BPA HEALTH RECOVERY SUPPORT SERVICES AUDIT
|
|
- Kerry Marsh
- 6 years ago
- Views:
Transcription
1 Provider: Reviewer: Site ID: CASE MANAGER SUPERVISION IDAPA Supervision. The case management program must provide and document at least one () hour of case management supervision per month for each case manager or as defined by Clinical Supervision if clinician Points # Case Manager Name S P Scoring: point possible per case manager per month (as indicated by competency rating) Supervision Sub-total 0 0 PR-3-0/06/05 Case Management
2 Provider: Reviewer: Site ID: Question # Progress Notes. Notes for each service charting the client's progress must include: * Date of session * Beginning and ending time of session * Description of the session * Signature of person conducting the session Standard. Client ID # Case Management Files - Pull up to 5 client files Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include: * Assessment of the client and client family strength and needs * Service planning * Linkage to other services * Client advocacy and monitoring Scoring point possible for each of the 4 items Points S P 3 Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days. per 90 days 4 5 Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] PR-3-0/06/05 Case Management
3 Provider: Reviewer: Site ID:. Client ID # Scoring Earned Possible Progress Notes. Notes for each service charting the client's progress must include: * Date of session * Beginning and ending time of session * Description of the session * Signature of person conducting the session 3 Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include: * Assessment of the client and client family strength and needs * Service planning * Linkage to other services * Client advocacy and monitoring Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days. point possible for each of the 4 items per 90 days 4 5 Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] PR-3-0/06/05 Case Management
4 Provider: Reviewer: Site ID: 3. Client ID # Scoring Earned Possible Progress Notes. Notes for each service charting the client's progress must include: * Date of session * Beginning and ending time of session * Description of the session * Signature of person conducting the session Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include: * Assessment of the client and client family strength and needs * Service planning * Linkage to other services * Client advocacy and monitoring point possible for each of the 4 items 3 Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days. per 90 days 4 Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client. 5 Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] PR-3-0/06/05 Case Management
5 Provider: Reviewer: Site ID: 4. Client ID # Scoring Earned Possible Progress Notes. Notes for each service charting the client's progress must include: * Date of session * Beginning and ending time of session * Description of the session * Signature of person conducting the session Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include: * Assessment of the client and client family strength and needs * Service planning * Linkage to other services * Client advocacy and monitoring point possible for each of the 4 items 3 Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days. per 90 days 4 Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client. 5 Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] PR-3-0/06/05 Case Management
6 Provider: Reviewer: Site ID: 5. Client ID # Scoring Earned Possible Progress Notes. Notes for each service charting the client's progress must include: * Date of session * Beginning and ending time of session * Description of the session * Signature of person conducting the session Case Management Comprehensive Service plan must completed within 30 days after first meeting and must include: * Assessment of the client and client family strength and needs * Service planning * Linkage to other services * Client advocacy and monitoring point possible for each of the 4 items 3 Comprehensive Case Management Service Plan Development. The case manager must update the plan every 90 days. per 90 days 4 Case Manager Contact and Availability. At least thirty (30) days, case managers must have face-to-face contact with the client, or have contact with the guardian, who can verify the client's well-being and whether services are being provided according to the written plan. The frequency, mode of contact, and person being contacted must be identified in the plan and must meet the needs of the client. 5 Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] Case Management File Sub-Total: 0 0 Case Management Total: 0 0 PR-3-0/06/05 Case Management
7 Provider: Reviewer: Site ID: PR-3-0/06/05 Case Management
8 Provider: 0 Site ID: 0 Question # Standard. Client ID # DRUG AND ALCOHOL TESTING Scoring Points S P Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a treatment provider agency, results should be communicated to the PO.] Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers]. Client ID # Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a treatment provider agency, results should be communicated to the PO.] Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] 3. Client ID # Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a treatment provider agency, results should be communicated to the PO.] Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] PR-3-0/06/05 Drug and Alcohol Testing
9 Provider: 0 Site ID: 0 Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a treatment provider agency, results should be communicated to the PO.] 4. Client ID # Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] 5. Client ID # Documentation that results were sent to requesting agency. [If the DT is not a stand-alone agency and is administered within a treatment provider agency, results should be communicated to the PO.] Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. [Referral agencies examples: IDOC, other providers] D & A Testing Total 0 0 PR-3-0/06/05 Drug and Alcohol Testing
10 Provider: 0 Site ID: 0 Question # Standard CHILD CARE Setting Ensures Safety. Provide a setting that promotes and ensures the health, well-being, and safety of the child or children in care. [CORE] [yes=5] Medicines, cleaning products, and other dangerous substances and articles are kept away from children at all times. Scoring No = 0 points No = 0 points Child Care Facility Sub-total 0 0 S Points P Question # CHILD CARE Standard. Client ID # Scoring S Points P 3 Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services. The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and names of individual(s) providing care. 4. Client ID # Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services. The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and names of individual(s) providing care. PR-3-0/06/05 Child Care
11 Provider: 0 Site ID: Client ID # Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services. The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and names of individual(s) providing care Client ID # Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services. The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and names of individual(s) providing care Client ID # Child Care Program Sign In for Billable Service Date. The program must maintain a register of all children receiving services. The register must include each child's full name, gender, date of birth, parents or guardian, the date and time of services, and names of individual(s) providing care. Child Care Sub-total 0 0 Child Care Total 0 0 PR-3-0/06/05 Child Care
12 Provider: 0 Site ID: 0 Question # Standard. Client ID # LIFE SKILLS Scoring point possible per date audited S Points P Encounter note for dates billed [review note and life skills plan] There is an identified curriculum/lesson for the Life Skills program being billed. PR-3-0/06/05 Life Skills Page 3 of 6
13 Provider: 0 Site ID: 0. Client ID # Encounter note for dates billed [review note and life skills plan] There is an identified curriculum/lesson for the Life Skills program being billed. point possible per date audited 3. Client ID # Encounter note for dates billed [review note and life skills plan] There is an identified curriculum/lesson for the Life Skills program being billed. point possible per date audited 4. Client ID # Encounter note for dates billed [review note and life skills plan] There is an identified curriculum/lesson for the Life Skills program being billed. point possible per date audited 5. Client ID # Encounter note for dates billed [review note and life skills plan] There is an identified curriculum/lesson for the Life Skills program being billed. point possible per date audited Life Skills Total 0 0 PR-3-0/06/05 Life Skills Page 4 of 6
14 Provider: 0 Site ID: 0 Recovery Coach Supervision Recovery Coach is Receiving Supervision Employee Name Scoring: point possible per recovery coach per month Supervision Sub-total 0 0 S Points P Question # Standard. Client ID # RECOVERY COACH Scoring S Points P Recovery Wellness Plan in Place. Client ID # S P Recovery Wellness Plan in Place 3. Client ID # S P Recovery Wellness Plan in Place 4. Client ID # S P Recovery Wellness Plan in Place 5. Client ID # S P Recovery Wellness Plan in Place Wellness Plan Sub-total 0 0 Recovery Coach Total 0 0
15 Provider: 0 Site ID: 0 TRANSPORTATION The minimum insurance required for all programs is professional liability, commerical general liability, and comprehensive liability for all program vehicles. All facilities must maintain professioanl liability insurance in the amount of at least five hundred-thousand to one million dollars ($500,000/$,000,000) and general liability and automobile insurance in the amount of at least one million to three million dollars ($,000,000/$3,000,000). Copies of the declarations face-sheet for all policies must be included with the application. Individual providers must carry at least the minium insurance requried by Idaho law. If an agency permits employees to transport clients in employee's personal vehicles, the agency must ensure that insurance coverage is carried to cover those circumstances. Points Each Vehicle Used Scoring: Per Vehicle No = 0 points Transportation Total 0 0 S P PR-3-0/06/05 Transportation
16 Provider: 0 Site ID: 0 SAFE AND SOBER HOUSING Question # Standard Scoring No facility concerns with regard to bedroom size, bed spacing or safety issues were noted. No = 0 points S Points P A minimum of one () fire drill must be held at last every thirty (30) days at unexpected times and under varying conditions to simulate unusual circumstances encountered in case of a fire. A record of drills must be maintained which includes the date and time of the drill, response of the personnel and clients, problems encountered and recommendations for improvements. No = 0 points 3 Adult Staffed Safe and Sober housing facilities must provide information regarding community resources to persons recovering from alcohol and substance use disorders. Sections 370 and 380 of these rules do not apply to this level of care in this setting. No = 0 points 4 Facility Inspection of an Adult Staffed Safe and Sober Housing Facility. Adult Staffed Safe and Sober Housing facilities must be inspected by staff weekly to determine if hazards or potential safety issues exist. A record of the inspection must be maintained that includes the date and time of the inspection, problems encountered, and recommendation for improvement. No = 0 points 5 Staffing of Safe and Sober Housing Facility. A house manager on-site a minimum of twenty (0) hours a week or a housing coordinator who is off-site but monitors house activities on a daily basis. No = 0 points Facility Sub-total 0 0 Question # Standard. Client ID # Scoring S P Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards.. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. PR-3-0/06/05 Safe and Sober Housing
17 Provider: 0 Site ID: 0 3. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. 4. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. PR-3-0/06/05 Safe and Sober Housing
18 Provider: 0 Site ID: 0 5. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. SSH Documentation Sub-total 0 0 SSH Total 0 0 PR-3-0/06/05 Safe and Sober Housing
19 Provider: 0 Site ID: 0 Halfway House Question # Standard Scoring S Points P No facility concerns with regard to bedroom size, bed spacing or safety issues were noted. No = 0 points Supervision for Adults Level III.. A Level III. treatment facility must be supervised by a qualified substance use disorders professional. No = 0 points 3 Staffing for Adults Level III.. A staff person must be available to residents twenty-four (4) hours per day, seven (7) days a week. The staff to client ratio must not exceed twelve () clients to one () staff person. No = 0 points Facility Sub-total 0 0 Question # Standard. Client ID # Scoring S P Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards.. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. PR-3-0/06/05 Halfway Housing Page 3 of 6
20 Provider: 0 Site ID: 0 3. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. 4. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. PR-3-0/06/05 Halfway Housing Page 4 of 6
21 Provider: 0 Site ID: 0 5. Client ID # Documentation that client was in the facility on billed date. Signed and dated releases with referral agencies. Must meet 4 CFR and HIPPA standards. Halfway House Documentation Sub-total 0 0 Halfway House Total 0 0 PR-3-0/06/05 Halfway Housing Page 5 of 6
22 DATE DUE: DATE CONDUCTED: PROVIDER: PROVIDER SITE ID: AUDIT CONDUCTED BY: BPA HEALTH TOTALS Section Score Earned Score Possible % Case Management: 0 0 0% D&A Testing: 0 0 0% Child Care: 0 0 0% Life Skills & Rec. Coach: 0 0 0% Transportation: 0 0 0% SSH 0 0 0% Halfway House 0 0 0% TOTAL 0 0 0% Recovery Support Services (yes=, no=0) Case Management Drug & Alcohol Test. Child Care Life Skills & Rec. Coach Transp. SSH Halfway House Date Results Sent: Date Next Audit Due: Follow-Up [yes=, no & NA=0] None (passed): Action Plan (failed): Perf. Imp. Plan (passed): # Claims Recouped: Date Plan Due: PR-3-0/06/05 Totals
Level 2.1- Intensive Outpatient Services (IOP)
QUALITY OF DOCUMENTATION Level 2.1- Intensive Outpatient Services (IOP) 1. Has the participant consented for treatment or with the consent of the participant, a parent or guardian has consented for treatment?
More information907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services.
907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services. RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 1396a(a)(23) STATUTORY AUTHORITY:
More informationThe Wellmet Project Incorporated 675 Massachusetts Avenue Cambridge, MA Phone: (617) Fax: (617) APPLICATION
The Wellmet Project Incorporated 675 Massachusetts Avenue Cambridge, MA 02139 Phone: (617) 491-2377 Fax: (617) 491-3195 APPLICATION SECTION 1 -- TO BE FILLED OUT BY REFERRING SOURCE: SOCIAL WORKER, THERAPIST,
More informationRULES OF DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES
RULES OF DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES CHAPTER 0940-5-29 MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH TABLE OF CONTENTS 0940-5-29-.01 Definition 0940-5-29-.06 Individual
More informationStrategic Plan
Strategic Plan 2017-2020 1 Our Vision Here s Help, Inc. believes clients can recover their lives and deserve a chance to succeed. To this end, our vision is to provide high-quality programs and services
More informationKent State University Health Services. Medical History Form
Kent State University Health Services Medical History Form 1. This form must be returned to the Student Health Service prior to being seen at UHS. 2. This form will become a part of the Student Medical
More informationSUD Rate Matrix - Treatment Services
SUD Rate Matrix - Treatment Services Alcohol or Drug Assessment Updated Assessment BILLABLE ITEM & RATE Code w/ H0001 15 min. Duration $12.40 H0001.HF 15 min. Duration $12.40 FY18 SUD CLINICAL TREATMENT
More informationRULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES
RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES CHAPTER 0940-5-41 MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG HALFWAY HOUSE TREATMENT FACILITIES TABLE OF CONTENTS
More informationSubstance Use Disorder Treatment Provider Programmatic Site Visit Monitoring Tool. Date of Review: Review for County Fiscal Year: -
Compliance Santa Ratings Barbara Key: County Y = Yes; N Department I= Needs Improvement; of Behavioral IA = Immediate Wellness Action; Alcohol NA = Not and Applicable Drug Program Substance Use Disorder
More informationAcute Crisis Units. Shelly Rhodes, Provider Relations Manager
Acute Crisis Units Shelly Rhodes, Provider Relations Manager Shelly.Rhodes@beaconhealthoptions.com Training Agenda Agenda: Transition and Certification Coverage of Services Service Code Definition Documentation
More information907 KAR 10:014. Outpatient hospital service coverage provisions and requirements.
907 KAR 10:014. Outpatient hospital service coverage provisions and requirements. RELATES TO: KRS 205.520, 42 C.F.R. 447.53 STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560, 205.6310,
More informationAgency for Health Care Administration
Page 1 of 103 ST - R0000 - INITIAL COMMENTS Title INITIAL COMMENTS Type Memo Tag These guidelines are meant solely to provide guidance to surveyors in the survey process. ST - R0001 - LICENSURE PROCEDURE
More informationProcedure. Applies To: UNM Hospitals Responsible Department: Quality Revised: 03/2014
Procedure Patient Age Group: ( ) N/A ( ) All Ages ( ) Newborns (X) Pediatric (x ) Adult DESCRIPTION/OVERVIEW UNM Hospitals (UNMH) is recognized as a large academic health care system providing services
More informationPO AILANI, INC. CONTINUUM OF CARE. Applicant s Data Descriptor Information (Please Complete Entire Form)
PO AILANI, INC. CONTINUUM OF CARE SCREENING FORM 74 KIHAPAI STREET TELEPHONE (808) 262-2799 KAILUA, HAWAII 96734 FAX (808) 262-0970 Referral Source Name/Title Date Funding Source (circle appropriate source)
More informationTreatment Planning. General Considerations
Treatment Planning CBH Compliance has been tasked with ensuring that our providers adhere to documentation standards presented in state regulations, bulletins, CBH contractual documents, etc. Complying
More informationState of Connecticut REGULATION of. Department of Social Services. Payment of Behavioral Health Clinic Services
R-39 Rev. 03/2012 (Title page) Page 1 of 17 IMPORTANT: Read instructions on back of last page (Certification Page) before completing this form. Failure to comply with instructions may cause disapproval
More informationSee next page of this notice for more information.
1 Date:. Patient Name: Address: 68 Long Court, Suite 2C, Thousand Oaks, CA 91360 T- 805-777-7234 F- 805-777-0101 Notice of Medicare Non-Coverage Service Start/Admission Date: Patient ID Number: Provider/Facility:
More informationBe it enacted by the General Assembly of the Commonwealth of Kentucky: The General Assembly hereby finds and declares that:
UNOFFICIAL COPY AS OF 0/0/0 0 REG. SESS. 0 RS BR AN ACT relating to minimum staffing requirements for long-term care facilities. Be it enacted by the General Assembly of the Commonwealth of Kentucky: 0
More informationGRANT AND FUNDING STRUCTURE
Request for Proposal (RFP) Expansion and Enhancement of Medication-Assisted (MAT) Treatment for Opioid Use Disorder (OUD) in Chicago Frequently Asked Questions (FAQs) Tuesday, February 25 th, 2017 GRANT
More informationIROC Treatment Provider FAQ
FAQ Version Summary ew Questions Added Answers Revised * Answers Archived 5/17/2018 8-10, 15, 22-29, 40-42, 4, 11 12, 14, 34 47-57, 59, 66-67 08/25/2017 1 thru 42 n/a n/a ew questions are identified with
More informationPerformance Standards
Performance Standards Community and School Based Behavioral Health (CSBBH) Team Performance Standards are intended to provide a foundation and serve as a tool to promote continuous quality improvement
More informationSHELTER PLUS CARE REFERRAL/APPLICATION PACKET
SHELTER PLUS CARE REFERRAL/APPLICATION PACKET Applicant s Name: Date: Referral Source: Received Date: Staff: Fairview Recovery Services helps people with the disease of alcoholism, chemical dependency,
More informationREQUEST FOR INFORMATION FOR SEASONS OF HOPE A SAFE HOUSE WITH OUTREACH PROGRAM. Re-released: August 8, 2011
REQUEST FOR INFORMATION FOR SEASONS OF HOPE A SAFE HOUSE WITH OUTREACH PROGRAM Re-released: August 8, 2011 RFI Response Date: 4:00 p.m., August 19, 2011 Overview The Alcohol, Drug Addiction, and Mental
More information2. Payment for Prescribed Drugs. Payment for prescribed drugs will be available as described in Subsection of these rules.
IDAHO ADMINISTRATIVE CODE Department of Health & Welfare IDAPA 16.03.09 Medicaid Basic Plan Benefits 2. Payment for Prescribed Drugs. Payment for prescribed drugs will be available as described in Subsection
More informationATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN
ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 SERIOUS MENTAL ILLNESS SPECIALTY PLAN The provisions in Attachment II and the MMA Exhibit apply to this Specialty Plan, unless otherwise specified
More informationTEXAS PEER ASSISTANCE PROGRAM FOR NURSES (TPAPN) ADVOCATE APPLICATION
TEXAS PEER ASSISTANCE PROGRAM FOR NURSES (TPAPN) ADVOCATE APPLICATION How were you recruited to become an advocate? Employer Friend Workshop BON Newsletter Advocate (name): Participant Other: Please answer
More informationSHELTER PLUS CARE REFERRAL/APPLICATION PACKET
SHELTER PLUS CARE REFERRAL/APPLICATION PACKET Updated August 2016 Applicant s Name: Date: Referral Source: Received Date: Staff: Fairview Recovery Services helps people with the disease of alcoholism,
More informationFor Substance Abuse Emergencies: Wright County will seek reimbursement for any and all services.
Wright County Community Services 115 1 st Street South East Post Office Box 4 Clarion, Iowa 50525 Phone: 515 532 3309 Fax: 515 532 6064 E Mail: wccs@trvnet.net Revised 8/1/2001 For Substance Abuse Emergencies:
More informationDepartment of Vermont Health Access Department of Mental Health. dvha.vermont.gov/ vtmedicaid.com/#/home
Department of Vermont Health Access Department of Mental Health dvha.vermont.gov/ vtmedicaid.com/#/home ... 2 INTRODUCTION... 3 CHILDREN AND ADOLESCENT PSYCHIATRIC ADMISSIONS... 7 VOLUNTARY ADULTS (NON-CRT)
More informationWhere does the Department s authority to regulate drug and alcohol services come from?
Where does the Department s authority to regulate drug and alcohol services come from? Act 50 of 2010, previously Act 63 of 1972 (71 P.S. 1690.102 through 1690.115), is the primary body of Pennsylvania
More informationResponse Team Volunteer Application
Thank you for your interest in volunteering. The ASPCA Response Team is a group of specially trained staff members and volunteers who respond to man-made and natural disasters throughout the country. Please
More informationHMO COMPLAINT - DATA PRACTICES NOTICE
HMO COMPLAINT - DATA PRACTICES NOTICE 1. The Minnesota Government Data Practices Act requires that we provide you with the following information: a) the purpose and intended use of the data you provide
More informationSan Francisco Department of Public Health Barbara A. Garcia, MPA Director of Health
Overview San Francisco Department of Public Health Medical Respite Fact Sheet December 18, 2017 The Medical Respite program has provided essential post-hospital care to homeless clients in San Francisco
More informationRADIOLOGICAL MONITORING AND SURVEYS
Radiological Monitoring Surveys Page 1 of 9 RADIOLOGICAL MONITORING AND SURVEYS 1.0 Objective The objective of this surveillance is to verify that the laboratory has established and implemented an effective
More informationSANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery. o--,-.m-a----,laa~-d-c~~~~~~~~~~-
Page 11 of 8 SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Departmental Policy and Procedure Section Sub-section Alcohol and Drug Program (ADP) Policy Drug Medi-Cal
More informationODS Waiver SUD Treatment Documentation. A high level overview of DMC-Organized Delivery System (ODS) Waiver documentation requirements
ODS Waiver SUD Treatment Documentation A high level overview of DMC-Organized Delivery System (ODS) Waiver documentation requirements 1 Overview Expanded Service Delivery Definition of LPHA Intake Physical
More informationAdult Health History
Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure
More informationIDAHO SCHOOL-BASED MENTAL HEALTH SERVICES (EFFECTIVE JULY 1, 2016) PSYCHOTHERAPY & COMMUNITY BASED REHABILITATION SERVICES (CBRS)
IDAHO SCHOOL-BASED MENTAL HEALTH SERVICES (EFFECTIVE JULY 1, 2016) PSYCHOTHERAPY & COMMUNITY BASED REHABILITATION SERVICES (CBRS) IMPORTANT Medicaid providers are required to provide services in accordance
More informationCity of Tamarac Community Development Department Housing Division Section 3 Plan
City of Tamarac Community Development Department Housing Division Section 3 Plan Section 3 of the Housing and Urban Development Act of 1968 (12 U.S.C. 1701u) (as amended), requires that economic opportunities
More informationINTEGRATED CASE MANAGEMENT ANNEX A
INTEGRATED CASE MANAGEMENT ANNEX A NAME OF AGENCY: CONTRACT NUMBER: CONTRACT TERM: TO BUDGET MATRIX CODE: 32 This Annex A specifies the Integrated Case Management services that the Provider Agency is authorized
More informationCuyahoga County Juvenile Court Intervention Center Behavioral Health Services RFP
Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board Request for Proposals for the Cuyahoga County Juvenile Court Intervention Center Behavioral Health Services Program Summary and Background:
More informationRequest for Proposal Crisis Intervention Services
Request for Proposal Crisis Intervention Services Issued by: Columbia County Health and Human Services Proposals must be submitted no later than 4:30pm CST Thursday, April 28, 2011 For further information
More informationRequired Activities (continued)
DMAS-CMHRS Manual Services based upon incomplete, missing, or outdated (more than a year old or not reflective of the individuals current level of need) intakes/re-assessments and ISPs shall be denied
More informationNurse Aide Training Program Policies
Nurse Aide Training Program Policies Division of Long Term Living, 7 th Floor PO Box 8206 Columbia, SC 29202 Phone: 803-898-2590 Fax: 803-255-8290 Email: scnar@scdhhs.gov 0741-24 0418 1 Overview of the
More informationMental Health Atlas Department of Mental Health and Substance Abuse, World Health Organization. Mongolia
GENERAL INFORMATION Mongolia Mongolia is a country with an approximate area of 1567 thousand square kilometers (O, 2008). The population is 2,701,117 and the sex ratio (men per hundred women) is 98 (O,
More informationFannin County Children s Center Volunteer Application
Fannin County Children s Center Volunteer Application Telephone: Home: ( ) Cell: ( ) Work: ( ) If employed: May you be called at work? YES NO Email address: Social Security # Date of Birth Marital Status:
More information1. Section Modifications
Table of Contents 1. Section Modifications... 1 2.... 2 2.1. Overview... 2 2.2. Division of Medicaid... 2 2.3. General Information... 2 2.3.1. Provider Qualifications... 2 2.3.2. Record Keeping... 2 2.3.3.
More informationTo Access Community Center Rehabilitative Behavioral Health Services (RBHS)
To Access Community Center Rehabilitative Behavioral Health Services (RBHS) I. Who Can Make Referrals Representatives from the following South Carolina State agencies may make referrals/authorize Rehabilitative
More information2017 HUD CoC Competition Evaluation Instrument
2017 HUD CoC Competition Evaluation Instrument For all HUD CoC-funded projects in the Chicago Continuum of Care [PROJECT COMPONENT] . General Instructions Each year, as the Collaborative Applicant, All
More information201 KAR 35:070. Supervision experience.
201 KAR 35:070. Supervision experience. RELATES TO: KRS 309.0814, 309.083(4), 309.0831, 309.0832, 309.0833 STATUTORY AUTHORITY: KRS 309.0813(1), (3), (5), 309.0814(1), 309.083(3), 309.0831(3), 309.0832(10),
More informationSUBSTANCE ABUSE & HEALTH CARE SERVICES HEALTH SERVICES. Fiscal Year rd Quarter
HEALTH SERVICES To administer and manage contracted services to eligible persons in need of health care or related support services, and to promote health maintenance through education and intervention.
More informationMICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY INTEROFFICE COMMUNICATION OPERATIONAL MEMO GEN-5 TO: FROM: SUBJECT: All Waste Management Division Staff Jim Sygo, Chief, Waste Management Division Enforcement
More informationNorth Sound Behavioral Health Organization Section 1500 Clinical: Intra-network Individual Transfers and Coordination of Care
Effective Date: 3/3/2008; 6/25/2004 Revised Date: 7/12/2017 Review Date: 7/12/2017 North Sound Behavioral Health Organization Section 1500 Clinical: Intra-network Individual Transfers and Coordination
More informationAuthorization Approval and ASAM. Overview. Funding and Services IDOC and IDHW Funding and Authorization
Authorization Approval and ASAM July 2017 Overview Funding and Services IDOC and IDHW Funding and Authorization Assessment Admission, Transfer, and Continuing Care Denials Discharge BPA Health website
More informationGeneral and Informed Consent to Treatment
Section 3.11 General and Informed Consent to Treatment 3.11.1 Introduction 3.11.2 References 3.11.3 Scope 3.11.4 Did you know? 3.11.5 Definitions 3.11.6 Objectives 3.11.7 Procedures 3.11.7-A. General requirements
More informationOPERATIONS MANUAL CARE CONNECTIONS PROGRAM LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES
OPERATIONS MANUAL CARE CONNECTIONS PROGRAM LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES SECTION: PATIENT REFERRAL and INTAKE PROCEDURES 1 P age 1 CCP Referral Procedure Referrals for the Care Connections
More informationDCH Site Review Interpretive Guidelines
A. CONSUMER INVOLVEMENT... 3 B. SERVICES 1. GENERAL... 5 B.2. Peer Delivered & Operated Drop In Centers... 11 B.3. HOME BASED... 13 B.4. ASSERTIVE COMMUNITY TREATMENT... 17 B.5. CLUBHOUSE PSYCHO-SOCIAL
More informationBlue Cross Blue Shield of Michigan MiPCT/PDCM Reimbursement Policy and Billing Guidelines Commercial
Purpose Beginning April 1, 2012 BCBSM began accepting and paying claims for Provider Delivered Care Management services delivered by qualified Primary Care Physicians to patients in physician practices
More informationAdherence Nurse. I. Description. Treatment Adherence Nurse is an individual level intervention designed to actively engage formerly
21 Currently/Formally Incarcerated Treatment Adherence Nurse Treatment Adherence Nurse is an individual level intervention designed to actively engage formerly incarcerated individuals who are HIV+ in
More informationStatewide Medicaid Managed Care Long-term Care Program Coverage Policy
Statewide Medicaid Managed Care Long-term Care Program Coverage Policy Coverage Policy Review June 16, 2017 Today s Presenters D.D. Pickle, AHC Administrator 2 Objectives Provide an overview of the changes
More informationADULT SERVICE COORDINATION PROVIDERS IN ALLEGHENY COUNTY
Allegheny County Department of Human Services Service Coordination Referral Form ADULT SERVICES FORM INSTRUCTIONS 1. Only one service provider can be requested at a time. 2. All sections of this document
More informationLEVEL OF CARE GUIDELINES: COMMON CRITERIA & CLINICAL BEST PRACTICES FOR ALL LEVELS OF CARE OPTUM IDAHO
OPTUM LEVEL OF CARE GUIDELINES: COMMON CRITERIA & BEST PRACTICES OPTUM IDAHO LEVEL OF CARE GUIDELINES: COMMON CRITERIA & CLINICAL BEST PRACTICES FOR ALL LEVELS OF CARE OPTUM IDAHO Guideline Number: Effective
More informationVersion Summary New Questions Added Answers Revised Answers Archived 08/25/ thru 42 n/a n/a
Version Summary New Questions Added Answers Revised Answers Archived 08/25/2017 1 thru 42 n/a n/a 1. Acronyms 2. BPA Health Network Process 3. Prescriber Agreements 4. Funding 5. Medications 6. Screening
More informationMental Health Rehabilitation Authorization Resource Kit
Mental Health Rehabilitation Authorization Resource Kit CONTENTS Introduction... 2 Provider Notice 2018-27: Revised and Streamlined MHR Authorization Process... 3 Process Overview & Submission Checklist...
More informationNEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION MEDICALLY FRAGILE WAIVER (MFW)
NEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION MEDICALLY FRAGILE WAIVER (MFW) CASE MANAGEMENT Effective January 1, 2011 MFW case management is a collaborative process of assessment,
More informationLOCADTR 3.0 Assessment (if no LOCADTR 3.0 is completed, have a LOCADTR consent signed)
Application for Admission Fax or email completed application with required documentation to Phil White Fax: (607) 273 1277 Scan/email: admissions@carsny.org Please call with any questions: (607) 273-5500
More informationNavigating Work Life Health. Affiliate Clinical Forms
Navigating Work Life Health Affiliate Clinical Forms Introduction Lytle EAP Partners is an independent consulting and service organization that provides development, implementation, and administration
More informationThe goal of this training is to provide school districts with the tools and resources they need to implement successful processes in order to ensure
The goal of this training is to provide school districts with the tools and resources they need to implement successful processes in order to ensure ongoing compliance with Medicaid regulations. 2 Medicaid
More informationTurkey. Note: A Mental Health Action plan is prepared but has not been published yet.
GENERAL INFORMATION Turkey Turkey is a country with an approximate area of 775 thousand square kilometers (O, 2008). The population is 75,705,147 and the sex ratio (men per hundred women) is 100 (O, 2009).
More information1. Section Modifications
Table of Contents 1. Section Modifications... 1 2.... 2 2.1. Overview... 2 2.2. Regional Medicaid Services... 2 2.3. General Information... 2 2.3.1. Provider Qualifications... 2 2.3.2. Record Keeping...
More informationPAGE R1 REVISOR S FULL-TEXT SIDE-BY-SIDE
69.11 ARTICLE 4 69.12 CONTINUING CARE 50.15 ARTICLE 4 50.16 CONTINUING CARE 69.13 Section 1. Minnesota Statutes 2010, section 62J.496, subdivision 2, is amended to read: 50.17 Section 1. Minnesota Statutes
More informationGUIDELINES FOR SCORING INDIVIDUAL RECORDS. Y = Meets Standard N = Does Not Meet Standard. N/A = Not Applicable
QUALITY OF DOCUMENTATION PHP GUIDELINES FOR SCORING INDIVIDUAL RECORDS Y = Meets Standard N = Does Not Meet Standard N/A = Not Applicable GUIDELINES FOR DETERMINING PROGRAM COMPLIANCE WITH STANDARDS Programs
More informationIntensive In-Home Services Training
Intensive In-Home Services Training Intensive In Home Services Definition Intensive In Home Services is an intensive, time-limited mental health service for youth and their families, provided in the home,
More informationCONNECTICUT CONSTRUCTION INDUSTRIES ASSOCIATION, INC.
CONNECTICUT CONSTRUCTION INDUSTRIES ASSOCIATION, INC. 017 CCIA Safety Recognition Award Application 1 Silas Deane Highway Wethersfield, CT 010 Tel: 80.5.855 Fax: 80.5.01 ccia-info@ctconstruction.org www.ctconstruction.org
More informationQuality Assurance. Peer Review Training
Quality Assurance Peer Review Training For individuals enrolled after 3/1/2012, is the Receipt of the Orientation Handbook &HIPAA Privacy Act 1 Acknowledgement signed by the individual in Carelogic? 2
More informationempowering people to build better lives their efforts to meet economic, social and emotional challenges and enhance their well-being
Community Care Alliance empowering people to build better lives Adult Mental Health Services Basic Needs Assistance Child & Family Services Education Employment & Training Housing Stabilization & Residential
More informationAngel Medical Services
Statement of purpose Health and Social Care Act 2008 Angel Medical Services Certificate Number: CRT1 522169817 Certificate Date: 15/11/2012 Provider ID: 1-199811911 Ritchie Street Group Practice CQC Statement
More informationNURSING FACILITY (NF) PASRR II-B NOTIFICATION FORM (To be completed by Nursing Facilities)
Attachment A NURSING FACILITY (NF) PASRR II-B NOTIFICATION FORM (To be completed by Nursing Facilities) RESIDENT NAME: J.H. NF NAME: Skilled Nursing Facility of Las Vegas NF DATE OF ADMISSION: 1/1/12 PASRR
More informationOlder Americans Act: Adult adult day service.
ACTION: Original DATE: 04/18/2016 5:01 PM 173-3-06.1 Older Americans Act: Adult adult day service. (A) "Adult day service" ("ADS") means a regularly-scheduled service delivered at an ADS center, which
More informationBarbara K. McEntee, Ph.D., PLLC 4815 S. Harvard Ave., Suite 470, Tulsa, Oklahoma 74135 Phone: 918-392-4866 Fax: 918-392-4867 www.barbaramcenteephd.com Thank you for the opportunity to provide psychological
More informationINVITATION TO NEGOTIATE (ITN) ADDENDUM #1. July 21, 2017
INVITATION TO NEGOTIATE (ITN) ADDENDUM #1 July 21, 2017 ITN Number: 10511 ITN Services: The Department seeks replies from qualified non-profit, for profit and government entities to serve as the single
More informationPrescriptive Authority & Protocol Agreement
Physician Information Name: License Number: Address of Primary Practice Address of Other Practice Address of Other Practice Prescriptive Authority & Protocol Agreement Advanced Practice Registered Nurse
More informationAMENDATORY SECTION (Amending WSR , filed 8/27/15, effective. WAC Inpatient psychiatric services. Purpose.
AMENDATORY SECTION (Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15) WAC 182-550-2600 Inpatient psychiatric services. Purpose. (1) The medicaid agency, on behalf of the mental health division
More informationSTANDARD / ELEMENT EXPLANATION SCORING PROCEDURE SCORE
31.00.00 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with 482.54 The Medicare Hospital Conditions
More informationAffordable Concierge New Patient Registration
Affordable Concierge New Patient Registration Patient Information Last name: First name: MI: DOB: [ ] Male [ ] Female Home address: City: State: Zip: Billing address: [ ] Same as home City: State: Zip:
More informationClient Information Form
Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a
More informationStudent Declaration of Understanding
Student Declaration of Understanding Workplace Safety and Insurance Board or Private Insurance Coverage for Students on Unpaid Placements Student coverage while on unpaid placement: The government of Ontario,
More informationINFORMATION AND FORMS FOR AGENCY SUPERVISORS
INFORMATION AND FORMS FOR AGENCY SUPERVISORS 1 NEW YORK CITY COLLEGE OF TECHNOLOGY of the City University of New York 300 Jay Street Brooklyn, New York 11201 Human Services Department Agency Field Work
More informationGENERIC RISK ASSESSMENT FOR ALL DERBY CITY SCHOOL SPORTS PARTNERSHIP ACTIVITIES
31 August 2014 The aim of this generic risk assessment is to provide general information on the type of hazards employees, pupils and others who attend the activities could be exposed to. This document
More informationFLORIDA - REGION DEPARTMENT OF COUNSELING AND PSYCHOLOGY CP 6659 INTERNSHIP (CLINICAL MENTAL HEALTH)
FLORIDA - REGION DEPARTMENT OF COUNSELING AND PSYCHOLOGY CP 6659 INTERNSHIP (CLINICAL MENTAL HEALTH) STUDENT: (last) (first) (mi) TROY EMAIL: STUDENT ID NUMBER: COURSE SECTION NUMBER (i.e. FPPA) SEMESTER
More informationDepartment of Veterans Affairs VHA HANDBOOK Washington, DC May 24, 2007 VOLUNTEER TRANSPORTATION NETWORK (VTN)
Department of Veterans Affairs VHA HANDBOOK 1620.02 Veterans Health Administration Transmittal Sheet Washington, DC 20420 May 24, 2007 VOLUNTEER TRANSPORTATION NETWORK (VTN) 1. REASON FOR ISSUE. This Veterans
More informationComprehensive Child and Family Assessment & Wrap-Around CCFA/WA Fiscal Year 2013
1 of 10 Approved Provider List Q: When will the CCFA/WA approved provider list be available? Only Providers who have received a fully executed contract will be listed as an approved CCFA/WA provider. This
More informationDIOCESE OF VENICE IN FLORIDA
DIOCESE OF VENICE IN FLORIDA I. Introduction Guidelines Concerning all Youth and Student Trips The following Guidelines Concerning all Youth and Student Trips has been approved by the Diocese of Venice
More informationVersion 1.1, 6/30/2016 Guidance for Abbreviated IDE Requirements
Version 1.1, 6/30/2016 Guidance for Abbreviated IDE Requirements The Principal Investigator of a study that is requesting an abbreviated IDE for use of a non-significant risk device must attest to the
More informationNETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS TARGETED CASE MANAGEMENT
NETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS TARGETED CASE MANAGEMENT Provider will comply with regulations and requirements as outlined in the Michigan Medicaid Provider Manual, Behavioral
More information2018 Summer Camp Registration
2018 Summer Camp Registration Registration is a 3-Step Process. Complete all of the steps listed below to secure your registration and rate. Incomplete forms and a delay in submitting the required documents
More informationTIME STUDY TRAINING. Prepared For: INDIANA MENTAL HEALTH PROVIDERS
TIME STUDY TRAINING Prepared For: INDIANA MENTAL HEALTH PROVIDERS Introduction This training is to give you the instructions necessary to complete the time study during the week of July 9 15, 2018. There
More informationOptum/OptumHealth Behavioral Solutions of California Facility Network Request Form / Credentialing Application
Optum/OptumHealth Behavioral Solutions of California Is the facility currently in the Optum network? Yes No Acceptance into the Optum/OptumHealth Behavioral Solutions of California (Optum) provider network
More informationPIONEER CENTER NORTH PIONEER CENTER EAST Substance Use Disorder (SUD) Residential Adult Long Term Care Statement of Work
PIONEER CENTER NORTH PIONEER CENTER EAST Substance Use Disorder (SUD) Residential Adult Long Term Care Statement of Work I. WORK STATEMENT The Contractor shall provide SUD residential treatment in the
More informationAgency for Health Care Administration
Page 1 of 24 ST - Q0000 - Initial Comments Title Initial Comments Statute or Rule Type Memo Tag These guidelines are meant solely to provide guidance to surveyors in the survey process. ST - Q0100 - License
More information