NORTHCARE NETWORK POLICY TITLE: EFFECTIVE DATE: 6/26/02 REVIEW DATE: 12/13/16 RESPONSIBLE PARTY: Training Coordinator CATEGORY: Provider Network Management BOARD APPROVAL DATE: 10/9/04 REVISION(S) TO OTHER POLICY STATEMENT: REVISION(S): No No CEO APPROVAL DATE: 12/13/16 William Slavin, CEO APPLIES TO NorthCare Network Personnel (Excludes Board Members) Network Providers POLICY All staff employed directly or under contract or sub-contract must successfully complete training requirements established by: licensing agencies, accreditation bodies, MDHHS, and NorthCare Network. Training related to recipient rights protection must be received within thirty (30) days after the commencement of employment or contract and annually thereafter. PURPOSE The policy outlines training requirements for NorthCare Network and sub-contract providers. This policy is not intended to be comprehensive of all trainings staff need to accomplish their job. The intensity of the training and need for specific and advanced training is determined by the employee s specific job and supervisor. DEFINITIONS 1. Credentialed Staff- Licensed healthcare practitioners providing direct care; and/or clinical supervision at an individual, group or program level; and/ or peer reviewers of clinical authorizations and/or clinical documentation. Staff requiring MDHHS certification (as identified on NorthCare Network Privileging Request Form) are considered credentialed staff. 2. Customer Service and Reception Staff responsible for implementing standards established in the MDHHS contract Attachment PIHP CUSTOMER SERVICES STANDARDS. 3. Direct Care Staff working in a licensed residential setting A subset of staff who provides daily support for the individuals residing in a 24 hour care licensed setting and must meet MDHHS minimal requirements for employment and complete all required MDHHS training. 4. Direct Care staff working in unlicensed settings A subset of staff that must meet all minimal MDHHS requirements for employment and meet training requirements (see page 8 of this policy) Page 1 of 7
5. Non-Credentialed Staff non-professional /paraprofessional personnel who do not require a degree or license to provide specific services and supports but may require specific training to provide specific services. 6. NorthCare Network Personnel refers to staff assigned to NorthCare Network on a full or part-time basis, students, volunteers, and interns. 7. Network Providers all providers under contract/sub-contract with NorthCare Network. REFERENCES 42 CFR, (Balanced Budget Act of 1997), 438.214 CARF Standards URAC Standards Medicaid Subcontract Agreement (PIHP/CMHSP), Section X NorthCare Network Credentialing Plan and Policies NorthCare Network Privileging Policy Michigan Licensing & Certification Standards NorthCare Network Customer Services Policy NorthCare Network Compliance Program HISTORY REVISION DATE: 8/29/13, 3/17/14, 3/3/15, 8/13/15, 6/30/16, 12/13/16 REVIEW: 1/13/11, 1/3/13, 8/29/13, 3/17/14, 3/3/15, 8/13/15, 6/30/16, 12/13/16 CEO APPROVAL: 1/30/13, 8/29/13, 3/17/14, 3/3/15,9/1/15, 8/2/16, 12/13/16 BOARD APPROVAL: 6/26/02, 8/27/03, 10/9/04 PROCEDURES A. It is expected that all employees will have access to source documents (most can be found on NorthCare Network s website) outlining requirements of their responsibilities including, but not limited to: 1. Medicaid Provider Manual 2. Michigan Mental Health Code 3. MDHHS/PIHP Master Contract and attachments 4. PIHP/CMHSP Contract 5. PIHP/SUD Provider Contracts as applicable 6. NorthCare Network Mental Health Services Provider Manual 7. NorthCare Network Substance Use Disorder Services Provider Manual 8. NorthCare Network Policies and Procedures and Plans 9. NorthCare Network Practice Guidelines 10. URAC Accreditation Standards B. All staff will be oriented to an organizational culture that emphasizes recovery, customer service, compliance and quality improvement that provides integrated healthcare in a welcoming, trauma informed environment at time of hire. Customer service, compliance with ethical and legal requirements and a commitment to quality Page 2 of 7
improvement are key aspects of the culture. All staff must be able to assist or direct the individual seeking treatment to the person who can help them with their specific concern. C. NorthCare Personnel Training 1. All NorthCare personnel: a. Initial NorthCare Employee Orientation training is provided by the CEO. Compliance Training will be provided by the Compliance Officer/Quality Improvement Coordinator. Human resources assigns the required trainings to complete orientation. b. Training is assigned by the Human Resource Coordinator per federal and state laws and regulations. 2. Additional trainings are assigned according to job and additional tasks assigned by the CEO. D. NorthCare Network Support of Network Providers 1. NorthCare contracts with a vendor for a regional online training curriculum. The CMHSPs have separate sites and are responsible for maintaining the site with the trainings required for their staff. The CMHSPs may add trainings at any time to their site. 2. NorthCare provides training in situations where standard training is required (i.e. Customer Service Training.) NorthCare will evaluate requests to create or find trainings that have value for the region. 3. Training is based on specific job requirements. All training for directly employed staff at NorthCare and the Member CMHSPs is documented in the electronic learning management system, mylearningpointe (mlp). NorthCare Network endorses the online training options available at improvingmipractices.org website with CEUS at no cost primarily for Adults with serious mental illness and the National Child Traumatic Stress Network website with free CEUs for staff working with children and trauma http://learn.nctsn.org. Other online trainings should be reviewed by the individual s supervisor before approval is given for online credit. E. Training Expectations by Staff Category The following categories are for the purposes of this policy only. Separate topics may be combined within a single training. The training coordinators must have a list of the training titles with the topics covered in the training available for site reviews. 1. Training required of all NorthCare Network staff: Code of Conduct/Ethics MI Act 196 of 1973 Conflict of Interest NorthCare Network Conflict of Interest general policy for listing of relevant federal and state regulations Page 3 of 7
Cultural Diversity and Limited English Proficiency (LEP) Customer Services Level I with Limited English Proficiency (LEP) Board Specific Policy RE: Drug Free Workplace Environmental Emergencies/Safety Specific to work location and responsibilities. BBA for cultural diversity and LEP; MDHHS/PIHP Contract 3.4.2 & LEP Federal Title VI of the Civil Rights Act of 1964; CMDHHS /PIHP Contract 15.7 P6.3.1 Customer Services Standards Model language in the State of Michigan Drug Free Workplace Notice 2012 MDHHS/PIHP Contract 15.1 Compliance with Applicable Laws No Grievance & Appeals General Orientation BBA, P6.3.1.1 Grievance and Appeal TR No Harassment in the Workplace Civil Rights Act of 1991 No Federal Public Law 104-191,1996; HIPAA Privacy and 45CFR160 & 164; 42CFR Part 2 Confidentiality and/or MI PA258 of 1974 and PA368 HIPAA Security 45CFR160 & 164, subparts A & C MDHHS P7.7.1.1 Reporting Monitoring Policy Incident Reporting May be Requirements; NorthCare Network part of rights training Death Reporting, Notification & Infection Control/Universal Precautions Occupational Safety and Health (OSH) Act of 1970 NorthCare Network Orientation NorthCare Network Training to include all Network Providers No Current Accreditation Standards as applicable Person-Centered Planning Level I (Philosophy of PCP) Recipient Rights Protection Regulatory Compliance (Includes: DRA, Whistleblowers Act, and False Claims Act) Recovery Based System of Care Accreditation MDHHS P4.4.1.1PCP Guideline Rev BBA/MI Mental Health Code Chapter 7 Federal laws - Deficit Reduction Act 2005; Whistleblower Protection Act of 1989 & Michigan False Claims Act Within 30 days of hire/contract Per Job Description MDHHS P4.13.1 Recovery Policy No Trauma informed System of Care Trauma Informed System of Care training on improvingmipractices.org Page 4 of 7
2. Additional Trainings Required of Credentialed Staff - In addition to training listed below, credentialed staff must receive a thorough orientation, that is documented, to: the basic principles and practices of integrated healthcare, how eligibility for services is determined, and the full array of services and providers available. Advance Directives BBA; MDHHS/PIHP Contract 6.8.6 Crisis/Intervention Planning May be part of Advance Directives or Emergency Services Documentation Requirements/Chart Reviews/Coding General Overview of Evidence Based Practices Grievance & Appeals MDHHS Clinical Practice Guidelines NorthCare Network Levels of Care Descriptions Person-Centered Planning- Level II Detailed PCP Process and Self Determination and Independent Facilitation Service Array/ Medical Necessity Trauma Assessment Services Verification NorthCare Network Practice Guidelines BBA, MDHHS_ Grievance and Appeal TR MDHHS Contract Attachments NorthCare Network Utilization Management Operating Manual, NorthCare Network LOC s most recent version MMHC, MDHHS P.4.4.1.1PCP Guideline Rev for FY14; 4.7.1 SD_FI Policy FY14; P.7.10.2.5 Family- Driven and Youth-Guided Policy and Practice Guideline FY14; Final Choice Voucher System for Children 11 21 12 on 1.2.13 BBA, Michigan Medicaid Provider Manual & MDHHS/PIHP Contract:2.2 Training specific to population clinician serves - updates recommended by NC - updates recommended by NC reassigned per job & privileging review review of selected MDHHS guidelines per job and privileging per quarterly update of MI Medicaid Provider manual as applicable to job Page 5 of 7
3. The following additional trainings are required for Credentialed Staff depending upon their job and/or privileging. MDHHS certification Required for all ACT team members 2 days initial 1 day annual Assertive Community Treatment (ACT) CMHP 24 hours of training specific to children. COD Co-Occurring Disorders Dialectical Behavior Training MDHHS professional qualification MDHHS use of DDCMHT to review COD programs MDHHS certification as a team member 24 hours within first year if experienced otherwise must complete 24 hours before CMHP credentialed Complete entire training package Emergency Services MI Mental Health Code Per CMH policy Family Psycho Education Infant Mental Health Integrated Dual Disorder Treatment (IDDT) Trauma specific training MDHHS Certification - PSS National IMH Association certification at a minimum of level 2 MDHHS Certification - Required for all team members MDHHS Policy & EBP practices per population 2 &1/2 days initial training Meet AIMH standards 24 hrs from annual by performance evaluation per job and privileging Maintain standards of a certified team- Team Leader to submit annual update of staff and training Per CMH policy Complete required supervision within 12 months and a one day of training every two years Meet AIMH standards for ongoing supervision 2 days initial 1 day annual As required by job and scope of practice as required by scope of practice 4. Additional Trainings required for Customer Service and Reception Staff Customer Services Level II MDHHS Page 6 of 7
Independent Facilitation MDHHS Grievance & Appeals Orientation BBA, MDHHS CPR First Aid 5. Additional Training Required for nurses, residential staff and staff who provide one to one services in the community. State Training Guidelines for Direct As required Care Staff by job Professional licensing requirements and certifying for RN,LPN,NP State Training Guidelines for Direct Care Staff Professional licensing requirements for RN,LPN,NP 6. Additional training required for all Direct Care Staff to fulfill the training requirements and options based on work setting and the needs of persons served. The MDHHS curriculum guides (below) will be used to ensure uniformity and the flexibility for reciprocity and to stay current in an everchanging environment. The following two MDHHS websites provide complete guidance as to requirements and curricula to meet the requirements: http://www.michigan.gov/dhs/0,4562,7-124-5455_27716_27717-251002--,00.html http://www.michigan.gov/dhs/0,1607,7-124-5455_27716_27717-224979--,00.html Each Network Provider will make available to NorthCare Network the approved curriculum used for Direct Care Staff training as updated. Written documentation of compliance with training shall be kept on file at the facility for not less than 3 years. Evidence of direct care staff training on the individual s IPOS includes documentation for specific training on the treatment plan & amendments to treatment plan including specialty services goals and objectives; behavior treatment plans (whether monitored by the BTC or not). The training of specialty goals and objectives must be provided by a practitioner working within the scope of their practice. The documentation of the training must be available for review in the electronic medical record on the NorthCare standard documentation form attached to the IPOS or upon request from the contract provider. agency As required by job and certifying agency Page 7 of 7