APRIL 2012 CRISIS SERVICES State Authorization: G. S. 122C-147.1; S.L. 2006-66 (Senate Bill 1741), Part X, Section 10.26 (a) - (f); S.L. 2007-323 (House Bill 1473), Part X, Section 10.49; S.L.2008-107 (House Bill 2436), Part X, Section 10.15 (l) (m); S.L. 2009-451 (Senate Bill 202), Part X, Section 10.12(b) N. C. Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services Agency Contact Person - Program Flo Stein, Chief Community Policy Management NC Division of MH/DD/SAS 3007 Mail Service Center Raleigh, NC 27699-3007 (919) 733-4670 Flo.Stein@dhhs.nc.gov Agency Contact Person Financial Bill Scott Chief Resource & Regulatory Management NC Division of MH/DD/SAS 3010 Mail Service Center Raleigh, NC 27699-3010 (919) 715-7774 Bill.Scott@dhhs.nc.gov N. C. DHHS Confirmation Reports: SFY 2012 audit confirmation reports for payments made to Counties, Local Management Entities (LMEs), Boards of Education, Councils of Government, District Health Departments and DHSR Grant Subrecipients will be available by early September at the following web address: http://www.dhhs.state.nc.us/control/. At this site, page down to Letters/reports/forms for ALL Agencies and click on Audit Confirmation Reports (State Fiscal Year 2011-2012). Additionally, audit confirmation reports for Nongovernmental entities receiving financial assistance from the DHHS are found at the same website except select Non- Governmental Audit Confirmation Reports (State Fiscal Years 2010-2012). The auditor should not consider the Supplement to be safe harbor for identifying audit procedures to apply in a particular engagement, but the auditor should be prepared to justify departures from the suggested procedures. The auditor can consider the Supplement a safe harbor for identification of compliance requirements to be tested if the auditor performs reasonable procedures to ensure that the requirements in the Supplement are current. The grantor agency may elect to review audit working papers to determine that audit tests are adequate. I. PROGRAM OBJECTIVES In July 2006, the General Assembly designated $5.2 million for LMEs to develop long-term plans and for operational start-up of local crisis services (Session 2006, Senate Bill 1741). Additional funds provided in S.L. 2007-323 (House Bill 1473, Section 10.49) were designated for continued implementation of these plans. Over State fiscal years 2007 and 2008, each LME developed a long-term plan and worked with providers to establish new crisis services. The goals of this program are to: Expand Crisis Services: Crisis funds available to DHHS are to be allocated to LMEs to continue to implement the crisis plans developed. Crisis funds available to DHHS are to be allocated to LMEs to continue increasing the crisis services available throughout the State of North Carolina. C-4 DHHS-54 1
Crisis services are to be made available to all age and disability groups, and are to be allocated as non-disability specific general services funds. Directs DHHS to develop a system for reporting on crisis visits to community hospital emergency departments. Since July 2008, LMEs report the use of State funds to help cover costs of crisis services and supports. Following are the numbers of LMEs (out of 23) who have utilized State funds to support costs of the particular crisis service: Facility-Based Crisis Services (15 LMEs) Currently a service for adults with efforts under way to expand for children and adolescents. Professional Treatment Services in a Facility- Based Crisis Program is a service persons who have a mental illness, intellectual/developmental disability (IDD), and/or substance abuse disorder and is provided in a 24-hour residential facility, licensed under 10A NCAC 27G.5000, with 16 beds or less, designated as an involuntary treatment facility by DHHS in accordance with 10A NCAC 26C.0100. The Facility-Based Crisis Program is under the clinical oversight of a psychiatrist. This is a short term service that provides disability-specific care and treatment in a nonhospital setting for individuals requiring acute crisis stabilization. This crisis stabilization service includes a comprehensive clinical assessment, treatment intervention, behavior management or support plan, and aftercare planning. This service is designed as a time-limited alternative to hospitalization for an individual in crisis. Local Inpatient Services (15 LMEs) Psychiatric inpatient services located in community hospitals. These hospitals have designated psychiatric units. Services are provided through a 3-way contract between DHHS-DMH/DD/SAS, the LME and the local hospital contractor. Mobile Crisis Team (23 LMEs) Mobile Crisis Management (MCM) services are delivered by members of a multidisciplinary team to provide integrated crisis response 24 hours a day, 7 days a week, 365 days a year. MCM is a short-term, situational crisis response service, not an ongoing treatment service. MCM services are offered face-to-face in the community to de-escalate and stabilize crisis events, with the goal of preventing psychiatric hospitalization. Services also include immediate telephonic triage, as well as assistance to the recipient to gain access and safe transition to clinically necessary mental health, developmental disabilities, and/or substance abuse services; treatment and supports for symptom reduction; and crisis stabilization. Crisis Respite Beds (21 LMEs) Crisis Respite may be used when a person cannot be safely supported in their home due to his/her behavior and implementation of formal behavior interventions have failed to stabilize the behaviors and/or all other approaches to insure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver participants who are unable to access regular respite due to the nature of their behaviors. Detox Services (22 LMEs) A continuum of services designed for the safe detoxification is an organized service delivered by medical and nursing professionals that provides for 24-hour medically supervised evaluation and withdrawal management in a permanent facility affiliated with a hospital or in a freestanding facility of 16 beds or less. Services are delivered under a defined set of physician-approved policies and physician-monitored procedures and clinical protocols. After-Hour Crisis Services (21 LMEs) 24/7/365 telephone access operated by the LMEs. Licensed professionals are available to triage and refer persons in crisis to any of these other services in the crisis continuum. C-4 DHHS-54 2
Transition Beds (14 LMEs) A transitional residential treatment program which provides 24- hour residential treatment and rehabilitation for adults who have a pattern of difficult behaviors related to mental illness which exceeds the capabilities of traditional community residential settings. Walk-In Crisis Services (23 LMEs) At a walk-in site an adult, adolescent, or family in crisis can receive immediate care. The care may include an assessment and diagnosis for mental illness, substance abuse, and developmental disability issues as well as planning and referral for future treatment. Other services may include medication management, outpatient treatment, and short-term follow-up care. Psychiatric aftercare may also assist consumers returning to the community from a state psychiatric hospital or alcohol and drug abuse treatment center until they are established with a local clinical provider. Peer Support Services (11 LMEs) A community-based service for adults age eighteen (18) and older who have a mental illness or a substance abuse disorder. PSS is provided by a Certified Peer Support Specialist who has self-identified as a person in recovery from mental illness or substance abuse issues and is committed to his or her own recovery. PSS provides structured, scheduled activities that promote recovery, self-determination, self-advocacy, and enhancement of community living skills. Peer Support Service is an individualized, recovery-focused service, based on a relationship of mutuality that allows the individual an opportunity to learn to manage his or her own recovery. Emergency Department Safe Areas (5 LMEs) A block or rooms or areas in community hospitals that are created specifically for persons experiencing psychiatric crises. The set up varies from hospital to hospital but all involve close observation in a safe protected setting. Telemedicine and/or Telepsychiatry (22 LMEs) A broad term referring to the provision of mental health care from a distance. Telemedicine for mental health includes mental health assessment, treatment, education, monitoring, and collaboration. Patients can be located in hospitals, clinics, schools, nursing facilities, prisons and homes. TMH providers and staff include psychiatrists, nurse practitioners, physician assistants, social workers, psychologists, counselors, primary care providers and nurses. The goal of the telemedicine provider is to eliminate disparities in patient access to quality, evidence-based, and emerging health care diagnostics and treatments. North Carolina Systemic, Therapeutic Assessment, Respite and Treatment (NC START) (3 host LMEs) North Carolina Session Law 2008 appropriated funds to implement NC START, an evidenced-based model of community based crisis prevention and intervention services for people with Intellectual/Developmental Disabilities (I/DD) who are at least 18 years of age and who experience crises due to mental health or complex behavioral health issues. The goal of NC START is to create a support network that is able to respond to crisis needs at the community level. The emphasis and focus of NC START is on prevention of crisis through identification of high risk individuals, and on crisis planning and prevention with detailed follow up of individuals served. A primary focus of the teams is to prevent unnecessary use of emergency mental health and psychiatric inpatient service for individuals with IDD and mental illness or challenging behaviors. Providing community based, person centered supports that enable individuals to remain in their home or community placement is the first priority. Funds are distributed to three host Local Management Entities (LME) to support six crisis/clinical teams; two teams per region of the State and twelve respite beds; four per region. The host LMEs contract with two selected providers to provide NC START services statewide. C-4 DHHS-54 3
The clinical teams provide crisis prevention and intervention services including assessment and treatment, training and consultation, and collaboration with community resources. Each region has a director who provides administrative oversight, a part-time PhD psychologist (.5 FTE) who serves as the clinical director, a part-time psychiatrist (.10 FTE) who serves as the medical director, and four qualified professionals, two per team. There are two crisis respite beds (up to 30 days per admission) and two planned respite beds (up to 72 hours per admission) for each site. Each respite home has one respite director and approximately 13 respite staff. Respite service elements include symptom and behavior monitoring, structured day activities, collaboration with the person s support team, and family support and education. S.L. 2009-451 provides funding for the continuation of NC START. All of the clinical teams became fully operational in January of 2009. The three respite homes are licensed and operational. II. PROGRAM PROCEDURES Expand Crisis Services: Implementation of the Crisis Plans o There is written evidence of a Division approved crisis plan by which LMEs within a crisis region shall work together to identify gaps in their ability to provide a continuum of crisis services for all consumers and use the funds allocated to them to develop and implement a plan to address those needs. At a minimum, the plan must address the development over time of the following components: 24-hour crisis telephone lines, walk-in crisis services, mobile crisis outreach, crisis respite/residential services, crisis stabilization units, 24-hour beds, facility-based crisis, in-patient crisis, detox, and transportation. Options for voluntary admissions to a secured facility must include at least one service appropriate to address the mental health, developmental disability, and substance abuse needs of adults, and the mental health, developmental disability, and substance abuse needs of children. Options for involuntary commitment to a secured facility must include at least one option in addition to admission to a State facility. o There is written evidence that if LMEs in a crisis region determine that a facility-based crisis center is needed and sustainable on a long-term basis, the crisis region shall first attempt to secure those services through a community hospital or other community facility. This written evidence shall document that if all the LMEs in the crisis region determine the region s crisis needs are being met, the LMEs may use the funds to meet local crisis service needs. Increasing the Crisis Services o There is written evidence that LME s shall work with sheriffs and county public health agencies to serve individuals who are incarcerated or being held in county jails and who are in need of crisis services. Implementation of NC START o Each of the providers was required to submit an implementation plan outlining how the elements of the NC START model would be implemented. o A comprehensive template and corresponding data base has been developed for quarterly reporting by the regional clinical teams and respite homes through the host LMEs who in turn submit the data to DMH/DD/SAS. Broad reporting components include: Information on individuals served, referral and crisis intervention services provided, planned services and training/education provided, and respite home utilization. C-4 DHHS-54 4
III. COMPLIANCE REQUIREMENTS Crosscutting Requirements The DHHS/Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMHDDSAS) mandates that all the testing included within the crosscutting section be performed by the local auditors. Please refer to that section, which is identified as DMH-0 for those mandated requirements. 1. ACTIVITIES ALLOWED OR UNALLOWED There is written evidence that these funds shall be used to develop a continuum of crisis services for all consumers in the LME s catchment area. At a minimum, these services include the following components: 24-hour crisis telephone lines, walk-in crisis services, mobile crisis outreach, crisis respite/residential services, crisis stabilization units, 24-hour beds, facility-based crisis, in-patient crisis, detox, and transportation. In addition, there shall be at least one service appropriate to address the MH/DD/SA needs of adults and of children respectively in a secured facility. Provision shall also be made for the availability of at least one secured facility to treat individuals under petition of involuntary commitment as an alternative to admission to a State facility. For NC START there is written evidence that these funds shall be used to develop and implement NC START services according to the required components of the model. At a minimum there must be six crisis/clinical teams; two teams per region of the state and twelve respite beds; four per region. a. Determine whether funds were expended only for allowable activities. : a. Crisis services funds are disbursed on a UCR and Non-UCR basis condensed into one account 1590 536996 without distinction by age or disability for these funds, sample local documentation on individual client record to verify that clients were enrolled in the Common Name Data System (CNDS), the Consumer Data Warehouse (CDW) and an approved IPRS target population and that services were provided. b. Verify that expenditures match the quarterly Non-UCR expenditure report submitted to DMH/DD/SAS regarding the use of crisis services funds. c. Review contract requirements and determine activities which are allowable for reimbursement. d. Sample monthly billings to the DMHDDSAS to verify that the activities billed for relate directly to the allowable activities to be reimbursed under the terms of the Contract. e. For NC START: o Determine whether the host LME monitored the contract with the provider of NC START services including review of billing for specific NC START activities. o Determine whether the host LME reviewed the NC START contract with providers to ensure adherence to the terms of the contract. 2. ALLOWABLE COSTS/COST PRINCIPLES C-4 DHHS-54 5
All grantees that expend State funds (including federal funds passed through the N. C. Department of Health and Human Services) are required to comply with the cost principles described in the N. C. Administrative Code at 09 NCAC 03M.0201. a. Determine whether funds expended were allowable and in accordance with the applicable cost principles. a. Review contract requirements and determine types of activities which are allowable for reimbursement under the terms of the Contract. b. Sample monthly billings to the DMHDDSAS to verify that the costs billed to the DMHDDSAS were accurate and relate directly to the allowable activities to be reimbursed under the terms of the Contract. 3. CASH MANAGEMENT This requirement does not apply at the local level. 4. CONFLICT OF INTEREST AND CERTIFICATION OF NO OVERDUE TAX DEBT All non-state entities (except those entities subject to the audit and other reporting requirements of the Local Government Commission) that receive, use or expend State funds (including federal funds passed through the N. C. Department of Health and Human Services) are subject to the financial reporting requirements of G. S. 143C-6-23 effective July 1, 2007. These requirements include the submission of a Notarized Conflict of Interest Policy (see G. S. 143C-6-23(b)) and a written statement (if applicable) that the entity does not have any overdue tax debts as defined by G. S. 105-243.1 at the federal, State or local level (see G. S. 143-6-23(c)). G. S. 143C-6-23(b) stipulates that every grantee shall file with the State agency disbursing funds to the grantee a copy of that grantee s policy addressing conflicts of interest that may arise involving the grantee s management employees and the members of its board of directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the grantee s employees or members of its board or other governing body, from the grantee s disbursing of State funds, and shall include actions to be taken by the grantee or the individual, or both, to avoid conflicts of interest and the appearance of impropriety. The policy shall be filed before the disbursing State agency may disburse the grant funds. All non-state entities that provide State funding to a non-state entity (except any non-state entity subject to the audit and other reporting requirements of the Local Government Commission) must hold the sub-grantee accountable for the legal and appropriate expenditure of those State grant funds. a. Determine whether the entity has adequate policies and procedures regarding the disclosure of possible conflicts of interest. a. Ascertain that the grantee has a conflict of interest policy. C-4 DHHS-54 6
b. Verify through Board minutes that the policy was adopted before the grantee received and disbursed State funds. 5. ELIGIBILITY Adults and children (age 3 and older) who have completed a Screening/Triage/Referral Interview and have received an Emergent triage determination, or who are currently enrolled in an MH/DD/SA target population and who are in need of crisis or emergency services beyond the capacity of the designated First Responder provider. Note: An individual who is eligible for Medicaid is not eligible for the Crisis Services target population, nor is an individual who is eligible for both Medicaid and IPRS services. The Crisis Services target population is limited to only those individuals who either: a) have no IPRS target population eligibility, or b) have only IPRS target population eligibility, but not Medicaid eligibility. Eligibility for the Crisis Services target population requires LME admission of consumer into the CDW through completion of the Identifying Information (Record 10 or 30), Demographics (Record 11 or 31), and Substance Abuse (Drug of Choice) Details (Record 17 or 37). The LME may establish the initial eligibility period in a Crisis Services (AMCS, CMCS, ASCS, CSCS, ADCS and CDCS) population group for up to fourteen (14) days. After the initial eligibility period, the consumer must be reassessed and determined to continue to be in need of crisis and emergency services to be considered for another fourteen (14) day eligibility period. People with Intellectual/Developmental Disabilities (I/DD) who are at least 18 years of age and who experience crises due to mental health or complex behavioral health issues are eligible for NC START services. a. Determine whether required eligibility determinations were made, (including obtaining any required documentation/verifications), that individual program participants or groups of participants (including area of service delivery) were determined to be eligible, and that only eligible individuals or groups of individuals (including area of service delivery) participated in the program. b. Determine whether sub awards were made only to eligible sub recipients. c. Determine whether amounts provided to or on behalf of eligibles were calculated in accordance with program requirements. a. Select a sample of client records for individuals served under the terms of the Contract; b. Review client records for documentation that allowed services were provided to individuals with any age/disability. c. NC START host LME will periodically select a sample of client records for individuals served for documentation that allowed services were provided only to individuals 18 years of age and older with I/DD and behavioral healthcare needs. C-4 DHHS-54 7
6. EQUIPMENT AND REAL PROPERTY MANAGEMENT Equipment Management This requirement refers to tangible property that has a useful life of more than one year and costs $5,000 or more. Such equipment may only be purchased per the conditions of the approved contract or grant agreement. Shall the contract be terminated, any equipment purchased under this program shall be returned to the Division. Real Property Management This requirement does not apply to DMH/DD/SAS programs. a. Determine whether the entity maintains proper records for equipment and adequately safeguards and maintains equipment. b. Determine whether disposition or encumbrance of any equipment or real property acquired under State awards is in accordance with State requirements and that the awarding agency was compensated for its share of any property sold. a. Obtain entity s policies and procedures for equipment management and ascertain if they comply with the State s policies and procedures. b. Select a sample of equipment transactions and test for compliance with the State s policies and procedures for management and disposition of equipment. 7. MATCHING, LEVEL OF EFFORT, EARMARKING This requirement does not apply at the local level. 8. PERIOD OF AVAILABILITY OF STATE FUNDS Not applicable. This program is supported by State Funds only. 9. PROCUREMENT AND SUSPENSION AND DEBARMENT This requirement does not apply to this program. 10. PROGRAM INCOME This requirement does not apply at the local level. 11. REAL PROPERTY ACQUISITION AND RELOCATION ASSISTANCE This requirement does not apply to DMH/DD/SAS programs. 12. REPORTING Semi-annual reports covering Mobile Crisis Management Team activities and Walk-in Crisis and Immediate Psychiatric Aftercare site activities will be due February 15, 2010 and will cover activity tracked from July 1 st, 2009 through December 31 st, 2009 and will continue on an on-going basis. Per G. S. 122C-147.1(d2), LMEs should implement a system to track funds expended on a Non-UCR basis for each disability and for each age/disability category and shall identify the C-4 DHHS-54 8
specific services purchased with these funds via the Non-UCR reimbursement report to the Division. Quarterly reports on NC START activities will be due by the 20 th of the month following the end of the quarter. a. Determine whether required reports include all activities of the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with program requirements. a. Review applicable laws, regulations and the provisions of the contract for reporting requirements. b. Verify that Contractor has provided semi-annual progress reports for Mobile Crisis and Walk-in Services. Reports for the period of July 1 - December 31 are due on February 15 th ; Reports for January 1 - June 30 are due on August 15 th. c. Verify that Contractor has provided a final year-end report. d. Ascertain if the financial reports were prepared in accordance with the required accounting basis. e. For Performance and special reports, verify that the data were accumulated and summarized in accordance with the required or stated criteria and methodology, including the accuracy and completeness of the reports. f. Obtain written representation from management that the reports provided to the auditor, are true copies of the reports submitted to the Division. g. For NC START, determine whether the host LME conducts a quarterly review of reporting requirements submitted to DMH/DD/SAS and the Division of State-Operated Healthcare Facilities (DSOHF) to ensure that the activities of NC START were provided. h. Review NC START quarterly reports to ensure that activities/components of the model are provided. 13. SUBRECIPIENT MONITORING Monitoring is required if the agency disburses or transfers any State funds to other organizations, except for the purchase of goods or services, the grantee shall require such organizations to file with it similar reports and statements as required by G.S. 143C-6-22 and 6-23 and the applicable prescribed requirements of the Office of the State Auditor s Audit Advisory #2 (as revised January 2004) including its attachments. If the agency disburses or transfers any pass-through federal funds received from the State to other organizations, the agency shall require such organizations to comply with the applicable requirements of OMB Circular A-133. Accordingly, the agency is responsible for monitoring programmatic and fiscal compliance of subcontractors based on the guidance provided in this compliance supplement and the audit procedures outlined in the DMH-0 Cross-cutting Supplement. a. Determine whether the pass-through entity properly identified State award information and compliance requirements to the sub recipient, and approved only allowable activities in the award documents. C-4 DHHS-54 9
b. Determine whether the pass-through entity monitored sub recipient activities to provide reasonable assurance that the sub recipient administers State awards in compliance with State requirements. c. Determine whether the pass-through entity ensured required audits are performed, issued a management decision on audit findings within 6 months after receipt of the sub recipient s audit report, and ensures that the sub recipient takes timely and appropriate corrective action on all audit findings. d. Determine whether in cases of continued inability or unwillingness of a sub recipient to have the required audits, the pass-through entity took appropriate action using sanctions. e. Determine whether the pass-through entity evaluates the impact of sub recipient activities on the pass-through entity. a. Gain an understanding of the pass-through entity s sub recipient procedures through a review of the pass-through entity s subrecipient monitoring policies and procedures (e.g., annual monitoring plan) and discussions with staff. This should include an understanding of the scope, frequency, and timeliness of monitoring activities and the number, size, and complexity of awards to subrecipients. b. Review the pass-through entity s documentation of during-the-award monitoring to ascertain if the pass-through entity s monitoring provided reasonable assurance that subrecipients used State awards for authorized purposes, complied with laws, regulations, and the provisions of contracts and grant agreements, and achieved performance goals. c. Review the pass-through entity s follow-up to ensure corrective action on deficiencies noted in during-the-award monitoring. d. Verify that in cases of continued inability or unwillingness of a sub recipient to have the required audits, the pass-through entity took appropriate action using sanctions. e. Verify that the effects of sub recipient noncompliance are properly reflected in the passthrough entity s records. 14. SPECIAL TESTS AND PROVISIONS All grantees are required to comply with the Department of Health and Human Services and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services records retention schedules and policies. Financial records shall be maintained in accordance with established federal and state guidelines. The records of the contractor shall be accessible for review by the staff of the North Carolina Department of Health and Human Services and the Office of the State Auditor for the purpose of monitoring services rendered, financial audits by third party payers, cost finding, and research and evaluation. Records shall be retained for a period of three years following the submission of the final Financial Status Report or three years following the submission of a revised final Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving these funds has been started before expiration of the three year retention period, the records must be retained until the completion of the action and resolution of all issues which arise from it, or until the end of the regular three year period, whichever is later. The grantee shall not destroy, purge or dispose of records related to these funds without the express written consent of DHHS/DMH/DD/SAS. The agency must comply with any additional requirements specified in the contract or to any other performance-based measures or agreements made subsequent to the initiation of the C-4 DHHS-54 10
contract including but not limited to findings requiring a plan of correction or remediation in order to bring the program into compliance. a. To ensure compliance with the DHHS and DMH/DD/SAS records retention schedules and policies. b. To ensure compliance with all federal and state policies, laws and rules that pertains to this fund source and/or to the contract/grant agreement. a. Verify that records related to this fund source are in compliance with DHHS- DMH/DD/SAS record retention schedules and policies. b. Review contract/grant agreement, LME Quarterly Report and other documentations to verify that the following special requirements for the crisis services program have been met: There are documented attempts to get additional capacity through existing resources, i.e. community hospitals or other community agency facilities. The LME s crisis plan factors in the need of all disability areas based upon the priority needs of the region and the local LME. The local LME crisis plan incorporates input from key stakeholders in the community. There is involvement from CFAC in the local crisis planning process. The LME conducts a comprehensive assessment of the crisis services component for each disability area. The crisis plan identifies other future crisis services and/or capacity gap needs and goals for each disability area. C-4 DHHS-54 11