Proactive Crisis Management by nlh14837

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									Reviewer:                                               NC DHHS              Provider:__________________________________
Date Reviewed:
                                                     DMH/DD/SAS             Site:_______________________________________
                                     Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                           NOT
                                                                 Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                            MET MET NA   COMMENTS
           Provider Requirements
        a. 1) Must be delivered by practitioners employed by
            a mhsa provider organization which meets
                                                                 Division of Medical Assistance
            standards (Core rules - 10A NCAC 27G .0201-
                                                                    Community Intervention
            .0204) established by the Division of MHDDSAS.           Services application (or
            These standards set forth the administrative,            Provider Endorsement
            financial, clinical, quality improvement, and         application) with all required
            information services infrastructure necessary to       supporting documentation
            provider services.                                      completed as required in
                                                                 endorsement policy; Program
                                                                 description;Policy & Procedure
                                                                 Manual;By-laws or Partnership
                                                                           Agreement


             2) Organizations must demonstrate that they
            meet these standards by being certified by the            DMA enrollment
            LME. Within 3 years of enrollment, must have         documentation; Certification of
            national accreditation                                      accreditation


            3) The organization must be established as a
            legally recognized entity in the US and registered      By-laws or Partnership
            to do business as a corporate entity in the State    Agreements; Other supporting
            of N.C.                                              documentation as required for
                                                                       business status


            4) CS providers must have the ability to deliver
            services in various environments, such as homes,     Program description;Policy &
            schools, detention centers & jails (state funds        Procedure Manual; PCP;
            only) homeless shelters, street locations, etc.        MOAs; Other supporting
                                                                       documentation




CS Child checksheet 10-07.xls                                         1 of 34                                              NC DMH/DD/SAS
Reviewer:                                                NC DHHS              Provider:__________________________________
Date Reviewed:
                                                      DMH/DD/SAS             Site:_______________________________________
                                      Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                            NOT
                                                                   Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                             MET MET NA   COMMENTS
            Provider Requirements (continued)
        b There is evidence of fidelity to EBP
          Staffing Requirements
        a 1) Persons who meet the requirements specified
            for Qualified Professional or Associate
            Professional status according to 10A NCAC                Employment application,
                                                                       license or certification
            27.G.0104, within the requirements specified in
                                                                       verification, and other
            the above rule.                                         documentation that indicate
                                                                  education,experience & training
                                                                    for staff are consistent with
                                                                          requirements and
                                                                            responsibilities


             2) Supervision is provided according to
            supervision requirements specified in 10A NCAC
                                                                      Supervision plans and
            27.G.0104 & according to licensure or certification
                                                                        supervision notes
            requirements of the appropriate discipline.

        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         Employment application and
            of the staff definition specific in the above role.   other supporting documentation
                                                                   that education and experience
                                                                         are consistent with
                                                                       requirements; Training;
                                                                  Documentation that supervision
                                                                    requirements are being met;
                                                                         Supervision plans.




CS Child checksheet 10-07.xls                                           2 of 34                                             NC DMH/DD/SAS
Reviewer:                                                  NC DHHS              Provider:__________________________________
Date Reviewed:
                                                        DMH/DD/SAS             Site:_______________________________________
                                        Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                              NOT
                                                                       Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                               MET MET NA   COMMENTS
            Staffing Requirements (continued)
             **2) When a paraprofessional provides CS
            services they must be under the supervision
            of a QP. Supervision shall be carried out
            according to 10A NCAC 27.G.0104.                              Supervision plans and
                                                                            supervision notes




        c QP, CCS, CCAS, LCAS can perform the following
            activities: Coordination & oversight of initial &
            ongoing assessment activities; initial development           Job descriptions; Policy &
            & ongoing revision of PCP; monitoring of                  procedure manual; Employment
            implementation of PCP.                                              application



        d AP and paraprofessional can perform the
            following activities: various skill building activities
            of daily & community living skills; socialization
                                                                         Job descriptions; Policy &
            skills, adaptation skills; symptom management
                                                                      procedure manual; Employment
            skills, wellness education; education substance              application; Training plan
            abuse; behavior & anger management
            techniques.

        e All staff providing CS services to children &
            families must complete a twenty hours of training            Training plan; Training
            specific to CS including crisis response within the       documentation for CS specific
            first 90 days of employment.                                 training requirements.




CS Child checksheet 10-07.xls                                              3 of 34                                            NC DMH/DD/SAS
Reviewer:                                               NC DHHS              Provider:__________________________________
Date Reviewed:
                                                     DMH/DD/SAS             Site:_______________________________________
                                     Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                           NOT
                                                                  Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                            MET MET NA   COMMENTS
            Service Type / Setting
        a   CS is a direct & indirect periodic service where
            the CS worker provides direct intervention & also
            arrange, coordinates, & monitors services on          Policy and Procedure; Program
                                                                   Description; Job Description;
            behalf of the recipient. Service is provided in any
                                                                   Service record; PCP; Claim
            location and may be provided to an individual or a
                                                                               form
            group of individuals.

        b 1) For persons residing in higher-level residential     Policy and Procedure; Program
            program (e.g., PRTF, residential levels II-IV), CS
                                                                   Description; Job Description;
            services are limited to individuals transitioning
                                                                   Service record; PCP; Claim
            from or to these residential programs.                             form

        c 1) CS also includes telephone time with the             Policy and Procedure; Program
            recipient & collateral contact with persons who        Description; Job Description;
            assist the recipient in meeting his/her                Service record; PCP; Claim
            rehabilitation goals.                                              form

            Program/Clinical Requirements
        a   All youth receiving CS must receive a minimum of
            two (2) contacts per month with one (1) contact        Service record; PCP; Service
            occurring face-to-face with the recipient.            notes; Contact log; Claim form




CS Child checksheet 10-07.xls                                          4 of 34                                             NC DMH/DD/SAS
Reviewer:                                                 NC DHHS              Provider:__________________________________
Date Reviewed:
                                                       DMH/DD/SAS             Site:_______________________________________
                                       Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                              NOT
                                                                   Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                               MET MET NA   COMMENTS
          Program/Clinical Reqs (continued)
        b Contact benchmarks shall be measured on an
          annual basis substantiating sixty per cent (60%)
          or more of CS services are delivered face-to-face
          with recipients & sixty per cent (60%) or more of        Service notes or contact log;
          staff time must be spent working outside of the                   Claim form
          agency's facility, with or on behalf of the
          consumers.

        c 1) Caseload size may not exceed 1:15 (one QP
            worker per fifteen (15) clients. 2) Groups size may     Staff caseload assignment;
            not exceed eight (8) individuals.                              Service record


        d The development, monitoring, revising and
            updating of the recipient's person centered plan is
            the responsibility of the qualified professional        Policy and Procedure; PCP;
                                                                           Service record



        e The Community Support must have policies and
            capacity to carry out "first responder"               Policy and Procedure, Staff call
            responsibilities for their recipients on a face to    rotation schedule, publication of
            face basis and also telephonically at all times        crisis number;access to crisis
            (24/7/365), with capacity for face-to-face            plans; Documentation in service
            emergency response within 2 hours.                                 record




CS Child checksheet 10-07.xls                                           5 of 34                                               NC DMH/DD/SAS
Reviewer:                                                  NC DHHS              Provider:__________________________________
Date Reviewed:
                                                        DMH/DD/SAS             Site:_______________________________________
                                        Community Support (MH/SA)- Children/ Adolescents
                                DESCRIPTION

                 COMMUNITY SUPPORT (MH/SA) -                                                                NOT
                                                                       Evidence of Compliance
                   CHILDREN/ADOLESCENTS                                                                 MET MET NA   COMMENTS
            Program/Clinical Reqs (continued)
        f   QP, CCS, LCAS performs the following activities:
            Coordination & oversight of initial & ongoing               Supporting dcoumentation of
            assessment activities; initial development &                     Child Family team
            ongoing revision of PCP; monitoring of                       meeting(s);compliance with
                                                                          PCPdocumentation (e.g.
            implementation of PCP.
                                                                             signatures, dates,
                                                                        credentials);review updates;
                                                                       Documentation of coordination,
                                                                          oversite and monitoring
                                                                                 activities.

        g AP and paraprofessional performs the following
            activities: various skill building activities of daily &
            community living skills; socialization skills,                Docmumentation of skill
                                                                         builidng interventions and
            adaptation skills; symptom management skills,
                                                                        progress as reflected in the
            wellness education; education substance abuse;
                                                                                     PCP
            behavior & anger management techniques.

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




CS Child checksheet 10-07.xls                                               6 of 34                                             NC DMH/DD/SAS
                                                                       NC DHHS
    Reviewer:
                                                                      DMH/DD/SAS
    Date Reviewed:                                      Community Support Team (CST-MH/SA Adults)
                                                               Conditional                           Full
                         DESCRIPTION                          Endorsement                        Endorsement
                                                              Evidence of             NOT         Evidence of               NOT
         Community Support Team (MH/SA) CST                                     MET   MET   NA                        MET   MET   NA    COMMENTS
                                                              Compliance                          Compliance
  Provider Requirements
a **1)CST services provided by a team must be
    delivered by practitioners employed by a MH/SA
    provider organization which meets standards                 Provider                            Provider
    established by the Division of MHDDSAS. These            application with                    application with
    standards set forth the administrative, financial,         all required                        all required
    clinical, quality improvement, and information             supporting                          supporting
    services infrastructure necessary to provide             documentation                       documentation
    services                                                  completed as                        completed as
    2) Provider organizations must demonstrate that they
                                                               required in                         required in
    meet these standards by being endorsed by LME.
                                                                 provider                           provider
    Within 3 years of enrollment, must have national
                                                               application;                        application;
    accreditation.
                                                                Program                             Program
    ** 3) The organization must be established as a
                                                               description;                        description;
    legally recognized entity in the U.S. and registered
                                                                 Policy &                           Policy &
    to do business in the State of N.C.
                                                               Procedure                           Procedure
    4) CST must have the ability to deliver services in
                                                                 Manual                              Manual
    various environments, such as homes, schools, jails (for
    state funds only), homeless shelters, street locations,
    etc.
b   There is evidence of fidelity to EBP                      training plan                      training records
    Staffing Requirements
a **1)CST must be comprised of a minimum of three
    (3) staff persons. The team leader must be a QP              Program                          Personnel files
    according to 10A NCAC who functions as leader at           description;                           or other
    least .5 FTE for clinical and administrative                Personnel                         documentation
    suppervision of the team and also functions as             Manual; Job                        that education,
    practicing clinician on the team                           descriptions                        experience &
    Staffing Requirements (continued)                                                            training for staff
b                                                                Program                           are consistent
    **  Persons who meet the requirements specified
                                                               description;                             with
    for QP or AP status according to 10A NCAC may                                                  requirements
                                                                Personnel
    deliver CST.                                                                                        and
                                                               Manual; Job
                                                               descriptions                      responsibilities.




                                                                                       Page 7                                          3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                          NC DHHS
    Reviewer:
                                                                         DMH/DD/SAS
    Date Reviewed:                                         Community Support Team (CST-MH/SA Adults)
                                                                  Conditional                          Full
                          DESCRIPTION                            Endorsement                       Endorsement
                                                                  Evidence of          NOT         Evidence of             NOT
         Community Support Team (MH/SA) CST                                      MET   MET   NA                      MET   MET   NA    COMMENTS
                                                                  Compliance                       Compliance
    Staffing Requirements (continued)
c 1) A Paraprofessional level staff or a Certified Peer                                           Personnel files;
    Specialist staff may be part of the 3 person team. They                                          Supervision
                                                                    Program
    must meet the requirements specified for                                                          plans and
                                                                  description;
    paraprofessional status according to 10A NCAC                                                  documentation
                                                                   Personnel
    27.G.0104 may deliver CST services within the                                                 that supervision
                                                                  Manual; Job
    requirements of the staff definition specific in the above                                      requirements
                                                                  descriptions
    role.                                                                                          are being met.
                                                                                                      and logs
d **3) Supervision is provided according to                                                       Personnel files;
    supervision requirements specified in 10 A                      Program                          Supervision
    NAC27.G.0104 & according to licensure                         description;                        plans and
    requirements of the appropriate discipline.                    Personnel                       documentation
                                                                  Manual; Job                     that supervision
                                                                  descriptions                      requirements
                                                                                                   are being met.
d 1) CST maintains a consumer to practitioner ratio of no           Program
    more than fifteen (15) consumers per staff person. 2)         description;
                                                                                                    Case load
    Staff -to -consumer ratio takes into consideration             Personnel
                                                                                                   assignments
    evening and weekend hours, needs of special                   Manual; Job
    populations, and geographical areas to be served.             descriptions
e   1) All staff providing CST services must have a minimum                                       Personnel files
    of one year documented experience with the adult                                                and/or other
                                                                    Program
    population and 2) completion of a minimum of twenty                                           documentation
                                                                  description;
    hours regarding crisis management & other components                                             of required
                                                                   Personnel
    of CST activities within the first 90 days of employment.                                     experience and
                                                                  Manual; Job
                                                                                                   completion of
                                                                  descriptions
                                                                                                       training
                                                                                                   requirements.
f All pre-requisites for training have been met                  training plan                    training records




                                                                                        Page 8                                        3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                          NC DHHS
    Reviewer:
                                                                         DMH/DD/SAS
    Date Reviewed:                                         Community Support Team (CST-MH/SA Adults)
                                                                   Conditional                         Full
                          DESCRIPTION                             Endorsement                      Endorsement
                                                                   Evidence of         NOT         Evidence of              NOT
         Community Support Team (MH/SA) CST                                      MET   MET   NA                       MET   MET   NA    COMMENTS
                                                                   Compliance                      Compliance
    Service Type/Setting
    1) CST is a direct and indirect periodic service in which
    the team provides direct intervention and also arranges,
    coordinates, & monitors services on behalf of the
                                                                                                  Program
    recipient & and is provided in any location. 2) CST
                                                                                                  description,
    services are primarily provided in a range of community Program
                                                                                                  PCP, service
    settings such as home, homeless shelters, libraries, etc. description
                                                                                                  notes, Medicaid
    3) CST also includes telephone time with the recipient
                                                                                                  RA forms
    and collateral contact with persons who assist the
    recipient in meeting their goals.

  Program / Clinical Requirements
a 1) For registered recipients, a minimum of eight (8)                                            PCP, service
                                                                  Program
    contacts must occur within the first month.                                                   notes, billing
                                                                  description
                                                                                                  tracking forms
b 1) Sixty per cent (60%) or more of CST services that are
    delivered are performed face to face with recipients, 2)
    ninety percent (90%) or more of staff time must be spent
                                                                  Program
    working outside of the agency's facility, with or on behalf
                                                                  description
    of consumers. 3) For an organization providing this                                           Annual
    service, these contact benchmarks are measured on an                                          aggregate
    annual basis.                                                                                 provider report
c   1) Services offered by the CST shall be documented in
    PCP and include: assistance & support for the
    individuals in crisis situations; service coordination;
    psycho-education & support for individuals and their                                          PCP, service
                                                                  Program
    families; individual restorative interventions for the                                        notes document
                                                                  description
    development of interpersonal, community coping &                                              these activities.
    independent living skills; development of symptom
    monitoring & management skills: monitoring medication
    & self medication.




                                                                                        Page 9                                         3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                    NC DHHS
   Reviewer:
                                                                   DMH/DD/SAS
   Date Reviewed:                                    Community Support Team (CST-MH/SA Adults)
                                                            Conditional                            Full
                      DESCRIPTION                          Endorsement                         Endorsement
                                                            Evidence of            NOT         Evidence of              NOT
       Community Support Team (MH/SA) CST                                    MET   MET   NA                       MET   MET   NA    COMMENTS
                                                            Compliance                         Compliance
  Program/Clinical Requirements(continued)
d **The development, monitoring, and revising of the                                          Policies and
  recipient's person centered plan is the responsibility                                      Procedures in
  of the CST qualified professional                                                           place for PCP
                                                           Policies and                       development.
                                                           Procedures in                      PCP in chart.
                                                           place for PCP                      Documentation
                                                           development                        of PC Planning
                                                           that include                       meetings, with
                                                           crisis planning                    consumer
                                                           and procedure                      participation and
                                                           for involvement                    input into all
                                                           of consumer                        decisions.
                                                           participation                      Service notes
                                                           and input into                     document
                                                           all decisions.                     implementation
                                                                                              of plan
                                                                                              consistent with
                                                                                              PCP.




                                                                                    Page 10                                        3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                     NC DHHS
   Reviewer:
                                                                    DMH/DD/SAS
   Date Reviewed:                                     Community Support Team (CST-MH/SA Adults)
                                                            Conditional                               Full
                       DESCRIPTION                         Endorsement                            Endorsement
                                                            Evidence of               NOT         Evidence of             NOT
        Community Support Team (MH/SA) CST                                      MET   MET   NA                      MET   MET   NA    COMMENTS
                                                            Compliance                            Compliance
  Program/Clinical Requirements(continued)
e **Must have policies and capacity to carry out first                                           Policies and
  responder for their recipients on a face to face basis                                         procedures in
  and also telephonically at all times (24/7/365), with                                          place for crisis
  capacity for face-to-face emergency response within                                            response. Crisis
                                                         Policies and
  2 hours.                                               Procedures in
                                                                                                 Plan in chart.
                                                           place for crisis                      Proactive Plan
                                                           response                              (with triggers)
                                                           implementation                        and Reactive
                                                           including: On call                    Plan (with
                                                           scheduling                            contacts and
                                                           process; process                      phone numbers)
                                                           for the on call                       included.
                                                           person to have
                                                                                                 Service notes
                                                           access to
                                                           consumer's crisis
                                                                                                 document
                                                           plan the includes                     implementation
                                                           proactive plan                        of crisis plan
                                                           (with triggers)                       when needed.
                                                           and reactive plan
                                                           (with contacts
                                                           and phone
                                                           numbers) and
                                                           procedures to
                                                           ensure that crisis
                                                           plan is followed
                                                           by provider.
   Documentation Requirements
   Minimum standard is a daily full service note that
  includes: 1) the purpose of contact, 2) describes the
                                                           Service record;
  provider's interventions; 3) the time spent performing
                                                           Policy &                              PCP; service
  the intervention, 4) the effectiveness of the            Procedure                             notes
  interventions. and 5) signature (degree/credentials or   Manual
  position) of the person providing the service




                                                                                       Page 11                                       3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                              NC DHHS
   Reviewer:
                                                                             DMH/DD/SAS
   Date Reviewed:                                                 Diagnostic Assessment (MH/DD/SA)
                                                               Conditional                                Full
                       DESCRIPTION                            Endorsement                             Endorsement
                                                               Evidence of               NOT           Evidence of               NOT
          Diagnostic Assessment (MH/SA)                                            MET   MET   NA                          MET   MET   NA    COMMENTS
                                                               Compliance                              Compliance
  Provider Requirements
a **1) Diagnostic/assessment must be conducted by
  practitioners employed by a mh/dd/sa provider                  Provider                                Provider
  organization which meets standards established by         application with all                    application with all
  the Division of MH/DD/SA. These standards set for              required                                required
  the administrative, financial, clinical, quality             supporting                              supporting
  improvement, & information services infrastructure         documentation                           documentation
  necessary to provide services.                              completed as                            completed as
  2) Provider organization must demonstrate they meet          required in                             required in
  these standards by being certified by the LME. Within 3        provider                                provider
  years of enrollment, must have national accreditation.       application;                            application;
                                                                 Program                                 Program
  **3) The organization must be established as a            description; Policy                     description; Policy
  legally recognized entity in the U.S. and                   & Procedure                             & Procedure
  qualified/registered to do business as a corporate              Manual                                  Manual
  entity in the State of NC

  Staffing Requirements
a **1) The diagnostic/assessment team must include
  at least two (2) qualified professionals (QP),                                                     Personnel files;
  according to 10A NCAC 27.G.0104, both of whom                                                         Review of
  are licensed or certified clinicians;                          Program
                                                                                                       assessment
  **2) one of the team members must be a licensed              description;
                                                                                                     documentation
  physician, licensed psychologist, nurse                       Personnel
                                                                                                     that shows that
  practitioner, or physician assistant.                        Manual; Job
                                                                                                    the required staff
   3) For SA focused diagnostic assessment the team            descriptions
                                                                                                        carried out
  must include a CCS or CCAS and for DD focused
                                                                                                     responsibilities.
  assessment, must include a Master's level QP with
  at least 2 years experience with DD.
  Service Type/Setting
  Diagnostic/Assessment is a direct periodic service which                                          Assessment
  can be provided in any location. .                       program                                  reports and
                                                           description                              consumer charts




                                                                                         12 of 34                                           3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                               NC DHHS
    Reviewer:
                                                                              DMH/DD/SAS
    Date Reviewed:                                                 Diagnostic Assessment (MH/DD/SA)
                                                                Conditional                            Full
                         DESCRIPTION                           Endorsement                         Endorsement
                                                               Evidence of            NOT           Evidence of            NOT
            Diagnostic Assessment (MH/SA)                                       MET   MET   NA                       MET   MET   NA    COMMENTS
                                                               Compliance                           Compliance
  Program Requirements
a An initial diagnostic / assessment shall be performed by                                       full assessment
   a diagnostic/assessment team for each recipient being                                         report with
   considered for receipt of services in the MH/DD/SA        program                             evidence of
   enhanced benefit package.                                 description                         required team
                                                                                                 member
                                                                                                 participation
b An intensive clinical & functional evaluation of a
   consumer's mental health, developmental disability or
   substance abuse condition that results in the issuance of
   a diagnostic assessment report with a recommendation
                                                             program                             assessment
   regarding whether the consumer meets target population
                                                             description                         results/ reports
   criteria, & includes recommendations for enhanced
   benefit service delivery that provides the basis for the
   development of a PCP.

c 1) For substance abuse focused diagnostic                                                      assessment
   assessment, the designated diagnostic tool specified by                                       results/ reports
   the division (e.g. SUDDS IV, ASI, SASSI) for specific SA                                      show that
   target populations, (i.e. Work first, DWI, etc) must be  program                              appropriate
   used.         2) In addition, any elements included in   description                          diagnostic tools
   this service definition that are not covered by the tool                                      are used for
   must be completed.                                                                            substance abuse
                                                                                                 assessment
   Documentation Requirements
a Documentation must include all 8 of the elements listed
  in the service definition                                  Service record;
                                                             Policy &                            Service notes;
                                                             Procedure Manual                    assessment report




                                                                                      13 of 34                                        3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                     NC DHHS
   Reviewer:
                                                                                   DMH/DD/SAS
   Date reviewed:                                                           Intensive In-Home Services
                                                                 Conditional                                 Full
                       DESCRIPTION                              Endorsement                              Endorsement
                                                                 Evidence of               NOT            Evidence of               NOT
               Intensive In-Home Services                                            MET   MET   NA                           MET   MET   NA   COMMENTS
                                                                 Compliance                               Compliance
  Provider Requirements
a **1) Must be delivered by practitioners employed by
  a MH/SA provider organization which meets
  standards established by Division of MHDDSAS.
  These standards set forth the administrative,                    Provider                                 Provider
  financial, clinical, quality improvement, &                 application with all                     application with all
  information services infrastructure necessary to                 required                                 required
  provide services.                                              supporting                               supporting
  2)Provider organizations must demonstrate they meet          documentation                            documentation
  these standards by being certified by the LME. Within 3       completed as                             completed as
  years of enrollment, must have national accreditation.         required in                              required in
                                                                   provider                                 provider
  **3) The organization must be established as a                 application;                             application;
  legally recognized entity in the U.S. and registered             Program                                  Program
  to do business as a corporate entity in the State of        description; Policy                      description; Policy
  N.C                                                           & Procedure                              & Procedure
  4) The provider must have the ability to deliver services         Manual                                   Manual
  in various environments, such as homes, schools,
  detention centers & jails (state funds only) homeless
  shelters, street locations, etc.
  Staffing Requirements
a **1) Service model includes a licensed professional              Program
  and a minimum of two (2) staff who are Associate               description;
                                                                                                        Personnel files;
  Professionals or provisionally licensed.                        Personnel
                                                                                                       Staff assignments
                                                                 Manual; Job
                                                                 descriptions
  2) The licensed professional who is the team leader                                                   Personnel files
  is responsible for coordinating the initial                      Program                              and consumer
  assessment & developing the PCP and for                        description;                            charts show
  providing or coordinating (with another licensed                Personnel                                Licensed
  professional) treatment for the youth or other                 Manual; Job                             Professional
  family members                                                 descriptions                          activities with/for
                                                                                                           consumer
  3) Service model requires that in-home staff provide             Program
  24 /7coverage                                                  description;                            Staff caseload
                                                                  Personnel                             assignment and
                                                                 Manual; Job                             service notes
                                                                 descriptions


                                                                                            14 of 34                                           3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                    NC DHHS
    Reviewer:
                                                                                  DMH/DD/SAS
    Date reviewed:                                                         Intensive In-Home Services
                                                                 Conditional                                Full
                        DESCRIPTION                             Endorsement                             Endorsement
                                                                 Evidence of              NOT            Evidence of            NOT
                Intensive In-Home Services                                          MET   MET   NA                        MET   MET   NA   COMMENTS
                                                                 Compliance                              Compliance
  Staffing Requirements (continued)
   4) Team to family ratio shall not exceed one to eight           Program
  (1 to 8) for each three person team.                           description;                           Staff caseload
                                                                  Personnel                            assignment and
                                                                 Manual; Job                            service notes
                                                                 descriptions
  5) intensive in-home services focused on substance                                                    Personnel files
                                                                   Program
  abuse intervention must include a CCS, CCAS, or                                                       and consumer
                                                                 description;
  CSAC.                                                                                                  charts show
                                                                  Personnel
                                                                                                           required
                                                                 Manual; Job
                                                                                                      involvement of SA
                                                                 descriptions
                                                                                                         professional
b 1) Persons who meet the requirements specified for QP
  or AP status according to 10A NCAC 27.G.0104 may
  deliver this service within the requirements of the staff
                                                                  Program                               Personnel file,
  definition specified in the above rule. 2) Supervision is
                                                                 description,                            supervision
  provided according to supervision requirements as
                                                               supervision plan                         plan/log, PCP
  specified in the above rule and according to licensure &
  certification requirements of the appropriate discipline.

d 1) All staff providing intensive in home services to        Personnel                               Personnel file,
  children and families must have a minimum of one year
                                                              policies, program                       supervision
  documented experience with this population and 2)
                                                              description,                            plan/log, PCP,
  complete intensive in-home services training within the
                                                              training plan                           training record
  first 90 days of employment.
  Service Type/Setting
  1) Services are direct & indirect periodic where the team
  provides direct intervention & also arranges,
  coordinates, & monitors services on behalf of the
  recipient and it is provided in any location. 2) Services
                                                              Program
  are primarily provided in a range of community settings
                                                              description; Policy                     PCP, service
  (recipient's home, school, homeless shelters, libraries,
                                                              & Procedure                             notes,
  etc.) 3) Services also include telephone time with the
                                                              Manual
  individual recipient and collateral contact with persons
  who assist the recipient in meeting their goals specified
  in their PCP.




                                                                                           15 of 34                                        3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                         NC DHHS
    Reviewer:
                                                                                       DMH/DD/SAS
    Date reviewed:                                                              Intensive In-Home Services
                                                                     Conditional                            Full
                         DESCRIPTION                                Endorsement                         Endorsement
                                                                    Evidence of           NOT           Evidence of             NOT
                Intensive In-Home Services                                          MET   MET   NA                        MET   MET   NA   COMMENTS
                                                                    Compliance                          Compliance
  Program / Clinical Requirements
a 1) For Intensive In-Home recipients,a minimum of twelve
  (12) contacts must occur within the first month (One                                                PCP, service
                                                                  Program
  contact will equal all visits occurring in a 24 hour period),                                       notes, Medicaid
                                                                  description
  and 2)for the second and third months, and average of 6                                             RA forms
  contacts per month must occur.
b 1) Sixty per cent (60%) or more of the contacts occur
  face to face with recipients and 2) sixty percent (60%)
  or more of staff time must be spent working outside of
                                                                  Program                             Annual aggregate
  the agency's facility, with or on behalf of consumers. 3)
                                                                  description                         provider report
  For an organization providing this service, these contact
  benchmarks are measured on an annual basis.

  Program / Clinical Requirements (continued)
c These services are delivered primarily to children in their
  family's home with a family focus to: 1) diffuse current
  crisis, evaluate its nature & intervene to reduce the
  likelihood of a recurrence; 2) ensure linkage to needed
  community services & resources; 3) provide self help &
                                                                  Program                             PCP, service
  living skills training for youth; 4) provide parenting skills
                                                                  description                         notes
  training to help the family build skills for coping with
  youth's disorder; 5) monitor & manage the presenting
  psychiatric & addiction symptoms; & 6) work with
  caregivers in the implementation of home based
  behavioral supports.
d This population has access to a variety of interventions                                            On call schedule,
  twenty four (24) hours a day, 7 days per week by staff          Program
                                                                                                      PCP, service
  that will maintain contact & intervene as one                   description
                                                                                                      notes
  organizational unit.
e 1) Team approach is structured face-to-face therapeutic
  interventions to provide support & guidance in all areas
  of functional domains; adaptive, communication,                 Program                             PCP, service
  psychosocial, problem solving, behavior management,             description                         notes
  etc. 2) This service IS NOT delivered in group setting.




                                                                                           16 of 34                                        3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                            NC DHHS
   Reviewer:
                                                                          DMH/DD/SAS
   Date reviewed:                                                  Intensive In-Home Services
                                                         Conditional                              Full
                      DESCRIPTION                       Endorsement                           Endorsement
                                                         Evidence of            NOT           Evidence of              NOT
               Intensive In-Home Services                                 MET   MET   NA                         MET   MET   NA   COMMENTS
                                                         Compliance                           Compliance
  Program/Clinical Requirements (continued)
f **The development, monitoring, and revising of the                                        Policies and
  recipient's person centered plan is the
                                                                                            Procedures in
  responsibility of the qualified professional
                                                                                            place for PCP
                                                                                            development that
                                                       Policies and
                                                                                            include having:.
                                                       procedures in
                                                                                            PCP including
                                                       place for PCP
                                                                                            crisis plan,
                                                       development that
                                                                                            documentation of
                                                       includes crisis
                                                                                            C&F Team
                                                       planning and
                                                                                            meetings with
                                                       procedure for
                                                                                            membership,
                                                       involvement of
                                                                                            roles,
                                                       child and family
                                                                                            responsibilities,
                                                       team.
                                                                                            and
                                                                                            documentation of
                                                                                            family involvement
                                                                                            in the chart.




                                                                                 17 of 34                                         3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                               NC DHHS
   Reviewer:
                                                                             DMH/DD/SAS
   Date reviewed:                                                     Intensive In-Home Services
                                                            Conditional                                Full
                      DESCRIPTION                          Endorsement                             Endorsement
                                                            Evidence of              NOT           Evidence of              NOT
               Intensive In-Home Services                                      MET   MET   NA                         MET   MET   NA   COMMENTS
                                                            Compliance                             Compliance
  Program/Clinical Requirements (continued)
g **Must have policies and capacity to carry out first
  responder responsibilities for their recipients on a   Policies and                            Policies and
  face to face basis and telephonically at all times     Procedures in                           procedures in
  (24/7/365), with capacity for face-to-face emergency   place for crisis                        place for crisis
  response within 2 hours .                              response                                response. Crisis
                                                         implementation                          Plans in charts.
                                                         including: On call                      Proactive Plan
                                                         scheduling                              with triggers and
                                                         process; process                        Reactive Plan with
                                                         for the on call                         contacts and
                                                         person to have                          phone numbers;
                                                         access to                               Service notes
                                                         consumer's crisis                       document
                                                         plan the includes                       implemetation of
                                                         proactive plan                          crisis plan when
                                                         (with triggers) and                     needed. On call
                                                         reactive plan (with                     rotation schedule.
                                                         contacts and                            On call person
                                                         phone numbers)                          has access to and
                                                         and procedures to                       follows
                                                         ensure that crisis                      consumer's crisis
                                                         plan is followed by                     plan when
                                                         provider.                               needed.
  Documentation Requirements
  Minimum standard is a daily full service note that
  includes: 1) the purpose of contact, 2) describes the
  provider's interventions, 3) the time spent performing Service record                          Policy and
  the intervention, 4) the effectiveness of the           policy and                             procedure, PCP,
  interventions, and 5) the signature( degree/credentials procedure                              service notes
  or position) of the person providing the service




                                                                                      18 of 34                                         3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                          NC DHHS
   Reviewer:
                                                                         DMH/DD/SAS
   Date Reviewed:
                                                              Community Support (CS-MH/SA Adults)
                                                              Conditional                             Full
                       DESCRIPTION                           Endorsement                          Endorsement
                                                              Evidence of            NOT           Evidence of               NOT
             Community Support - Adults                                        MET   MET    NA                         MET   MET   NA     COMMENTS
                                                              Compliance                           Compliance
  Provider Requirements
a **1) Must be delivered by practitioners employed by                                            DMA Community
  a mhsa provider organization which meets the
                                                                                                     Intervention
  standards established by the Division of MHDDSAS.
                                                                                                       Services
  These standards set for the administrative,                                                      application (or
  financial, clinical, quality improvement, and          Provider                                      provider
  information services infrastructure necessary to  application with all                            endorsement
  provider services.                                     required                                 application) with
                                                       supporting                                     all required
                                                     documentation                                    supporting
                                                      completed as                                 documentation
                                                       required in                                  completed as
                                                         provider                                     required in
                                                       application;                                    provider
                                                         Program                                     application;
                                                    description; Policy                                Program
                                                      & Procedure                                description; Policy
                                                          Manual                                    & Procedure
                                                                                                 Manual; By-laws,
                                                                                                        General
                                                                                                     Partnership
                                                                                                      Agreement
  2) Provider organization must demonstrate they meet                                             DMA enrollment
  these standards by being endorsed by the LME. Within                                            documentation;
  3 years of enrollment, must have national accreditation                                          Certification of
                                                                                                    accreditation
  **3) The organization must be established as a                By-laws or                           By-laws or
  legally recognized entity in the U.S. & registered to        Partnership                           Partnership
  do business as a corporate entity in N.C.                 agreement; Other                     agreement; Other
                                                                supporting                           supporting
                                                            documentation as                     documentation as
                                                               required for                         required for
                                                             business status                      business status




                                                                                       19                                               3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                            NC DHHS
   Reviewer:
                                                                           DMH/DD/SAS
   Date Reviewed:
                                                                Community Support (CS-MH/SA Adults)
                                                                Conditional                                Full
                       DESCRIPTION                             Endorsement                             Endorsement
                                                                Evidence of              NOT            Evidence of              NOT
             Community Support - Adults                                            MET   MET    NA                         MET   MET   NA     COMMENTS
                                                                Compliance                              Compliance
   4) CS must have the ability to deliver services in
                                                                                                         Program
  various environments, such as homes, schools, jails (for
                                                                                                     description; Plicly
  state funds only), homeless shelters, street locations,
                                                                                                       & procedure
  etc.
                                                                                                      manual; PCP;
                                                                                                       MOAs; Other
                                                                                                        supporting
                                                                                                      documentation

b There is evidence of fidelity to EBP                          training plan                         training records
  Staffing Requirements
a **Persons who meet the requirements specified for              Employment                              Employment
  Qualified Professional or Associate Professional               application;                            application;
  status according to 10A NCAC 27.G.0104 may                       license                                 license
  deliver CS. QP are responsible for developing &               orcertification                         orcertification
  coordinating the PCP. AP & paraprofessionals may            verification, and                       verification, and
  deliver CS services to perform daily case                          other                                   other
  management functions and assist the consumer to              documentation                           documentation
  develop critical daily living & coping skills.                that indicates                          that indicates
                                                                  education,                              education,
                                                                experience &                            experience &
                                                              training for staff                      training for staff
                                                             are consistent with                     are consistent with
                                                               requirements &                          requirements &
                                                               responsibilities                        responsibilities
b **1) Paraprofessionals providing CS must be
  supervised by a qualified professional. Supervision
  must be provided according to supervision                                                          Supervision plans
  requirements specified in 10A. NCAC 27.G.0104 and Supervision plans                                 & supervision
  according to licensure and certification                                                                notes
  requirements of the appropriate discipline.




                                                                                           20                                               3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                              NC DHHS
    Reviewer:
                                                                             DMH/DD/SAS
    Date Reviewed:
                                                                  Community Support (CS-MH/SA Adults)
                                                                 Conditional                                 Full
                         DESCRIPTION                            Endorsement                              Endorsement
                                                                 Evidence of               NOT           Evidence of                NOT
               Community Support - Adults                                            MET   MET    NA                          MET   MET   NA     COMMENTS
                                                                 Compliance                              Compliance
  Staffing Requirements (continued)
c Paraprofessional level providers who meet the                    Employment                              Employment
  requirements specified for paraprofessional status may         application and                         application and
  deliver CS services within the requirements of the staff      other supporting                        other supporting
  definition specific in the above role. When a                  documentation                           documentation
  paraprofessional provides CS, a QP is responsible for         that education &                        that education &
  overseeing the development of the consumer's person            experience are                          experience are
  centered plan.                                                 consistent with                         consistent with
                                                                  requirements;                           requirements;
                                                                     Training;                               Training;
                                                                 Documentation                           Documentation
                                                                that supervision                        that supervision
                                                               requirements are                        requirements are
                                                                    being met;                              being met;
                                                               Supervision plans                       Supervision plans
d A certified clinical supervisor (CCS), licensed clinical                                              Job description;
   addictions specialist (LCAS) and certified clinical
                                                               Training plan; Job                         Employment
   addiction specialist (CCAS) may deliver CS as qualified
                                                                  description;                         application; Policy
   professionals to deliver the following services:
                                                                 Employment                               & procedure
   coordination & oversight of initial and ongoing
                                                               application; Policy                      manual; Service
   assessment activities, initial development & ongoing
                                                                  & procedure                            records; PCP;
   revision of PC; monitoring of implementation of PCP.
                                                                     manual                            Other supporting
                                                                                                        documentation

f Associate professionals and paraprofessionals may
  perform the following activities: skill building including        Program                              Personnel files
  daily & community living skills; socialization skills,          description;                           and consumer
  adaptation skills, development of leisure time                   Personnel                           charts to show AP
  interests/activities; symptom management skills;                Manual; Job                            and Para-prof
  wellness education; education substance abuse; work             descriptions                          activities with/for
  readiness                                                                                                consumer.
g 1) All staff providing CS to adults must have a minimum          Program                               Personnel files
  of 20 hours of training specific to the required servuce       description;                             and/or other
  definition components (including crisis response) within        Personnel                            documentation of
  the first 90 days of employment.                             Manual; Plan for                          completion of
                                                               meeting training                              training
                                                                requirements                             requirements.




                                                                                             21                                                3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                             NC DHHS
    Reviewer:
                                                                            DMH/DD/SAS
    Date Reviewed:
                                                                 Community Support (CS-MH/SA Adults)
                                                                 Conditional                           Full
                        DESCRIPTION                             Endorsement                        Endorsement
                                                                 Evidence of         NOT           Evidence of             NOT
              Community Support - Adults                                       MET   MET    NA                       MET   MET   NA     COMMENTS
                                                                 Compliance                        Compliance
  Service Type / Setting
a CS is a direct and indirect periodic service where the CS
  worker provides direct intervention & arranges,                                                program
                                                              program
  coordinates,& monitors services on behalf of the                                               description, PCP,
                                                              description
  recipient. Service is provided in any location and may be                                      service notes
  provided to an individual or a group of individuals.
b 1) CS provided in range of community settings and can
  be billed for individuals living in independent living or
  supervised living (low or moderate). 2) CS also includes                                       program
  telephone time with the individual recipient & collateral                                      description, PCP,
                                                              program
  contact with persons who assist the recipient in meeting                                       service notes,
                                                              description,
  his/her rehabilitation goals. 3) CS activities include                                         Medicaid RA
  person-centered planning meetings & meetings for                                               forms
  treatment/service plan development.

   Program/Clinical Requirements
a Individuals must receive a minimum of two (2) contacts program                                 PCP, service
  per month with one (1) contact occurring face-to-face                                          notes, billing
                                                              description
  with the recipient.                                                                            tracking forms,
b Contact benchmark shall be measured on an annual
  basis substantiating sixty percent (60%) or more of CS
  services delivered face to face with recipients and sixty   program                            Annual aggregate
  per cent (60%) or more of staff time must be spent          description                        provider report
  working outside of the facility with or on behalf of the
  consumers.
c 1) Caseload size may not exceed 1:30 (one QP worker         program                            case load
  per 30 clients). 2) group size may not exceed 8             description                        assignment, group
  individuals.                                                                                   attendance roster




                                                                                       22                                             3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                           NC DHHS
   Reviewer:
                                                                          DMH/DD/SAS
   Date Reviewed:
                                                               Community Support (CS-MH/SA Adults)
                                                              Conditional                                  Full
                       DESCRIPTION                           Endorsement                               Endorsement
                                                              Evidence of                NOT            Evidence of              NOT
             Community Support - Adults                                            MET   MET    NA                         MET   MET   NA     COMMENTS
                                                              Compliance                                Compliance
  Program/Clinical Requirements (continued)
d **The development, monitoring, and revising of the       Policies and                              Policies and
  recipient's person centered plan is the                  Procedures in place                       Procedures in
  responsibility of the qualified professionals            for PCP                                   place for PCP
                                                           development that
                                                                                                     development.
                                                           include process for
                                                           having:. PCP
                                                                                                     PCP in chart.
                                                           including crisis plan                     Documentation of
                                                           and documentation                         PC Planning
                                                           of PC Planning                            meetings, with
                                                           meetings with                             consumer
                                                           consumer                                  participation and
                                                           participation and                         input into all
                                                           input into all                            decisions. Service
                                                           decisions.
                                                                                                     notes document
                                                                                                     implementation of
                                                                                                     plan consistent
                                                                                                     with PCP

e **Must have policies and capacity to carry out first     Policies and                              Policies and
  responder for their recipients on a face to face basis   Procedures in place                       procedures in
  and also telephonically at all times (24/7/365), with    for crisis response                       place for crisis
                                                           implementation
  capacity for face-to-face emergency response                                                       response. Crisis
                                                           including: On call
  within 2 hours.                                          scheduling process;
                                                                                                     Plan in chart.
                                                           process for the on                        Proactive Plan
                                                           call person to have                       (with triggers) and
                                                           access to                                 Reactive Plan
                                                           consumer's crisis                         (with contacts and
                                                           plan the includes                         phone numbers)
                                                           proactive plan (with                      included. Service
                                                           triggers) and                             notes document
                                                           reactive plan (with
                                                                                                     implementation of
                                                           contacts and phone
                                                           numbers) and
                                                                                                     crisis plan when
                                                           procedures to                             needed.
                                                           ensure that crisis
                                                           plan is followed by
                                                           provider.




                                                                                           23                                               3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                             NC DHHS
    Reviewer:
                                                                            DMH/DD/SAS
    Date Reviewed:
                                                                 Community Support (CS-MH/SA Adults)
                                                                 Conditional                           Full
                        DESCRIPTION                             Endorsement                        Endorsement
                                                                Evidence of          NOT            Evidence of            NOT
              Community Support - Adults                                       MET   MET    NA                       MET   MET   NA     COMMENTS
                                                                Compliance                          Compliance
  Program/Clinical Requirements (continued)
f 1) Interventions include: identification & interventions to
  address barriers that impede the development of skills
  necessary for independent functioning in the community,
  development & revision of PCP, one-on-one
  interventions with the community to develop
                                                                                                 PCP, service
  interpersonal & community coping skills, including          program
                                                                                                 notes document
  adaptation to home, school, work environments;              description
                                                                                                 these activities.
  therapeutic mentoring; symptom monitoring, monitoring
  medications & self management of symptoms. 2) Include
  case management activities as well as assessment &
  reassessment of need for services.

g 1) CS workers inform & assist, arrange for the recipient
   to access, and receive benefits and services within the
   community as well as monitor the provision of those
   services. 2) CS worker must consult with identified                                           PCP & service
                                                              program
   providers, include their input into the service planning                                      notes document
                                                              description
   process, inform stakeholders, monitor status of the                                           these activities
   recipient in relationship to the treatment goals. 3) The
   organization assumes the roles of advocate,

   Documentation Requirements
   Minimum standard is a daily full service note that
   includes: 1) the purpose of contact, 2) describes the
                                                            Service record;
   provider's interventions, 3) includes the time spent                                          PCP; service
                                                            Policy &
   performing the interventions 4) effectiveness of the                                          notes
                                                            Procedure Manual
   intervention, and5) the signature (degree/credentials or
   position) of the person providing the service




                                                                                       24                                             3937a131-74c4-40c5-af5a-a8e11f45ef78.xls]
                                                                                NC DHHS
   Reviewer:
                                                                              DMH/DD/SAS
   Date reviewed:                                                Mobile Crisis Management (MH/DD/SA)
                                                                   Conditional                                 Full
                           DESCRIPTION                            Endorsement                              Endorsement
                                                                   Evidence of             NOT             Evidence of               NOT
            Mobile Crisis Management (MH/SA)                                        MET    MET       NA                        MET   MET   NA    COMMENTS
                                                                   Compliance                              Compliance
  Provider Requirements
a 1)  ** MCM services must be delivered by a team of                Provider                                 Provider
  practitioners employed by a MH/DD/SA provider                  application with                         application with
  organization which meets standards established by the            all required                             all required
                                                                   supporting                               supporting
  Division of MHDDSAS. These standards set forth the
                                                                 documentation                            documentation
  administrative, financial, clinical, quality improvement, &
                                                                  completed as                             completed as
  information services infrastructure necessary to provide
                                                                   required in                              required in
  services.
  2) Provider organizations must demonstrate they meet these         provider                                 provider
  standards by being endorsed by the LME. Within 3 years of        application;                             application;
  enrollment as a provider, the orgranization must have achieved    Program                                  Program
  national accreditation.                                          description;                             description;
  **3) The organization must be established as a legally             Policy &                                 Policy &
  recognized entity in the U.S. and qualified/registered to        Procedure                                Procedure
  do business as a corporate entity in the State of N.C.             Manual                                   Manual
  Staffing Requirements
  **1) MCM services must be delivered by a team of
                                                                                                           Personnel files;
  individuals that includes a qualified professional
                                                                                                           review of MCM
  according to 10A NCAC 27.G.0104 who must be either a
                                                                                                          charts/documen
  nurse, clinical social worker or psychologist as defined in       Program
                                                                                                             tation shows
  this administrative code. 2) One of the team members             description;
                                                                                                          that the required
  must be a Certified Clinical Addictions Specialist (CCAS),        Personnel
                                                                                                           staff carried out
  Certified clinical supervisor (CCS) or a certified substance     Manual; Job
                                                                                                           responsibilities
  abuse counselor (CSAC). 3) Each organization providing           description
                                                                                                               based on
  crisis management (CM) must have 24/7/365 access to a                                                        consumer
  board certified or eligible psychiatrist supervision.                                                          needs.




                                                                                          25 of 34                                              3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                NC DHHS
   Reviewer:
                                                                              DMH/DD/SAS
   Date reviewed:                                                Mobile Crisis Management (MH/DD/SA)
                                                                   Conditional                              Full
                           DESCRIPTION                            Endorsement                           Endorsement
                                                                  Evidence of           NOT             Evidence of               NOT
             Mobile Crisis Management (MH/SA)                                    MET    MET       NA                        MET   MET   NA    COMMENTS
                                                                  Compliance                            Compliance
  Staffing Requirements (continued)
  **1) The psychiatrist MUST be available for face to face or
                                                                                                         Personnel file,
  phone consultation to crisis staff. 2) A QP or AP with
                                                                                                        review of MCM
  experience in developmental disabilities must be available
                                                                                                       charts/documen
  to them as well. 3) Paraprofessionals with competency in
                                                                                                          tation shows
  crisis management may also be a member of the CM                                                     that the required
  team. 4) Paraprofessional with competency in CM who              Program                              staff carried out
  meet the requirements in 10A NCAC 27.G.0104 may be              description;                          responsibilities
  members of a team when supervised by the QP. 5) A                Personnel                                based on
  supervising professional must be available for                  Manual; Job                               consumer
  consultation when a paraprofessional is providing               description                                 needs;
  services .                                                                                            documentation
                                                                                                              shows
                                                                                                         supervision of
                                                                                                       paraprofessiona
                                                                                                            ls by QP.

b 1) All staff providing MCM services must demonstrate                                                  Personnel file
  competencies in crisis response & crisis prevention. 2) At a
                                                                                                         and/or other
  minimum, these staff must have: a minimum of one year's
                                                                   Program                             documentation
  experience in providing crisis management services in the
                                                                  description;                           shows staff
  following settings: assertive outreach, assertive community
                                                                   Personnel                            have required
  treatment, emergency department, or other services providing
                                                                  Manual; Job                          experience and
  24/7 response in emergent or urgent situations AND twenty
                                                                  description                          have completed
  (20) hours of training in appropriate crisis intervention
                                                                                                           training
  strategies within the first 90 days employment.
                                                                                                        requirements.

c **1) Professional staff must have appropriate licenses,          Program
                                                                                                        Personnel file,
  certification, training, & experience 2) non-licensed staff     description;
                                                                                                       supervision plan
  must have appropriate training & experience.                     Personnel
                                                                                                       and logs, on call
                                                                  Manual; Job
                                                                                                          schedule
                                                                  description




                                                                                       26 of 34                                              3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                      NC DHHS
    Reviewer:
                                                                                    DMH/DD/SAS
    Date reviewed:                                                     Mobile Crisis Management (MH/DD/SA)
                                                                         Conditional                                Full
                             DESCRIPTION                                Endorsement                             Endorsement
                                                                        Evidence of             NOT             Evidence of             NOT
              Mobile Crisis Management (MH/SA)                                           MET    MET       NA                      MET   MET   NA    COMMENTS
                                                                        Compliance                              Compliance
  Service Type / Setting
a 1) MCM is a direct & periodic service that is available at all                                                 Personnel file
   times, 24/7/365. 2) It is a "second level" service, in that other                                              and/or other
   services should be accessed before MCM, as appropriate.                                                      documentation
                                                                                                                  shows staff
                                                                       Program
                                                                                                                 have required
                                                                       description, on
                                                                                                                 credentials &
                                                                       call plan
                                                                                                                experience and
                                                                                                                have completed
                                                                                                                    training
                                                                                                                 requirements.
b 1) MCM may be provided at any location. 2) For an                                                            Service notes,
   organization providing these services, contact benchmarks                                                   on call
   shall be measured on an annual basis substantiating service                                                 schedule,
   is provided at least 80% of their units on a face-to face basis.                                            assessment
   4) If a face-to-face assessment is required, this assessment                                                information, and
                                                                    Program
   must be delivered in the least restrictive environment &                                                    annual
                                                                    description, on
   provided in or as close as possible to a person's home, in the                                              aggregate
                                                                    call plan
   individual's natural setting, school, work, local ER, etc. 5)                                               provider report
   Result of the assessment should identify the appropriate crisis                                             shows that face
   stabilization intervention, 6) This response must be mobile.                                                to face
                                                                                                               requirements
                                                                                                               are being met.
  Program Requirements
a Crisis response provides an immediate evaluation, triage &
   access to acute MHDDSAS services, treatment, & supports, to
   effect symptom reduction, harm reduction and/or to safely                                                   PCP Crisis
   transition persons in acute crisis to appropriate crisis                                                    Plan, service
   stabilization & detoxification supports/services. Includes: Program                                         notes document
   immediate telephonic response to assess the crisis &        description, on                                 appropriate
   determine the risk, mental status, medical stability, &     call plan                                       professional/
   appropriate response. Also includes crisis prevention &                                                     clinical
   supports which are designed to reduce the incidence of                                                      intervention
   recurring crisis.




                                                                                               27 of 34                                            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                 NC DHHS
    Reviewer:
                                                                               DMH/DD/SAS
    Date reviewed:                                                Mobile Crisis Management (MH/DD/SA)
                                                                     Conditional                                Full
                            DESCRIPTION                             Endorsement                             Endorsement
                                                                     Evidence of            NOT             Evidence of             NOT
              Mobile Crisis Management (MH/SA)                                       MET    MET       NA                      MET   MET   NA    COMMENTS
                                                                     Compliance                             Compliance
  Program Requirements (continued)
b MCM services are available at all times, 24/7/365. Supports &
  services are delivered as specified in PCP Crisis Plans of                                               PCP Crisis
  recipients.                                                                                              Plan; service
                                                                   Program
                                                                                                           notes document
                                                                   description, on
                                                                                                           services were
                                                                   call plan
                                                                                                           consistent with
                                                                                                           PCP crisis
                                                                                                           plans.
c MCM services should be delivered in the least restrictive                                                PCP Crisis
   environment & provided in or as close as possible to a                                                  Plan, service
   person's home.                                                  Program                                 notes show
                                                                   description, on                         services
                                                                   call plan                               provided in
                                                                                                           appropriate
                                                                                                           locations
d **MCM services must be capable of addressing all                                                         PCP Crisis
   psychiatric, substance abuse and developmental                                                          Plan, service
                                                                   Program
   disabilities crises for all ages to help restore (at a                                                  notes show that
                                                                   description, on
                                                                                                           needs of
   minimum) an individual to their previous level of               call plan
                                                                                                           individuals were
   functioning.                                                                                            addressed
e MCM services may be delivered by one (1) or more individual Program
   practitioners on the team.                                      description, on                         Service notes
                                                                   call plan
f For recipients new to the public system, MCM must develop a
   crisis plan before discharge. 2) The crisis plan should be                                              Service notes
   provided to the individual, caregivers (if appropriate) & any                                           document
                                                                   Program
   agencies which may provide ongoing treatment & supports                                                 recommendatio
                                                                   description, on
   after the crisis has been stabilized. 3) For recipients who are                                         ns for follow up
                                                                   call plan
   already receiving services, MCM should recommend revisions                                              and revised
   to existing crisis plan components in the PCP, as appropriate.                                          crisis plans.

   Documentation Requirements
   Minimum standard is a service note which includes: 1) a
   description of staff intervention; 2) the time spent performing Service record                          Service notes,
   the intervention, 3) the outcome of the intervention and 4)     policy and                              policy and
   signature (credential/degree or position) of the person         procedure                               procedure
   providing the service

                                                                                           28 of 34                                            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                     NC DHHS
   Reviewer:
                                                                                   DMH/DD/SAS
   Date reviewed:                                                          Multisystemic Therapy (MST)
                         DESCRIPTION                                Conditional Endorsement                                   Full Endorsement
                                                                                                            NOT                                                     NOT
               Multisystemic Therapy (MST)                           Evidence of Compliance           MET   MET   NA      Evidence of Compliance             MET    MET     NA
  Provider Requirements
a **1) MST services must be delivered by practitioners
  employed by a MH/SA provider organization which
  meets standards established by the Division of
  MHDDSAS. These standards set forth the
  administrative, financial, clinical, quality improvement,
  & information services infrastructure necessary to
  provide services..                                                                                                     Provider application with all
  2) Provider organization must demonstrate that they meet          Provider application with all
                                                                                                                             required supporting
  these standards by being endorsed by the LME. Within 3         required supporting documentation
                                                                                                                        documentation completed as
  years of enrollment, must have national accreditation           completed as required in provider
                                                                                                                       required in provider application;
                                                                  application; Program description;
                                                                                                                        Program description; Policy &
  **3) The organization must be established as a legally            Policy & Procedure Manual
                                                                                                                              Procedure Manual
  recognized entity in the U.S. and registered to do
  business as a corporate entity in the State of N.C.

   4) MST providers must have ability to deliver services in
  various environments, such as homes, schools, detention
  centers & jails (state funds only) homeless shelters, street
  locations, etc.

  ** 5) MST providers must be licensed to use the MST
                                                                    Valid MST license from MST                           Valid MST license from MST
  technology by MST Services of Charleston, SC and the
                                                                      Services of Charleston                               Services of Charleston
  Family Services Research Center of the Medical
  University of South Carolina (www.mstservices.com).
  Staffing Requirements
  **1) Service model includes at a minimum a master's
  level QP who is the team supervisor and three (3) QP
  staff who provide available 24-hour coverage, 7 days
  per week.                                                                                                            Personnel files and schedules; ;
  **2) Staff are required to participate in MST                                                                        Training plans; Documentation of
  introductory training & quarterly training on topics            Program description; Personnel                       participation in required training;
  directly related to the needs of MST youth & their             Manual; Job descriptions; Training                      that required supervision and
  family on an ongoing basis                                                   Plan                                      consultation were provided; &
   ** 3) All staff on the MST team shall receive a                                                                       that staff to family ratios were
  minimum of one (1) hour of group supervision and one                                                                                  met.
  (1) hour of telephone consultation per week.




                                                                                            29 of 34                                             3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                       NC DHHS                    Personnel files and schedules; ;
    Reviewer:
                                                                                     DMH/DD/SAS                   Training plans; Documentation of
                                                                Program description; Personnel                    participation in required training;
    Date reviewed:                                                      Multisystemic Therapy (MST)
                                                               Manual; Job descriptions; Training                   that required supervision and
                                                                            Plan                                    consultation were provided; &
                          DESCRIPTION                             Conditional Endorsement                                 Full Endorsement
                                                                                                                    that staff to family ratios were
                                                                                                       NOT                         met.                       NOT
                Multisystemic Therapy (MST)                        Evidence of Compliance        MET   MET   NA       Evidence of Compliance          MET     MET     NA
   ** 4) MST team to family ratio shall not exceed one to
   five (1:5) for each team member
   Service Type/Setting
   1) MST is a direct & indirect periodic service where the MST
   worker provides direct intervention & also arranges,
   coordinates, & monitors services on behalf of the recipient
   and is provided in any location. 2) MST services are
                                                                                                                    Program description; PCP,
   primarily provided in a range of community settings such as Program description; Policy &
                                                                                                                    service notes, Medicaid RA
   (home, school, homeless shelters, libraries, etc). 3) MST    Procedure Manual
                                                                                                                               forms
   also includes telephone time with the individual recipient
   and collateral contact with persons who assist the recipient
   in meeting their goals specified in the PCP. .

   Clinical Requirements
a For an organization providing these services, contact                                                           Annual aggregate provider report
  benchmarks shall be measured on an annual basis
                                                              Program description                                 re time spent outside agency's
  substantiating sixty (60%) or more of staff time spent
                                                                                                                  facility.
  working outside of the agency's facility.




                                                                                          30 of 34                                         3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                                                                                  NC DHHS
   Reviewer:
                                                                                DMH/DD/SAS
   Date reviewed:                                                       Multisystemic Therapy (MST)
                        DESCRIPTION                              Conditional Endorsement                                    Full Endorsement
                                                                                                          NOT                                                    NOT
               Multisystemic Therapy (MST)                        Evidence of Compliance            MET   MET   NA      Evidence of Compliance            MET    MET     NA
b **The development, monitoring, and revising of the
  recipient's person centered plan is the responsibility of Policies and Procedures in place                         Policies and Procedures in place
  the MST qualified professional                            for PCP development that include                         for PCP development. PCP in
                                                            having:. PCP including crisis plan,                      chart. Documentation of C&F
                                                            documentation of C&F Team                                Team meetings, with
                                                            meetings with membership, roles,                         membership, roles,
                                                            responsibilities, and                                    responsibilities. Documentation
                                                            documentation of family                                  of family involvement; Service
                                                            involvement in the chart.                                notes document implementation
                                                                                                                     of plan consistent with PCP.
  Clinical Requirements (continued)
c **Must have policies and capacity to carry out first        Policies and Procedures in place                       Policies and Procedures in place
  responder responsibilities for their recipients on a face   for crisis response implementation                     for crisis response. On call
  to face basis and also telephonically at all times          including: On call scheduling                          schedule. On call person has
  (24/7/365), with capacity for face-to-face emergency        process; process for the on call                       access to and follows consumer's
  response within 2 hours.                                    person to have access to                               crisis plan. Crisis Plan in chart.
                                                              consumer's crisis plan the includes                    Proactive Plan (with triggers) and
                                                              proactive plan (with triggers) and                     Reactive Plan (with contacts and
                                                              reactive plan (with contacts and                       phone numbers) included;
                                                              phone numbers) and procedures                          Service notes document
                                                              to ensure that crisis plan is                          impementation of crisis plan
                                                              followed by provider.                                  when needed in accordance with
                                                                                                                     required timeliness for
                                                                                                                     emergency response.



   Documentation Requirements




                                                                                          31 of 34                                            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                             NC DHHS
  Reviewer:
                           DMH/DD/SAS
  Date reviewed:   Multisystemic Therapy (MST)


COMMENTS




                             32 of 34            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                             NC DHHS
  Reviewer:
                           DMH/DD/SAS
  Date reviewed:   Multisystemic Therapy (MST)


COMMENTS




                             33 of 34            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls
                             NC DHHS
  Reviewer:
                           DMH/DD/SAS
  Date reviewed:   Multisystemic Therapy (MST)


COMMENTS




                             34 of 34            3937a131-74c4-40c5-af5a-a8e11f45ef78.xls

								
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