Emotional and Behavioral Disorders Sample Case by oxm44899

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									                                                                                             NC DHHS
    Reviewer:                                                                              DMH/DD/SAS
    Date Reviewed:                                                                  Residenital Treatment Level IV

                                                                                        Conditional                               Full
                                    DESCRIPTION                                        Endorsement                           Endorsement
                                                                                        Evidence of              NOT          Evidence of              NOT
                          Residential Treatment Level IV
                                                                                        Compliance         MET   MET   NA     Compliance         MET   MET   NA   COMMENTS
1 Provider Requirements
a **Must be delivered by provider organization that meets the standards                    Provider                              Provider
  established by the Division of MH/DD/SAS & 10A NCAC 27G. These                      application with                      application with
  standards set for the administrative, financial, clinical, quality improvement,        all required                          all required
  and information services infrastructure necessary to provide services.                  supporting                            supporting
                                                                                       documentation                         documentation
b Must demonstrate compliance to standards through LME endorsement.                     completed as                          completed as
                                                                                         required in                           required in
c **The organization must be established as a legally recognized entity in the             provider                              provider
  U.S. & registered to do business as a corporate entity in N.C.                         application;                          application;
                                                                                           Program                               Program
                                                                                         description.                          description;
                                                                                           Policy /                               Policy/
                                                                                          Procedure                             Procedure
                                                                                           Manual                                Manual
2 Staffing Requirements
a ** Each facility must have one full-time professional who holds a license or
  provisional license issued by the governing board regulating human service                                                  Personnel files
                                                                                           Program
  provision in NC. For substance related disorders this shall include a LCAS or                                                   or other
                                                                                         description;
  CCS. Clinical and administrative responsibilities include supervision of direct                                             documentation
                                                                                          Personnel
  care staff, oversight of emergencies, provision of direct clinical services,                                               that licensure or
                                                                                         Manual; Job
  participation in treatment planning meetings. as specified in 10A NCAC 27G                                                 certification for
                                                                                         description;
  .1802.                                                                                                                          staff are
                                                                                           Policies
                                                                                                                              consistent with
                                                                                       consistent with
                                                                                                                               requirements/
                                                                                      required clinical/
                                                                                                                             responsibilities.
                                                                                        administrative
                                                                                                                            Required polices
                                                                                       responsibilities.
                                                                                                                            are implemented.




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                                                                                          NC DHHS
    Reviewer:                                                                           DMH/DD/SAS
    Date Reviewed:                                                               Residenital Treatment Level IV

                                                                                       Conditional                                  Full
                                    DESCRIPTION                                       Endorsement                              Endorsement
                                                                                       Evidence of                NOT           Evidence of              NOT
                          Residential Treatment Level IV
                                                                                       Compliance           MET   MET   NA      Compliance         MET   MET   NA   COMMENTS
b ** Each facility shall have at least one full-time QP, who meet meet rules set
  for in 10A NCAC27G.0104(18) & shall have 2 years of direct client care                                                      Personnel files/
  experience, who will perform clinical/administrative responsibilities a                                                      documentation
  minimum of 40 hours each week. 75% shall occur when children/                          Program                                that licensure/
  adolescents are awake/present in the facility. Responsibilities of the QP            description;                                 degree/
  include: management of day to day operations; supervision of                          Personnel                              certification is
  paraprofessionals regarding implementation of each child's/adolescent's              Manual; Job                             consistent with
  treatment plan, participation in treatment planning meetings; and provision of       description.                             requirements/
  basic case management functions as specified in 10A NCAC 27G .1803.                    Policies                             responsibilities/
                                                                                      consistent with                          documentation
                                                                                     required clinical                       such as staff sign
                                                                                           and                                in sheets or logs
                                                                                      administrative                             that required
                                                                                     responsibilities.                         staff are on site
                                                                                                                               supervising the
                                                                                                                                   program.

c ** Psychiatric consultation shall be available as needed by for residents. A         Policy and                               Policy and
  qualified professional shall be available by phone or page and a direct care        procedure for                           procedure for
  staff shall be available to reach the facility within 30 minutes at all time as     availability of                         availability of
  specified in 10A NCAC 27G .1804 (a). When the child's/adolescent's plan               these staff                             these staff.
  requires sex offender specific treatment, special training is required for staff                                           Documentation
  regarding this treatment and supervision by a Qualified Professional with sex                                                   of staff
  offender specific expertise is on-site per shift.                                                                            availability.
                                                                                                                             Documentation
                                                                                                                             of staff training/
                                                                                                                              supervision if
                                                                                                                              providing sex
                                                                                                                                 offender
                                                                                                                             treatment in the
                                                                                                                                  facility.




    c1b18fe0-fd2c-4b44-94f2-e738499e4426.xls                                                            2
                                                                                                NC DHHS
    Reviewer:                                                                                 DMH/DD/SAS
    Date Reviewed:                                                                     Residenital Treatment Level IV

                                                                                           Conditional                                  Full
                                      DESCRIPTION                                         Endorsement                              Endorsement
                                                                                           Evidence of                NOT           Evidence of              NOT
                           Residential Treatment Level IV
                                                                                           Compliance           MET   MET   NA      Compliance         MET   MET   NA   COMMENTS
d ** Minimum staffing that applies to each unit or building when children are
  present and awake is 3 direct care staff for up to 6 children; 4 direct care staff       Staffing plan,                         Documentation
  for 7, 8, or 9 children;and 5 direct care staff for 10,11,0r 12 children as                 position                           such as staff sign
  specified in 10A NCAC 27G.1804(b) and (c).                                             descriptions and                         in sheets or logs
                                                                                             policy for                          that the required
                                                                                           availability of                         staff are on site
                                                                                          additional staff                           as required.

e ** Minimum staffing during sleep hours is for 3 direct care staff present, 2 of
  which shall be awake and the 3rd may be asleep as specified in 10A NCAC
  27G.1804(d) .


                                                                                            Personnel
                                                                                          manual Job                              Documentation
                                                                                          descriptions;                          such as staff sign
                                                                                         Personnel files;                           in sheets/logs
   Treatment services shall be provided 8 hours per week per child. (DMA Clinical            license,                            that the required
   Coverage Policy No. 8D-2 9.0)                                                          certification,                           staff are on site
                                                                                           experience                             as required and
                                                                                          verification,                            documentation
                                                                                           Supervision                            that services are
                                                                                         plan,. Staffing                          provided on stie
                                                                                         schedule, and                               as required
                                                                                         training plans.
f In addition to the number of direct care staff, more direct care staff may be
  required in the facility/unit based on children's/adolescent's individual needs as
  specified in the treatment plan as specified in 10 A NCAC 27G.1804 (e).


3 Service Type / Setting
a ** This is a residential treatment program that requires licensure by DFS
  under 10A NCAC27G.1800.
                                                                                      Verification of                             Verification of
b Intensive treatment services are in a physically secured, locked environment in a
                                                                                     license based on                            license based on
  program setting, provides more intensive treatment/supervision than available in a
                                                                                        10A NCAC                                    10A NCAC
  staff secure setting that serves no more than 12 children or adolescents.
                                                                                         27G.1800                                    27G.1800




    c1b18fe0-fd2c-4b44-94f2-e738499e4426.xls                                                                3
                                                                                           NC DHHS
    Reviewer:                                                                            DMH/DD/SAS
    Date Reviewed:                                                                Residenital Treatment Level IV

                                                                                         Conditional                               Full
                                     DESCRIPTION                                        Endorsement                           Endorsement
                                                                                         Evidence of              NOT          Evidence of              NOT
                          Residential Treatment Level IV
                                                                                         Compliance         MET   MET   NA     Compliance         MET   MET   NA   COMMENTS
4 Program / Clinical Requirements
a Services provide intensive treatment in a structured living environment within a
  system of care approach for children/adolescents who require intensive
  treatment/supervision is a locked setting. It serves children/ adolescents who                                               Programming
  have a primary diagnosis of mental illness, severe emotional/ behavioral disorders                                             schedule/
  or substance related disorders. Services are to assist in the development of                                                implementation
  symptom & behavior management skills; include intensive, frequent and pre-                                                  consistent with
  planned crisis managment; provide containment/ safety from potential harmful or                                                policies/
  destructive behaviors, promote involvement in regular productive activity, such as                                            procedures.
  school or work; & support the child or adolescent in skills acquisition needed for       Program                            Plans in record
  reintegration into community living. Educational services within the facility are      Description;                            & reflect
  arranged to maintain the educational development of the child/adolescent.              Policy and                            interventions
  Service is coordinated with other individuals/agencies within the                       Procedure                           consistent with
  child's/adolescent's system of care.                                                     Manual.                                 goals.
                                                                                                                               Verification of
                                                                                                                             use of restrictive
                                                                                                                               procedures as
                                                                                                                             being consistent
                                                                                                                                with policy/
                                                                                                                                procedure.


b If sex offender treatment is being provided, programming and interventions are
  based on clinically appropriate interventions and are delivered by staff who have
  had specific training with supervision by a Qualified Professional who has had
  specific training.                                                                                                         Review sample
                                                                                         Policies and
                                                                                                                               of applicable
                                                                                        Procedure that
                                                                                                                               cases where
                                                                                            address
                                                                                                                                restrictive
                                                                                         treatment of
                                                                                                                             procedures were
                                                                                           children/
                                                                                                                              used to verify
                                                                                       adolescents with
                                                                                                                                policy and
                                                                                       sexual offending
                                                                                                                             procedures were
                                                                                           behavior.
                                                                                                                                 followed.




    c1b18fe0-fd2c-4b44-94f2-e738499e4426.xls                                                            4
                                                                                             NC DHHS
    Reviewer:                                                                              DMH/DD/SAS
    Date Reviewed:                                                                  Residenital Treatment Level IV

                                                                                          Conditional                                 Full
                                      DESCRIPTION                                        Endorsement                             Endorsement
                                                                                          Evidence of               NOT           Evidence of              NOT
                           Residential Treatment Level IV
                                                                                          Compliance          MET   MET   NA      Compliance         MET   MET   NA   COMMENTS
5 Documentation Requirements
a Full service note per shift that documents interventions/activities that are directly                                        Records include
  related to child's/adolescent's identified need, preferences or choices, specific                                            service notes
  goals, services & interventions based on the child's/adolescent's treatment plan.                                            reflecting
  In addition, critical events, significant events or changes in status in the course of                                       interventions as
  treatment shall be in the child's/adolescent's medical record as appropriate.          Service Record
                                                                                                                               specified in
                                                                                         Policy &
                                                                                                                               plans based on
                                                                                         Procedure
                                                                                                                               goals.
                                                                                         Manual
                                                                                                                               Significant
                                                                                                                               events &
                                                                                                                               changes are
                                                                                                                               documented.
b If applicable documentation includes the specific goals of sex offender treatment
  as supported and carried out in the therapeutic milieu and the interventions in the
  individual's plan                                                                   Policy regarding                         If applicable,
                                                                                      documentation                            service plan and
                                                                                      of interventions                         shift notes reflect
                                                                                      related to these                         treatment as
                                                                                      goals.                                   specified in plan.




    c1b18fe0-fd2c-4b44-94f2-e738499e4426.xls                                                              5

								
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