birth: DOB: Age: Gender: Last 4 Digits of Social Security #: Medicaid ID#: County of Residence: If the patient has been admitted to the RRSY, the date of admission: Admission Review Team Action INSTRUCTIONS: Please complete both the Provider Information and the Prospective Patient Information sections. The only line that can be left blank in those sections may be the patient s date of admission if the prospective patient has not yet been admitted. (Please see the CERTIFICATION section for additional information regarding the date of admission.) It is most desired that a youth be a Medicaid-card carrier. However, prospective patients with pending, inactive, or unknown Medicaid status will be certified. Please indicate the prospective patient s Medicaid status on the line labeled Medicaid ID #. It is the RRSY s responsibility to ensure the patient has active Medicaid insurance for the purpose of billing Medicaid. Managed Care-Medicaid youth will be certified. However, the youth needs to be carvedout from Managed Care by the RRSY so that Medicaid can pay for residential services. Facilities may need to discuss this issue with Local Departments of Social Services to develop a co-operative process to remove youth from Managed Care and convert to straight Medicaid. The Admission Review Team Action section, including the narrative summary section, is for the use of the ART. 02/01/2008 2

7 Page 2 (The Prospective Patient s ID # may be any number or code the agency assigns.) The Clinical Assessment. It needs to be determined that the youth is appropriate for chemical dependency treatment. Appropriate responses are needed to each of the 4 statements below. The prospective patient is documented as less than 21 years of age on the date of admission. Yes No The prospective patient appears to be in need of treatment for chemical dependence. Yes No The prospective patient appears to be free of serious communicable disease that can be transmitted through ordinary contact. Yes No The prospective patient does not need acute hospital care, acute psychiatric care, or Part 816 crisis services. Is this correct? Yes No INSTRUCTIONS: The prospective patient is documented as less than 21 years of age on the date of admission. Part (a)(1) YES The prospective patient needs to be less than 21 years of age at admission, but a patient can have a 21 st birthday while in RRSY treatment. Please be aware that no Medicaid reimbursement is available for RRSY treatment after the patient reaches the age of 22. Part (o) (7) The prospective patient appears to be in need of treatment for chemical dependence. Part (a)(1) YES The prospective patient is assessed as using a quantity of substances at a frequency that increases risk of harmful consequences. 1 (The harmful consequences might include issues with: a legal system, physical health, mental health, emotional responses, behavioral actions, familial relationships, educational goals, employment responsibilities, impairment in hygiene, and indiscriminate/unprotected sexual contact.) The prospective patient is unable to interrupt a high severity pattern of use with the risk of dangerous consequences and is in need of intensive motivating strategies, activities and processes available in a 24-hr setting. The prospective patient appears to be free of serious communicable disease that can be transmitted through ordinary contact. Part (a)(2) YES The qualified health professional will need to base a response on the appearance and verbal responses of the prospective patient regarding the presence of illness. Patients who have not had a physical examination within six months shall receive a physical examination within seven days after admission by a physician, physician s assistant, or a nurse practitioner. Part (b) (1) The prospective patient does not need acute hospital care, acute psychiatric care, or Part 816 crisis services. Is this correct? Part (a)(3) YES The prospective patient shall be immediately referred to an acute care facility when presenting with physical or mental health complications or any co-morbid conditions requiring an acute level of care. The prospective patient may need Part 816 crisis services when there is substantial risk of physical harm to the individual or others due to the youth 1 1. SAMHSA. Series; Screening and Assessing Adolescents for Substance use Disorders. Treatment Improvement Protocol (TIP) 02/01/2008 3

8 presenting as incapacitated by substances, and/or presenting with signs and symptoms of severe withdrawal. Required: The prospective patient has a Substance Dependence or a Substance Abuse condition. Indicated Level of Care yes, continue no Provide Alternate Referral. The prospective patient has Substance Dependence or a Substance Abuse condition. Part (a)(1) An affirmative answer is required for this statement. A prospective patient must have an alcohol or substance abuse condition in accordance with the criteria of the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. When documenting the prospective patient s alcohol and other drug use, a complete history would record: -A history for each substance used that includes age of onset, progression of use, route, current amount and frequency of use, and the date of last use. -The reason -precipitating factor- for most recent use. -A summary of the substance of choice/preference and the prospective patient s perception of use. -Method of obtaining each substance. -Symptoms and consequences for each substance used. -Medical problems the prospective patient thinks resulted from use. 02/01/2008 4

9 One or more of the following must constitute a substantial factor in the persistence of the chemical dependence condition and improvement of this factor is necessary for initiation and/or maintenance of recovery. (Please refer to PART 817 RESIDENTIAL REHABILITATION SERVICES FOR YOUTH LEVEL OF CARE DEFINITIONS) 1. The prospective patient has accessed a less intensive level of care, of which a treatment goal has included abstinence, and failed to become or remain abstinent yes Residential Rehabilitation. for a reasonable period of time. no, continue 2. The prospective patient s living environment is not yes Residential Rehabilitation. conducive to recovery. no, continue 3. The prospective patient has a physical or a mental comorbidity requiring medical management, observation, yes Residential Rehabilitation. and evaluation. no, continue 4. The prospective patient lacks judgment, insight and yes Residential Rehabilitation. motivation such as to require 24-hour supervision. no, continue 5. The prospective patient has substantial deficits in behavioral or functional skills as evidenced by activities of daily living, interpersonal skills, vocational or educational skills, and/or maladaptive social behavior (e.g., criminal justice involvement). yes no Residential Rehabilitation. Outpatient Services. INSTRUCTIONS: To support the need for admission to a RRSY, one or more of the following factors must be at a level of intensity that improvement of that factor is absolutely necessary for some success in treatment towards recovery from substance dependence or substance abuse. 1. The prospective patient has accessed a less intensive level of care, of which a treatment goal has included abstinence, and failed to become or remain abstinent for a reasonable period of time (g)(1) Document alcohol and other drug treatment history to include dates/length of past treatment episodes in crisis, inpatient, community residential services, outpatient, support groups, private counseling, etc. Document any periods of abstinence, and the reason the prospective patient began to use again. Also, indicate the prospective patient s referral source for entering substance abuse treatment and the prospective patient s judgement regarding the outcome including completion- of each reported treatment episode. OR, briefly explain in the medical record the absence of a treatment history. 2. The prospective patient s living environment is not conducive to recovery (g)(2) Document a description of the patient s living situation. Does the prospective patient live in high risk of being neglected or abused? Is a household member using? Include family history and functional status of individual household members and their relationship with the patient. Add information about the home environment, including the length of time living at that residence. Is the neighborhood a high-risk area for substance abuse? Also, state the circumstances that make the home environment an adverse recovery environment with residential placement preferred to maintenance in the family setting. 02/01/2008 5

10 3. The prospective patient has a physical or a mental co-morbidity requiring medical management, observation, and evaluation (g)(3) Continued use places the youth at imminent risk of serious physical health consequences due to a condition that requires medical monitoring, such as brittle diabetes, pregnancy, or HIV. A physical co-morbidity might include, but is not limited to, pregnancy; moderate to severe organ damage; or other medical problems that require 24 hour observation and evaluation Document medical history, accidents, emergency care, ob-gyn care, prescribed medications and the prospective patient s adherence to taking medication as prescribed. State any report of organ damage that would support admission to a residential rehabilitation A mental co-morbidity might include, but is not limited to, psychiatric illness, or a developmental disability For mental health complications, document a history of emergency care, and both outpatient and inpatient treatment. Indicate the most recent mental health treatment received and the status at discharge. Provide a history of prescribed medications and the prospective patient s adherence to taking mediation as prescribed. List reported diagnoses, indicating if a diagnosis is by report or by history. Question how the symptoms manifest themselves. Assess lethality Is the prospective patient at moderate risk of harming self or others? Is the prospective patient unstable emotionally or behaviorally? 4. The prospective patient lacks judgment, insights and motivation such as to require 24- hour supervision (g)(4) Documentation for this criterion would include evidence that the prospective patient is likely to relapse when released from a controlled environment. Document if the prospective patient has a history of non-compliance with mandated sanctions, a history of resistance to treatment, and consistently failing to consider the potential negative consequences of using substances. The prospective patient may have an external locus of control, blaming their problems on others and situations not within their control. If so, record this observation. 5. The prospective patient has substantial deficits in behavioral or functional skills as evidenced by activities of daily living, interpersonal skills, vocational or educational skills, and/or maladaptive social behavior (e.g., criminal justice involvement) (g)(5) ADL s (Activities of Daily Living)- This category includes hygiene, adequate diet, keeping appointments, taking medication as prescribed, accessing school/community resources, and coping adequately with everyday situations. Interpersonal skills- Might involve difficulty with: communicating when help is needed, maintaining a positive social network, leisure time activities, behaving in a socially appropriate manner, sound decision making, self-absorption and insensitivity, irresponsibility, or anger being used to control others. 02/01/2008 6

11 Vocational or educational skills- Indicate a lack of educational achievement, and basic literacy. Also state if the prospective patient doesn t set reasonable goals, has poor attendance, is not going to school or work, fails to present well at work or school (dress, grooming, speech), has a lack of marketable job skills or education, or has an income reliant on illegal activity. Maladaptive social behavior- The prospective patient has difficulty conforming to social norms, such as: not respecting the property of others, is verbally abusive towards others who are less powerful, lying, criminal behavior, lack of remorse, and is unable to accept authority and rules. THE ATTESTATION: The below signature of a qualified health professional is an attestation that the RRSY provider has documentation in a written record to substantiate the above statements. NAME AND CREDENTIALS OF THE RESPONSIBLE STAFF SIGNATURE AND CREDENTIALS OF AUTHORIZED REPRESENTATIVE / /20 DATE Please fax completed Pre-Admission Review forms to: Admissions Review Team (518) /01/2008 7

12 St. Peter's Behavioral Health Management Admission Review Team ART TIMEFRAME STANDARDS FOR DETERMINATIONS The ART will make every effort to complete the determination process and provide notification of the determination to the RRSY provider within 48 hours of receipt of a complete Pre-Admission Review form. Communication of the determination will be in writing, transmitted via fax, with the issuance of either a certification letter or a denial letter. 1) Should there be a conflicting determination amongst the three ART members; the ART may take an additional 24 hours to reach a consensus in order to deliver a determination. ART team members may ask the provider for additional information. Any additional information submitted will need to be in writing. 2) ART may determine information presented as incomplete or not accurate. Additional information or clarity of information may be requested from the RRSY provider; and until that written information is received to the satisfaction of the ART, the Pre-Admission Review form will be considered incomplete. An incomplete Pre- Admission Review form will need to be completed within 48 hours of the original date of receipt. Following the receipt of the additional information, a determination will be made within 48 hours. 3) Pre-Admission Review forms, as well as any additional information, received on or after 3:00 PM on Monday, Tuesday, Wednesday and Thursday will be logged-in as received at 9:00 AM on the next normal business day. 4) Pre-Admission Review forms received on and after 12 noon on Fridays and the day before Holidays, as well as any Pre-Admission Review form received during the weekend or on a holiday (New Years day, Memorial Day, Independence Day, Labor Day, Thanksgiving day, Christmas day) will be logged-in as received at 9:00 AM on the next normal business day. There is a three-year schedule, beginning in 2007, for OASAS to convert 21 facilities to be RRSY providers in New York State. Some facilities may have several existing Medicaid Youth in their programs that will need to be certified as soon as the facility s conversion is complete. In those instances, it may take ART up to two weeks to complete the certification process.

13 St. Peter's Behavioral Health Management Admission Review Team ART SECOND REVIEW (Appeals) A provider may request a second review of a Pre-Admission Review when an adverse determination is made by the Admission Review Team. The second review request must be made within the timeframe specified in the denial letter issued to the provider. 1. When the ART has made a denial determination for certification requested for a youth by a RRSY provider, a denial letter with specific rationale is sent to the provider advising the RRSY provider of the denial. Instructions are stated in the denial letter if the provider wishes to submit a request for a second review. The denial letter is also sent to OASAS. 2. The provider has the right to initiate a second review in writing, by fax, within thirty (30) days from the date the provider received the denial letter. A cover letter requesting a second review with additional written information to support a request for a second review is needed in order for ART to honor the request and proceed with a second review. 3. The details of the second review, including all aspects of the actions taken to process the second review, will be documented internally by ART. 4. For a clinical denial: The ART Program Manager will assign two-credentialed behavioral health practitioners external to the ART team to conduct a second clinical review of the presented information when the denial was issued due to lack of clinical appropriateness. The behavioral health practitioners may contact the provider to discuss clinical information. All previous documentation will be made available for the second review in conjunction to the updated and additional information provided with the second review request. For an administrative denial: At least one St. Peter s Addiction Recovery Center Administrator will review all the information submitted. 5. The second review determination will be issued in writing to the provider via fax. The second review determination will be made within ten (10) business days of receiving the written request for a standard review. If the denial decision is reversed, a certification will be issued at that time. Verbal notification will also be provided via telephone, as a courtesy. A copy of the determination letter is also provided to OASAS. 6. An expedited second review is conducted and the determination communicated as stated above. However, a viable explanation for an expedited second review is required, that is verbally accepted by the receiving ART member, followed by written information that is supportive of a second review. The determination would then be made within three (3) business days following the receipt of the written information. 7. If the resolution and determination of either the standard or expedited second review is unsatisfactory to the requesting provider, any further action initiated by the referent is to be coordinated with the NYS OASAS field office in Albany, NY. 10/2008

14 St. Peter's Behavioral Health Management Admission Review Team ART Medical Record Documentation Check List Summary Facilities are encouraged to use this list, or adapt this list into existing interagency tools, when performing Quality Assurance/Improvement checks on medical records. DOCUMENTATION REQUIREMENT: Section (a)(4): A comprehensive evaluation must be completed no later than seven days after admission. By documenting the following information on pages 1 through 4, this requirement will be fulfilled. SUBSTANCES USED It is essential for diagnosis and treatment to obtain a complete pattern of substance use. Use of a table can provide a clear visual: Age of Currently: Date of Last Substance Onset Progression of use Route Am t Used, Frequency Use Additional needed information: The reason for most recent use. The substance of choice. Method of obtaining each substance. Symptoms (effect) of each substance used. Consequences for each substance used. Medical problems that the patient thinks may have resulted from their use. 01/23/2009 1

15 GENERAL ADMISSION REQUIREMENTS 1. SUBSTANCE ABUSE TREATMENT HISTORY Dates/Length of Dates / Length of Past Treatment Name and Type of Facility Referent Abstinence Reason for Return to Use Obtain the prospective patient s judgment concerning the outcome for each treatment episode. Request information on self-help involvement. 2. LIVING ENVIRONMENT Describe the socio-economic class of the home neighborhood. Obtain information regarding the home environment -including the length of residence, cultural and ethnic background. Report any substance abuse history of family members, both parents and siblings -include impact of the prospective patient s use of substances on household members. Describe the relationship the prospective patient has with individual family members. Question for any history of domestic violence, physical, sexual, mental, or emotional abuse. State circumstances that make the home environment an adverse recovery environment -with residential placement preferred to maintenance in the family setting. 3. PHYSICAL CO-MORBIDITY REQUIRING MEDICAL MANAGEMENT State the physical diagnosis that requires 24-hour observation and evaluation. Document any chronic medical conditions. List prescribed medications and the youth s adherence to taking medication as prescribed. Record the date of the youth s last physical examination. Record the date and results of the most recent HIV test. Report any current medical treatment being received and contact information for the medical provider. Document the medical history Clearly state any allergies and sensitivities to medications -include any developmental medical issues, accidents, emergency care, nutritional information including daily diet, dental history and past medications. Sexual activity -include sexual preference, safe-sex practices, nature of sexual contacts (limited, prostitution, casual), STD s, ob-gyn care. Perform a risk assessment for HIV, TB, hepatitis and other communicable diseases. 01/23/2009 2

16 3. MENTAL HEALTH CO-MORBIDITY REQUIRING MEDICAL MANAGEMENT State the mental health diagnosis that requires 24-hour observation and evaluation -question how symptoms manifest. Document any mental illness diagnoses, indicating if a diagnosis is by history or by report. List prescribed medications and the youth s adherence to taking medication as prescribed. Report current mental health treatment being received and contact information for any providers. Record the history of mental health treatment -include any emergency care, both outpatient and inpatient treatment, and medications. Assess for presence of any suicide or homicidal ideation -perform a lethality assessment (is patient a danger to himself or others?). 4. A LACK IN JUDGMENT & MOTIVIATION TO REQUIRE 24-HOUR SUPERVISION Is there any evidence that the prospective patient is likely to have a rapid relapse when released from a controlled environment. Report any history of non-compliance with mandated sanctions. State any history of resistance to treatment. Question if the prospective patient ever considers the potential negative consequences of using substances. State if there is an external locus of control -blaming others for their problems, and blaming situations not within their control for their problems. 5. SUBSTANTIAL DEFICITS IN BEHAVIORAL OR FUNCTIONAL SKILLS Activities of daily living: Observe and note personal hygiene. Is the prospective patient adequately nourished. Are necessary appointments made and kept. Is there an ability to take medications independently. Is the prospective patient able to use available transportation. Are community resources being accessed. Does the prospective patient have an ability to handle everyday situations. 01/23/2009 3

17 Interpersonal skills: State any difficulty in communicating clearly and asking for help when needed. Is the social support network positive or negative. Is there any engagement in recreational activities that are not focused on alcohol or drugs. Is there any sober friendship group. Does the prospective patient engage in family activities. Question for self-absorption and/or insensitivity. Does the prospective patient exercise judgment and decision making. Ask how conflicts with others are handled. Is there a conscious irresponsibility. Vocational or educational skills: Is there a lack of marketable job skills or educational background. Is the prospective patient reliant on hustling or illegal activity for income. Is the prospective patient either attending school or employed. Report if there is a lack of adequate educational achievement. Assess basic literacy. Are there thoughts of reasonable goals and expectations. What is the prospective youth s attendance and punctuality record for either work or school. Are norms being followed of dress, grooming and speech in the work or school setting. Maladaptive social behavior; Report any past and present legal involvement. Does the prospective patient have little or no respect for the property of others. Is the youth verbally assaultive of others. Are there threats of physical abuse towards others. Does the prospective patient abuse others who are less powerful. Does the prospective patient use chronic lying or conning. Report if the youth indulges in criminally reckless behavior patterns. Does the prospective patient have a lack of remorse or guilt. Does there appear to be an inability to accept authority and rules. 01/23/2009 4

18 ADDITIONAL DOCUMENTATION REQUIREMENTS: Section (b) Include medical history and a summary of the most recent physical examination preformed within the past six months. Obtain the youth s medical history and determine if the prospective patient has had a physical examination during the past six months. If not, patients are required to have a physical examination performed within seven days after admission, and the results need to be placed in each patient s medical record Section (d) When indicated, document that medical care is recommended. Identify any referrals to outside programs and the results of the referral. Section (f) A preliminary written individual treatment plan needs to be developed and implemented within 3 days after admission. The preliminary treatment plan must be signed and dated by the clinician, a QHP, and by the patient. A comprehensive written individual treatment plan needs to be developed, implemented and signed and dated by the patient, the responsible clinical staff member and a physician, within 14 days after admission. Section (l) The treatment plan shall be reviewed and revised at least every thirty days by the clinical staff member, with consultation of the patient and the multidisciplinary team. All reviewing individuals, as well as a physician, need to sign and date the treatment plan. Section (n) (1) Progress notes must be written, signed and dated by the primary clinical staff member responsible for that case no less often than once per week. 01/23/2009 5

19 St. Peter's Behavioral Health Management Admission Review Team ART FAX: Pre-Admission Review for Medicaid Eligible Youth Residential Rehabilitation Services for Youth Provider Information Counselor Submitting This Application: Facility: Telephone: Fax: Prospective Patient Information First 2 Letters of Name: Last Name at Birth: DOB: Age: Gender: Last 4 Digits of Social Security #: Medicaid ID#: County of Residence: If the patient has been admitted to the RRSY, the date of admission: Actual Date and Time Received, If different from Deemed Date: Deemed Date Received: Time: Admission Review Team Action: Physician Certification: Yes No Date: Review Time: Initials CSW Certification: Yes No Date: Review Time: Initials CASAC Certification: Yes No Date: Review Time: Initials Summary of findings and conclusions: 12/2007 1

20 St. Peter's Behavioral Health Management Admission Review Team ART Pre-Admission Review for Medicaid Eligible Youth for admission to RESIDENTIAL REHABILITATION SERVICES FOR YOUTH Prospective Patient s Name: Prospective Patient s ID #: A prospective patient must be unable to participate or adhere to treatment outside of a 24-hour structured treatment setting. The prospective patient is documented as less than 21 years of age on the date of admission. Yes No The prospective patient appears to be in need of treatment for chemical dependence. Yes No The prospective patient appears to be free of serious communicable disease that can be transmitted through ordinary contact. Yes No The prospective patient does not need acute hospital care, acute psychiatric care, or Part 816 crisis services. Is this correct? Yes No Required: The prospective patient has a Substance Dependence or a Substance Abuse condition. Indicated Level of Care yes, continue no Provide Alternate Referral. One or more of the following must constitute a substantial factor in the persistence of the chemical dependence condition and improvement of this factor is necessary for initiation and/or maintenance of recovery. (Please refer to PART 817 RESIDENTIAL REHABILITATION SERVICES FOR YOUTH LEVEL OF CARE DEFINITIONS) 1. The prospective patient has accessed a less intensive level of care, of which a treatment goal has included abstinence, and failed to become or remain abstinent yes Residential Rehabilitation. for a reasonable period of time. no, continue 2. The prospective patient s living environment is not yes Residential Rehabilitation. conducive to recovery. no, continue 3. The prospective patient has a physical or a mental comorbidity requiring medical management, observation, yes Residential Rehabilitation. and evaluation. no, continue 4. The prospective patient lacks judgment, insight and yes Residential Rehabilitation. motivation such as to require 24-hour supervision. no, continue 5. The prospective patient has substantial deficits in behavioral or functional skills as evidenced by activities of daily living, interpersonal skills, vocational or educational skills, and/or maladaptive social behavior (e.g., criminal justice involvement). Additional information: yes no Residential Rehabilitation. Outpatient Services. The below signature of a qualified health professional is an attestation that the RRSY provider has documentation in a written record to substantiate the above statements. SIGNATURE AND CREDENTIALS OF AUTHORIZED REPRESENTATIVE DATE 11/2008 2