Substance Use Disorder Treatment Provider Manual

Substance Use Disorder Treatment Provider Manual February 2017

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Contents SUBSTANCE USE DISORDER TREATMENT PROVIDER MANUAL INTRODUCTION... 6 SFHN PHILOSOPHY OF CARE... 6 SUBSTANCE USE DISORDER TREATMENT SERVICES PROGRAM OVERSIGHT... 6 DHCS VOLUNTARY TREATMENT CERTIFICATION & DMC CERTIFICATION 6 NEW TITLE 22: DRUG MEDI-CAL PROGRAM INTEGRITY REGULATIONS... 7 Substance Use Disorder Treatment Provider Manual AFFORDABLE CARE ACT OF 2010 AND DRUG MEDI-CAL CERTIFICATION... 8 DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM WAIVER & SFHN-BHS REQUIREMENTS... 8 MODALITIES COVERED BY PROVIDER MANUAL... 9 ROLE OF THE MEDICAL DIRECTOR... 9 THE SUD TREATMENT PROCESS... 10 Client Engagement... 10 Key SUD Intake, Admission and Treatment Process Milestones... 11 Intake, Assessment and Admission Requirements... 12 Physical Examinations... 12 Naltrexone Treatment Admission Requirements... 13 Narcotic Treatment Program Admission Requirements... 13 Perinatal Treatment Admission Requirements... 14 Non-DMC Residential Treatment Admission Requirements... 14 Initial Treatment Plan... 14 Updated Treatment Plans... 15 Non-DMC Residential Updated Treatment Plan Requirements... 16 2 Client Contacts... 16 Table of Client Contact Requirements... 18 Day Care Habilitative... 18 Collateral Services... 19

Individual Counseling... 19 Crisis Intervention Counseling... 19 Progress Notes... 19 Table of Progress Note Timelines... 20 Day Care Habilitative... 20 Continuing Services... 20 Discharge Plan... 21 Discharge Summary... 22 CLIENT FAIR HEARING RIGHTS... 22 AVATAR AND CALOMS TREATMENT DATA ENTRY REQUIREMENTS... 22 CLIENT RECORD AND RETENTION REQUIREMENTS... 23 BILLING... 24 SFHN Services Code Project... 24 DMC Multiple Same Day Services... 24 DMC Client Share of Cost... 25 Good Cause Codes... 25 PROGRAM COMPLIANCE... 25 GLOSSARY OF TERMS... 27 ABOUT THE CONTRIBUTORS... 32 APPENDIX A SFHN-BHS PHILOSOPHY OF CARE... 34 Substance Use Disorder Treatment Provider Manual APPENDIX B DPH DRUG MEDI-CAL CERTIFICATION REQUIREMENT CHECKLIST... 38 APPENDIX C DHCS SUBSTANCE USE DISORDER MODALITY MATRIX... 39 APPENDIX D SUBSTANCE USE DISORDER TREATMENT SERVICES BY MODALITY... 41 3 Outpatient Drug Free Treatment... 41 Day Care Habilitative... 41

Narcotic Treatment Program... 41 Naltrexone Treatment... 42 Residentially Based Substance Use Disorder Treatment... 42 APPENDIX E - INDIVIDUAL CLIENT RECORD DATA SET LIST... 43 APPENDIX F SAMPLE COMPLIANCE AUDIT TOOL... 45 Substance Use Disorder Treatment Provider Manual 4

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Substance Use Disorder Treatment Provider Manual Introduction The SFHN Substance Use Disorder (SUD) Treatment Provider Manual ( Provider Manual ) offers user friendly guidance to all City and County of San Francisco contracted and civil service SUD treatment providers, including Drug Medi-Cal (DMC) certified providers, in complying with State and San Francisco Health Network Behavioral Health Services (SFHN-BHS) SUD treatment requirements and standards. The Provider Manual reflects the best possible quality client care standards and seeks to prevent program deficiencies that can lead to the assessment of recoupments. It has been developed in partnership with SUD treatment providers in the spirit of collaboration and transparency. Substance Use Disorder Treatment Provider Manual SFHN Philosophy of Care The SFHN-BHS supports a philosophy of care that embraces the Quadruple Aim approach to optimizing health care system performance by improving the patient experience of care (including quality and satisfaction), improving the health of populations, reducing the per capita cost of health care, and striving for workforce excellence. Treatment is delivered through the lens of cultural humility and using a Wellness and Recovery Model that is infused with hope and a belief that all clients can achieve their life goals (Appendix A). Consistent with the philosophy of care for the SFHN-BHS, substance use disorder treatment services reflect harm reduction, a public health philosophy that promotes reducing the physical, social, emotional, and economic harm associated with drug and alcohol use, along with other harmful behaviors on individuals and their community. Harm reduction is free of judgment or blame and actively engages clients in setting their own treatment goals and their recovery. Please visit Harm Reduction Policy and Guiding Principles. Substance Use Disorder Treatment Services Program Oversight The Department of Health Care Services (DHCS) is responsible for administering SUD treatment in California (DHCS Substance Use Disorder Services). The San Francisco Department of Public Health SFHN-BHS contracts with DHCS to fund local SUD treatment services. As part of the contract with DHCS, SFHN-BHS ensures that state SUD treatment requirements and standards are met by maintaining fiscal management systems, monitoring provider billing, conducting compliance site visits, processing claims for reimbursement, and offering training and technical assistance to SUD treatment providers. DHCS Voluntary Treatment Certification & DMC Certification The Department of Health Care Services offers voluntary facility certification to programs providing outpatient, intensive outpatient, and nonresidential detoxification treatment. This voluntary certification is granted to programs that exceed minimum levels of service quality and are in substantial compliance with State program standards, specifically the Alcohol and/or Other Drug Certification Standards. 6 In addition, DHCS provides Drug Medi-Cal Certification to SUD treatment providers that meet requirements found under Title 22 of the California Code of Regulations (CCR): 1) Section 51431.1 Program Administration; 2) Section 51490.1 Claim Submissions Requirements; and 3) Section 51561.1 Reimbursement Rates and Requirements. Title 22 refers and ties to Title 9 of the CCR which governs requirements for Narcotic Treatment Programs. Providers are encouraged to learn more about state licensing and certification requirements by visiting the DHCS website.

Title 22: Drug Medi-Cal Program Integrity Regulations As a result of the findings of targeted field reviews of DMC providers suspected of committing fraud and abuse within the State, the DHCS has promulgated new regulations under CCR, Title 22, Section 51341.1 in the form of a California State Plan Amendment. The DHCS DMC Program Integrity regulations address abusive and fraudulent practices, promote treatment practices that are based sound medical practice, and provide DHCS with increased regulatory authority to ensure both program integrity and that providers meet performance expectations. The Provider Manual incorporates the DHCS DMC Program Integrity Regulations which have been approved by the federal government and became effective July 1, 2015. DMC regulations cover documentation requirements for DHCS reviews, clarify existing regulations, and make programmatic changes to DMC regulations that impact individual and group counseling sessions, physical examination requirements, physician review requirements, client treatment plans, progress notes, and discharge planning. Following is a summary of DMC regulatory changes: Strengthening physical examination requirements during the intake process (physical examination waivers are no longer allowed); Requiring licensed physicians to review client personal, medical and substance use histories during the intake process; Allowing therapists, physician assistants, or nurse practitioners to evaluate clients to diagnose whether a client has a DSM 5 Substance Use Disorder, subject to a physician s review and written approval; Requiring face-to-face contact occur in person at a certified facility (telephone contacts, home visits, and hospital visits are not considered face-to-face); Prohibiting minors from participating in group counseling sessions with adults except at certified school sites; Establishing a group counseling size of two to twelve participants (with at least one Medi-Cal eligible participant) for Outpatient Drug-Free, Narcotic Treatment Program, and Day Care Habilitative services; Revising requirements for group counseling session sign-in sheets; Requiring individual and group counseling sessions be conducted in confidential settings; Requiring clients, counselors, therapists and physicians to type or legibly print their name and date treatment plans, progress notes and discharge plans; Requiring client treatment plans to include client diagnoses and goals related to physical exams and medical illnesses; Requiring clients to participant in the preparation and review of their treatment plans and sign their treatment plans; Specifying when counselors and therapists must prepare progress notes; Requiring a licensed physician to review additional documents in determining whether continued services are medically necessary for a client; and Establishing a requirement for providers to prepare client discharge plans including plan content and documentation requirements. Substance Use Disorder Treatment Provider Manual 7

Affordable Care Act of 2010 and Drug Medi-Cal Certification Currently, the Substance Abuse Prevention and Treatment (SAPT) Block Grant is a primary source of support for SUD treatment programs in San Francisco. SAPT funding requirements do not allow grant funds to be used for services that have become an entitlement under Medicaid (Medi-Cal in California). Under the federal Affordable Care Act (ACA) of 2010, drug rehabilitation is a new essential benefit (entitlement) that must be provided by health insurance sold on health insurance exchanges or provided by Medicaid to certain newly eligible adults. In other words, substance use disorder treatment services have become an entitlement under Medi-Cal. While the ACA offers an important new opportunity to leverage Medi-Cal funding to support increased local access to SUD treatment, it also will significantly impact local SUD treatment programs funded through SAPT. Substance Use Disorder Treatment Provider Manual Given the expected increase in the number of individuals who will be eligible to receive SUD treatment under the ACA, the SFHN-BHS will encourage SUD treatment providers to begin the process of obtaining DMC certification. It is expected that in the future, SFHN-BHS will require all funded SUD treatment providers to be DMC certified to continue to receive SFHN-BHS funding for SUD treatment services. The SFHN-BHS is committed to supporting SUD treatment providers in obtaining DMC certification. A DMC certification requirement checklist has been developed as a guide (Appendix B). For more information regarding DMC certification, please contact the DPH Business Contract Compliance Office at (415) 255-3400. Drug Medi-Cal Organized Delivery System Waiver & SFHN-BHS Requirements The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a State Pilot to test a new paradigm for the organized delivery of health care services for Medicaid eligible individuals with substance use disorders. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs. Critical elements of the DMC-ODS Pilot include providing a continuum of care modeled after the American Society of Addiction Medicine (ASAM) Criteria for substance use disorder treatment services, increased local control and accountability, greater administrative oversight, new utilization controls to improve care and efficient use of resources, evidence-based practices in substance abuse treatment, and increased coordination with other systems of care. The DMC-ODS Pilot approach is expected to provide Medi-Cal clients with improved access to care and to support the level of system interaction needed to achieve sustainable recovery. The City and County of San Francisco will participate as a Phase I county under the DMC-ODS, effectively beginning in Fiscal Year 2015-16. Not only do DMC treatment standards and requirements reflect good clinical practice, but also they offer San Francisco the opportunity to improve access to high quality care under the DMC- ODS Pilot program. In an effort to encourage SFHN-BHS funded SUD treatment providers to obtain DMC certification and align SFHN-BHS SUD treatment requirements under the DMC- ODS Pilot, beginning in Fiscal Year 2015-16 and beyond, all SUD treatment providers will be 8 required to adhere to DMC treatment standards and requirements unless otherwise stated in the Provider Manual.

Modalities Covered by Provider Manual The SFHN-BHS Provider Manual covers the following SUD treatment modalities 1 : Outpatient Drug Free (ODF) Narcotic Treatment Program (NTP) Naltrexone Treatment Intensive Outpatient Services (see note below re: formerly Day Care Habilitative Service) Residentially Based Substance Use Disorder Services (incorporates Perinatal Residential Substance Use Disorder Services) While intake/assessment and treatment plans are standardized across SUD treatment modalities, there are some differences in the type and frequency of required client services by modality. Please see Appendix C & Appendix D for modality service descriptions and a DHCS matrix depicting substance use disorder services by treatment modality. Role of the Medical Director While SUD treatment providers may have more than one physician or medical director on staff, the medical director has medical responsibility for all clients and must be available on a regularly scheduled basis. Duties of a medical director may vary, but at a minimum, DMC certified treatment provider medical directors must be responsible for: Establishing, reviewing, maintaining medical policies and standards; Ensuring the quality of medical services provided to all clients; Ensuring that at least one physician providing services for the provider has admitting privileges to a general acute hospital; and Ensuring that a physician has assumed medical responsibility for all clients treated by the provider. Medical Necessity All SUD treatment providers must ensure that treatment services are medically necessary. Medical necessity is established when a client is diagnosed with a substance use disorder based on the Diagnostic and Statistical Manual (DSM) of Mental Health Disorders 5, and the DSM diagnosis is documented in the individual client record within 30 calendar days of the client s admission to treatment date, no sooner than 5 months and no later than 6 months after a client s admission to treatment, or the completion of the most recent justification for services. DSM codes that may be used include mental, emotional, psychological, behavioral and substance use codes. To bill DMC the client must have a substance use DSM code documented in the record. Medical necessity also may include a physical examination and laboratory testing by staff lawfully authorized to provide such services. Physicians, therapists, physician assistants, or nurse practitioners acting within the scope of their respective practices may evaluate whether a client has a substance use disorder at intake. Where a therapist, physician assistant or nurse practitioner performs a client diagnosis, a physician must review each client s diagnosis and document his or her approval of the diagnosis by legibly printing, signing and dating the client s treatment plan. Substance Use Disorder Treatment Provider Manual 9 1 The DHCS has proposed medically necessary Intensive Inpatient Detoxification as a new substance use disorder treatment service for the general treatment population. The DPH DMC Provider Manual will be revised to cover this new service when additional information is available from DHCS regarding specific regulatory requirements. 2 The DMC-ODS Organized Delivery Pilot requires counties to provide Intensive Outpatient Services which are similar in scope to day care habilitative services.

For all DMC certified providers, medical necessity must be established by the Medical Director who must be a physician licensed by the Medical Board of California or the Osteopathic Medical Board of California. Throughout the treatment process, client records must document and demonstrate that a physician directed the provision of treatment including the establishment of medical necessity at admission and for continuing services, the development and review of client treatment plans, and medical consultation and evaluation. SUD Treatment Process If any of the SUD treatment process steps are not completed, the chances for positive client and program compliance outcomes are greatly reduced. Please see the table on the next page which summarizes the treatment process. Substance Use Disorder Treatment Provider Manual 10 10

Key SUD Intake, Admission and Treatment Process Milestones Intake and Admission Initial Treatment Plan Treatment Plan Update(s) Medical Necessity for Continued Services Must complete a personal, medical, and substance use history for each client that evaluates the cause or nature of each client s mental, emotional, psychological, behavioral and substance use disorders. Must complete DPH Health Questionnaire for each client. Must assess each client for whether he/she had physical examination within last 12 months; if none, then physician, registered nurse practitioner, or physician s assistant must conduct an exam within 30 calendar days of the client s admission to treatment date OR must include a goal within the client s initial and updated treatment plans to obtain a physical examination until completed. Must evaluate each client to diagnose DSM 5 substance use disorder within 30 calendar days of the client s admission to treatment date; must be completed by a physician OR can be done by therapist, physician assistant, or nurse practitioner (with review/approval of a physician). Must determine medical necessity within 30 calendar days of a client s admission to treatment date (must be determined by physician). Must conduct laboratory tests (Naltrexone and NTP clients) and certify fitness for treatment (Naltrexone clients). Must be completed, signed and dated within 30 calendar days of a client s admission to treatment date and signed by the therapist or counselor and the client (28 calendar days for NTP clients). Must be reviewed for medical necessity by physician, signed and dated 15 calendar days of the signature of the therapist or counselor. Must be completed, signed and dated by a therapist or counselor no later than 90 calendar days after signing the initial treatment plan, and no later than 90 days calendar days thereafter or when a change in problem identification or focus of treatment occurs. Must be reviewed, approved, signed and dated by client indicating whether client participated in the preparation of the plan within 30 calendar days of the signature of the therapist or counselor. Must be reviewed for medical necessity by physician, signed and dated 15 calendar days of the signature of the therapist or counselor. Must determine need for continued treatment no sooner than 5 months and no later than 6 months after client admission to treatment date or date of completion of most recent justification for continuing services. Must be determined and documented by a physician. Substance Use Disorder Treatment Provider Manual Discharge Plan Discharge Summary Must be completed for all discharged clients by the therapist or counselor within 30 calendar days prior to the last face-to-face treatment with the client. Must be signed by the therapist or counselor and the client with a copy provided to the client and placed in the client record. Must be completed by the provider within 30 calendar days of the last face-to-face contact for each client with whom the provider has lost contact and for all involuntary discharges. 11

Intake, Assessment and Admission Requirements 3 The first step in the treatment process is client intake and assessment. Drug Medi-Cal requires all providers to have written documentation on procedures for client admission to SUD treatment. The SFHN-BHS is adopting this standard for all SUD treatment providers regardless of their DMC certification status. A client admission to treatment date is the date on which any face-to-face treatment service is provided to a client. Once an individual has completed the intake and assessment process, the individual becomes a client of the program. All SUD treatment providers must complete a personal, medical and substance use history 4 for each client upon admission to treatment to support the treatment plan for each client. In addition, all providers must complete a SFHN Health Questionnaire for each client and enter the required information into Avatar, the SFHN-BHS electronic behavioral health record system. Substance Use Disorder Treatment Provider Manual For DMC certified programs, a licensed physician must review each client s history within 30 calendar days of each client s admission to treatment date. Physical Examinations 5 Substance use can complicate and lead to serious health conditions making it important to assess medical illnesses that clients may face. If left untreated, significant medical illnesses may lead to poor treatment outcomes and years of life lost. Additionally, a central element of the San Francisco Health Network s philosophy of care is to provide whole person care that meets a client s behavioral health and primary care needs wherever a client accesses services. All SUD treatment providers must consider client physical health information when developing SUD treatment plan goals. For DMC certified programs, all clients must be assessed for whether they have had a physical examination within the twelve-month period prior to admission to treatment. Physical examination waivers are no longer allowable for DMC certified providers. Consistent with the SFHN-BHS philosophy of care, the SFHN-BHS is adopting this DMC physical examination standard for all SUD treatment providers regardless of their DMC certification status. If documentation of a physical examination cannot be obtained, providers must describe in the client record efforts taken to obtain documentation. For all clients in DMC certified programs that had physical exams within the twelve months prior to treatment admission, a physician must review the exam within 30 calendar days of the treatment admission date to determine whether the client has any significant medical illnesses. A copy of the physical exam must be included in the client record. For any significant medical illnesses, the client s initial and updated treatment plans must incorporate a goal to obtain appropriate treatment for the illnesses. For non-dmc certified providers, program staff must consider client physical health information in developing and updating client treatment plans. When there is no documentation of a client physical exam within the last twelve months from 12 the admission to treatment date, DMC certified providers must either incorporate a physical 3 Section 51341.1(h), Title 22, CCR 4 Section 51341.1(b)(13), Title 22, CCR 5 Section 51341.1(h)(1)(A)(iv)(a)(b)&(c), Title 22, CCR

exam as a client goal in the initial and updated treatment plans or conduct a physical exam of the client within 30 calendar days of the admission to treatment date. A physician, registered nurse practitioner or physician s assistant may conduct the exam. A copy of the exam must be included in each client record. It is not sufficient to include a progress note alone that the exam was completed. The SFHN-BHS is adopting this DMC standard for all SUD treatment providers regardless of their DMC certification status. Naltrexone Treatment Admission Requirements All Naltrexone treatment providers must comply with the following requirements in addition to client intake and admission requirements listed in the prior section above. Naltrexone providers must confirm that each client meets all of the following requirements: Has a documented history of opiate addiction; Is at least 18 years of age; Has been opiate free for a period of time to be determined by a licensed physician based on the physician s clinical judgment (this includes the administration of a body specimen test to confirm the opiate free status of the client); and Is not pregnant (a client must be discharged from treatment if she becomes pregnant during treatment). In addition, a licensed physician must certify each client s fitness for treatment based on the client s physical examination, medical history, and laboratory results. The physician also must advise each client of the overdose risk should he or she return to opiate use while taking Naltrexone and the ineffectiveness of pain relievers while on Naltrexone. Narcotic Treatment Program Admission Requirements 6 For DMC certified programs providing Narcotic Treatment Program services, the following DMC regulations must be met before an individual may be admitted into detoxification or maintenance treatment. The medical director (licensed physician) must conduct a medical evaluation or document the review and concurrence of a medical evaluation for each client which includes at a minimum: 1. A medical history, including the individual s history of illicit drug use; 2. Laboratory tests for determination of narcotic drug use, tuberculosis and syphilis (unless the medical director has determined the individual s subcutaneous veins are severely damaged to the extent that a blood specimen cannot be obtained); and Substance Use Disorder Treatment Provider Manual 3. A physical examination including, at minimum, the following: a. An evaluation of the individual s organ systems for possibility of infectious diseases; pulmonary, liver or cardiac abnormalities; and negative dermatologic impacts of addiction; b. A record of the individual s vital signs (temperature, pulse, blood pressure and respiratory rate); c. An examination of the individual s head, ears, eyes, nose, throat (including 13 thyroid), chest (including heart, lungs, and breasts), abdomen, extremities, skin and general appearance; 6 Section 10270, Title 9, CCR

d. An assessment of the individual s neurological system; and e. A record of the physician s overall impression which identifies any medical condition or health problem for which treatment is warranted. In addition, before a client can be admitted to detoxification or to maintenance treatment, the medical director (licensed physician) must: 1. Document the evidence or review and concur with the documentation of evidence used from the medical evaluation to determine physical dependence and addiction to opiates; and 2. Document the final determination concerning physical dependence and addiction to opiates. Substance Use Disorder Treatment Provider Manual Perinatal Treatment Admission Requirements 7 SUD treatment providers serving pregnant and postpartum women must meet additional admission criteria that include: Confirming that a client is eligible for and received Medi-Cal during the last month of pregnancy; Having medical documentation that substantiates the client s pregnancy and last day of pregnancy; Receiving enhanced reimbursement rate only during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy; Terminating eligibility for perinatal treatment services on the last day of the month in which the 60 th day occurs. Initial Treatment Plan The SFHN-BHS is adopting DMC initial treatment plan requirements for all SUD treatment providers. An initial treatment plan must be completed, signed and dated for each client within 30 calendar days of a client s treatment admission date by a therapist or counselor and the client. If a client refuses to sign the treatment plan, providers must document in the client record the reason for refusal and the strategy to engage the client to participate in treatment. For Narcotic Treatment Program clients, the initial treatment plan must be completed within 28 days after the initiation of maintenance treatment. 9 14 7 Sections 50260, 51303, 51341.1(c)(1), 51341.1(g)(1)(A)(iii), Title 22, CCR 8 Section 12070, Alcohol and/or Other Drug Certification Standards 9 Section 10305, Title 9, CCR

Each treatment plan must be documented, individualized, and based on information obtained during the intake and assessment. There also must be clear and documented links between client needs, treatment goals and provided services. In addition, the rationale and justification for the content of each of client treatment plan components must be well documented. In assessing treatment needs, all SUD treatment providers must consider, at a minimum, client needs in the following areas: 1) educational opportunity/attainment; 2) vocational counseling and training; 3) job referral and placement; 4) legal services; 5) medical and dental services; 6) social/recreational services; and 7) individual and group counseling. Each client treatment plan must be legible and include: A statement of challenges to be addressed; Goals to be reached which address each challenge identified; Action steps which will be taken by the provider and/or client to accomplish identified goals; Target dates for the accomplishment of action steps and goals; A description of the services including type and frequency of counseling to be provided; Client diagnosis; A physical examination goal if the client has not had a physical exam within the twelve months prior to the client s admission to treatment date; A goal that the client obtain appropriate treatment for any significant medical illness indicated/documented by a physical examination which occurred within the twelve months prior to treatment admission; Include the names of the assigned primary therapist or counselor and physician. For DMC certified providers, all initial treatment plans must be reviewed for medical necessity by a licensed physician and signed and dated by the physician within 15 calendar days of the date of the signature of the therapist or counselor. For NTP providers, all initial maintenance treatment plans must include: Short-term goals tied to client needs based on intake and admission data (specific time 90 days or less for the client to achieve); Long-term goals tied to client needs based on intake and admission data (specified time in excess of 90 days for the client to achieve); Specific behavioral tasks the client must accomplish to complete each short-term and long-term goal; A description of the type and frequency of counseling services to be provided; An effective date based on the day the primary counselor signed the initial treatment plan. Substance Use Disorder Treatment Provider Manual Updated Treatment Plans 10 All client treatment plans must be updated, signed and dated by a therapist or counselor no later than 90 calendar days after signing the initial treatment plan, and no later than 90 calendar days 15 thereafter, or when a change in problem identification or focus of treatment occurs. 10 Section 51341.1(h)(2), Title 22, CCR

Each updated treatment plan must include all of the components included in the initial treatment plan and be reviewed, approved, signed and dated by client within 30 calendar days of the signature of the therapist or counselor. The treatment plan also must indicate whether the client participated in the preparation of the plan. If a client refuses to sign the treatment plan, providers must document in the client record the reason for refusal and the strategy to engage the client to participate in treatment. Substance Use Disorder Treatment Provider Manual Narcotic Treatment Program Updated Treatment Plan Requirements 11 For NTP providers, updated treatment plans must be reviewed and signed within 14 calendar days from the effective date and reviewed and signed by the medical director within 14 calendar days form the effective date. Client updated treatment plans also must include: 1) a summary of the client s progress or lack of progress toward each goal identified on the previous treatment plan; and 2) new goals and behavioral tasks for any newly identified needs or related changes in the type and frequency of counseling services to be provided to the client; and 3) an effective date based on the day the primary counselor signed the updated treatment plan. Group Counseling Confidentiality Group counseling sessions must be face-to-face and conducted in a confidential setting where individuals not participating in the counseling session cannot hear the comments of the client or therapist/counselor. Group Counseling Age Requirements SFHN is adopting the DMC standard for age considerations for all SUD treatment providers, regardless of DMC certification status. A client who is seventeen years of age or younger cannot participate in group counseling with clients who are eighteen years of age or older unless the counseling occurs at a DMC certified program s school site. Group Counseling Age Requirements SFHN is adopting the DMC standard for age considerations for all SUD treatment providers, regardless of DMC certification status. A client who is seventeen years of age or younger cannot participate in group counseling with clients who are eighteen years of age or older unless the counseling occurs at a DMC certified program s school site. Group Counseling Age Requirements SFHN is adopting the DMC standard for age considerations for all SUD treatment providers, regardless of DMC certification status. A client who is seventeen years of age or younger cannot participate in group counseling with clients who are eighteen years of age or older unless the counseling occurs at a DMC certified program s school site. 16 11 Section 10270, Title 9, CCR 12 Section 12070, Alcohol and/or Other Drug Certification Standard

Group Counseling Sign-In Requirements All SUD treatment providers must document the focus of group counseling sessions and must have a sign-in sheet, which includes all of the following: 1. The name and signature of the therapist and/or counselor conducting the counseling session; 2. The date of the counseling session; 3. The topic of the counseling sessions. 4. The start and end time of the counseling session; and 5. Each participant s printed name and signature of each participant that attended the counseling session. The sign-in sheet must be signed at the start of or during the counseling session. By signing the sign-in sheet, therapists and counselors are certifying that the sign-in sheet is accurate and complete. Substance Use Disorder Treatment Provider Manual 17

Table of Client Contact Requirements SUD Modality Notes about the Minimum Minimum Maximum # of DMC Group & Progress Contact # of # of Beneficiaries Note Requirements Clients Clients for Required per for Groups Group Groups Substance Use Disorder Treatment Provider Manual 18 ODF NTP Intensive Outpatient Treatment Residential Sessions must focus on short-term personal, family, employment, educational and other client needs and their relationship to substance use or a return to substance use. Sessions must focus on short-term personal, family, employment, educational and other client needs and their relationship to substance use or a return to substance use. Structured activities must meet treatment goals and objectives for increased social responsibility, selfmotivation and integration into the community. These activities may include employment, educational or volunteer hours outside the program site. Each client must receive at least two group counseling sessions per month. Each client must receive a minimum of 50 minutes of counseling per calendar month. Each client must receive counseling sessions and/or structured therapeutic activities a minimum of three hours per day for three days per week. Each client must receive counseling sessions and/or structured activities a minimum of 20 hours per week. No less than 2 clients No less than 2 clients No less than 2 clients No more than 12 clients No more than 12 clients No more than 12 clients Only one client needs to be a Medi-Cal beneficiary Only one client needs to be a Medi-Cal beneficiary Only one client needs to be a Medi-Cal beneficiary

Collateral Services For all SUD treatment providers, collateral services must be provided by therapists and counselors. Collateral services are defined as face-to-face contact with significant persons in the life of the client. Significant persons are defined as individuals that have a personal, not official or professional, relationship with the client. For example, a client s social worker would not meet the significant persons criteria. Each collateral service must focus on the treatment needs of the client to support the achievement of treatment plan goals. A client does not need to be present at the collateral service for the service to billable to DMC. Narcotic Treatment Program - Medical Psychotherapy Sessions For clients in NTP programs, medical psychotherapy sessions are defined as face-to-face discussions between the medical director and/or physician and the client on issues identified in the client treatment plan. Individual Counseling Individual counseling sessions between a therapist or counselor and a client must be face-toface and be conducted in a confidential setting where individuals not participating in the counseling session cannot hear the comments of the client, therapist or counselor. Individual counseling sessions cannot be provided via telephone, home visits or hospital visits and are limited for ODF clients to intake, crisis intervention, collateral services and discharge planning. Crisis Intervention Counseling Crisis intervention counseling must be provided face-to-face between a therapist or a counselor and a client in crisis. A crisis must be an actual relapse or an unforeseen event or circumstance causing imminent threat of relapse. Crisis intervention services must include a focus on alleviating crisis challenges and must be limited to stabilization of the client s emergency situation. Progress Notes The SFHN-BHS is adopting the DMC standards for progress notes for all SUD treatment providers regardless of DMC certification status. Progress notes tell a client s treatment story. While progress note requirements vary depending on the treatment modality, a client s therapist or counselor must document, sign and date each progress note. For ODF and Naltrexone treatment, each progress note must include the following elements: Substance Use Disorder Treatment Provider Manual 1. The topic of the session; 2. A description of the client s progress on treatment plan challenges, goals, action steps, objectives and/or referrals; 3. Information on the client s attendance including the date, start and end times of each individual and group counseling session. For Narcotic Treatment Programs, the counselor conducting the counseling session must document for each client participating in the counseling session the: 1. Date of counseling session; 2. Type of counseling format (e.g. individual or group); 19

3. Duration of counseling session in ten-minute intervals excluding the time required to document the session; 4. Summary of the session including one or more of the following: a) client progress toward one or more treatment plan goals; b) response to a drug-screening specimen which is positive for illicit drugs or negative for the replacement narcotic therapy medication dispensed under the program; c) new issue or challenge that affects the client s treatment; d) nature of prenatal support provided by the program or other appropriate health care providers; and e) goal and/or purpose of the group session, the subjects discussed, and a brief summary of the client s participation. Please see the table below for progress note timeline and content requirements. Table of Progress Note Timelines Substance Use Disorder Treatment Provider Manual Program Type ODF/Naltrexone NTP Intensive Outpatient Treatment Residential When to Record Progress Note For each individual and group counseling session, the therapist or counselor who conducted the session must record a progress note for each participating client and type or legibly print his or her name, and sign and date the progress note within seven calendar days of the counseling session. The counselor must record a progress note for each participating client within fourteen calendar days of the counseling session. The therapist or counselor must record a minimum of one progress note per calendar week for each client participating in structured activities including counseling sessions. The therapist or counselor must record a minimum of one progress note per calendar week for each client participating in structured activities including counseling sessions. Continuing Services 13 The SFHN-BHS is adopting DMC standards for continuing service for all SUD treatment providers, regardless of DMC certification status. No sooner than five months and no later than six months after treatment admission or the date of completion of the most recent justification for continuing services, the need for continued treatment must be determined. A client s therapist or counselor must review the client s progress and eligibility to continue to receive SUD treatment and recommend whether the client should continue to receive treatment services. All of the following continuing service justification areas must be considered in making a recommendation for continuing services: 20 A client s personal, medical and substance use history; Documentation of a client s most recent physical examination; A client s progress notes and treatment plan goals; and 13 Section 51341.1(h)(5)(A)(i), Title 22, CCR

A client s prognosis. A physician must determine whether continued services are medically necessary. The determination of medical necessity must be documented the physician in the client record and shall include all of the above continuing service justification areas in addition to the therapist s or counselor s recommendation for continuing services. A physician signed updated treatment plan at the six month point of treatment services does not meet the continuing service requirement. There must be an actual determination by a physician of the need for continued treatment based on medical necessity. The therapist or counselor must discharge the client from treatment if the physician determines that continuing treatment for the client is not medically necessary. For all SUD treatment providers all billings submitted after the date that the justification is due may be disallowed if the justification to continue services is missing from a client record. Narcotic Treatment Program Continuing Service Requirements For NTP programs, the medical director and/or physician must discontinue a client s maintenance treatment within two consecutive years after treatment began unless the medical director and/or physician complete the following: Evaluates client progress or lack of progress in achieving treatment goals in the progress notes; and Determines through clinical judgment that the client status indicates that such treatment should be continued for a longer period of time as discontinuance from treatment would lead to a return to opiate addiction. Client status in treatment must be re-evaluated at least annually after two consecutive years of maintenance treatment. The medical director and/or physician must document the facts justifying the decision to continue client treatment in the client record. Discharge Plan The SFHN-BHS is adopting the DMC standards for discharge for all SUD treatment providers, regardless of DMC certification status. Substance Use Disorder Treatment Provider Manual Clients may be discharged voluntarily or involuntarily from SUD treatment. When SUD treatment is completed and the therapist or counselor determines that the client has made sufficient progress toward or accomplished treatment plan goals, the counselor/therapist may discharge the client. As part of discharge, the therapist or counselor works with the client to develop a discharge plan that must include at a minimum: A description of the client s relapse triggers 14 and a plan to assist the client to avoid relapse when confronted with each relapse trigger; and A support plan. 15 21 14 A relapse trigger is defined as event(s), circumstance(s), place(s), or person(s) that puts a client at risk of relapse (single instance substance use or pattern of substance use). 15 A support plan is a list of individuals and/or organizations that can provide support and assistance to a client to maintain sobriety.

For DMC certified providers, when a physician determines that continuing treatment services is not medically necessary, a client discharge plan must be completed by the assigned therapist or counselor within 30 calendar days prior to the date of the last face-to-face treatment with the client. During the last face-to-face treatment, the therapist/counselor and the client must document their names legibly, sign and date the discharge plan. A copy of the discharge plan must be provided to the client and must become part of the client record. Discharge Summary For a client with whom a provider has lost contact or who does not attend treatment for more than 30 days, providers must discharge the client and complete a discharge summary within 30 calendar days of the date of the provider s last face-to-face treatment contact with the client. The discharge summary must include: 1) the duration of the client s treatment, as determined by the dates of admission to and discharge from treatment; 2) the reason for discharge; 3) a narrative summary of the treatment episode; and 4) the client s prognosis. Substance Use Disorder Treatment Provider Manual Narcotic Treatment Program Discharge Requirements NTP counselors must develop a discharge summary for each client who is voluntarily or involuntarily discharged from the program that includes at a minimum: 1) client name; 2) date of discharge; 3) reason for discharge, and 4) summary of the client s progress during treatment. Client Fair Hearing Rights 16 In addition to other appeal processes that may be required, DMC providers must advise clients of their Medi-Cal fair hearing rights upon the denial, reduction or termination of DMC services as these relate to their eligibility or benefits. This requirement applies to all clients who discharge involuntarily as well. This notification must be in writing at least 10 calendar days prior to the effective date of the intended action to terminate or reduce services. The written notification must include: 1. A statement of the action the provide intends to take; 2. The reason for the intended action; 3. A citation of the specific regulation(s) supporting the intended action; 4. An explanation of a client s right to a fair hearing for the purpose of appealing the intended action; 5. A statement that the provider must continue treatment services pending a fair hearing decision only if the client appeals in writing within 10 calendar days of the mailing or personal delivery of the notice of intended action to the Department of Social Services; 6. The address where the client must submit his or her request for a fair hearing: Department of Social Services State Hearing Division P.O. Box 944243, MS 9-17-37 Sacramento, California 94244-2430 1 (800) 952-5253 TDD 1 (800) 952-8349 22 Avatar and CalOMS Treatment Data Entry Requirements California Outcomes Measurement System (CalOMS) Treatment (Tx) is California's data collection and reporting system for SUD treatment. By entering SUD and recovery data in 16 Section 51341.1(p), Title 22, CCR

California, CalOMS Tx provides information for improving treatment client outcomes, supporting cost effective services and meeting legally mandated federal and state reporting requirements. Regardless of DMC certification status, all SUD treatment providers must input client treatment data which is sent to DHCS each month. All SFHN SUD treatment providers must enter required CalOMS Tx data in Avatar. In addition to client demographic data, data entered into Avatar builds a comprehensive picture of client behavior including alcohol and drug use data, employment and education data, criminal justice data, medical and physical health data, mental health data and family and social life data. In addition, Avatar captures client discharge data. Summary reports created from CalOMS Tx outcome data contributes to the understanding of treatment and the improvement of substance use disorder treatment programs in the continuum of prevention, treatment and recovery services. Client Record and Retention Requirements All SUD provider regardless of DMC certification status must establish, maintain, and update as necessary an individual client record for each client admitted to treatment and receiving services. This includes, but is not limited to: Intake and admission data, including a physical examination if applicable; Treatment plans; Evidence of compliance with minimum client contact requirements; Progress notes; Continuing services justifications; Laboratory test orders and results; Referrals; Counseling notes; Discharge plan; Discharge summary; Evidence of compliance with multiple billing requirements;17 Evidence of compliance with specific treatment modality requirements;18 and Any other information relating to the treatment services provided to the client. For pregnant and postpartum women, medical documentation also must substantiate a client s pregnancy and the last day of pregnancy19. Substance Use Disorder Treatment Provider Manual 23 All SUD providers must maintain the following documentation in the individual client record for a minimum of seven (7) years from the date of the last face-to-face contact with the client.20 If an audit takes place during the seven year period, the provider must maintain records until the audit is completed: 23