Reviewer NC DHHS Provider Date Reviewed by xzv17862

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									    Reviewer:                                                                              NC DHHS                              Provider:___________________________________
    Date Reviewed:                                                                                                               Site:______________________________________
                                                                                          DMH/DD/SAS
                                                                                            SAIOP
                                                                    Endorsement Review                                      Findings
    Substance Abuse Intensive                                      Evidence of Compliance                               (Identify review) 60 Day Review
    Outpatient Program (SAIOP)                                             Clinical                                           NOT          Evidence of
                                                                 Desk                 On Site
                                                                          Interview                                     MET MET NA         Compliance               Comments
   Provider Requirements
a Services are delivered by practitioners employed
   by a MH/SA provider organization which meets
   standards established by the Division of Medical        Provider application
   Assistance (DMA) and the Division of Mental               with all required
   Health, Developmental Disabilities and Substance              supporting
   Abuse Services (DMHDDSAS) that set forth the              documentation;
   administrative, financial, clinical, quality            Program description;
   improvement, and information services                    Policy & Procedure
   infrastructure necessary to provider services.          Manual, NEAs from
                                                                other LMEs


b 1) The organization must be established as a
   legally recognized entity in the U.S. & registered to   Documentation from
   do business as a corporate entity in N.C.                Secretary of State,
   2) Within 1 year of enrollment, must have national         Certificate of
   accreditation.                                             Accreditation


   Staffing Requirements
a Persons who meet the requirements specified for
   CCS. LCAS. and CSAC under Article 5C may                                     Personnel Files,       Program
   deliver the SAIOP program.                              Program Description;        Job           description;
                                                            Personnel Manual;    Applications, Personnel Manual;
                                                             Job Descriptions    Resume, Staff Job descriptions;
                                                                                   interviews      Personnel files;
                                                                                                 documentation that
b The program must be under the clinical                                                             licensure or
   supervision of a LCAS or CCS who is on site a                                                    certification for
   minimum of 50% of the hours the service is in                                                                                         Documentation such as
                                                                                                 staff are consistent
   operation.                                              Program Description;                                                           staff sign in sheets or
                                                                                                  with requirements
                                                            Personnel Manual;                                                            logs that required staff
                                                                                                           and
                                                             Job Descriptions                                                            are on site supervising
                                                                                                   responsibilities,
                                                                                                                                               the program..
                                                                                                    staff interview




    SAIOP 07262010                                                                                 1 of 5                                                           NC DMH/DD/SAS
    Reviewer:                                                                        NC DHHS                                Provider:___________________________________
    Date Reviewed:                                                                                                           Site:______________________________________
                                                                                    DMH/DD/SAS
                                                                                      SAIOP
                                                                Endorsement Review                                      Findings
    Substance Abuse Intensive                                  Evidence of Compliance                               (Identify review) 60 Day Review
    Outpatient Program (SAIOP)                                         Clinical                                           NOT          Evidence of
                                                             Desk                 On Site
                                                                      Interview                                     MET MET NA         Compliance              Comments
   Staffing Requirements Cont.
c Clinical services may also be provided by staff who
   meet the requirements for Qualified Professional or                                                                                   Personnel files;
   Associate Professional for Substance Abuse                                                                                         Supervision plans and
   according to 10A NCAC 27G.0104 under the            Program Description;                                                           documentation, such
                                                                                               Personnel files;
   supervision of a LCAS or CCS.                        Personnel Manual;                                                              as supervision logs,
                                                                                              Supervision plans
                                                         Job Descriptions                                                                that supervision
                                                                                                                                     requirements are being
                                                                                                                                       met, staff interview

d The maximum face-to-face staff to client ratio is
   not more than 12 adult consumers to 1 QP. The
   maximum face-to-face staff to client ratio is not
                                                                                                                                        Staff schedule;
   more than 6 adolescent consumers to 1 QP.                                                      Program
                                                        Program Description                                                          Consumer attendance
                                                                                                 Description
                                                                                                                                     roster; staff interview



e Paraprofessional level providers who meet the
   requirements for paraprofessional status according
   to 10A NCAC 27G .0104 and who have the
   knowledge, skills and abilities required by the                                                  Program
   population and age to be served may deliver                                                    description;
   SAIOP services under the supervision of a LCAS                                             Personnel Manual;
                                                                           Personnel Files,
   or CCS. Paraprofessional level staff may not                                                Job descriptions;
                                                      Program Description;        Job
   provide services in lieu of on-site provision to                                           Personnel files and
                                                       Personnel Manual;    Applications,
   recipients by a qualified CCS, CSAC or LCAS.                                                supervision plans
                                                        Job Descriptions    Resume, Staff
                                                                                              that document that
                                                                              interviews
                                                                                                  supervision
                                                                                               requirements are
                                                                                                      met.




    SAIOP 07262010                                                                             2 of 5                                                          NC DMH/DD/SAS
    Reviewer:                                                                            NC DHHS                             Provider:___________________________________
    Date Reviewed:                                                                                                            Site:______________________________________
                                                                                        DMH/DD/SAS
                                                                                          SAIOP
                                                                  Endorsement Review                                     Findings
    Substance Abuse Intensive                                    Evidence of Compliance                              (Identify review) 60 Day Review
    Outpatient Program (SAIOP)                                           Clinical                                          NOT          Evidence of
                                                               Desk                 On Site
                                                                        Interview                                    MET MET NA         Compliance             Comments
   Service Type / Setting
a SA Intensive Outpatient Program (SAIOP) means
   structured individual and group addiction activities
                                                                                                                                          Service notes
   and services that are provided at an outpatient
                                                                                                                                          documenting
   program designed to assist adult and adolescent                                                 Program
                                                          Program Description                                                           implementation of
   consumers to begin recovery and learn skills for                                               Description
                                                                                                                                       appropriate program
   recovery maintenance.
                                                                                                                                             content


b Facility licensed under 10A NCAC 27G.4400.               Evidence of 10A      Evidence of 10A Evidence of 10A
                                                           NCAC 27G .4400         NCAC 27G      NCAC 27G .4400
                                                               license           .4400 license      license

   Program Requirements/
   Clinical Requirements
a The following included in the SAIOP program:
   1. Individual counseling and support;
   2. Group counseling and support;
   3. Family counseling, training or support;
   4. Biochemical assays to identify recent drug use
   (e.g. urine drug screens);
   5. Strategies for relapse prevention to include
   community and social support systems in                                                                                            operational schedule,
   treatment;                                                                                                                         service notes showing
   6. Life skills;                                                                                 Program                             service provided that
   7. Crisis contingency planning;                     Program Description                      Description, staff                       are appropriate to
   8. Disease Management; and                                                                      interview                            participant's needs,
   9. Treatment support activities that have been                                                                                        paid claims, staff
   adapted or specifically designed for persons with                                                                                         interviews
   physical disabilities, or persons with co-occurring
   disorders of mental illness and substance
   abuse/dependence or mental
   retardation/developmental disability and substance
   abuse/dependence.




    SAIOP 07262010                                                                              3 of 5                                                         NC DMH/DD/SAS
    Reviewer:                                                                     NC DHHS                        Provider:___________________________________
    Date Reviewed:                                                                                                Site:______________________________________
                                                                                 DMH/DD/SAS
                                                                                   SAIOP
                                                                   Endorsement Review                        Findings
    Substance Abuse Intensive                                     Evidence of Compliance                 (Identify review) 60 Day Review
    Outpatient Program (SAIOP)                                            Clinical                             NOT          Evidence of
                                                                Desk                 On Site
                                                                         Interview                       MET MET NA         Compliance              Comments
   Program Requirements/
   Clinical Requirements Cont.
b SAIOP includes case management to arrange, link
   or integrate multiple services as well as
   assessment and reassessment of the recipient’s                                                                         operational schedule,
   need for services. SAIOP services also informs the                                                                     service notes showing
   recipient about benefits, community resources,                                      Program                             service provided that
   and services; assists the recipient in accessing     Program Description         Description, staff                       are appropriate to
   benefits and services; arranges for the recipient to                                interview                            participant's needs,
   receive benefits and services; and monitors the                                                                           paid claims, staff
   provision of services.                                                                                                        interviews


c SAIOP may not operate more than 19 hours per
   week. Offers a minimum of 3 hours of scheduled                                      Program
   services per day, with at least 3 days per week        Program Description       Description, staff                     operational schedule
   with no more than 2 consecutive days without                                        interview
   services available.

d The recipient must be in attendance for a minimum
   of 3 hours per day for any scheduled day of                                                                             Recipient attendance
                                                                                       Program
   service. Group counseling services must be                                                                             records; Service notes,
                                                          Program Description       Description, staff
   offered each day the program operates.                                                                                    paid claims, staff
                                                                                       interview
                                                                                                                                interviews

e The development, monitoring, and revising of the
   recipient's person centered plan is the                                                                                     PCP in chart.
   responsibility of the qualified professionals if the                                                                    Documentation of PC
   person was admitted to SAIOP prior to the                                                                              Planning meetings with
                                                                                      Policies and
   development of a PCP.                                       Policies and                                               consumer participation
                                                                                     Procedures in
                                                           Procedures in place                                               and input into all
                                                                                     place for PCP
                                                          for PCP development                                             decisions. Service note
                                                                                     development
                                                                                                                                 document
                                                                                                                          implementation of plan
                                                                                                                           consistent with PCP




    SAIOP 07262010                                                                  4 of 5                                                          NC DMH/DD/SAS
     Reviewer:                                                                             NC DHHS                            Provider:___________________________________
     Date Reviewed:                                                                                                            Site:______________________________________
                                                                                          DMH/DD/SAS
                                                                                            SAIOP
                                                                      Endorsement Review                                  Findings
     Substance Abuse Intensive                                       Evidence of Compliance                           (Identify review) 60 Day Review
     Outpatient Program (SAIOP)                                              Clinical                                       NOT          Evidence of
                                                                   Desk                 On Site
                                                                            Interview                                 MET MET NA         Compliance               Comments
    Program Requirements/
    Clinical Requirements Cont.
f Must have policies and capacity to carry out first
    responder for their recipients on a face to face                                                                                   Crisis Plan in chart. On
    basis and also telephonically at all times                                                                                                call scheduling
    (24/7/365), with capacity for face-to-face                                                       Policies and                        including process for
    emergency response within 2 hours.                            Policies and                      procedures in                      on call person's access
                                                              procedures in place                  place for crisis                       to consumer's crisis
                                                              for crisis response.                 response, staff                         plan. Service notes
                                                                                                      interview                                 document
                                                                                                                                            implementation of
                                                                                                                                        crisis plan as needed.

g Staff will demonstrate their knowledge and
    understanding of the service as well as
                                                                                      Clinical
    demonstrate their clinical expertise and skill level
                                                                                     Interview
    by successfully completing a clinical interview.


    Documentation Requirements
a   All clinically significant contacts must be
    documented in the service record. Minimum
    standard is a daily full service note that includes: 1)
    Recipient's name, 2) Medicaid Identification
    Number, 3) date of service, 4) the purpose of
    contact, 5) describes the provider's interventions,       Policy & Procedure                 Policy & Procedure
                                                                                                                                            Service notes
    6) includes the time spent performing the                       Manual                             Manual
    interventions 7) effectiveness of the intervention,
    and 8) the signature (degree/credentials or
    position) of the person providing the service


b A documented discharge plan will be discussed
    with the recipient and included in the record                                                                                       Evidence of discharge
                                                              Policy & Procedure                 Policy & Procedure                      plan and discussion
                                                              Manual; RM & DM                          Manual                            with recipient in the
                                                                                                                                            service record


     SAIOP 07262010                                                                               5 of 5                                                          NC DMH/DD/SAS

								
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