Job Application Draft by qhu43966

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									                                                                      NC DHHS
   Reviewer:
                                                                   DMH/DD/SAS
   Date Reviewed:                                  Community Support (MH/SA)- Children/ Adolescents
                                                            Conditional                       Full
                        DESCRIPTION                        Endorsement                   Endorsement
           COMMUNITY SUPPORT (MH/SA) -                      Evidence of      NOT          Evidence of               NOT
             CHILDREN/ADOLESCENTS                           Compliance MET   MET   NA     Compliance          MET   MET   NA   COMMENTS
   Provider Requirements
a. **1) Must be delivered by practitioners employed by
  a mhsa provider organization which meets
  standards established by the Division of                     Provider
                                                                                            Provider
  MHDDSAS. These standards set forth the                      application
                                                                                         application with
  administrative, financial, clinical, quality                   with all
                                                                                           all required
  improvement, and information services                         required
                                                                                           supporting
  infrastructure necessary to provider services.              supporting
                                                                                         documentation
   2) Organizations must demonstrate that they meet         documentation
                                                                                          completed as
  these standards by being certified by the LME. Within 3 completed as
                                                                                           required in
  years of enrollment, must have national accreditation       required in
                                                                                            provider
                                                                provider
                                                                                           application;
  ** 3) The organization must be established as a             application;
                                                                                            Program
  legally recognized entity in the US and registered to        Program
                                                                                           description;
  do business as a corporate entity in the State of           description;
                                                                                            Policy &
  N.C.                                                          Policy &
                                                                                           Procedure
  4) CS providers must have the ability to deliver services   Procedure
                                                                                             Manual
  in various environments, such as homes, schools,               Manual
  detention centers & jails (state funds only) homeless
  shelters, street locations, etc.
b There is evidence of fidelity to EBP                       training plan               training records
   Staffing Requirements
a **1) Persons who meet the requirements specified                                       Personnel files;
   for Qualified Professional or Associate Professional                                     Supervision
   status according to 10A NCAC 27.G.0104, within                                            plans and
   the requirements specified in the above rule. 2)                                       documentation
                                                              Program
   Supervision is provided according to supervision                                       that education,
                                                            description;
   requirements specified in 10A NCAC 27.G.0104 &                                          experience &
                                                             Personnel
   according to licensure or certification requirements                                  training for staff
                                                            Manual; Job
   of the appropriate discipline.                                                          are consistent
                                                            descriptions
                                                                                                with
                                                                                           requirements
                                                                                                and
                                                                                         responsibilities.




                                                                               1 of 12                                         95af2779-8981-411f-94a1-af4ae0de4643.xls
                                                                         NC DHHS
    Reviewer:
                                                                      DMH/DD/SAS
    Date Reviewed:                                    Community Support (MH/SA)- Children/ Adolescents
                                                                 Conditional                        Full
                         DESCRIPTION                            Endorsement                    Endorsement
           COMMUNITY SUPPORT (MH/SA) -                           Evidence of      NOT           Evidence of             NOT
              CHILDREN/ADOLESCENTS                               Compliance MET   MET   NA      Compliance        MET   MET   NA   COMMENTS
  Staffing Requirements (continued)
b **1) Paraprofessional level providers who meet the
  requirements specified for paraprofessional status
  according to 10A NCAC 27.G.0104 N.C. may deliver
  CS services within the requirements of the staff                                             Personnel files;
  definition specific in the above role. **2) When a              Program                        Supervision
  paraprofessional provides CS services they must               description;                      plans and
  be under the supervision of a QP. Supervision                  Personnel                      documentation
  shall be carried out according to 10A NCAC                    Manual; Job                    that supervision
  27.G.0104.                                                    descriptions                  requirements are
   **2) When a paraprofessional provides CS                                                       being met.
  services they must be under the supervision of a
  QP. Supervision shall be carried out according to
  10A NCAC 27.G.0104.
c QP, CCS, CCAS can perform the following activities:             Program                     Personnel files
  Coordination & oversight of initial & ongoing                 description;                   and consumer
  assessment activities; initial development & ongoing           Personnel                     charts to show
  revision of PCP; monitoring of implementation of PCP.         Manual; Job                     QP actions re
                                                                descriptions                          PCP
d AP and paraprofessional can perform the following               Program                     Personnel files
    activities: various skill building activities of daily &    description;                   and consumer
    community living skills; socialization skills, adaptation    Personnel                     charts to show
    skills; symptom management skills, wellness education;      Manual; Job                     AP and Para-
    education substance abuse; behavior & anger                 descriptions                    prof activities
    management techniques.                                                                          with/for
                                                                                                 consuumer.
e    Staff providing CS services to children & families must      Program                     Personnel files
    complete a twenty hours of training specific to CS          description;                     showing that
    including crisis response within the first 90 days of        Personnel                       staff have at
    employment.                                                 Manual; Job                    least minimum
                                                                descriptions                  experience and
                                                                                              documentation
                                                                                              of completion of
                                                                                                    training
                                                                                                requirements.




                                                                                    2 of 12                                        95af2779-8981-411f-94a1-af4ae0de4643.xls
                                                                         NC DHHS
    Reviewer:
                                                                      DMH/DD/SAS
    Date Reviewed:                                    Community Support (MH/SA)- Children/ Adolescents
                                                                 Conditional                        Full
                         DESCRIPTION                            Endorsement                    Endorsement
            COMMUNITY SUPPORT (MH/SA) -                          Evidence of      NOT           Evidence of           NOT
              CHILDREN/ADOLESCENTS                               Compliance MET   MET   NA      Compliance      MET   MET   NA   COMMENTS
  Service Type / Setting
a CS is a direct & indirect periodic service where the CS
   worker provides direct intervention & also arrange,                                        Program
   coordinates, & monitors services on behalf of the            Program                       description,
   recipient. Service is provided in any location and may       description                   PCP, service
   be provided to an individual or a group of individuals.                                    notes

b 1) For persons residing in higher-level residential           Program                       Program
   program (e.g., PRTF, residential levels II-IV), CS           description                   description,
   services are limited to individuals transitioning from or to                               PCP, service
   these residential programs.                                                                notes, Medicaid
                                                                                              RA forms
c 1) CS also includes telephone time with the recipient & Program                             PCP, service
   collateral contact with persons who assist the recipient     description                   notes, Medicaid
   in meeting his/her rehabilitation goals.                                                   RA statements
  Program/Clinical Requirements
a All youth receiving CS must receive a minimum of two          program                       PCP, service
  (2) contacts per month with one (1) contact occurring         description                   notes, billing
  face-to-face with the recipient.                                                            tracking forms
b Contact benchmarks shall be measured on an annual             program                       Annual
  basis substantiating sixty per cent (60%) or more of CS       description                   aggregate
  services are delivered face-to-face with recipients &                                       provider report
  sixty per cent (60%) or more of staff time must be spent
  working outside of the agency's facility, with or on behalf
  of the consumers.
c 1) Caseload size may not exceed 1:15 (one QP worker           program                       staff caseload
  per fifteen (15) clients. 2) Groups size may not exceed       description                   assignment,
  eight (8) individuals.                                                                      group
                                                                                              attendance
                                                                                              roster




                                                                                    3 of 12                                      95af2779-8981-411f-94a1-af4ae0de4643.xls
                                                                   NC DHHS
   Reviewer:
                                                                DMH/DD/SAS
   Date Reviewed:                               Community Support (MH/SA)- Children/ Adolescents
                                                         Conditional                        Full
                       DESCRIPTION                      Endorsement                    Endorsement
          COMMUNITY SUPPORT (MH/SA) -                    Evidence of      NOT           Evidence of             NOT
            CHILDREN/ADOLESCENTS                         Compliance MET   MET   NA      Compliance        MET   MET   NA   COMMENTS
  Program/Clinical Requirements (continued)
d **The development, monitoring, revising and           Policies and                  Policies and
  updating of the recipient's person centered plan is   Procedures in                 Procedures in
  the responsibility of the qualified professional      place for PCP                 place for PCP
                                                        development                   development.
                                                        that includes                 PCP in chart.
                                                        crisis planning               Documentation
                                                        and procedure                 of C&F Team
                                                        for involvement               meetings, with
                                                        of child and                  membership,
                                                        family team.                  roles,
                                                                                      responsibilities.
                                                                                      Documentation
                                                                                      of family
                                                                                      involvement.




                                                                            4 of 12                                        95af2779-8981-411f-94a1-af4ae0de4643.xls
                                                                       NC DHHS
    Reviewer:
                                                                    DMH/DD/SAS
    Date Reviewed:                                  Community Support (MH/SA)- Children/ Adolescents
                                                              Conditional                          Full
                         DESCRIPTION                         Endorsement                     Endorsement
            COMMUNITY SUPPORT (MH/SA) -                       Evidence of      NOT            Evidence of      NOT
               CHILDREN/ADOLESCENTS                           Compliance MET   MET   NA       Compliance MET   MET   NA   COMMENTS
e   **The Community Support must have policies and          Policies and                   Policies and
    capacity to carry out "first responder"                 procedutes in                  procedures in
    responsibilities for their recipients on a face to face place for crisis               place for crisis
    basis and also telephonically at all times (24/7/365), response                        response. Crisis
    with capacity for face-to-face emergency response implementation                       Plans in charts.
    within 2 hours.                                         including on                   Proactive Plan
                                                            call scheduling                with triggers and
                                                            process;                       Reactive Plane
                                                            process for the                with contacts
                                                            on call person                 and phone
                                                            to have access                 numbers;
                                                            to consumer's                  Service notes
                                                            crisis plan that               document
                                                            includes                       implementation
                                                            proactive plan                 of crisis plan
                                                            with triggers                  when needed.
                                                            and reactive                   On call rotation
                                                            plan with                      schedule. On
                                                            contacts &                     call person has
                                                            phone                          access to and
                                                            numbers and                    follows
                                                            procedures to                  consumer's crisis
                                                            ensure that                    plan.
                                                            crisis plan is
                                                            followed by
                                                            provider.


    Documentation Requirements
    Minimum standard is a daily full service note that      Service record;                PCP; service
    includes: 1) the purpose of contact, 2) describes the   Policy &                       notes document
    provider's interventions, 3) effectiveness of the       Procedure                      these items.
    intervention, 4) the time spent performing the          Manual
    intervention, and 5) signature (degree/credentials or
    position) of person providing service




                                                                                 5 of 12                                  95af2779-8981-411f-94a1-af4ae0de4643.xls
Reviewer:                                                        NC DHHS                                                 Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                               Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                                       60-day review
                  Psychosocial Rehabilittion (PSR)                       Evidence of Compliance               NOT       Evidence of
                                                                                                          MET MET NA    Compliance      COMMENTS
      Provider Requirements
  a   1) Agency has current, valid business verification.                 NEA from another LME or
                                                                           Business Verification
                                                                             completed locally
      Staffing Requirements
  a   Each PSR site must be staffed by the following:

      • At least one (1) full time program director per site who meets
      the requirements specified for a Qualified Professional and
      has a minimum of two years experience in adult mental health
      treatment services who must be actively involved in program
      development, implementation, and service delivery;
      AND
      • At least one (1) FTE Qualified Professional or Associate
      Professional                                                      Organizational Chart for PSR;
      AND                                                                  Program description; Job
      • At least one (1) additional FTE (Qualified Professional,          description consistent with
      Associate Professional, Paraprofessional, or Certified Peer      Provider Agency Policy for PSR
      Support Specialist)                                               service definition; Personnel
                                                                        files per core rules checklist;
                                                                            License/certification (if
                                                                            applicable); experience
                                                                          verification; staff schedule;
                                                                        Organizational Chart for PSR;
  b                                                                  Program description; Job
                                                                    description consistent with
      Persons who meet the requirements specified for QP or AP   Provider Agency Policy for PSR
      status according to 10A NCAC 27G. 0104 and a minimum of 1 service definition; Personnel
      year of documented experience with the adult MH population  files per core rules checklist;
      may deliver PSR                                                 License/certification (if




PSR 9-28-09...... DRAFT                                                    Page 6                                                      NC DMH/DD/SAS
Reviewer:                                                         NC DHHS                                                  Provider:_________________
Date Reviewed:                                                  DMH/DD/SAS                                                Site:______________________

                                                  Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                                         60-day review
                  Psychosocial Rehabilittion (PSR)                         Evidence of Compliance               NOT       Evidence of
                                                                                                            MET MET NA    Compliance      COMMENTS
  c A Paraprofessional level staff may provide PSR services.
      They must meet the requirements specified for                      Organizational Chart for PSR;
      paraprofessional status according to 10A NCAC 27.G.0104                Program description; Job
      and have a minimum of 1 year of documented experience with            description consistent with
      the adult MH population and may deliver PSR services within Provider Agency Policy for PSR
      the requirements of the staff definition specific in the above      service definition; Personnel
      role.                                                               files per core rules checklist;
                                                                              License/certification (if
                                                                              applicable); experience
                                                                            verification; Individualized
                                                                           Supervision Plan/Contract;
                                                                              staff schedule; Clinical
                                                                                      Interviews
  d   A NC Certified Peer Support Specialist staff may deliver PSR
      services within the requirements of the staff definition specific Organizational Chart for PSR;
      in the above role. A NC Certified Peer Support Specialist is not       Program description; Job
      required to demonstrate 1 year of documented experience in            description consistent with
      working with the adult MH population, as his or her personal      Provider Agency Policy for PSR
      experience in MH services fulfills that requirement.                service definition; Personnel
                                                                          files per core rules checklist;
                                                                            NC Certified Peer Support
                                                                         Specialist certificate issued by
                                                                        BHRP verifying certified status,
                                                                              experience verification;
                                                                            Individualized Supervision
                                                                        Plan/Contract; staff schedule;




PSR 9-28-09...... DRAFT                                                     Page 7                                                       NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                                   Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                 Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                                        60-day review
                 Psychosocial Rehabilittion (PSR)                       Evidence of Compliance               NOT         Evidence of
                                                                                                         MET MET NA      Compliance       COMMENTS
  e Individualized Supervision is provided according to supervision
     requirements specified in 10 A NAC27.G.0104 & .0203.              Organizational Chart for PSR;
                                                                          Program description; Job
                                                                         description consistent with
                                                                      Provider Agency Policy for PSR
                                                                       service definition; Personnel
                                                                       files per core rules checklist;
                                                                           License/certification (if
                                                                           applicable); experience
                                                                         verification; Individualized
                                                                        Supervision Plan/Contract;
                                                                           staff schedule; Clinical
                                                                                   Interviews
  f PSR staff ratios must be as follows:
     • At least one (1) staff member on site for each (8) eight or
     fewer recipients in average daily attendance shall be
     maintained.                                                      Program description; Personnel
                                                                       Manual; Policy and Procedure
     • One Qualified Professional must be on staff for every 24          manuals, Job description
     recipients, based on average daily attendance. The PSR           consistent with Provider Agency
     Program Director may serve as this Qualified Professional.           Policy for PSR service
                                                                         definition, staff schedule                   caseload list;
     • One of the staff (other than the program director) must be                                                     billing/tracking
     designated to address the vocational needs of the recipients.                                                    forms; service
                                                                                                                      notes




PSR 9-28-09...... DRAFT                                                   Page 8                                                         NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                                    Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                  Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                                         60-day review
                  Psychosocial Rehabilittion (PSR)                        Evidence of Compliance              NOT         Evidence of
                                                                                                          MET MET NA      Compliance        COMMENTS
  g All PSR staff must complete a minimum of 20 hours of training Program description; Personnel
      specific to the required components of the PSR service
                                                                            Manual; Job descriptions.
      definition, including crisis response and person-centered
                                                                           Personnel files and/or other
      thinking, within the first 90 days of each staff member’s
                                                                           documentation of required
      delivery of this service. Qualified Professional staff responsible
                                                                         experience and completion of
      for Person Centered Plan development shall also participate in
                                                                         training requirements per core
      “PCP Instructional Elements” training within the same time
                                                                             rules checklist; training
      frame. All pre-requisites for training have been met per 10A
                                                                            certificates. Agency staff
      NCAC 27G .0202 & .0203.
                                                                                    training plan

      Service Type/Setting
  a   PSR is a day/night service provided in a licensed facility
      meeting the requirements of 10A NCAC 27G.1200. PSR shall         Program description; job
      be available at least five hours a day. The PSR program must     descriptions; policy and
      include off site service activities related to transferring      procedure manuals;agency
      rehabilitative skills to the community for the purpose of        license, staff schedule,                        PCP, service
      achieving the goals outlined in the Person Centered Plan.        interview with PSR staff.                       notes, Medicaid
                                                                                                                       RA forms
      Program / Clinical Requirements
  a PSR services must be available five or more hours per day, at Program description; job
      least five days per week, and may be provided on weekends        descriptions; policy and
      or in the evening. The number of hours that a recipient          procedure manuals;                              PCP; service
      receives PSR services are to be specified in his/her Person      supervision plans; Team                         notes; billing
      Centered Plan.                                                   Meeting Minutes, Clinical                       tracking forms;
                                                                       Interviews                                      client interviews
  b                                                                    Program description; job
                                                                       descriptions; policy and
      Each PSR facility shall provide transitional or supported
                                                                       procedure manuals;
      employment services to facilitate the recipient’s entry into     supervision plans; Team                         Service Notes;
      competitive employment in accordance with 10A NCAC               Meeting Minutes Clinical                        PCP; Team
      27G.1203.                                                        Interviews                                      meeting minutes.



PSR 9-28-09...... DRAFT                                                    Page 9                                                          NC DMH/DD/SAS
Reviewer:                                                       NC DHHS                                              Provider:_________________
Date Reviewed:                                                DMH/DD/SAS                                            Site:______________________

                                                Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                                  60-day review
                 Psychosocial Rehabilittion (PSR)                         Evidence of Compliance        NOT        Evidence of
    This is a service that provides structured rehabilitative                                       MET MET NA     Compliance        COMMENTS
  c interventions designed to:
    • assist the recipient in achieving recovery goals identified in
    the Person Centered Plan;
    • promote healthy lifestyles that reduce psychiatric symptoms;
    • promote symptom stability and wellness management, such
    as self-management of medication, psychoeducation, relapse
    prevention training, and coping skills training; restore
    personal, social, and community living skills necessary for
    independent self-management;
    • assist individuals in gaining access to necessary services in
    all life domains (emotional, social, safety, housing, medical
                                                                        Program description; job
    and health, educational, vocational, and legal);                    descriptions; policy and
    • provide psychoeducational information to the recipients,          procedure manuals;
    families, and/or other individuals involved with the                supervision plans, Team
    recipient’s care about the recipient’s diagnosis, condition, and    Meeting Minutes, Clinical
    treatment to support recovery and encourage problem solving         Interviews
    strategies;
    • establish or restore prevocational skills that focus on the
    development of positive work habits and abilities, talents, and
    skills that increase the individual’s self worth, purpose and
    confidence; these activities are not to be job-specific training;
    increase the ability to access financial entitlement, housing,
    work, and social opportunities in the community;
    • provide or make provision for transitional or supported                                                    Service Notes;
    employment services                                                                                          PCP; Team
                                                                                                                 meeting minutes.




PSR 9-28-09...... DRAFT                                                    Page 10                                                  NC DMH/DD/SAS
Reviewer:                                                        NC DHHS                                                   Provider:_________________
Date Reviewed:                                                 DMH/DD/SAS                                                 Site:______________________

                                                 Psychosocial Rehabilitation (PSR-MH Adults)
                               DESCRIPTION
                                                                                                                        60-day review
                   Psychosocial Rehabilittion (PSR)                      Evidence of Compliance               NOT        Evidence of
                                                                                                          MET MET NA     Compliance        COMMENTS
  d
       Expected rehabilitative outcomes include but are not limited
       to the following:
       • achieved recovery goals identified in the Person Centered
       Plan;
       • reduced psychiatric symptoms;
                                                                       Policies and Procedures in
       • increased symptom stability and management;                   place for PCP development. ;
       • improved personal, social, and community living skills;       Team Meeting Minutes;
       • increased access to necessary services in all life domains;   Program description; job
       • improved problem solving strategies;                          descriptions; supervision plans,
       • improved use of appropriate coping skills;                    Clinical Interviews
       • improved functioning in community roles;
       • established or restored prevocational skills; and
       • increased ability to access financial entitlement, housing,
       work, and social opportunities in the community.                                                                Service Notes;
       .                                                                                                               PCP; Team
                                                                                                                       meeting minutes.
  e.                                                                                                                   PCP; service
       Signed Order based on individualized assessment.                                                                notes;
       Documentation Requirements




PSR 9-28-09...... DRAFT                                                   Page 11                                                         NC DMH/DD/SAS
Reviewer:                                                       NC DHHS                                                   Provider:_________________
Date Reviewed:                                                DMH/DD/SAS                                                 Site:______________________

                                                Psychosocial Rehabilitation (PSR-MH Adults)
                              DESCRIPTION
                                                                                                                       60-day review
                 Psychosocial Rehabilittion (PSR)                        Evidence of Compliance              NOT        Evidence of
                                                                                                         MET MET NA     Compliance      COMMENTS
     Full service note for each contact or intervention (such as
     individual counseling, case management, crisis response), for
     each date of service, written and signed by the person(s) who
     provided the service, that includes the following:
     • Recipient’s name
     • Medicaid identification number
     • Service provided (for example, CST)
     • Date of service
     • Place of service                                                  Program Description; Policy &
     • Type of contact (face-to-face, telephone call, collateral)        Procedure Manual, job
     • Purpose of the contact                                            descriptions.
     • Description of the provider’s interventions
     • Amount of time spent performing the interventions
     • Description of the effectiveness of the interventions
     • Signature and credentials of the staff member(s) providing
     the service (for paraprofessionals, position is required in lieu of
     credentials with staff signature)
                                                                                                                      PCP; service
                                                                                                                      notes




PSR 9-28-09...... DRAFT                                                   Page 12                                                      NC DMH/DD/SAS

								
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