Unique Regulatoy and Documentation Standads fo Inpatient Behavioal Health May 21, 2014 John A. Coleman, MSW, ACSW Vice Pesident, Clinical Sevices 2014 Hoizon Mental Health Management, LLC. All ights eseved.
Why ae Behavioal Health Standads Diffeent Fom Othe Inpatient Requiements? Behavioal Health does not follow pedictable clinical pathways Inpatient Psych. has been exempt fom DRGs Cause, effect, and teatment ae moe complex Special Conditions apply to Feestanding Psychiatic Hospitals Exempt Psychiatic Units Inpatient Pospective Payment System (IPPS) Povide (Psychiatist and othe pofessionals) have the obligation to detemine what teatment is easonable and necessay fo the patient. 2
Reasonable and Necessay Requies Physician Cetification and Re-Cetification Sevices povided unde an individualized plan of teatment Sevices must be easonably expected to impove the patient s condition o esult in diagnostic conclusions Sevices must be supevised and evaluated by a Physician 3
CMS Conditions of Paticipation (CoP) Geneal Povisions 482.2 Povision of Emegency Sevices Administation 482.21 Compliance with Fedeal, State, and Local Laws 482.12 Govening Body 482.13 Patient Rights See Handout page 2 4
CMS Conditions of Paticipation (CoP) Basic Hospital Functions 482.21 Quality Assuance 482.22 Medical Staff 482.23 Nusing Sevices 482.24 Medical Recods 482.25 Phamacy 482.26 Radiology 482.27 Laboatoy 482.28 Food and Dietay 482.30 Utilization Review 482.41 Physical Envionment 482.42 Infection Contol 482.43 Dischage Planning 482.44 Ogan Tissue and Eye Pocuement 5
CMS Conditions of Paticipation (CoP) Optional Hospital Sevices 482.51 Sugical Sevices 482.52 Anesthesia 482.53 Nuclea Medicine 482.54 Outpatient Sevices 482.55 Emegency Sevices 482.56 Rehabilitation Sevices 482.57 Respiatoy Cae Sevices 6
CMS Conditions of Paticipation (CoP) Requiements fo Specialty Hospitals 482.60 Special Conditions: Psychiatic Hospitals 482.61 Medical Recod Requiements: Psychiatic 482.62 Staffing Requiements: Psychiatic 482.66 Long Tem Cae EMTALA/COBRA 489.20 Anti-Dumping and Emegency Tansfe 7
Tag Condition Standads 8 Intepetive Guidelines
What Do CMS Conditions Obligate You To? All Hospitals paticipating in Medicae o Medicaid must fully comply with all CoP s. Most State Licensue suveys utilize the CMS Conditions of Paticipation. Joint Commission Deemed Status Being out-of-compliance with one o moe standads equies a coective action plan. Being out on a condition (CoP) means you hospital is in jeopady of losing: Medicae Funding Medicaid Funding License To Opeate Hospital In You State 9
One Standad Can Tigge Multiple Citations Staffing: 482.62 Nusing Diecto Medical Diecto Sufficient # of staff Qualified staff Teatment plan goals not measuable Govening Body: 482.12 Dischage Planning: 482.43 Medical Recods: 482.61 10
Medical Recod Special Condition 42 CFR 482.61 Assessments B104 though B117 READY Teatment Plan B118 though B124 Pogess Notes B125 though B132 AIM FIRE Dischage Plan and Summay B133 though B135 11
Assessments B104 B117 B104 Histoy of Illness B105 Legal Status B106 Admitting Diagnosis B107 Reasons fo Admission to Hospital B108 Psychosocial Assessment B109 Neuological Exam 12
Psychiatic Evaluation 482.61(b) B110 Psychiatic Evaluation B111 Completed within 60 hous of admission B112 Includes Medical Histoy B113 Recods mental status B114 Notes onset of illness and cicumstances leading to admission B115 Descibes patients attitudes and behavios B116 Estimate of intellectual function, memoy, oientation B117 Desciptive inventoy of patient assets See Handout pages 3-6 Also pages 12-14 13
Admission Physical Examination 482.61(a)(5) B109 Physical Examination Thoough Histoy and Physical upon admission Include all laboatoy examinations Sufficient to cove all stuctual, functional, systemic, and metabolic disodes Past physical disodes Substance abuse Neuological sceening to include testing of Canial Neves II-XII Look fo signs of cuent illness Detemine if psychiatic symptoms may be due to medical condition o substance-elated disode See Handout pages 7-8 14
Neuological Sceening includes Canial Neves II-XII 482.61(a)(5) CRANIAL NERVES: (Cicle each test used) YES NO OLFACTORY I: Smells feshly buned match, fesh coffee, o alcohol swab OPTICAL II: Distinguishes numbe of finges in cental field. Distinguishes movements in peipheal field. OCULOMOTOR III: TROCHLEAR IV: ABDUDENS VI: Gazes symmetically up, down, sideways TRIGEM V: Distinguishes 1 fom 2 point touch symmetically on foehead, cheeks, and chin; chews symmetically. FACIAL VII: Uppe: fowns symmetically Lowe: smiles symmetically AUDITORY VII: Heas finge ubbing o snapping equally in both eas GLOSSO-PHARYNGEAL IX: VAGUS: ACCESORY XI: HYPOLGLOSSAL XII: Has gag eflex Can make guttual sounds Shugs shouldes symmetically Can stick tongue out without temos o fasolculations 15
Geneal Guidelines fo Assessments Distinguish histoy-taking fom assessment Histoy is a un-intepeted data; a pofile of significant symptoms o cicumstances Assessment is an evaluation of this data by a qualified clinician who then daws conclusions and ecommendations. Give Suppoting Evidence Summaize conclusions in an evaluation Declae medical necessity Seveity of illness Offe specific ecommendations fo teatment All majo clinical disciplines and teatment modalities Intensity of Sevice 16 See Handout: Example pages 12-13
Teatment Planning B118 B125 B118 Each patient has individualized, compehensive teatment plan B119 Based on inventoy of patient s stengths and disabilities Teatment Plan Must Include: B120 Substantiated diagnosis B121 Shot-tem and Long-ange goals B122 Specific teatment modalities B123 Responsibilities of each membe of the teatment team B124 Adequate documentation to justify diagnosis and inteventions B125 Documentation of all active theapeutic effots See Handout pages 15-16 17
Pogess Notes B126 - B132 Pogess Notes Requied By: B126 B127 B128 B129 Physician Nusing Social Woke Othe significantly-involved disciplines B130 B131 B132 Fequency of notes sufficient fo patients condition Pogess notes include ecommendations fo evisions in the teatment plan Assess pogess (o lack theeof) towads established teatment goals 18
Dischage Planning B134 - B135 B134 Dischage Summay contains ecommendations fo appopiate sevices following dischage. Aftecae appointments (complete with dates) Dischage medications Housing needs Financial needs elative to aftecae Recommended family esouces/involvement Receational and leisue needs B135 Bief summay of patient s condition on dischage See Handout pages 9-10 19
Special Condition Staffing Psychiatic 42 CFR 482.62 Sufficient and Qualified Pesonnel - B137 B140 Medical Diecto and medical staff - B141 B145 Nusing Sevices - B146 B150 (mastes-level RN) Psychological Sevices - B151 Social Sevices - B152 B155 (MSW leads social sevices) Theapeutic Activities B156 B158 20
Patient Rights 42 CFR 482.13 A 751 Notice of Rights A 752 Gievance Pocess A 760 Pt. Involvement in Tx Plan A 761 Advanced Diectives A 763 Pivacy and Safety Right to safe envionment A 766 Confidentiality A 767 Pt. Right to Access PHI A 769-791 Seclusion & Restaint 21
Refeences To obtain had copy of Special Conditions of Paticipation fo Psychiatic Units See you Hoizon Pogam Diecto To download a full set of Conditions of Paticipation http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 22
How Does You Behavioal Health Unit Stand? Tools at you disposal: Daily Concuent Recod Review Make coections while you still can Hoizon Monthly Audit Sample size fo extenal eview Hoizon Annual Compehensive Audit Hoizon VP, Clinical Sevices Site visits Taining 23
Questions? 24