Definitions Program Requirement 1: STAFFING Criteria 1.A: General Staffing 1.a.1 As part of the process leading to certification, the state will prepare an assessment of the needs of the target consumer population and a staffing plan for prospective CCBHCs. The needs assessment will include cultural, linguistic and treatment needs. The needs assessment is performed prior to certification of the CCBHCs in order to inform staffing and services. After certification, the CCBHC will update the needs assessment and the staffing plan, including both consumer and family/caregiver input. The needs assessment and staffing plan will be updated regularly, but no less frequently than every three years. Definitions are consistent with the CARF standards Requirements CARF does not require this exact needs assessment, but covers much of the same material and with the same intent through the following standards: 1.A.5. The organization implements a cultural competency and diversity plan that: a. Addresses: (1) Persons served. (2) Personnel. (3) Other stakeholders. b. Is based on the consideration of the following areas: (1) Culture. (2) Age. (3) Gender. (4) Sexual orientation. (5) Spiritual beliefs. (6) Socioeconomic status. (7) Language. c. Is reviewed at least annually for relevance. d. Is updated as needed. 1.L.1. The organization s leadership: a. Assesses the accessibility needs of the: (1) Persons served. (2) Personnel. (3) Other stakeholders. b. Implements an ongoing process for identification of barriers in the following areas: 1
(1) Architecture. (2) Environment. (3) Attitudes. (4) Finances. (5) Employment. (6) Communication. (7) Technology. (8) Transportation. (9) Community integration, when appropriate. (10) Any other barrier identified by the: (a) (b) (c) Persons served. Personnel. Other stakeholders. 1.D.1. The organization demonstrates that it obtains input: a. On an ongoing basis. b. From: (1) Persons served. (2) Personnel. (3) Other stakeholders. c. Using a variety of mechanisms. 1.I.4 The organization: a. Identifies the competencies needed by personnel to: (1) Assist the persons served in the accomplishment of their established outcomes. And, through: 2.A.10. Each core program for which the organization is seeking accreditation has a written program description that guides the delivery of services and includes: 2
a. A description of the program. b. The philosophy of the program. c. Program goals. d. Description of the service/treatment modalities to be provided to achieve the program objectives. e. Identification or a description of special populations and mechanisms to address their needs. 1.a.2 The staff (both clinical and nonclinical) is appropriate for serving the consumer population in terms of size and composition and providing the types of services the CCBHC is required to and proposes to offer. Note: See criteria 4.K relating to required staffing of services for veterans. 1.a.3 The Chief Executive Officer (CEO) of the CCBHC maintains a fully staffed management team as appropriate for the size and needs of the clinic as determined by the current needs assessment and staffing plan. The management team will include, at a minimum, a CEO or Executive Director/Project Director, and a psychiatrist as Medical Director. The Medical Director need not be a fulltime employee of the CCBHC. 1.I.1. There are an adequate number of personnel to: a. Meet the established outcomes of the persons served. b. Ensure the safety of persons served. c. Deal with unplanned absences of personnel. d. Meet the performance expectations of the organization. 1.I.4 The organization: a. Identifies the competencies needed by personnel to: (1) Assist the persons served in the accomplishment of their established outcomes. CARF standards do not dictate the positions per se, but state: 1.A.1. The organization identifies: 1.I.9. a. Its leadership structure. b. The responsibilities of each level of leadership. As applicable, the organization demonstrates a process that addresses the provision of services by personnel that are consistent with relevant: a. Legislation governing practices. b. Licensure requirements. c. Registration requirements. d. Certification requirements. 3
Depending on the size of the CCBHC, both positions (CEO/Executive Director/Project Director and the Medical Director) may be held by the same person. The Medical Director will ensure the medical component of care and the integration of behavioral health (including addictions) and primary care are facilitated. Note: If a CCBHC is unable, after reasonable and consistent efforts, to employ or contract with a psychiatrist as Medical Director because of a documented behavioral health professional shortage in its vicinity (as determined by the Health Resources and Services Administration (HRSA) (Health Resources and Services Administration [2015]), psychiatric consultation will be obtained on the medical component of care and the integration of behavioral health and primary care, and a medically trained behavioral health care provider with appropriate education and licensure with prescriptive authority in psychopharmacology who can prescribe and manage medications independently pursuant to state law will serve as the Medical Director. 1.a.4 The CCBHC maintains e. Professional degrees. f. Professional training to maintain established competency levels. g. On-the-job training requirements. h. Professional standards of practice. 2.A.15. The program receives medical consultation regarding medically related policies or procedures, when appropriate. 2.A.16. In a medically supervised program, there is a medical director who is a physician. 1.G.2. As part of risk management, the insurance package of the organization: a. Is reviewed: 4
liability/malpractice insurance adequate for the staffing and scope of services provided. Criteria 1.B: Licensure and Credentialing 1.b.1 All CCBHC providers who furnish services directly, and any Designated Collaborating Organization (DCO) providers that furnish services under arrangement with the CCBHC, are legally authorized in accordance with federal, state and local laws, and act only within the scope of their respective state licenses, certifications, or registrations and in accordance with all applicable laws and regulations, including any applicable state Medicaid billing regulations or policies. Pursuant to the requirements of the statute (PAMA 223 (a)(2)(a)), CCBHC providers have and maintain all necessary state-required licenses, certifications, or other credentialing, with providers working toward licensure, and appropriate (1) For adequacy. (2) On an annual basis. b. Protects assets. c. Includes: (1) Property coverage. (2) Liability coverage. (3) Other coverage, as appropriate. 1.E.1. The organization demonstrates a process to comply with the following obligations: 1.I.9. a. Legal. b. Regulatory. e. Licensing. k. Employment practices. As applicable, the organization demonstrates a process that addresses the provision of services by personnel that are consistent with relevant: a. Legislation governing practices. b. Licensure requirements. c. Registration requirements. d. Certification requirements. e. Professional degrees. f. Professional training to maintain established competency levels. g. On-the-job training requirements. h. Professional standards of practice. 5
supervision in accordance with applicable state law. 1.b.2 The CCBHC staffing plan meets the requirements of the state behavioral health authority and any accreditation standards required by the state, is informed by the state s initial needs assessment, and includes clinical and peer staff. In accordance with the staffing plan, the CCBHC maintains a core staff comprised of employed and, as needed, contracted staff, as appropriate to the needs of CCBHC consumers as stated in consumers individual treatment plans and as required by program requirements 3 and 4 of these criteria. States specify which staff disciplines they will require as part of certification but must include a medically trained behavioral health care provider, either employed or available through formal arrangement, who can prescribe and manage medications independently under state law, including buprenorphine and other medications used to treat opioid and alcohol use disorders. The CCBHC must have staff, either employed or available through formal arrangements, who are credentialed substance abuse specialists. Providers must include individuals with expertise in addressing trauma and promoting the recovery of CARF standards are not as prescriptive with regard to how the organization arranges staffing, but it is implied and expected that the programs would employ all the types of credentialed professionals described in the CCBHC draft criteria and also specify: 2.A.16. In a medically supervised program, there is a medical director who is a physician. 2.B.10. Assessments are conducted by qualified personnel: a. Knowledgeable to assess the specific needs of the persons served. b. Trained in the use of applicable tools, tests, or instruments prior to administration. c. Able to communicate with the persons served. 2.B.11. When assessment results in diagnosis(es), the diagnosis is determined by a practitioner legally qualified to do so in accordance with all applicable laws and regulations. For OTP Programs: 2.A.32. The program has a qualified medical director who is responsible for: a. Administering or supervising all medical services. b. Ensuring that the program is in conformance with all applicable local, state, and federal regulations regarding the medical treatment of opioid addiction. And these standards: 1.I.1. There are an adequate number of personnel to: 1.I.9. a. Meet the established outcomes of the persons served. b. Ensure the safety of persons served. c. Deal with unplanned absences of personnel. d. Meet the performance expectations of the organization. As applicable, the organization demonstrates a process that addresses the provision of services by personnel that are consistent with relevant: 6
children and adolescents with serious emotional disturbance (SED) and adults with serious mental illness (SMI) and those with substance use disorders. Examples of staff the state might require include a combination of the following: (1) psychiatrists (including child, adolescent, and geriatric psychiatrists), (2) nurses trained to work with consumers across the lifespan, (3) licensed independent clinical social workers, (4) licensed mental health counselors, (5) licensed psychologists, (6) licensed marriage and family therapists, (7) licensed occupational therapists, (8) staff trained to provide case management, (9) peer specialist(s)/recovery coaches, (10) licensed addiction counselors, (11) staff trained to provide family support, (12) medical assistants, and (13) community health workers. The CCBHC supplements its core staff, as necessary given program requirements 3 and 4 and individual treatment plans, through arrangements with and referrals to other providers. Note: Recognizing professional shortages exist for many behavioral health providers: (1) some services may be provided by contract or part-time or as needed; (2) in CCBHC organizations comprised of multiple clinics, providers may be shared among clinics; and (3) CCBHCs may utilize telehealth/ telemedicine and on-line services to alleviate shortages. CCBHCs are not a. Legislation governing practices. b. Licensure requirements. c. Registration requirements. d. Certification requirements. e. Professional degrees. f. Professional training to maintain established competency levels. g. On-the-job training requirements. h. Professional standards of practice. 2.A.27. through 2.A.33. The organization implements policies and procedures that are inclusive of a peer workforce. 7
precluded by anything in this criterion from utilizing providers working towards licensure, provided they are working under the requisite supervision. Criteria 1.C: Cultural Competence and Other Training 1.c.1 The CCBHC has a training plan, for all employed and contract staff, and for providers at DCOs who have contact with CCBHC consumers or their families, which satisfies and includes requirements of the state behavioral health authority and any accreditation standards on training which may be required by the state. Training must address cultural competence; personcentered and family-centered, recovery-oriented, evidence-based and trauma-informed care; and primary care/behavioral health integration. This training, as well as training on the clinic s continuity plan, occurs at orientation and thereafter at reasonable intervals as may be required by the state or accrediting agencies. At orientation and annually thereafter, the CCBHC provides training about: (1) risk assessment, suicide prevention and suicide response; (2) the roles of families and peers; and (3) such other trainings as may be required by the state or accrediting agency on an annual 1.A.5. The organization implements a cultural competency and diversity plan that: 1.I.5. a. Addresses: (1) Persons served. (2) Personnel. (3) Other stakeholders. b. Is based on the consideration of the following areas: (1) Culture. (2) Age. (3) Gender. (4) Sexual orientation. (5) Spiritual beliefs. (6) Socioeconomic status. (7) Language. c. Is reviewed at least annually for relevance. d. Is updated as needed. The organization provides documented personnel training: a. At: (1) Orientation. (2) Regular intervals. b. That addresses, at a minimum: (1) The identified competencies needed by personnel. (2) Confidentiality requirements. 8
basis. If necessary, trainings may be provided on-line. Cultural competency training addresses diversity within the organization s service population and, to the extent active duty military or veterans are being served, must include information related to military culture. Examples of cultural competency training and materials include, but are not limited to, those available through the website of the US Department of Health & Human Services (DHHS), the SAMHSA website through the website of the DHHS, Office of Minority Health, or through the website of the DHHS, Health Resources and Services Administration. Note: See criteria 4.K relating to cultural competency requirements in services for veterans. 1.c.2 The CCBHC assess the skills and competence of each individual furnishing services and, as necessary, provides in-service training and education programs. The CCBHC has written policies and procedures describing its method(s) of assessing competency and maintains a written accounting of the in-service training provided during (3) Customer service. (4) Diversity. (5) Ethical codes of conduct. (6) Promoting wellness of the persons served. (7) Person-centered practice. 2.A.22. Team members, in response to the needs of the persons served: 1.I.5. a. Help empower each person served to actively participate with the team to promote recovery, progress, or well-being. b. Provide services that are consistent with the needs of each person served through direct intera with that person and/or with individuals identified by that person. c. Are culturally and linguistically competent. The organization provides documented personnel training: a. At: (1) Orientation. (2) Regular intervals. b. That addresses, at a minimum: (1) The identified competencies needed by personnel. 2.A.21. For personnel providing direct services, the organization includes the following in its assessment of competency and competency-based training: a. Areas that reflect the specific needs of the persons served. 9
the previous 12 months. b. Clinical skills that are appropriate to the position. c. Person-centered plan development. d. Interviewing skills. e. Program-related research-based treatment approaches. 1.c.3 The CCBHC documents in the staff personnel records that the training and demonstration of competency are successfully completed. CARF standards require documented competency-based training. 1.I.6. Performance management includes: b. Performance evaluations for all personnel directly employed by the organization that are: (1) Based on: (a) Job functions. (b) Identified competencies. (2) Evident in personnel files. 1.c.4 Individuals providing annual staff training are qualified as evidenced by education, training and experience. Criteria 1.D: Linguistic Competence 1.I.9. As applicable, the organization demonstrates a process that addresses the provision of services by personnel that are consistent with relevant: a. Legislation governing practices. b. Licensure requirements. c. Registration requirements. d. Certification requirements. e. Professional degrees. f. Professional training to maintain established competency levels. g. On-the-job training requirements. h. Professional standards of practice. 1.d.1 If the CCBHC serves individuals with limited English This is consistent with the CARF standards. 2.A.22. Team members, in response to the needs of the persons served: 10
proficiency (LEP) or with languagebased disabilities, the CCBHC takes reasonable steps to provide meaningful access to their services. a. Help empower each person served to actively participate with the team to promote recovery, progress, or well-being. b. Provide services that are consistent with the needs of each person served through direct intera with that person and/or with individuals identified by that person. c. Are culturally and linguistically competent. 1.d.2 Interpretation/translation service(s) are provided that are appropriate and timely for the size/needs of the LEP CCBHC consumer population (e.g., bilingual providers, onsite interpreters, language telephone line). To the extent interpreters are used, such translation service providers are trained to function in a medical and, preferably, a behavioral health setting. 1.d.3 Auxiliary aids and services are readily available, ADA compliant, and responsive to the needs of consumers with disabilities (e.g., sign language interpreters, TTY lines). This is consistent with the CARF standards, but not required per se. Services must be provided that are understandable, throughout the continuum of care. CARF standards do not require ADA compliance, but ensure that during the assessment process under 2.B.14 that the need for assistive technology is addressed. The standards also require the ongoing identification of accessibility needs and barriers. 1.L.1. The organization s leadership: a. Assesses the accessibility needs of the: (1) Persons served. (2) Personnel. (3) Other stakeholders. b. Implements an ongoing process for identification of barriers in the following areas: (1) Architecture. 11
(2) Environment. (3) Attitudes. (4) Finances. (5) Employment. (6) Communication. (7) Technology. (8) Transportation. (9) Community integration, when appropriate. (10) Any other barrier identified by the: (a) Persons served. (b) Personnel. (c) Other stakeholders. 1.d.4 Documents or messages vital to a consumer s ability to access CCBHC services (for example, registration forms, sliding scale fee discount schedule, after-hours coverage, signage) are available for consumers in languages common in the community served, taking account of literacy levels and the need for alternative formats (for consumers with disabilities). Such materials are provided in a timely manner at intake. The requisite languages will be informed by the needs assessment prepared prior to certification, and as updated. 2.A.1. Each program/service: b. Shares information about the scope of services with: (1) The persons served. (2) Families/support systems, in accordance with the choices of the persons served. (3) Referral sources. (4) Payers and funding sources. (5) Other relevant stakeholders. (6) The general public. It is expected that all of the information provided is understandable to the person served. 12
1.d.5 The CCBHC s policies have explicit provisions for ensuring all employees, affiliated providers, and interpreters understand and adhere to confidentiality and privacy requirements applicable to the service provider, including but not limited to the requirements of Health Insurance Portability and Accountability Act (HIPAA) (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine and often critical communications between health care providers and a consumer's family and friends, so long as the consumer consents or does not object. If a consumer is amenable and has the capacity to make health care decisions, health care providers may communicate with a consumer's family and friends. 1.A.3. The identified leadership guides the following: j. Compliance with: (1) All legal requirements. (2) All regulatory requirements. 1.E.1. The organization demonstrates a process to comply with the following obligations: a. Legal. b. Regulatory. c. Confidentiality. j. Privacy of the persons served. 1.E.3. Policies and written procedures address: a. Confidential administrative records. b. The records of the persons served. c. Security of all records. d. Confidentiality of records. e. Compliance with applicable laws concerning records. f. Time frames for documentation in the records of the persons served. 1.K.2. The organization implements policies promoting the following rights of the persons served: a. Confidentiality of information. d. Access to: (1) Information pertinent to the person served in sufficient time to facilitate his or her decision making. (2) Their own records. e. Informed consent or refusal or expression of choice regarding: (1) Service delivery. (2) Release of information. 13
2.A.23. A designated individual(s) assists in coordinating services for each person served by: g. Communicating information regarding progress of the person served to the appropriate persons. i. Involving the family or legal guardian, when applicable or permitted. 2.B.12. The assessment process includes information obtained from: a. The person served. b. Family members/legal guardian, when applicable and permitted. c. Other collateral sources, when applicable and permitted. 2.C.1. A written person-centered plan is: a. Developed with: (1) The active participation of the person served. (2) The involvement of family/legal guardian of the person served, when applicable and permitted. 2.G.1. The organization implements policies and procedures regarding information to be transmitted to other individuals or agencies that include: a. The identification of information that can legally be shared without an authorization for release of information. b. Forms to authorize release of information that: (1) Comply with applicable laws. (2) Identify, at a minimum: (a) (b) (c) (d) (e) The name of the person about whom information is to be released. The content to be released. To whom the information is to be released. The purpose for which the information is to be released. The date on which the release is signed. 14
(f) The date, event, or condition upon which the authorization expires. (g) Information as to how and when the authorization can be revoked. (h) The signature of the person who is legally authorized to sign the release. Program Requirement Two: AVAILABILITY AND ACCESSIBILITY OF SERVICES Criteria 2.A: General Requirements. 2.a.1 The CCBHC provides a safe, functional, clean, and welcoming environment, for consumers and staff, conducive to the provision of services identified in program requirement 4. 2.a.2 The CCBHC provides outpatient clinical services during times that ensure accessibility and meet the needs of the consumer population to be served, including some nights and weekend hours. 2.a.3 The CCBHC provides services at locations that ensure Access and Availability 1.H.1. The organization maintains a healthy and safe environment. This would be expected and would be addresses as part of Accessibility planning under 1.L.1. 1.L.1. The organization s leadership: a. Assesses the accessibility needs of the: (1) Persons served. (2) Personnel. (3) Other stakeholders. b. Implements an ongoing process for identification of barriers in the following areas: (1) Architecture. (2) Environment. (3) Attitudes. (4) Finances. (5) Employment. 15
accessibility and meet the needs of the consumer population to be served. (6) Communication. (7) Technology. (8) Transportation. (9) Community integration, when appropriate. (10) Any other barrier identified by the: (a) (b) (c) Persons served. Personnel. Other stakeholders. 3.Q.4. To maximize the opportunity of the persons served to participate in the program, services are provided: a. In locations that meet the needs of the persons served. b. At times that meet the needs of the persons served. c. On days that meet the needs of the persons served. 2.a.4 To the extent possible within the state Medicaid program or other funding or programs, the CCBHC provides transportation or transportation vouchers for consumers. 2.a.5 To the extent possible within the state Medicaid program and as allowed by state law, CCBHCs utilize mobile in-home, telehealth/telemedicine, and on-line 1.E.1. The organization demonstrates a process to comply with the following obligations: a. Legal. b. Regulatory. 1.L.1. The organization s leadership: b. Implements an ongoing process for identification of barriers in the following areas: (8) Transportation. Not required per se., but programs are expected to be designed to facilitate access to services, which could mean mobile in-home supports and: 3.Q.4. To maximize the opportunity of the persons served to participate in the program, services are provided: a. In locations that meet the needs of the persons served. b. At times that meet the needs of the persons served. 16
treatment services to ensure consumers have access to all required services. c. On days that meet the needs of the persons served. 3.Q.5. To meet the needs of the persons served, the program demonstrates how it uses technology to: a. Increase access to services. b. Increase supports. c. Enhance services. 2.a.6 The CCBHC engages in outreach and engagement activities to assist consumers and families to access benefits, and formal or informal services to address behavioral health conditions and needs. This is expected as part of the continuum of care provided. 2.A.11. Services are designed and implemented to: a. Support the recovery, health, or well-being of the persons or families served. b. Enhance the quality of life of the persons served. c. Reduce symptoms or needs and build resilience. d. Restore and/or improve functioning. e. Support the integration of the persons served into the community. 2.A.18. The program ensures that information and education that is relevant to the needs of the persons served is provided. 2.a.7 Services are subject to all state standards including the provision for voluntary and court ordered services. 2.A.19. As appropriate, families are: a. Encouraged to participate in educational programs offered by the organization. b. Invited to participate in clinical programs or services with the persons served, with consent or legal right. 1.E.1. The organization demonstrates a process to comply with the following obligations: a. Legal. b. Regulatory. c. Confidentiality. d. Reporting. e. Licensing. 17
f. Contractual. g. Debt covenants. h. Corporate status. i. Rights of the persons served. j. Privacy of the persons served. k. Employment practices. l. Mandatory employee testing. 2.a.8 CCBHCs have in place a continuity of operations/disaster plan. 1.H.5. There are written emergency procedures: a. For: (1) Fires. (2) Bomb threats. (3) Natural disasters. (4) Utility failures. (5) Medical emergencies. Initial (6) Violent or other threatening situations. b. That satisfy: (1) The requirements of applicable authorities. (2) Practices appropriate for the locale. c. That address, as follows: (1) When evacuation is appropriate. (2) Complete evacuation from the physical facility. (3) When sheltering in place is appropriate. (4) The safety of all persons involved. (5) Accounting for all persons involved. (6) Temporary shelter, when applicable. (7) Identification of essential services. (8) Continuation of essential services. 18
Criteria 2.B: Services and Initial and Comprehensive Evaluation for New Consumers (9) Emergency phone numbers. (10) Notification of the appropriate emergency authorities. 1.J.1. The organization implements a technology and system plan that: a. Includes: (7) Disaster recovery preparedness. 2.b.1 All new consumers requesting or being referred for behavioral health services will, at the time of first contact, receive a preliminary screening and risk assessment to determine acuity of needs. That screening may occur telephonically. The preliminary screening will be followed by: (1) an initial evaluation, and (2) a comprehensive personcentered and family-centered diagnostic and treatment planning evaluation, with the components of each specified in program requirement 4. Each evaluation builds upon what came before it. Subject to more stringent state, federal, or applicable accreditation standards: 2.B.1. Person-centered care is demonstrated throughout the screening and/or assessment process. 2.B.2. The program demonstrates efforts to minimize the times between first contact, screening, and admission or referral. 2.B.3. The organization implements policies and written procedures that define: a. If/how screening is conducted. b. Eligibility for services. c. How admissions are: (1) Conducted. (2) Prioritized, if necessary. d. Who is responsible for making admission decisions. e. Exclusionary or ineligibility criteria. 2.B.4. When screening is conducted by the organization, it: a. Is documented. b. Includes a review of each person s eligibility for admission based on: (1) Presenting problem(s). 19
If the screening identifies an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up. If the screening identifies an urgent need, clinical services are provided and the initial evaluation completed within one business day of the time the request is made. If the screening identifies routine needs, services will be provided and the initial evaluation completed within 10 business days. For those presenting with emergency or urgent needs, the initial evaluation may be conducted telephonically or by telehealth/telemedicine but an inperson evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved the consumer must be seen in person at the next subsequent encounter and the initial evaluation reviewed. Subject to more stringent state, federal or applicable accreditation standards, all new consumers will receive a more comprehensive person-centered and family-centered diagnostic and treatment planning (2) Identification and documentation of any urgent or critical needs of the person to be served. (3) Legal eligibility criteria, when applicable. (4) Availability of funding sources. c. Identifies: (1) Whether the organization can provide the appropriate services needed. (2) Alternate resources when services cannot be provided. d. Includes: (1) An interview with the person to be served or referral source. (2) When appropriate, a preadmission on-site visit to the organization and its programs by the person to be served/legal guardian. e. Ensures that: (1) Screening tools used are uniformly administered. (2) Personnel are trained on use of tools prior to administration. 2.B.5. If the screening identifies an urgent and critical need, appropriate action is taken immediately. 2.B.6. If a crisis assessment is conducted: a. It is documented. b. The following are addressed: (1) Suicide risk. (2) Danger to self or others. (3) Urgent or critical medical condition(s). (4) Immediate threat(s). 2.B.7. If the screening identifies unsafe substance use: a. A brief intervention is conducted either directly, through referral, or as part of the treatment program. b. The individual is referred for a full assessment, if needed. 20
evaluation to be completed within 60 calendar days of the first request for services. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the 60 day period. Note: Requirements for these screenings and evaluations are specified in criteria 4.D. 2.B.12. The assessment process includes information obtained from: a. The person served. b. Family members/legal guardian, when applicable and permitted. c. Other collateral sources, when applicable and permitted. d. External sources, when the need for specified assessments not able to be provided by the organization is identified. 2.B.13. The assessment process: a. Focuses on the person s specific needs. b. Identifies the goals and expectations of the person served. c. Is responsive to the changing needs of the person served. d. Includes provisions for communicating the results of the assessments to: (1) The person served/legal guardian. (2) Applicable personnel. (3) Others as appropriate. e. Provides the basis for legally required notification when applicable. f. Occurs within time frames established by the organization or external regulatory requirements. g. Reflects significant life or status changes of the person served. 2.B.14. The assessment process gathers and records sufficient information to develop a comprehensive person-centered plan for each person served, including information about the person s: a. Presenting issues from the perspective of the person served. b. Urgent needs, including: (1) Suicide risk. (2) Personal safety. (3) Risk to others. c. Personal strengths. d. Individual needs. 21
e. Abilities and/or interests. f. Preferences. g. Previous behavioral health services, including: (1) Diagnostic history. (2) Treatment history. h. Mental status. i. Medication, including: (1) Medication history and current use profile. (2) Efficacy of current or previously used medication. (3) Medication allergies or adverse reactions to medications. j. Physical health issues, including: (1) Health history. (2) Current health needs. (3) Current pregnancy and prenatal care. k. Co-occurring disabilities, disorders, and medical conditions. l. Current level of functioning. m. Pertinent current and historical life information, including his or her: (1) Age. (2) Gender, sexual orientation, and gender expression. (3) Culture. (4) Spiritual beliefs. (5) Education history. (6) Employment history. (7) Living situation. (8) Legal involvement. (9) Family history. (10) Relationships, including families, friends, community members, and other interested parties. 22
n. History of trauma: (1) That is: (a) Experienced. (b) Witnessed. (2) Including: (a) Abuse. (b) Neglect. (c) Violence. (d) Sexual assault. o. Use of alcohol, tobacco, and/or other drugs. p. Risk-taking behaviors. q. Literacy level. r. Need for assistive technology in the provision of services. s. Need for, and availability of, social supports. t. Advance directives, when applicable. u. Psychological and social adjustment to disabilities and/or disorders. v. Resultant diagnosis(es), if identified. 2.b.2 The comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is updated by the treatment team, in agreement with and endorsed by the consumer and in consultation with the primary care provider (if any), when changes in the consumer s status, responses to treatment, or goal achievement have occurred. 1.E.1. The organization demonstrates a process to comply with the following obligations: a. Legal. b. Regulatory. 2.B.13. The assessment process: a. Focuses on the person s specific needs. b. Identifies the goals and expectations of the person served. c. Is responsive to the changing needs of the person served. d. Includes provisions for communicating the results of the assessments to: (1) The person served/legal guardian. 23
The assessment must be updated no less frequently than every 90 calendar days unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent. (2) Applicable personnel. (3) Others as appropriate. e. Provides the basis for legally required notification when applicable. f. Occurs within time frames established by the organization or external regulatory requirements. g. Reflects significant life or status changes of the person served. 2.C.1. A written person-centered plan is: a. Developed with: (1) The active participation of the person served. (2) The involvement of family/legal guardian of the person served, when applicable and permitted. b. Prepared using the information from the assessment process. c. Based upon the person s: (1) Strengths. (2) Needs. (3) Abilities. (4) Preferences. d. Focused on the integration and inclusion of the person served into: (1) His or her community. (2) The family, when appropriate. (3) Natural support systems. (4) Other needed services. e. Communicated to the person served in a manner that is understandable. f. Provided to the person served, when applicable. 2.C.3. Person-centered plans are reviewed periodically with the person served to: a. Reflect current issues. b. Maintain relevance. 24
c. Modify goals, objectives, and interventions, when necessary. d. Maintain visitation plans and/or court orders, when applicable. 2.C.7. Progress notes: a. Document: b. Are: (1) Progress toward achievement of identified: (a) (b) Objectives. Goals. (2) Significant events or changes in the life of the person served. (3) The delivery and outcome of specific interventions, modalities, and/or services that support the person-centered plan. (4) Changes in: (a) (b) (1) Signed. (2) Dated. Frequency of services. Levels of care. 2.G.5. Entries to the records of the persons served follow the organization s policy that specifies time frames for entries. 2.b.3 Outpatient clinical services for established CCBHC consumers seeking an appointment for routine needs must be provided within 10 business days of the requested date for service, unless the state has established a standard that meets 25
the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent. If an established consumer presents with an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up. If an established consumer presents with an urgent need, clinical services are provided within one business day of the time the request is made. Criteria 2.C: 24/7 Access to Crisis Coverage 2.c.1 In accordance with the requirements of program requirement 4, the CCBHC provides crisis management services that are available and accessible 24-hours a day and delivered within three hours. 2.A.20. Written procedures specify that the program provides or arranges for crisis intervention services. 2.c.2 The methods for providing a continuum of crisis prevention, response, and postvention services are clearly described in the policies 2.A.20. Written procedures specify that the program provides or arranges for crisis intervention services. Under 2.B.9, orientation of persons served, it includes access to after hours crisis services. 26
and procedures of the CCBHC and are available to the public. 2.c.3 Individuals who are served by the CCBHC are educated about crisis management services and Psychiatric Advanced Directives and how to access crisis services, including suicide or crisis hotlines and warmlines, at the time of the initial evaluation. This includes individuals with LEP or disabilities (i.e., CCBHC provides instructions on how to access services in the appropriate methods, language(s), and literacy levels in accordance with program requirement 1). 2.c.4 In accordance with the requirements of program requirement 3, CCBHCs maintain a working relationship with local EDs. Protocols are established for CCBHC staff to address the needs of CCBHC consumers in psychiatric crisis who come to those EDs. Under 2.B.9, orientation, education on advance directives is provided. 2.C.4. When assessment identifies a potential risk for dangerous behaviors, a personal safety plan: a. Is completed: (1) With the person served. (2) As soon as possible after admission. b. Includes: (1) Triggers. (2) Current coping skills. (3) Warning signs. (4) Preferred interventions necessary for: (a) Personal safety. (b) Public safety. (5) Advance directives, when available. 2.A.20. Written procedures specify that the program provides or arranges for crisis intervention services. 27
2.c.5 Protocols, including protocols for the involvement of law enforcement, are in place to reduce delays for initiating services during and following a psychiatric crisis. Note: See criterion 3.c.5 regarding specific care coordination requirements related to discharge from hospital or ED following a psychiatric crisis. Not addressed. 2.c.6 Following a psychiatric emergency or crisis involving a CCBHC consumer, in conjunction with the consumer, the CCBHC creates, maintains, and follows a crisis plan to prevent and de-escalate future crisis situations, with the goal of preventing future crises for the consumer and their family. Note: See criterion 3.a.4 where precautionary crisis planning is addressed. 2.C.4. When assessment identifies a potential risk for dangerous behaviors, a personal safety plan: a. Is completed: (1) With the person served. (2) As soon as possible after admission. b. Includes: (1) Triggers. (2) Current coping skills. (3) Warning signs. (4) Preferred interventions necessary for: (a) Personal safety. (b) Public safety. (5) Advance directives, when available. Note: A personal safety plan may be referred to as a crisis intervention or behavioral management treatment plan, a crisis plan, or may be referred to in a psychiatric advance directive. Criteria 2.D: No refusal 28
of services due to a lack of ability to pay. 2.d.1 The CCBHC ensures: (1) no individuals are denied behavioral health care services, including but not limited to crisis management services, because of an individual s inability to pay for such services (PAMA 223 (a)(2)(b)), and (2) any fees or payments required by the clinic for such services will be reduced or waived to enable the clinic to fulfill the assurance described in clause (1). Not addressed. 2.d.2 The CCBHC has a published sliding fee discount schedule(s) that includes all services the CCBHC proposes to offer pursuant to these criteria. Such fee schedule will be included on the CCBHC website, posted in the CCBHC waiting room and readily accessible to consumers and families. The sliding fee discount schedule is communicated in languages/formats appropriate for individuals seeking services who have LEP or disabilities. 1.F.8. The organization, if responsible for fee structures: a. Identifies the basis of the fee structures. b. Demonstrates: (1) Review of fee schedules. (2) Comparison of fee schedules. (3) Modifications when necessary. c. Discloses to the persons served all fees for which they will be responsible 2.d.3 Not addressed. 29
The fee schedules, to the extent relevant, conform to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics; absent applicable state or federal requirements, the schedule is based on locally prevailing rates or charges and includes reasonable costs of operation. 2.d.4 The CCBHC has written policies and procedures describing eligibility for and implementation of the sliding fee discount schedule. Those policies are applied equally to all individuals seeking services. Not addressed. Criteria 2.E: Provision of Services Regardless of Residence 2.e.1 The CCBHC ensures no individual is denied behavioral health care services, including but not limited to crisis management services, because of place of residence or Not addressed, but this is consistent with the CARF standard s emphasis on person-centered, accessible services. 30
homelessness or lack of a permanent address. 2.e.2. CCBHCs have protocols addressing the needs of consumers who do not live close to a CCBHC or within the CCBHC catchment area as established by the state. CCBHCs are responsible for providing, at a minimum, crisis response, evaluation, and stabilization services regardless of place of residence. The required protocols should address management of the individual s on-going treatment needs beyond that. Protocols may provide for agreements with clinics in other localities, allowing CCBHCs to refer and track consumers seeking non-crisis services to the CCBHC or other clinic serving the consumer s county of residence. For distant consumers within the CCBHC s catchment area, CCBHCs should consider use of telehealth/telemedicine to the extent practicable. In no circumstances (and in accordance with PAMA 223 (a)(2)(b)), may any consumer be refused services because of place of residence. Program Requirement 3: CARE Not addressed per se but such necessary collaborations would be expected. 31
COORDINATION Criteria 3.A: General Requirements of Care Coordination 3.a.1 Based on a person and familycentered plan of care aligned with the requirements of Section 2402(a) of the ACA and aligned with state regulations and consistent with best practices, the CCBHC coordinates care across the spectrum of health services, including access to highquality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. Note: See criteria 4.K relating to care coordination requirements for veterans. This is expected and would be covered under 1.E.1. And, for all persons served: 2.A.23. A designated individual(s) assists in coordinating services for each person served by: a. Assuming responsibility for ensuring the implementation of the person-centered plan, if applicable. b. Ensuring that the person served is oriented to his or her services. c. Promoting the participation of the person served on an ongoing basis in discussions of his or her plans, goals, and status. d. Identifying and addressing gaps in service provision. e. Sharing information on how to access community resources relevant to his or her needs. f. Advocating for the person served, when applicable. g. Communicating information regarding progress of the person served to the appropriate persons. h. Facilitating the transition process, including arrangements for follow-up services. i. Involving the family or legal guardian, when applicable or permitted. j. Coordinating services provided outside of the organization. Under the Health Home Program Standards: 3.L.1. The written program description clearly defines the following: a. Population served. b. How primary care and other healthcare services will be: (1) Provided. (2) Accessed. (3) Coordinated. c. Referral procedures for external services needed by persons served. 32
d. The process for providing care coordination and disease management supports for the person served: (1) Internally. (2) To external service providers. 3.L.3. When primary care or other healthcare services are provided directly by the health home, support for these services includes: a. Co-location with appropriate physical space. b. Implemented written procedures regarding: (1) Access to primary care or other medical services. (2) Sharing of information. (3) Coordination of care. c. Cross training for the most common chronic medical and behavioral illnesses prevalent in the population served. 3.L.4. The program: a. Identifies hours when healthcare services are available. b. Ensures the availability of the following during program hours: (1) Psychiatrist or psychologist. (2) Primary care provider. (3) When needed, other professional legally authorized to prescribe. (4) Care coordinator. (5) Based on the needs of the persons served, other qualified behavioral health practitioner(s). 3.a.2 The CCBHC maintains the necessary documentation to satisfy 1.A.3. The identified leadership guides the following: j. Compliance with: 33
the requirements of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state privacy laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine and often critical communications between health care providers and a consumer's family and friends. Health care providers may always listen to a consumer s family and friends. If a consumer consents and has the capacity to make health care decisions, health care providers may communicate protected health care information to a consumer's family and friends. Given this, the CCBHC ensures consumers preferences, and those of families of children and youth and families of adults, for shared information are adequately documented in clinical records, consistent with the philosophy of person and family-centered care. Necessary consent for release of information is obtained from CCBHC consumers for all care coordination relationships. If CCBHCs are unable, after reasonable attempts, to obtain consent for any care coordination activity specified in program requirement 3, such attempts must (1) All legal requirements. (2) All regulatory requirements. 1.E.1. The organization demonstrates a process to comply with the following obligations: a. Legal. b. Regulatory. c. Confidentiality. j. Privacy of the persons served. 1.E.3. Policies and written procedures address: a. Confidential administrative records. b. The records of the persons served. c. Security of all records. d. Confidentiality of records. e. Compliance with applicable laws concerning records. f. Time frames for documentation in the records of the persons served. 1.K.2. The organization implements policies promoting the following rights of the persons served: a. Confidentiality of information. d. Access to: (1) Information pertinent to the person served in sufficient time to facilitate his or her decision making. (2) Their own records. e. Informed consent or refusal or expression of choice regarding: (1) Service delivery. (2) Release of information. 2.A.23. A designated individual(s) assists in coordinating services for each person served by: 34