r: a g e 11 of 5 Department Policy and Procedure Section Sub-section Clinical Documentation Effective: 4/1/2009. Policy Policy# 8.101 Client Treatment Plans Last 2/10/2016 Revised: Director's Approval ---~---~-. - Date?;/;~/; Alice Gleghorn, PhD Strategy Officer's Approval ~ Form Ref. Authority: (statutes, regs, etc) Supersedes: CL-8.101 1. PURPOSE/SCOPE Suzann~ CCR, Title 9, Ch. 11, 1810.205.2, 1810.254, 1810.440(c)(1 )(2), 1840.112(b)(2.5), 1840.314(d)(e); CCR, Title 16, 1820.5; WIC, 5751.2; DHCS MHP PP #77 - Client Plans Date I. 3- I g--l)o Audit 2/10/2019 Date: 1.1. To utilize the treatment planning process to ensure the involvement of clients (and/or their legal guardians) in the development and implementation of a comprehensive plan of outpatient Specialty Mental Health Services. 1.2. This policy applies to all programs of the Santa Barbara County Department of Behavioral Wellness (hereafter "Department"), including county-operated and contracted organizational providers. 2. DEFINITIONS The following terms are limited to the purposes of this policy: 2.1. Clinician - an individual employed by the Department or any Department contracted agency who meet one or more of the following criteria: 1. Holds a valid California license as a psychiatrist (or staff physician), allopathic (MD) or osteopathic (DO), nurse practitioner (NP), physician's assistant (PA), psychologist, licensed clinical social worker (LCSW), or marriage and family therapist (MFT). 2. Holds a valid California license as a registered nurse (RN) and is certified as a Psychiatric/Mental Health Nurse by the California Board of Registered Nursing. 3. Holds a valid California registration as an associate clinical social worker (ASW) or marriage and family intern (IMF). 4. Holds a valid waiver from the Department of Health Care Services (DHCS) to perform the duties of a psychologist.
Client Treatment Plans Page I 2 of 6 2.2. Planned Mental Health Service - a Specialty Mental Health Service provided by Department program other than "Crisis Intervention" or "Assessment". 2.3. Outpatient Mental Health Program - a Department program that provides Specialty Mental Health Services. 2.4. Initial Admission - a client is admitted to an outpatient mental health program, and the client meets either of the following criteria: 1. The client has never had an open admission!~ an outpatient mental health program. 2. The client has had no open admission to any outpatient mental health program for -------at-least-69-days-. ---------------------------- 2.5. Transfer of a Client - a client has an open admission, or had an open admission within the previous 60 days, to any outpatient mental health program, and an admission is opened to a different outpatient mental health program. In Clinician's Gateway (CG), the following definitions apply: 2.6. Renew - an update to the annual treatment plan; involves a comprehensive look at the entire set of interventions and progress made by the client. 2.7. Revise - does not change the treatment plan end date; used when the existing treatment plan continues to meet the client's needs, and only a minor revision to reflect new objectives, goals, or interventions is necessary, or when a client is transferred to another service provider. 2.8. Finalize - the client plan has been authorized by all staff indicated in the "Authorization" section and the client/guardian has signed the plan. 2.9. Reimbursable Service - a service code utilized to designate services eligible for reimbursement by mental health Medi-Cal. Examples include "Assessment", "Crisis Intervention", "Crisis Residential", "Evaluation & Plan Development", "MD Visit", "Medication Administration", "Medication Support", "Rehabilitation", "Targeted Case Management" (TCM), and ''Therapy". 2.10. Non-Reimbursable Service - a service code that prevents submission of non-billable claims to Medi-Cal for certain activities. Most common activities are "Client No-Show", "Staff Cancelled", "Client Cancelled", and "Targeted Case Management (Non Billable)".
Client Treatment Plans Page I 3 of 6 3. POLICY 3.1. It is the policy of the Department to comply with all state and federal laws and regulations, as well as all provisions of the Mental Health Plan contract with the California Department of Health Care Services (DHCS), with regard to the timeliness and content of client treatment plans. 3.2. Any client with an open admission to an outpatient mental health program must have an active treatment plan with the exception of "Mobile Crisis" and "Crisis Stabilization Unit" programs. 4. TIMELINESS 4.1. Before any outpatient mental health services other than "Assessment", "Plan Development", and/or "Crisis Intervention" are claimed to Medi-Cal, a valid treatment plan must be finalized and Medical Necessity established, as defined by Title 9 of the California Code of Regulations and the Mental Health Plan (MHP) contract with the Department of Health Care Services (DHCS). 4.2. The treatment plan (based on an assessment), with the active participation of the client and/or legal guardian, and authorized by a clinician and the client and/or legal guardian, must be completed no later than 60 days after admission. 5. TREATMENT PLAN RENEWAL AND REVISION 5.1. A treatment plan must be renewed no less frequently than every 12 months. The treatment plan anniversary is one year from the date the initial treatment plan was finalized. For example, if a client's initial treatment plan was finalized on August 19, the annual treatment plan update must be completed by August 19 of the following year. 5.2. A treatment plan can be revised if new objectives, goals, or interventions have been identified and/or a client is transferred to another service provider. 6. CONCURRENT CLIENT PLANS 6.1. All planned Specialty Mental Health Services are authorized and coordinated through a single client plan. 7. RESPONSIBILITY FOR DEVELOPING AND/OR MODIFYING TREATMENT PLANS 7.1. Responsibility for developing and modifying the treatment plan for each client will be assigned by the Department to a single program to which the client has an open admission. 7.2. The assigned program will be responsible for coordinating goals and interventions with any other program that also provides services to the client.
Client Treatment Plans Page 14 of 6 8. TRANSFER OF A CLIENT 8.1. When a client has an open admission to an outpatient mental health program, and transfers to a different program which becomes responsible for the treatment plan: 1. The best practice process would be to plan the transfer and modify the treatment plan before the transfer, with participation by the client or legal guardian. 2. If this does not occur, the program to which the client is transferred will coordinate relevant treatment plan modifications with the client and/or legal guardian within no more than 60 days of the admission to that program. 3. A transferred treatment plan with revisions does not change the established anniversary date for renewal. 9. TIMELINESS FOR PROGRAM ADDITIONS OR TRANSFERS 9.1. When a client is transferred or a new program added to their treatment, the treatment plan must be modified and authorized by a clinician and signed by the client/guardian within 60 days of the admission to the new program or transfer. 10. CONTENT OF A TREATMENT PLAN 10.1. Every treatment plan must include: 1. A statement of the client's strengths, using the client's words to the fullest extent possible. 2. Any special needs, as well as a brief statement of the methods to be used to address such special needs. 3. Specific, measurable, observable goals which address symptoms and/or functional impairments identified through assessment services. 10.2. For each goal, the plan must include at least one intervention. 1. Interventions must specify the facility/program authorized to provide services and the Medi-Cal service codes which describe those services. 2. Interventions must include descriptions of specific services addressing the client's symptoms and/or functional impairments identified in the assessment. 3. Interventions must specify the duration of authorization, up to a maximum of 12 months following the start date of the treatment plan. 4. Assessment services are clinically required for all clients receiving services, and assessment services therefore do not require authorization by a treatment plan. 10.3. "Crisis Intervention", "Crisis Residential", and crisis-related medical services are not planned services and therefore do not require authorization by a treatment plan.
Client Treatment Plans Page I 5 of 6 10.4. Mental health interventions not listed in the treatment plan may be provided for a maximum of five (5) days without modification of the treatment plan if: 1. A client encounters an unplanned event or unplanned circumstances that significantly affects the client's mental and emotional state and; 2. The client's mental and emotional state is related to a mental health diagnosis eligible for Medi-Cal reimbursement. 10.5. If, as a result of such events or circumstances, a client requires interventions lasting more than five (5) days, and the interventions are not included on the current treatment plan, the plan must be modified before further services are claimed to Medi-Cal. 11. AUTHORIZATIONS 11.1. At the time of initial approval, annual renewal, or whenever a change is made in the treatment plan, the treatment plan must be signed by a clinician and the client/guardian. 1. For Medicare beneficiaries, the treatment plan must also be authorized by a psychiatrist (either through signature, or through documented verbal or written authorization for a psychiatrist not affiliated with the Department) in order for the plan to comply with Medicare regulations, and no services may be claimed to Medicare without such authorization. 11.2. If a client/guardian refuses to sign the treatment plan, a valid and specific justification must be documented in a progress note stating why the client's/guardian's signature was not obtained. ASSISTANCE Elizabeth Barbosa, RN, MAOM, MSN, PhD, Psychiatric Nurse Senior Gordana Brabson, MFT, QCM Manager Susan Soderman, IMF, QCM Coordinator Clinical Documentation Sub-Committee REFERENCE California Code of Regulations - Rehabilitative and Developmental Services Tftle 9, Chapter 11, Sections 1810.205.2, 1810.254, 1810.440(c) (1) (2), 1840.112(b) (2-5), 1840.314(d) (e), California Code of Regulations - Professional and Vocational Regulations Tftle 9, Chapter 16, Division 18, Article 3, Section 1820. 5 California Welfare and Institutions Code Section 5751.2 Department of Health Care Services - Mental Health Plan Exhibft A, Attachment I
Client Treatment Plans P age I 6 of 6 REVISION RECORD DATE VERSION REVISION DESCRIPTION. Culturally and Linguistically Competent Pollcies The Department of Behavioral Wellness is committed to the tenets of cultural competency and understands that culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse individuals. All policies and procedures are intended to reflect the integration of diversity and cultural literacy throughout the Department. To the fullest extent possible, information, services and treatments will be provided (in verbal and/or written form) in the individual's preferred language or mode of communication (i.e. assistive devices for blind/deaf).