NETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS COMMUNITY LIVING SUPPORTS (CLS)

Transcription

1 NETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS COMMUNITY LIVING SUPPORTS (CLS) Provider will comply with regulations and requirements as outlined in the Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services chapter, including specific sections Additional Mental Health Services (B3 s) and Community Living Supports, as well as the Lakeshore Regional Entity Contract Attachment A: Service Description for Community Living Supports (CLS) Services. In addition to these, Provider must adhere to the following specific requirements. COMMUNITY LIVING SUPPORTS (CLS) SERVICES FOR ADULTS WITH MENTAL ILLNESS Community Living Supports in a Licensed Facility (Excluding Specialized Residential Services) Providers of this service must also adhere to the requirements specified in the Lakeshore Regional Entity Contract Attachment A: Service Description for Personal Care in a Licensed Specialized Residential Setting. The purpose of this service is to provide medically necessary Community Living Supports (CLS) services to adults with serious mental illness and/or co-occurring disorder (MI and SUD) who live in a licensed facility. CLS services provided in a licensed facility are supports provided over and above those required of the facility through licensing of that facility, and cannot supplant licensing requirements. Services 1. Ensure receipt of a copy of the completed individual plan of service (IPOS) in order to guide service provision. 2. Provider will implement activities designed to accomplish the goals and objectives for CLS as outlined in the IPOS. 3. Provider shall maintain adequate communication with the Targeted Case Management Provider, including appropriate documentation supporting provision of services, as well as input on progress toward goals. Eligibility The individual must be receiving Targeted Case Management services. Access and Authorization 1. Following the process identified within the CLS Authorization Request Form, Case Managers will complete the form to demonstrate the assessed need for service as identified through the personcentered planning process. 2. The CLS Authorization Request Form will be submitted with appropriate accompanying documentation to Network180 for review and authorization. 3. Services must be authorized prior to delivery of services. 4. Network180 staff will review the request and supporting documentation and make a decision within 14 days of receipt of all documentation necessary to make the decision. 5. Services may be authorized for up to 13 months, coinciding with the IPOS timelines and process. 6. If medical necessity for services is not met, or a reduction is service needs is identified, the appropriate process will be followed, including sending a Notice of Action and appeals information. 1 Rev: 7/9/18

2 7. Case Managers are responsible for completing and submitting the request for services days prior to expiration of any current authorization for services. Individual Community Living Supports in an Unlicensed Facility The purpose of this service is to provide medically necessary Community Living Supports (CLS) services to adults with serious mental illness and/or co-occurring disorder (MI and SUD) who live in an unlicensed facility, including the individual s private residence. Services 1. Eligibility for Home Help Services through the Michigan Department of Health and Human Services (MDHHS) must be pursued prior to application for CLS services through Network180. CLS services may not supplant, but may compliment, services for which the individual may be eligible through Home Help. 2. Services may be provided through one of Network180 s paneled providers, or through a provider of choice utilizing a Self-Determination arrangement. 3. If a Self-Determination arrangement is preferred, the process for access and authorization must be completed. Once medical necessity is determined to be met, the process for Self-Determination must be completed. For this process, please refer to Self-Determination documents and guidelines. 4. Provider shall ensure receipt of a copy of the completed individual plan of service (IPOS) in order to guide service provision. 5. Provider will implement activities designed to accomplish the goals and objectives for CLS as outlined in the IPOS. 6. Provider shall maintain adequate communication with the Targeted Case Management Provider, including appropriate documentation supporting provision of services, as well as input on progress toward goals. Eligibility The individual is receiving Targeted Case Management services. Access and Authorization 1. Following the process identified within the CLS Authorization Request Form, Case Managers will complete the form to demonstrate the assessed need for service as identified through the personcentered planning process. 2. The CLS Authorization Request Form will be submitted with appropriate accompanying documentation to Network180 for review and authorization. 3. Services must be authorized prior to delivery of services. 4. Network180 staff will review the request and supporting documentation and make a decision within 14 days of receipt of all documentation necessary to make the decision. 5. Services may be authorized for up to 13 months, coinciding with the IPOS timelines and process. 6. If medical necessity for services is not met, or a reduction is service needs is identified, the appropriate process will be followed, including sending a Notice of Action and appeals information. 7. Case Managers are responsible for completing and submitting the request for services days prior to expiration of any current authorization for services. Community Living Supports and Personal Care in a Specialized Residential Setting (Specialized Residential Services) In addition to meeting the regulations and requirements outlined at the top of this document, Provider must meet the regulations and requirements outlined in the Michigan Medicaid Provider Manual, the Behavioral Health and Intellectual and Developmental Disability Supports and Services chapter, specific sections 2 Rev: 7/9/18

3 Personal Care in Licensed Specialized Residential Settings, Peer Delivered or Operated Services, and Assessments, Medication Administration, Medication Review, and Health Services. Provider must also adhere to the requirements specified in the Lakeshore Regional Entity Contract Attachment A: Service Description for Personal Care in a Licensed Specialized Residential Setting. The purpose of this service is to provide medically necessary Community Living Supports (CLS) and Personal Care (PC) services to adults with serious mental illness or co-occurring disorder (MI and SUD) who live in a licensed setting. In addition, Specialized Residential services provide varying levels of supervision to individuals assessed to require and could benefit from an increased level of service intensity. Services 1. Provide services consistent with the proposal/program description and staffing information submitted to Network180, ensuring staff/individual ratios are sufficient to adequately and safely meet the needs of individuals. 2. Participate in all residential placement processes coordinated by Network180 for collaborative system resource management. 3. Have the capacity and flexibility to meet the changing needs of individuals, focusing on a recoveryorientation. 4. Ensure individuals identified as needing behavior supports as part of their treatment have an individualized behavior plan approved through the appropriate process. All staff must be trained in the treatment approaches. 5. Assist individuals in accessing supports and services that will promote transitioning to the least restrictive environment, with the least intensive services possible, including Supported Employment and Clubhouse, if clinically appropriate and supported in the individual plan of service (IPOS). 6. Enhanced staffing requests must be made through Network180 prior to increasing service provision, as safety allows. Eligibility 1. The individual must be currently authorized and receiving mental health or co-occurring (MI and SUD) services. 2. A less restrictive level of service is not adequate to meet the needs of the individual as assessed, determined through a person-centered planning process and outlined in the IPOS. Access and Authorization 1. Referral, authorization, and reauthorization occur through a residential placement process coordinated by Network180 wherein admission, continued stay, transfer, and/or discharge requests are reviewed, approved or disapproved. Intensive residential placements are solely for support of the successful implementation of the IPOS. 2. These services must be reviewed and authorized through the appropriate process prior to accessing. 3. Referrals will be received by the Network180 Ombudsperson through the supervisor of the agency s Case Management team or program currently providing services. The supervisor will have provided consultation to the Case Manager around the circumstances leading to the referral. 4. Current Case Management staff will provide documentation as directed by the Ombudsperson supporting the need for intensive services, including documentation outlining all other options have been assessed and/or tried, and exhausted. Documentation should outline what options have been considered, why certain options have not been pursued, and circumstances around the failure of options that were tried. Documentation includes, but is not limited to, completed CLS Authorization Request Form, current IPOS and Addendums, and relevant case notes. 5. The Network180 Ombudsperson will review the case with appropriate Network180 staff. In some cases a consultation meeting may be convened with Network180 staff, the individual s Case 3 Rev: 7/9/18

4 Manager, the Case Manager s supervisor, and other relevant individuals, possibly including other case management agency supervisors. 6. If a transition to this level of care is recommended, the Network180 Ombudsperson will also recommend placement in a specific program. The Network180 Ombudsperson will facilitate a referral to that program by contacting admissions for that program. The Case Manager will complete appropriate referral paperwork and documentation, and submit it to the program directly. 7. If Targeted Case Management services will not be provided by the Residential Provider, the current Targeted Case Management Provider may retain provision of services, or transfer to another provider, as appropriate. 8. If Targeted Case Management services are being transferred, the current Targeted Case Management Provider will retain responsibility for services to the individual until the individual is successfully transitioned to the residence. To promote success transition, it may be necessary for the transferring Targeted Case Management Provider to overlap services with the receiving agency. 9. If the individual leaves the home against clinical advice, the assigned Targeted Case Management Provider will provide re-engagement services. 10. In all circumstances the Targeted Case Management Provider, residential staff, and Network180 will collaborate to provide continuity of care for individuals entering or leaving a program or residence. Reauthorization 1. Referral, authorization, and reauthorization occur through a residential placement process coordinated by Network180 wherein admission, continued stay, transfer, and/or discharge requests are reviewed, approved, or disapproved. Intensive specialized residential placements are solely for support of the successful implementation of the IPOS. 2. If the Targeted Case Management Provider, in consultation with the residential staff, determines the individual needs continued intensive residential placement, beyond the current authorization, the Case Manager must complete the Residential Reauthorization Request Form on the Network180 Collaboration SharePoint site and follow the process coordinated by Network180. Requests for authorization must be received on, or before the last date of the authorized service, preferably days prior to expiration of the current authorization. Network180 will not be responsible for financial reimbursement for services delivered that have not been approved. 3. If the Case Management Provider, in consultation with residential staff needs to be transferred to another residential program, either prior to expiration, or at expiration of the current authorization, the Case Manager must receive prior verbal authorization from the Network180 Ombudsperson. The Specialized Residential Transfer Verification Form must be submitted no later than the day after transfer. Network180 will not be responsible for financial reimbursement of services delivered that have not been approved. Discharge 1. If the Targeted Case Management Provider, in consultation with residential staff, determines the individual should be discharged, the Case Manager must receive verbal approval from the Network180 Ombudsperson. The Specialized Residential Discharge Verification Form must be submitted no later than the day after discharge. Network180 will not be responsible for financial reimbursement of services delivered that have not been approved. 2. If intensive residential services are to reduced or terminated, the Notice of Action and provision of appeal paperwork process will be followed. If the individual wishes to appeal the decision, the Case Manager will assist with filing an appeal, as necessary. Intensity of Services Individuals will be assessed to benefit from services, and for intensity of services, based on the following: 4 Rev: 7/9/18

5 High Intensity Enhanced (Medical or Psychiatric) Severity of Illness: Meets #1 and at least two of # Psychiatric Signs and Symptoms a. Symptom driven behavior and disordered thought processes are primary and consistently observable and expected to persist b. Close staff supervision required to adjust to a highly stimulating environment 2. Disruptions in Self-Care and Independent Functioning a. Close supervision for risk management off-site b. Psychosis prevents independence with self-care and other essentials of daily living c. Close supervision required for participation in educational/occupational activities 3. Danger to Self a. Evidence of thoughts and actions may occur intermittently and can be addressed through staff intervention 4. Danger to Others b. Potential of danger due to impairment of thought or judgment may at times require physical management 5. Drug/Medicaid/Medical Issues a. Close staff supervision required to maintain psychiatric stability with medication b. Medical condition may require monitoring and intervention Intensity of Service: 1. High intensity intervention 2. Restricted community access 3. Behavioral management services 4. In-house skill building or structured day program Moderate/High Intensity Severity of Illness: Meets #1 and at least two of # Psychiatric Signs and Symptoms a. Symptom driven behavior and disordered thought processes are primary and consistently observed b. Symptoms are exacerbated in a more stimulating environment 2. Disruptions in Self-Care and Independent functioning a. Symptoms may impair judgment regarding decisions and personal safety in the community b. May require prompting to consistently perform self-care and other essentials of daily living c. Staff supervision required for participation in community-based educational/employment settings 3. Danger to Self a. Thoughts or actions may occur intermittently and can be managed by staff intervention 4. Danger to Others a. Thoughts or actions may occur intermittently and can be managed by self-intervention 5. Drug/Medication/Medical Issues a. Staff teaching required to self-administer medication Intensity of Service: 1. Behavior management programming 2. Limited community access 3. In-house skill building or structured day program 4. Environment modifications to promote safety Moderate Intensity/Medical Severity of Illness: Meets #1 and at least two of #2 5 5 Rev: 7/9/18

6 1. Psychiatric Signs and Symptoms a. Symptom driven behavior and disordered thought process may at times require redirection and are expected to persist b. Unable to adjust to a highly stimulating environment 2. Disruptions in Self-Care and Independent Functioning a. Close supervision for risk management off-site b. Psychosis/medical problems prevent independent care of self and other essentials of daily life c. Close staff supervision required for participation in community based activities 3. Danger to Self a. Evidence of thoughts and actions without intent to follow through, or can be prevented by staff intervention b. Potential to place self at risk due to impaired judgment 4. Danger to Others a. Potential of danger due to impairment of perceptions, thought or judgment b. Intermittent verbalizations not supported by plan, intent, or ability 5. Drug/Medication/Medical Issues a. Close staff supervision required to maintain medication stability b. Potential to engage in behaviors that may present medical risk c. Close staff supervision required to monitor medical needs associated with aging, or a complicated medical condition, requiring moderate to high medical intervention. Intensity of Service: 1. Behavior management programming 2. Medium intensity medical intervention 3. Limited community access 4. Long-term length of stay 5. In-house skill building or structured day program Low to Moderate Intensity/Medical Severity of Illness: Meets #1 and at least two of # Psychiatric Signs and Symptoms a. Symptom driven behavior and disordered thought processes may at times require redirection, but in general, symptoms are present at a stable level and are expected to persist 2. Disruptions in Self-Care and Independent Functioning a. Symptoms may impair judgment regarding decisions and personal safety in community b. Staff supervision required to perform self-care or other essentials of daily living c. Close staff supervision required to attend community based occupational activities 3. Danger to Self a. Intermittent verbalizations not supported by individual s plan, actual intent or ability b. Potential to place self at risk due to impaired judgment 4. Danger to Others a. Potential of danger due to impairment of thought, perceptions, or judgment b. Intermittent verbalizations not supported by individual s plan, actual intent or ability 5. Drug/Medication/Medical Issues a. Age related medical condition, or complicated medical condition, requires moderate monitoring and intervention b. Limited potential to self-administer medication Intensity of Service: 1. Medication Administration 6 Rev: 7/9/18

7 2. Consistent behavior observation 3. Moderate medical intervention 4. In-house skill building or structured day program 5. Behavior management programming 6. Limited community access Low to Moderate Intensity Severity of Illness: Meets #1 and at least two of # Psychiatric signs and Symptoms a. Symptom driven behavior and disordered thought processes may require redirection b. Behavior modification is required to maintain psychiatric stability c. Behavior modification and treatment are necessary to promote greater independence 2. Disruptions in Self-Care and Independent Functioning a. Staff teaching required to promote self-care or other essentials of daily living b. Symptoms may impair judgment regarding decisions and personal safety in community 3. Danger to Self a. Thoughts or actions may occur intermittently but can be redirected by staff intervention 4. Danger to Others a. Thoughts or actions may occur intermittently but can be redirected by staff intervention 5. Drug/Medication/Medical Issues a. Staff teaching required to consistently self-administer medication Intensity of Service: 1. Behavior Management Programming 2. Limited in-house skill building or structured day program 3. Limited medical intervention 4. Open community access COMMUNITY LIVING SUPPORTS SERVICES FOR ADULTS WITH INTELLECTUAL/DEVELOPMENTAL DISABILITIES The Case Manager or Supports Coordinator is responsible to give the CLS Provider a copy of the individual plan of service (IPOS) and any addendums. Individual Community Living Supports 1. Provider will support individuals to have authority over their budget. This includes, at a minimum, maintaining a monthly utilization report. Provider must notify the Case Manager/Supports Coordinator if the budgeted units are over or under by 10% or more and provide the report to the Case Manager/Supports Coordinator or individual when requested. 2. Provider will support individuals to exercise their choice and control over who provides services and supports and how they are provided. This includes, at a minimum, meeting staff before they work, being given the opportunity to interview potential staff, having a choice of when staff work (based on the recommendations from the Case Manager/Supports Coordinator), and having the ability to tell the agency to not send a specific worker back to their house if they do not want that person to work with them. 3. I/DD agencies that provide Individual CLS must also have individual in-home Respite Services available. CLS cannot be used for the purpose of relieving the individual s primary caregiver. If Respite Services are provided, please refer to the LRE Service Description for Respite Services. 7 Rev: 7/9/18

8 4. The provision of CLS services when there is one staff working with multiple individuals shall be driven by the person-centered planning process and the resulting IPOS. The IPOS must state which areas of service may be provided in a shared staffing manner. All 15-minute units shall be authorized at the 1:1 rate. Units (15 minutes) of service that are provided when there is one staff working with multiple individuals shall be documented using the TT modifier and billed at the shared rate. 5. Provider is responsible for backup staffing coverage. 6. Individuals determined eligible for daily level of care who receive services in an unlicensed setting and meet medical/clinical necessity for Respite Services per the initial screen section of the Respite Services worksheet, may use up to 30% of their budget for Respite Services. Life Skills Community Living Supports The purpose of the Life Skills CLS program is to provide medically necessary supports in a large group setting to adults with intellectual/developmental disabilities who are interested in planned, purposeful, meaningful daily activities in the community (who do not chose to prepare for paid work positions). Life Skills CLS activities are used to increase or maintain personal self-sufficiency, facilitating an individual s achievement of his or her goals of community inclusion and participation, and independence when identified in the IPOS as one or more goals developed during person-centered planning. 1. Provider will provide services in the community (not a licensed setting) as much as possible. 2. If this service is provided in a facility, the site must be a Michigan Department of Health and Human Services (MDHHS) approved day program site. 3. Life Skills CLS activities are not intended to be vocational preparatory activities. 4. Individuals will be actively engaged in all aspects of their day, such as choosing, planning, doing, creating, and developing volunteer opportunities, educational activates, relationship building, recreation, and membership in clubs and organizations within the community. 5. Programs are generally no more than six hours per day with a half hour break for lunch. 6. Direct staff support/supervision must be provided according to need, as identified in the IPOS. Average staff to consumer ratio may vary but typically would average 1:5. 7. Agencies providing Life Skills CLS services shall participate in Network180 meetings for collaborative system resource management. 8. Provider must coordinate and collaborate with the Supports Coordinator to ensure that authorizations and reauthorizations for services are completed accurately and in a timely manner. 9. Services include transportation assistance to the individual as needed. The least restrictive transportation options will be utilized. Provider will work with individuals to increase independence skills surrounding transportation issues. Outcome Measure Measure % of time spent in the community How Measure is Calculated Total time spent in the community / Total time billed Source of Who Collects How Benchmark Data Data Often Provider 75% Provider Quarterly Life Skills Community Living Supports-Intensive Supports The purpose of the Life Skills CLS-Intensive Supports program is to provide medically necessary supports in a small group setting to adults with intellectual/developmental disabilities who are interested in planned, purposeful, meaningful daily activities in the community (who do not chose to prepare for paid work 8 Rev: 7/9/18

9 positions). Life Skills CLS activities are used to increase or maintain personal self-sufficiency, facilitating an individual s achievement of his or her goals of community inclusion and participation, and independence when identified in the IPOS as one or more goals developed during person-centered planning. 1. Provider will provide services in the community (not a licensed setting) as much as possible. 2. If this service is provided in a facility, the site must be an MDHHS approved day program site. 3. Life Skills CLS activities are not intended to be vocational preparatory activities. 4. Individuals will be actively engaged in all aspects of their day, such as choosing, planning, doing, creating, and developing volunteer opportunities, educational activates, relationship building, recreation, and membership in clubs and organizations within the community. 5. Programs are generally no more than six hours per day with a half hour break for lunch. 6. Direct staff support/supervision must be provided according to need, as identified in the IPOS. 7. Agencies providing Life Skills CLS-Intensive Supports shall participate in Network180 meetings for collaborative system resource management. 8. Provider must coordinate and collaborate with the Supports Coordinator to ensure that authorizations and reauthorizations for services are completed accurately and in a timely manner. 9. Services include transportation assistance to the individual as needed. The least restrictive transportation options will be utilized. Provider will work with individuals to increase independence skills surrounding transportation issues. Residential Treatment Providers of this service must also adhere to the requirements specified in the Lakeshore Regional Entity Contract Attachment A: Service Description for Personal Care in a Licensed Specialized Residential Setting. The purpose of Residential Treatment is designed for adults with intellectual/developmental disabilities who meet the eligibility criteria for Community Living Supports (CLS) and Personal Care (PC) at the daily level of care. Residential Treatment provides training, supervision, and support to individuals in paneled provider licensed settings. One home may serve multiple levels of care as required by individuals needs. Provider must have the capacity and the flexibility to adjust to meet the changing needs of individuals. 1. Referral will occur through the Interagency Clinical Team (ICT), a process coordinated by Network180. Placements in Residential Treatment are solely for the support of successful implementation of the individual plan of service (IPOS). 2. Provider shall participate in all ICT meetings for collaborative system resource management. 3. Effective treatment of individuals with intellectual/developmental disabilities requires coordination and collaboration with all community agencies and organizations identified as needed to attain independence and integration into the community, particularly Supports Coordination. 4. Services must be provided in an environment that supports individuals with co-occurring needs, trauma informed care, and physical health care integration. 5. Services must be provided in an environment that supports the central purpose of teaching a feeling of companionship and community. 6. Supports and coaching will be provided in the areas of hobby and interest development, acceptance and initiation of kindness, and how to do things with and for caregivers, housemates, and friends. 7. Provider will nurture a culture for delivering supports and guidance to help people feel safe and valued, to value others, and to become engaged with others. This includes: a. Individualized schedule of activities for opportunities to build relationships (rather than skill development) b. Individualized schedule of activities that builds structure and predictability. c. Use of words, eyes, touch, and presence to teach companionship. 9 Rev: 7/9/18

10 Outcome Measure Measure % of staff turnover How Measure is Calculated # of residential staff separated (resigned/discharged) / Average # of residential staff employed for the period of to Source of Who Collects How Benchmark Data Data Often Provider 30% Provider Annually Residential Treatment-Short Term Providers of this service must also adhere to the requirements specified in the Lakeshore Regional Entity Contract Attachment A: Service Description for Personal Care in a Licensed Specialized Residential Setting. The purpose of Residential Treatment-Short Term is to provide Residential Treatment for adults with intellectual/developmental disabilities who have exhausted all other options of support and training and who cannot remain in their current living arrangement. Residential Treatment-Short Term provides training using gentle approaches for interacting with and responding to individuals in a licensed setting. The Residential Treatment-Short Term Provider must have the capacity to provide all levels of support within the home in order to meet the varying needs of individuals. The home must be able to admit individuals with little or no notice, on a 24-hour, 7-day a week basis. The home must have licensed capacity for six individuals and be licensed for mental illness and intellectual/developmental disabilities. 1. Provider Clinical Program Manager or staff will request the following information for admission into the program: a. Contact information for physicians, including psychiatrists b. Physical (including blood work, medication list, other physical needs) c. Current individual plan of service (IPOS)/social assessment and any current support plans d. School or vocational contacts e. Any reports of current involvement with the justice system f. Support (paid and natural) utilized in current living environment g. Description of the current living environment (current situation, brief description of needs) h. Medication prescriptions i. Any additional information pertinent to this individual 2. Direct staff support and supervision is provided as identified in the IPOS and/or intake assessment. 3. Provider must formulate and implement a temporary treatment plan within 48 hours of admission based on the recommendations of the Supports Coordinator. 4. A safety plan must be implemented at the time of admission. 5. The individualized plan of supports and discharge will be developed within seven days of admission, based on the philosophy of the Culture of Gentleness. 6. Service planning and execution remain the responsibility of the referring Supports Coordinator, with the Provider Clinical Program Manager providing supplemental and augmented safety plan services. 7. Provider must collaborate with the Supports Coordinator to determine the CLS level of care required for successful discharge. 8. Individuals served will be supported by strategies that: a. Teach that they are safe emotionally and physically b. Reduce events/interactions that make the individual feel unsafe or insecure 10 Rev: 7/9/18

11 c. Teach that they are valued, respected, and loved d. Teach that it is good to value, respect, and love others e. Teach that is it good to do things with and for others f. Provide predictability and structure to the day g. Provide the opportunity to make choices throughout the day h. Allow the individual to express their needs in a safe manner i. Emphasize community inclusion, if possible j. Services must be provided in an environment that supports individuals with co-occurring needs, trauma informed care, and physical health care integration 9. Additional forms of treatment or support (OT services, sensory programming, counseling/therapy, etc.) will be coordinated as needed. 10. The treatment team, including the Provider Clinical Program Manager, Supports Coordinator, and any other professional disciplines as needed will conduct weekly reviews of plan implementation transition planning that will identify staff training needs, and debrief any challenging situations. The Clinical Program Manager will share information with Network180 once per week. In addition, the Clinical Program Manager will share information with the Supports Coordinator a minimum of once per week, and the Supports Coordinator will share information with the family/guardian weekly. 11. All attempts will be made to ensure that the individual is able to engage in favorite activities, have access to favorite foods, and maintain contact with family and friends while living at the Residential Treatment-Short Term home. 12. Authorizations will not exceed a 90-day time frame. 13. During the last week of placement, caregivers from the next living arrangement will work with the Clinical Program Manager. The purpose of this is training and mentoring as well as assisting with the transition to the next living arrangement. When it is determined that the needs are met, an exit meeting will be held in the week prior to discharge with the Supports Coordinator and caretakers from the next living arrangement to share recommendations and to outline future support needs. 14. Provider must have a dedicated staff responsible for ensuring 24 hour/day, 7 day/week on-call service, admission, support, and discharge planning. Responsibility also includes updates to Interagency Clinical Team for collaborative system resource management, facilitation of weekly transition planning meetings, and review and approval of CLS worksheets. 15. Services include the provision of medical supplies and equipment as indicated in the IPOS and/or intake assessment. 16. The home will provide up to 1:1 daytime staffing as needed and up to 1:2 staffing during sleep hours as needed. The home will have a lead staff on all day and afternoon shifts, including weekends. 17. Additional training requirement includes Co-Occurring/Complex Needs. COMMUNITY LIVING SUPPORTS (CLS) SERVICES FOR CHILDREN AND FAMLIES Community Living Supports (CLS) Services 1. Any child receiving an authorization for CLS services must have the Network180 CLS Outcome Scale completed at intake (with CLS Needs Assessment) and at discharge from CLS services. 2. Case notes must be completed on the CLS Tracking Sheet and must clearly document the CLS services that were provided specific to the identified goals. Notes must identify the type of CLS that was provided (e.g., assistance with skill development, support, training, observing, monitoring 11 Rev: 7/9/18

12 of pro-social behaviors, etc.) as well as progress made/not made on the goal. Case notes must be in compliance with documentation guidelines. 3. Staff providing CLS services may not dispense medication to any recipient. Authorization 1. Provider must complete the CLS Needs Assessment. 2. If requesting services for a sibling of an authorized child, the Sibling Services Brief Screening Form and Demographic Intake and Financial Intake Forms must be included with the request for services. The Network180 Utilization Management (UM) Department will review the authorization request and authorize as appropriate. 3. It is the goal of CLS to stabilize teaching, training, and assisting needs during the initial authorization. Reauthorization 1. Criteria for Reauthorization for the Identified Symptom Bearer: a. The CLS Needs Assessment must be completed at a minimum of every six months, or when there is a significant change. 2. Criteria for Reauthorization for Siblings: a. High probability of decompensation without continued CLS services. b. Treatment goals have not been completed but progress is anticipated. c. Provider will complete the CLS Needs Assessment and must be submitted to the Access Center at least ten business days prior to the expiration date of the current authorization. d. Access Center staff will review the material and make a determination of whether there is medical necessity for the continuation of CLS services. e. If appropriate, reauthorization will be given for at most three months. f. Access Center staff will notify Provider of the reauthorization determination within seven business days. An authorization will automatically be faxed back to Provider. g. Network180 will notify Provider if the reauthorization request is denied. Provider will have five business days to file an informal appeal based on additional information being available to the reviewer. h. If there is further disagreement, Provider s Clinical Supervisor may appeal to the Network180 Planning Director within three business days. 3. Network180 will send Notice of Action and appeal information to the individual or guardian as appropriate. Provider shall be available to the individual or guardian to discuss the rationale for the utilization decision, assist with other options as suggested, and, if requested, provide assistance with filing a local appeal and/or requesting a Medicaid Fair Hearing. Community Living Supports and Personal Care in a Specialized Residential Setting (Specialized Residential Services) The purpose this service is to provide Specialized Residential Treatment for children under the age of 18 who require a structured, out of home setting in support their primary mental health treatment services. The Community Residential philosophy is driven by the following: Every family and youth can develop skills that allow for healthy family functioning. The primary intention of treatment shall be movement to the least restrictive setting possible, including independent living, and/or return to family. Specialized placements may be accessed for needs including, but not limited to: safe and effective administration of medication for stabilization; close observation to ensure safety of the individual and others; monitoring and assessing for unsupervised community access; protection from consequences of decisions made during periods of impaired judgment and in some situations, monitoring and treatment of medical conditions. 12 Rev: 7/9/18

13 All Specialized Residential programs are licensed by, and maintain certification as a Child Caring Institution by the Office of Children and Adult Licensing Department within the Michigan Department of Health and Human Services (MDHHS). The Specialized Residential program must operate in full compliance with the Michigan Mental Health Code. Services 1. Person/family-centered planning is required. The plan will address all of the child s needs in the pertinent domains and will be modified as necessary. 2. Family-focused community treatment will be maintained during the child s placement. Families will be expected to be directly involved with the community-based therapist and residential staff during the course of the child s treatment out of home. 3. Provide services and/or interventions that are stage-matched with ongoing evaluation to meet changing needs and abilities, including referrals to alternative services as needed. 4. Provide 24-hour care and supervision. 5. With the exception of Dawes, children requiring 1:1 staffing require prior approval from Child and Family Ombudsperson. 6. Provide educational services available either on or off site. 7. Provide a barrier free environment as appropriate to meet the individual s needs. 8. Support services provided by professional staff as identified, but not limited to the following areas: Community Living Supports (CLS), behavior specialist, therapist, tutor, etc. 9. Psychiatric services provided include linking and communication as necessary with the Home- Based Services or Targeted Case Management psychiatrist. 10. Psychiatric coverage will remain the responsibility of the Provider for up to 30 days post-discharge. 11. The different residential programs include: a. Community Residential (Dawes): The Community Residential Program will utilize concepts from TFCBT, PMTO, and DBT to deliver clinically driven interventions for families. Family involvement in treatment is critical for the ongoing success of each child served. The youth will receive a minimum of weekly individual therapy, biweekly family therapy, and group therapy a minimum of twice per week. Continued connection of the youth in the family home is critical. Visits home will be an integral part of treatment with an emphasis on the relationship between family members and parenting skills being taught/ reinforced. Youth in this program will participate in community inclusion activities two to four times per week. These activities will allow the youth opportunities to practice skills learned and participate in their community as full members. Adolescents in the program attend schooling in the community. Daytime/evening staff ratio is 3:1. CLS may be utilized, and billed separately for, to meet the individualized needs of the child. A CLS plan and documentation log will be kept for each youth who receives CLS services. b. Crossroads Program: This open program provides intensive treatment for adolescents with sexual behavior problems (adjudicated and non-adjudicated). There is a strong peer accountability model, including three to five hours of group therapy per week along with individual therapy. Family therapy is scheduled as appropriate. Most adolescents attend on-campus school in a secure setting and transition into community schools when appropriate. A cognitive behavioral treatment approach is used. There is a strong emphasis on integrating the adolescent back into the community. Daytime/evening staff ratio is 3:1. Adolescent males only, ages c. Children s Secure Residential: The family will receive weekly individual therapy and family therapy as determined appropriate. The child will reside in a secure housing unit. Milieu and group activities as specified by the residential unit. Family visits on the unit and home visits are a part of the treatment plan and reunification plan. The focus of treatment is on trauma, cognitive behavioral therapy, stabilization of mental health and co- 13 Rev: 7/9/18

14 occurring issues, and transition to less intensive services. Adolescents in the program attend schooling on the campus. Daytime/evening staff ratio is 3:1. d. VanderArk Program: This program provides services to children with a developmental disability or a co-occurring MI/DD diagnosis. The child will reside in a secure housing unit. Milieu and group activities will occur as specified by the residential unit. Family visits on the unit and home visits are a part of the treatment plan and reunification plan. Youth in this program will participate in community inclusion as identified in their treatment plan. Adolescents in the program attend schooling in the community. Children will receive individual and family ABA (Applied Behavior Analysis) therapy, Speech therapy (when indicated), occupational and sensory integration services, academic and educational programming via community school partnership, milieu treatment, emotional regulation training, preparation for adulthood, discharge planning, and aftercare services as needed utilizing an in-home ABA tutor. e. Glen Hollow: Specialized Residential Behavioral Home: This program provides services to children with a developmental disability or a co-occurring MI/DD diagnosis. Milieu and group activities will occur as specified by the home. Family visits and home visits are a part of the treatment plan and reunification plan. Youth in this program will participate in community inclusion as identified in their treatment plan. Adolescents in the program attend schooling in the community. Children will receive individual and family ABA therapy, Speech Therapy (when indicated), occupational and sensory integration services, academic and educational programming via community school partnership, milieu treatment, emotional regulation training, preparation for adulthood, discharge planning, and aftercare services as needed utilizing an in-home ABA tutor. Access and Authorization All Specialized Residential services must be prior authorized. Children may be identified through a person/family-centered planning process, which includes the Home-Based Services/Targeted Case Management provider and other systems such as the Department of Human Services and the Circuit Court- Family Division. Family members may attend the Children s Residential Services Network Team and participate in the process. Children eligible for this service will be reviewed by the Children s Residential Services Network Team to prioritize and coordinate referrals with out of home care providers. Reauthorization 1. Reauthorization shall occur through the Children s Residential Services Network Team. 2. Reauthorization determination will be made when there is a request to extend the length of stay beyond the initial authorization. 3. If the request is denied or Specialized Residential services are to be reduced or terminated, the Children s Residential Services Network Team will provide the family with the appropriate notice of action and appeal information. Discharge Discharge data is forwarded to the Network180 Children s Residential Services Network Team Representative who will enter the data into the authorization system. 14 Rev: 7/9/18