SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Page 11 of 7 Departmental Policy and Procedure Section Sub-section Policy Clinical Documentation Mental Health Client Assessment Policy# 8.100 Director's Approval _... @... ~- Alice Gleghorn, PhD ) Clinical Division Chief's Approval Supersedes: Ana Vicuna, LCSW #57 - Consumer Assessment.,-~------...,-------- Effective: 10/25/2010 Last 12/14/2016 Revised: Date Date,z /z1 I I~ I ' Audit 12/14/2019 Date: 1. PURPOSE/SCOPE 1.1. To provide guidance to clinicians of the Santa Barbara County Department of Behavioral Wellness (hereafter "Department") on proper clinical assessment practices and procedures. 2. POLICY 2.1. It is the policy of the Department that all laws and regulations regarding the provision of Medi-Cal Specialty Mental Health Services will be observed, and that clinical assessments will be conducted in a manner consistent with professional standards. 2.2. Any client with an open admission to an outpatient mental health program must have an active Comprehensive Assessment, with the exception of "Mobile Crisis" and "Crisis Stabilization Unit" programs. 2.3. This policy applies to all programs of the Department, including county-operated and contracted organizational providers. 3. DEFINITIONS The following terms are limited to the purposes of this policy: 3.1. Clinician - an individual employed by the MHP or any MHP contracted agency who meet one or more of the following criteria: 1. Holds a valid California license as a f>sychiatrist (or staff physician), allopathic (MD) or osteopathic (DO), nurse practitioner (NP), physician's assistant (PA), psychologist, licensed clinical social worker (LCSW), marriage and family therapist (MFT), or licensed professional clinical counselor (LPCC).
Mental Health Client Assessment Page I 2 of 7 2. Holds a valid California license as a registered nurse (RN), hold a master's degree in nursing, 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. 3.2. Comprehensive Assessment - a service activity that evaluates the current status of a client's mental, emotional, or behavioral health. It includes, but is not limited to, one or more of the following: mental status determination; analysis of client's clinical history; analysis of cultural issues and history; developmental issues and history; diagnosis; and use of testing procedures. 3.3. Assessment Update - an abridged version of the Comprehensive Assessment that captures major, significant life changes in the client's life and/or changes in clinical presentation (i.e. functional impairments, diagnoses), that is completed as needed. The Assessment Update aids in determining if the client continues to meet Medical Necessity for Specialty Mental Health Services. 3.4. Transfer of a Client - a client has an open admission, or had an open admission to any outpatient mental health program, and an admission is opened to a different outpatient mental health program. 4. COMPREHENSIVE ASSESSMENT 4.1. Comprehensive Assessment is completed when a client meets either of the following criteria: 1. The client has never had an open admission to an outpatient mental health program. 2. The client has been receiving outpatient mental health services for the past three (3) years, and a new Comprehensive Assessment is now due. 3. The client's case was closed, and at some point following discharge experiences significant life changes, or his/her condition has worsened significantly, and as a result returns to the outpatient mental health program. Regardless of the time that has lapsed since discharge, the client will be considered "new" and a Comprehensive Assessment must be completed as soon as possible following the client's return. Comprehensive Assessment and treatment plan completion deadlines for new clients will apply. 4.2. The initial Comprehensive Assessment, meeting all requirements, will be completed as soon as possible but no later than 60 days after admission. Best practice dictates that Comprehensive Assessments are completed as soon as possible. However, more time may be needed to fully assess and gain an accurate impression of a client presenting
Mental Health Client Assessment Page I 3 of 7 with challenging and complex issues. In these cases, the initial Comprehensive Assessment will be completed no later than 60 days after admission. 4.3. Should a client not engage in services following admission, and within the span of 60 days makes no further efforts to engage, the completion of a Comprehensive Assessment is not required. 4.4. A Comprehensive Assessment will be considered current and valid for a period of three (3) years, unless a clinician determines that there is a reasonable probability that significant clinical information in the existing comprehensive assessment may not be currently accurate, or that there have been significant changes in some aspect of the client's condition since the Comprehensive Assessment was completed, such as a recent hospitalization. 4.5. The Comprehensive Assessment will meet the standards for assessments set forth in the current Mental Health Plan contract with the Department of Health Care Services (DHCS), any state or federal laws or regulations, and any additional requirements set forth in this policy. Specifically, the Comprehensive Assessment must meet the following requirements: 1. Establishes and documents whether or not the client meets Medical Necessity criteria for Medi-Cal Specialty Mental Health Services, outlining the functional impairments that justify that Medical Necessity was met. 2. Documentation will describe client strengths in achieving client plan goals. 3. A diagnosis from the most current DSM, or a diagnosis from the most current ICD, will be documented, consistent with the symptoms, functional impairments and/or other assessment information. 4. Relevant physical health conditions as it relates to mental health impairments and functioning reported by the client will be prominently identified and updated as appropriate. 5. Presenting problems and relevant conditions affecting the client's physical health and mental health status shall be documented. Examples include living situation, daily activities, social support, substance use conditions and disorders. 6. Relevant information pertaining to client's cultural experiences, identity and needs will be documented. 7. Special status situations that present a risk to the client or others will be prominently documented and updated as appropriate. 8. Documentation will include prescribed medications, dosages of each medication, dates of initial prescriptions and refills, and documentation of informed consent for medications. 9. Client self-report of allergies and adverse reactions to medications, or lack of known allergies/sensitivities will be clearly documented.
Mental Health Client Assessment Page 14 of 7 10. A mental health history will be documented, including: previous treatment dates, providers, therapeutic interventions and responses, sources of clinical data, relevant family information, relevant results of lab tests, and consultation reports. 11. For children and adolescents, pre-natal and perinatal events and complete developmental history will be documented. 12. Documentation will include past and present use of tobacco, alcohol, and caffeine, as well as illicit, prescribed and over-the counter drugs. 13. A relevant Mental Status Examination will be documented. 14. Trauma history, including being a victim of or having exposure to past abuse, neglect, and/or domestic violence. 5. ASSESSMENT UPDATE FOR CONTINUING CLIENTS 5.1. An Assessment Update must be completed for every client receiving Specialty Mental Health Services when one of the following occurs: 1. When a clinician determines that there is a reasonable probability that significant clinical information in the existing Comprehensive Assessment may not be currently accurate. 2. To reflect significant changes in some aspect of the client's life and/or condition (i.e. changes in diagnosis and/or functional impairments, housing or vocational status) since the previous assessment was completed. 5.2. Due to frequent and ongoing changes in condition, placement and developmental milestones, children and adolescents under the age of 18 may require more frequent Assessment Updates. 1. Using currently adopted outcome measurement tools, clinicians will assess functional needs and update treatment plan goals and interventions as needed. 5.3. All Assessment Updates will result in modification to the client's treatment plan goals and interventions to ensure parity with the conditions and impairments evaluated and documented in the Assessment Update. 5.4. A new Comprehensive Assessment shall be completed every three (3) years for every client receiving Specialty Mental Health Services. All required elements listed in section 4.5 of this policy must be evaluated and documented as part of the Comprehensive Assessment. Stating that there has been no change or "see previous assessment" is not acceptable.
Mental Health Client Assessment Page I 5 of 7 6. TRANSFER OF A CLIENT 6.1. If a client is transferred or a new program added to his or her treatment, the clinician must use one of the following options: 1. If transferring to a similar level of care, accept the existing Comprehensive Assessment and complete an Assessment Update to document any and all significant changes. 2. Accept the prior Comprehensive Assessment, if satisfactory, as long as it was completed within the past three (3) years, unless a client is transitioning to a different level of care. In these cases, an Assessment Update will be completed by the transferring program and must indicate the justification for the change in the level of care. 6.2. If a prior Comprehensive Assessment is incomplete or noncompliant with the minimum documentation requirements set in this policy, a new Comprehensive Assessment must be completed as soon as possible following the client's transfer. 7. DISCHARGED CLIENTS RETURNING FOR SERVICES 7.1. For a variety of reasons (i.e. string of appointment no-shows), a client's case may be closed and he/she will officially be discharged from the outpatient mental health program. If a client returns and/or requests services within 60 days of discharge, the client's case may be reopened and the last current and valid Comprehensive Assessment may be accepted. 7.2. However, if a client's case was closed, and at some point following discharge experiences significant life changes, or his/her condition has worsened significantly, and as a result returns to the outpatient mental health program, a new Comprehensive Assessment will be completed as soon as possible following the client's return. The client will be considered "new" regardless of the time that has lapsed since discharge. Comprehensive Assessment and treatment plan completion deadlines for new clients will apply. 8. CHANGES IN LEVEL OF CARE 8.1. When a client requires a higher or lower level of care, a clinician shall complete an Assessment Update that indicates the rationale for the change. The Assessment Update must capture various elements that demonstrate justification for a new level of care, including but not limited to progress made and/or events in the client's life leading to the change, changes in functional impairments and Medical Necessity, and level of care recommendations and decisions. 9. MEDI-CAL CLAIMING FOR ASSESSMENT SERVICES 9.1. For Medi-Cal beneficiaries, time required for assessment services to determine Medical Necessity for reimbursement of Specialty Mental Health Services [CCR Title 9, 1830.205] may be claimed to Medi-Cal regardless of whether or not Medical Necessity is found to exist [CCR Title 9, 1820.345].
Mental Health Client Assessment Page I 6 of 7 9.2. If the assessment determines that Medical Necessity does not exist, no further services will be claimed to Medi-Cal, unless a subsequent assessment finds Medical Necessity. 10. INCOMPLETE AND NONCOMPLIANT COMPREHENSIVE ASSESSMENTS 10.1. When a current comprehensive assessment does not meet minimum documentation requirements as stated in this policy, the comprehensive assessment must be redone immediately. A brief assessment update cannot be used to address a missing, incomplete or noncompliant comprehensive assessment and will not be accepted. ASSISTANCE Elizabeth Barbosa, RN, MAOM, MSN, PhD, Psychiatric Nurse Senior Susan Soderman, IMF, QCM Coordinator Deana Huddleston, MFT, QCM Manager Ana Vicuna, LCSW, Division Chief of Clinical Operations Clinical Documentation Sub-Committee Clinical Leads REFERENCE California Code of Regulations - Rehabilitative and Developmental Services Title 9, Chapter 11, Sections 1810.204, 1840.112(b)(1-4), 1840.314(d)(e) Title 9, Chapter 4, Section 851- Lanterman-Petris Act Department of Health Care Services - Mental Health Plan Exhibit A, Attachment I
Mental Health Client Assessment Page I 7 of 7 REVISION RECORD DATE VERSION REVISION DESCRIPTION 12/6/16 2.1 Added definition for "Assessment Update". In section 4.1, clarified situations in which a Comprehensive Assessment is required. Added section 7 explaining assessment completion requirements for discharged clients returning for services. Culturally and Linguistically Competent Policies 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).