TITLE 7 HEALTH
CHAPTER 20 MENTAL HEALTH
PART 11 CERTIFICATION
REQUIREMENTS FOR CHILD AND ADOLESCENT MENTAL
HEALTH
SERVICES
7.20.11.1 ISSUING
AGENCY: Children, Youth and Families
Department
[7.20.11.1 NMAC - Rp 7
NMAC 20.11.1, 03/29/02]
7.20.11.2 SCOPE: This policy applies to all child and
adolescent behavioral health programs described herein.
[7.20.11.2 NMAC - Rp 7
NMAC 20.11.2, 03/29/02]
7.20.11.3 STATUTORY AUTHORITY: 1978 NMSA Sections 32A-12.1.et seq.
[7.20.11.3 NMAC - Rp 7
NMAC 20.11.3, 03/29/02]
7.20.11.4 DURATION:
Permanent
[7.20.11.4
NMAC - Rp 7 NMAC 20.11.4, 03/29/02]
7.20.11.5 EFFECTIVE
DATE: March 29, 2002 unless a later
date is cited at the end of section.
[7.20.11.5 NMAC - Rp 7
NMAC 20.11.5, 03/29/02]
7.20.11.6 OBJECTIVES:
A. to establish certification
requirements for behavioral health services provided to children and
adolescents of New Mexico through the medicaid program (Title XIX of the Social
Security Act);
B. to provide for monitoring of agency compliance with these certification
requirements to identify any factors that could affect the health, safety, and
welfare of the clients or the staff;
C. to
assure that the agency establishes and follows written policies and procedures
that specify how these certification requirements are met; and
D. to
assure that adequate supervision is provided at all times.
[7.20.11.6 NMAC - Rp 7
NMAC 20.11.6, 03/29/02]
7.20.11.7 DEFINITIONS:
A. ABUSE means an intentional or
negligent infliction of physical or psychological harm; intentional or
negligent sexual contact or sexual exploitation; intentional or negligent
behavior that jeopardizes life or health; torture, cruel confinement or
corporal punishment.
B. ACCREDITED means written
acknowledgement from a national organization that an agency or program meets
the published standards of the organization issuing the accreditation.
C. ACCREDITED RESIDENTIAL TREATMENT
CENTER (ARTC) means a facility with 16 beds or less that may be attached to, or
housed within, a hospital or other institution; that provides residential
treatment services pursuant to these requirements; and that is accredited by
JCAHO.
D. ACTION PLAN means a written document
that may be required by the licensing and certification authority (LCA)
detailing an agency’s proposed actions for resolving deficiencies identified by
the LCA.
E. ACTIVE STATUS means a type of
certification granted to a program currently serving clients.
F. ADMINISTRATOR means the person in
charge of the day-to-day operation of an agency. The administrator may also be referred to as
the director or operator.
G. ADMISSIONS HOLD means a type of
sanction under which a program is prohibited from admitting new clients until
the LCA determines that identified deficiencies are corrected, and lifts the
sanction.
H. ADVANCE DIRECTIVES means an optional
component of the comprehensive service plan. An individual has the right to
make decisions in advance, including behavioral health treatment decisions,
through a process called advance directive. An advance directive can be used to
state the individual’s treatment choices, preferences or instructions regarding
pre-cursor crisis strategies, or can be used to name a health care agent that
is someone that will make health care decisions for the individual. This section
of the comprehensive service plan provides the individual the opportunity to
take part in behavioral health care decisions if at some point in the future
the individual is unable. This document allows the individual to express
consent or refusal to medications and other health care decisions, including
use of the seclusion and restraints.
I. AGENCY means the legally
responsible organizational entity administering the facility or program(s) of
specific services identified and certified pursuant to these certification
requirements.
J. ASSISTANCE WITH SELF-ADMINISTRATION
OF MEDICATION means the supervision and assistance given to a client in the
self-administration of a drug.
K. BEHAVIORAL HEALTH ASSESSMENT means
an assessment by an integrated series of procedures conducted with an
individual to provide the basis for the development of an effective,
comprehensive and individualized treatment plan.
L. BEHAVIORAL HEALTH SERVICES means
services designed to meet behavioral and mental health and substance abuse
needs of medicaid recipients in certified services.
M. BEHAVIOR MANAGEMENT means the use of
basic techniques, such as reinforcement, redirection and voluntary time-outs to
teach clients skills for managing and improving their own behavior; and the use
of verbal de-escalation, therapeutic holds, personal restraint and seclusion in
order to maintain a safe and therapeutic environment and to enhance the
abilities of clients and care givers to manage client behavior.
N. BEHAVIOR MANAGEMENT SKILLS
DEVELOPMENT SERVICES (BMS) means services provided on a staff-to-child ratio of
at least 1:1. Behavior management skills
development services are for children and adolescents with psychological,
emotional, behavioral, neurobiological or substance abuse problems in the home,
community or school when such problems are of such severity that highly
supportive and structured therapeutic behavioral interventions are required.
These services are designed to maintain the client in his/her home, community
or school setting.
O. BEHAVIOR MANAGEMENT SERVICES PLAN
means a service plan used in behavior management skills development services.
P. CANCELLATION means an LCA action
nullifying a program’s certification.
Q. CAPACITY means the maximum number of
clients allowed to receive services in a licensed facility at any specified
time in accordance with these certifications requirements.
R. CASE MANAGEMENT SERVICES means
services provided in order to assist children and adolescents with identifying
and meeting multiple and complex, special physical, cognitive and behavioral
health care needs through planning, securing, monitoring, advocating and
coordinating services.
S. CARF means council on accreditation
of rehabilitation facilities.
T. CERTIFICATION means an authorized
status conferred by the department on a program that meets these certification
requirements for providing service(s) to children and adolescents.
U. CERTIFIED FAMILY SPECIALISTS (CFS)
means an individual 18 years of age or older who has personal experience navigating
any of the child or family-serving systems or advocating for family members who
have a knowledge of and are involved with the behavioral health systems and are
certified by an approved state of New Mexico certification program.
V. CERTIFIED PEER SPECIALISTS (CPS)
means a self-identified current or former consumer, 18 years of age or older,
of mental health or substance abuse services and has at least one year of
mental health or substance abuse recovery and is certified as a CPS by an
approved state of New Mexico certification program.
W. CHEMICAL RESTRAINT means the
administration of a medication(s) which is neither a standard treatment for the
client’s medical or psychiatric condition nor a part of the client’s daily
medication regimen, and is used for the primary purpose of controlling a
client’s behavior or restricting a client’s freedom of movement.
X. CHILD/ADOLESCENT means a person
under the chronological age of 21 years.
Y. CLEARED STAFF MEMBER means an
individual who has been approved by the department for employment in the
immediate presence of children and adolescents by means of a state and federal
criminal background clearance.
Z. CLIENT means any child or adolescent
who receives treatment from a service certified by the department.
AA. COA means council on accreditation for
children and family services.
AB. CLINICAL STAFF means licensed mental
health practitioners and treatment coordinators.
AC. CLINICAL SUPERVISOR means a staff
member who is a licensed independent practitioner and who has responsibility
and authority for supervising other clinical staff.
AD. COMMUNITY SUPPORTS means the
coordination of resources to individuals/families necessary for them to
implement strategies to promote recovery, rehabilitation and resilience.
AE. COMMUNITY SUPPORT WORKER (CSW) means
the primary staff responsible for assisting the client and family with
implementation of the comprehensive service plan and coordinating or
facilitating family and treatment team meetings and is certified by an approved
state of New Mexico certification program.
AF. COMPREHENSIVE COMMUNITY SUPPORT SERVICES
(CCSS) means a variety of interventions, primarily face-to-face and in
community locations that address barriers that impede the development of skills
necessary to independent functioning in the community. It provides assistance
with identifying and coordinating services and supports identified in an
individual’s comprehensive service plan; supporting an individual and family in
crisis situations; and providing individual interventions to develop or enhance
an individual’s ability to make informed and independent choices. The target
population for CCSS includes children, youth and adults with significant
behavioral health disorders and who meet other criteria as identified by the
collaborative.
AG. CONTRACTOR means an individual who
provides direct services to clients through contracts with the agency.
AH. CORPORAL PUNISHMENT means a form of
discipline or behavior control that involves forced exercise or touching a child’s
body with the intent to induce pain and includes, but is not limited to,
shaking, spanking, hitting, hair pulling, and ear pulling.
AI. CRIMINAL RECORDS CHECK (CRC) means the
process of submitting state and FBI approved fingerprint cards and any additional
required background information to the department for the purpose of
determining whether or not an individual has state or federal convictions on
record that may disqualify the individual from direct unsupervised contact with
children/adolescents and, when applicable, for the purpose of obtaining and
reviewing a record of convictions.
AJ. CRIMINAL RECORDS CLEARANCE means a
determination made by the department, based on the results of the criminal
records check, that an individual may work directly and unsupervised with
children and adolescents.
AK. CRISIS MANAGEMENT SERVICES means those
services identified in the individual’s crisis plan. Such services are located
in the community, include natural supports and are available to the client and
family after the agency’s normal operating hours.
AL. CRISIS PLAN means a component of the
comprehensive service plan that clearly identifies the level of intensity and
severity of potential crisis events and how they will be managed after normal
business hours with specific resources identified for the client, family and
natural supports. The crisis plan shall
include defined client, family and treatment team roles and activities.
AM. CULTURAL COMPETENCE means the
involvement, integration and transformation of knowledge, information and data
about individuals and groups of people into specific clinical standards,
service approaches, techniques and marketing programs. Cultural competence is
illustrated by congruent behaviors, attitudes and policies that match a
client’s culture to increase the quality and appropriateness of behavioral
health care and outcomes.
AN. CULTURALLY COMPETENT ASSESSMENT means
the relevant cultural considerations in the assessment of the behavioral health
needs of a client.
AO. DAY TREATMENT SERVICES (DTS) means a
coordinated and intensive set of structured individualized therapeutic
services, in a school, or a facility licensed by the LCA, provided for
children, adolescents and their families who are living in the community.
AP. DEFICIENCY means a violation of, or
failure to comply with, a provision(s) of these certification requirements.
AQ. DENIAL means a sanction imposed by the
LCA to refuse to issue a certification, based on a determination made by the
LCA.
AR. DEPARTMENT means the New Mexico
children, youth and families department.
AS. DESIGNATED AGENCY means the agency that
has the primary responsibility of partnering with the client and family for
implementation of the comprehensive service plan.
AT. DIRECT PHYSICAL SUPERVISION means, with
reference to criminal records clearances, either continuous visual observation
or live video observation of a non-cleared agency staff member by a cleared
agency staff member or by the client’s legal guardian, while the non-cleared
staff is in immediate presence of the client.
AU. DIRECT SERVICE STAFF means supervisors,
physicians, nurses, therapists, client care workers, coordinators or other
agency personnel who work in immediate direct unsupervised contact with
children.
AV. DIRECT UNSUPERVISED CONTACT means
physical proximity to clients, such that physical contact or abuse could occur,
without being observed or noticed by another staff member who has been cleared
by the department.
AW. DIRECTED ACTION means a formal action(s)
specified by the LCA that the agency is required to undertake or complete in
order to correct a deficiency(ies) within a specified time frame.
AX. DISCHARGE CRITERIA means specific
clinically-based indicator(s) used to measure the client’s degree of readiness
for release from a given level of care stated in terms of achievement of
treatment goals or reduction of symptoms; discharge criteria may also include
indicators that a given level of care is inappropriate for a client due to such
factors as dangerousness or non-responsiveness to treatment.
AY. DISCHARGE PLAN means a written section
of a treatment plan/service plan and treatment plan/service plan reviews
containing the following elements: behavioral and other clinical criteria that
describe the conditions under which discharge will occur, identification of
barriers to discharge; the level of care, specific services to be delivered,
and the living situation into which discharge is projected to occur; the
projected date of discharge, individuals responsible for implementing each
action specified in the discharge plan, and, when indicated, revisions.
AZ. DISCIPLINE means non-abusive training
that enables a client to develop self-control and orderly conduct in
relationship to others.
BA. DOCUMENTATION means the written or
printed record of information supporting the facts related to the certified
services being provided to clients found in client files, personnel files, and
other pertinent printed sources.
BB. EARLY AND PERIODIC, SCREENING,
DIAGNOSIS AND TREATMENT (EPSDT) means periodic, comprehensive services to
persons under 21 years of age; these services are defined in the medicaid
program policies.
BC. EMERGENCY SAFETY INTERVENTION means
personal restraint or seclusion.
BD. EMERGENCY SANCTION means an immediate
requirement that is imposed on a program by the LCA in response to a finding of
health or safety deficiency(ies).
BE. EMERGENCY SERVICE means an
unanticipated admission to an acute medical or psychiatric facility or the
provision of other medical services by paramedics or other emergency or urgent
care personnel.
BF. EMERGENCY SUSPENSION means an
immediate and temporary cancellation of a certification due to an existing
health or safety deficiency(ies), pending an appeal hearing and correction of
health or safety deficiencies. During a period of emergency suspension, the
medicaid provider agreement is not in effect.
BG. EMPLOYMENT HISTORY means a verifiable
written summary of employment including names, addresses and telephone numbers
of employers, immediate supervisors as well as dates of and explanations for
any period(s) of unemployment for a minimum of three years immediately prior to
hire for employment by a certified program.
BH. ENHANCED SERVICE means, in the medicaid
managed care system, any and all services beyond the scope of the medicaid
(fee-for-service) benefit package available to recipients in the medicaid
managed care program.
BI. EXCLUSIONARY CRITERIA means
agency-written criteria that define the diagnoses, behaviors, or conditions that
preclude admission to the certified program.
BJ. EXEMPLARY means a certified status
conferred by the LCA on a program that has no history of temporary
certification, sanctions or loss of certification in the previous two years and
meets all of the certification requirements with minor or no deficiencies.
BK. EXPANSION HOLD means a type of sanction
under which an agency is prohibited from obtaining certification for additional
services until the LCA determines that identified deficiencies are corrected
and lifts the sanction.
BL. EXPLOITATION means the act or process
of using a client or client’s property for another person’s profit, advantage
or benefit.
BM. FACILITY means the physical plant and
building(s) licensed by the LCA in which residential or day treatment mental
health services are provided.
BN. FUNCTIONAL LEVEL means a determination
of the client and as applicable, his family’s, functional skills in multiple
domains.
BO. GENERAL PROVISIONS means the series of
certification requirements found in Sections 9 through 25 of these
certification requirements.
BP. GOVERNING BODY means the
organizational entity of an agency that has the ultimate responsibility for all
planning, direction, control, and management of the activities and functions of
a program certified pursuant to these certification requirements.
BQ. GROUP HOME SERVICES (GHS) means mental
and behavioral health services offered in a supervised, licensed facility that
provides structured therapeutic group living for children/adolescents with
moderate behavioral, psychological, neurobiological, or emotional problems,
when clinical history and opinion establish that the needs of the client cannot
be met in a less restrictive environment.
BR. HEALTH OR SAFETY DEFICIENCY means a
deficiency that poses an immediate threat to the welfare of clients up to and
including loss of life; physical harm; physical, sexual, psychological abuse or
exploitation.
BS. HUMAN SERVICES DEGREE means an
approved bachelors or masters degree from an accredited school in one of the
following degrees: counseling and therapy, rehabilitation, psychology, criminal
justice, social work/social services, or human development. If workforce issues
are identified in a region of the state, the some other defined degrees may be
considered as human services degrees. However, any experience required in the
service definition must be met. In order for an agency to utilize staff with
these degrees, they must submit a written waiver request to LCA with
documentation supporting the workforce issues. Those alternative degrees may
include nursing, sociology, public health, education, occupational therapy,
speech and hearing sciences, speech-language pathology, communication sciences
and disorders, gerontology, or social sciences.
BT. INACTIVE STATUS means a type of
certification granted to a program that is not currently serving clients.
BU. INCIDENT REPORT means the document(s)
describing a serious incident or alleged serious incident.
BV. INFORMAL RESOLUTION CONFERENCE means
an informal meeting and problem-solving process between the department and an
agency to resolve any filed or potential appeal arising from the imposition or
potential imposition of a sanction(s).
BW. INFORMED CONSENT means a document that
reflects that a client and the legal guardian(s) are advised of the benefits,
risks, and alternatives of a given medication or treatment and agree to the use
of the medication or treatment. Clients
age 14 and above may consent to the use of a medication or treatment without
the approval of their legal guardian(s).
BX. INITIAL CERTIFICATION means a type of
certification granted to a program that has met the minimum requirements to
implement a program to provide services pursuant to these requirements.
BY. INVESTIGATION means a formal process
of inquiry used by the LCA to: determine the validity of complaints or
allegations made against certified agencies; or to determine whether trends in
incidents reported to the LCA that affect the health and safety of clients are
the result of negligent practices, insufficient supervision of personnel or
clients, or any other factor that requires correction; or to determine whether
or not an agency has made corrective responses to resolve matters of threat to
client health and safety substantiated by the LCA.
BZ. JCAHO means the joint commission on
accreditation of healthcare organizations.
CA LICENSE means the written
authorization issued by the LCA pursuant to 7.20.12 NMAC granting right to
operate the designated facility for a specified period of time; or, in context,
any necessary authorization by the appropriate credentialing authority to
undertake the professional activity in question.
CB. LICENSED INDEPENDENT PRACTITIONER
means New Mexico-licensed clinical staff who are authorized to practice at the
independent level.
CC. LICENSED INDEPENDENT MEDICAL
PRACTITIONER means a New Mexico licensed medical doctor (MD), doctor of
osteopathy (DO), certified nurse practitioner (CNP), clinical nurse specialist
(LCNS), or physician assistant (PA).
CD. LICENSING AND CERTIFICATION AUTHORITY
(LCA) means the licensing and certification unit of the children’s behavioral
health and community services bureau of the prevention and intervention
division of the department.
CE. MAINTENANCE OR REDUCTION IN PROGRAM
CAPACITY means a sanction that directs the agency to maintain or reduce the
capacity of the program to a designated census until the LCA determines that
deficiencies resulting in the sanction have been corrected.
CF. MECHANICAL RESTRAINT means use of a
mechanical device(s) to physically restrict a client’s freedom of movement,
performance of physical activity, or normal access to his or her body, and is
distinct from personal restraint as defined below.
CG. MEDICAID means Title XIX of the Social
Security Act; the joint federal-state program that pays for medical care for
low-income persons.
CH. MONITORING means the ongoing review of
a program’s progress in correcting deficiencies. During a period of
certification, monitoring is done at the discretion of the LCA. Monitoring may be implemented by means of a
monitoring plan, and may require that specified documentation be submitted to
the LCA by the agency or may include the use of on-site surveys by the LCA to ascertain
compliance in specified areas.
CI. MONITORING PLAN means a written set
of guidelines and instructions specified by the LCA for a program to follow for
the purpose of correcting deficiencies.
CJ. MORAL TURPITUDE means conduct
contrary to justice, honesty, modesty or good morals, as further specified in
8.8.3 NMAC.
CK. MULTISYSTEMIC THERAPY (MST) is an
intensive family and community-based treatment program that addresses the known
determinants of serious antisocial behavior in adolescents and their families.
MST treats the factors in the youth's environment that are contributing to his
or her behavior problems. Such factors might pertain to individual
characteristics of the youth (poor problem solving skills), family relations
(inept discipline), peer relations (association with deviant peers) and school
performance. Treatment goals for therapeutic change are developed on an
individualized basis in collaboration with the family.
CL. NEGLECT by individuals or an agency
means:
(1) failure to provide any
treatment, service, care, medication or item that is reasonably necessary to
maintain the health or safety of a client; or
(2) failure to take any
reasonable precaution that is necessary to prevent damage to the health or
safety of a client; or
(3) failure to carry out a
duty to supervise properly or control the provision of any treatment, care,
good service or medication reasonably necessary to maintain the health or
safety of a client; or
(4) failure to take any
reasonable precaution that would prevent the physical abuse, sexual abuse, or
sexual exploitation of a client, as defined in the Children’s Code at 1978 NMSA
32A-4-2, or the lack of which causes the client to become an abused child or neglected
child as defined in the Children’s Code at NMSA 1978 32A-4-2.
CM. NON-ACCREDITED RTC means a program that
provides residential treatment services pursuant to these requirements that is
not accredited by JCAHO.
CN. NON-RENEWAL means a sanction whereby
certification is cancelled on or about the date of expiration.
CO. NON-RESIDENTIAL SERVICES means a
program that provides certified services other than twenty-four-hour continuous
care within the confines of a facility or treatment foster home.
CP. NOTICE OF CONTEMPLATED ACTION means a
letter issued by the LCA identifying grounds for sanction of a program.
CQ. NOTICE OF EMERGENCY SANCTION means a
letter issued by the LCA when an emergency sanction is imposed.
CR. NOTICE OF FINAL ACTION means a letter
issued by the LCA stating that the sanctions proposed in a previous notice of
contemplated action are in effect. This
letter is issued upon the conclusion of any appeal/informal resolution
proceeding or the expiration of the appeal period to the notice of contemplated
action.
CS. PARTIAL COMPLIANCE means a
determination by the LCA that a program is found to have moderate and few
deficiencies, none of which immediately compromises the health or safety of the
clients.
CT. PARTIALLY SUBSTANTIATED COMPLAINT
means a complaint that the LCA has determined is factually accurate in part,
but not factually accurate in its entirety.
CU. PERMANENCY PLAN means the long-term
plan for the child/adolescent developed by the protective services division of
the department with one of the following outcomes: reunification, permanent
guardianship, adoption, permanent placement with a fit and willing relative, or
planned permanent living arrangements.
CV. PERSONAL RESTRAINT means the
application of physical force without the use of any device, for the purposes
of restraining the free movement of a client’s body. The term personal restraint is distinct from
therapeutic hold and mechanical restraint as defined herein and does not include
briefly holding a client, without undue force, in order to calm or comfort him
or her, or holding a client’s hand to safely escort a client from one area to
another.
CW. PHYSICAL ESCORT means the temporary
touching or holding of the hand, wrist, arm, shoulder or back for the purposes
of inducing a client who is exhibiting unsafe or potentially unsafe behavior to
walk to a safe location.
CX. PHYSICAL HARM means physical injury
that requires treatment beyond basic first aid; or that results in loss of
functional use of a bodily member or organ or of a major life activity for a
prolonged period of time; or results in loss of consciousness for any amount of
time.
CY. PHYSICIAN means an individual who has
received a degree of doctor of medicine or doctor of osteopathic medicine and
is licensed to practice medicine in the state of New Mexico.
CZ. POLICY means a statement of principle
that guides and determines present and future decisions and actions.
DA. PREMISES means all parts of buildings,
grounds, vehicles and equipment of a facility.
DB. PRE-SERVICE TRAINING means training
that is provided to a newly hired employee prior to the employee’s provision of
direct services.
DC. PROCEDURE means the action(s) that will
be taken to implement a policy; and the written description of such action(s) that
serves as instruction to agency staff.
DD. PROGRAM means an agency, or subdivision
of an agency, operated with the intent to provide certified services.
DE. PROVIDER means an agency or its
personnel who have a medicaid provider number and deliver direct services to
clients.
DF. PSYCHIATRIST means a physician who
specializes in the treatment of psychiatric disorders, has completed an
accredited psychiatric residency program, and holds a current license to
practice medicine in the state of New Mexico.
DG. PSYCHOLOGICAL HARM means harm that
causes symptoms of mental or emotional trauma, or that causes distress of
sufficient magnitude to cause behavioral change, or physical symptoms that may
require psychological or psychiatric evaluation or treatment.
DH. PSYCHOLOGIST means a doctoral level
psychologist who specializes in assessing and treating psychological disorders
and holds a current license to practice in the state of New Mexico.
DI. PUNISHMENT means a penalty imposed on
a child/adolescent by one in authority for wrongdoing.
DJ. RECOVERY means the process, outlook,
vision and guiding principle that stresses that hope and restoration of a
meaningful life are possible, despite serious mental illness. Instead of
focusing primarily on symptom relief, as the medical model dictates, recovery
casts a much wider spotlight on restoration of self-esteem and identity and on
attaining meaningful roles in society (adapted from Mental Health: A Report to the Surgeon General, Chapter 2, 1999).
DK. RECOVERY/RESILIENCY MANAGEMENT PLAN
means the foundational component for building the comprehensive service plan.
The recovery/resiliency management plan component focuses on strengths and
preferences based on identified competencies, the process of autonomy (independence),
and developing a system of natural supports (satisfying and supportive social
relationships). The recovery/resiliency management plan component shall
include:
(1) the client and family’s
personal choice of service options and priorities in service delivery with a
client centered focus;
(2) client driven
interventions including attainable objective to address the client’s defined
needs;
(3) a clear identification of
the environment in which the client lives including: family, school peers,
community and home, and how each will play a part in the comprehensive service
plan; and
(4) a clear approach to the
development of resiliency based on life skills identified by the client and
service team.
DL. REFERENCE CHECK means a documented
contact with previous employers, supervisors, co-workers, or other sources,
initiated by the agency to evaluate a prospective employee prior to hire by
establishing the accuracy of his/her employment history and to obtain other
information relevant to potential hire.
DM. REHABILITATION means a process that
enhances the efficacy of clients with functional limitations due to behavioral
health disorders to obtain information, develop skills and access resources
needed to make decisions and implement strategies to be successful and
satisfied in the living, working, learning, and social environments of their
choice. Rehabilitation services are driven by the client’s desire for recovery
and resiliency based outcomes and are individualized, collaborative and person
directed.
DN. RESIDENTIAL FACILITY means a facility
licensed by the LCA, in which 24-hour continuous therapeutic care is provided
to a group of children/adolescents in accordance with these certification
requirements.
DO. RESIDENTIAL TREATMENT SERVICES means a
program that provides 24-hour therapeutic care to children/adolescents with
severe behavioral, psychological, neurobiological, or emotional problems, who
are in need of psychosocial rehabilitation in a residential facility.
DP. RESTRAINT/SECLUSION CLINICIAN means a
New Mexico licensed medical doctor (MD), doctor of osteopathy (DO), certified
nurse practitioner (CNP), clinical nurse specialist (LCNS), physician assistant
(PA) or doctoral level psychologist (Psy.D., Ph.D., or Ed.D.), who is trained
in the use of emergency safety interventions.
DQ. REVOCATION means a type of sanction
making a certification null and void through its cancellation.
DR. SANCTION means a measure imposed by the
LCA on a certified program, pursuant to these certification requirements, in
response to findings(s) of a deficiency(ies), with the intent of obtaining
increased compliance with these certification requirements.
DS. SECLUSION means a behavior management
technique that involves locked isolation.
Seclusion is distinct from therapeutic time-out.
DT. SERIOUS INCIDENT means an incident
involving the death of a client, suicide attempt by a client; psychological or
physical harm to a client; serious homicidal threat to or by a client; physical
or sexual abuse/perpetration to, or by, a client or a staff member; the use,
possession, or distribution of illegal substances by clients or staff; neglect
or exploitation of a client by staff; AMA or emergency discharge; arrest or
detention of a client; natural disasters, or contagious disease outbreaks; or
agency knowledge that a staff member has been charged with, or convicted of, a
felony or of a misdemeanor involving moral turpitude, including but not limited
to convictions referenced in 8.8.3 NMAC.
DU. SEXUAL ABUSE means any intentional and
uninvited contact, demand or enticement of a sexual nature, including contact
with another person’s clothed or unclothed genital area, anus, buttocks, or
breast(s) if the recipient is female; or, intentional causing of another person
to touch any of these areas on one’s own or a third party’s body; or,
consensual contact with any of these areas if the initiator is in a position of
significant influence over the recipient by reason of differences in age,
physical size, development, intellectual sophistication, sexual sophistication,
or position of authority; or, a verbal request, offer, or demand such as would
initiate such contact when the initiator of the verbal behavior is in a
position of significant influence as described above. Physical contact, as described above,
includes contact between clothed or unclothed body parts of individuals, or may
be between clothed or unclothed body parts of one person and an object.
DV. STAFF means a person who has contact
with children in a certified program and includes the owner, operator or
director of a program, volunteers, full-time, part-time, contract employees,
and treatment foster parents.
DW. STAY means the department is temporarily
refraining from taking an action on a sanction, revocation, or suspension of
certification.
DX. SUBSTANTIAL COMPLIANCE means a
determination by the LCA that a program is found to be without deficiencies, or
with minor and few deficiencies, none of which compromise the health and safety
of clients.
DY. SUBSTANTIATED COMPLAINT means a
complaint or allegation that the LCA has determined is factual.
DZ. SUPERVISION means one of the following,
as indicated by context: the monitoring of clients’ whereabouts and activities
by the program staff in order to ensure their health, safety, and welfare; or
the clinical or managerial oversight of staff.
EA. SURVEY means examination, or other
review, of a program’s premises, records or other documents; or interview of
client(s) or staff, at the discretion of the LCA, pursuant to these
certification requirements.
EB. SUSPENSION means a type of sanction
whereby certification is temporarily revoked, during which time the medicaid
provider agreement is not in effect.
EC. THERAPEUTIC HOLD means the brief
physical holding of a client, without undue force, used as part of a behavioral
plan by an individual trained and certified by a state recognized body in the
use of therapeutic holds and personal
restraints, in a manner consistent with written agency policy, for the
purpose of providing emotional comfort or calming to the client, or physical
safety to the client, other clients, staff member(s) or others. Therapeutic
hold is distinct from personal restraint and mechanical restraint as defined
above.
ED. THERAPEUTIC LEAVE means a period of
time during which a treatment foster care services client is temporarily placed
in a different treatment foster home.
This affords the primary treatment foster parents a period of authorized
leave.
EE. THERAPEUTIC TIME-OUT means a technique
involving individual isolation used as part of a written behavioral plan to
prevent or decrease the potential for unsafe behavior and to give the client
the opportunity to regain control.
EF. THERAPIST means a person who has a
license from an appropriate licensing authority to provide direct clinical care
services such as individual, family, or group therapy.
EG. TREATMENT FOSTER CARE SERVICES (TFC)
LEVEL I means a program that provides therapeutic services to children or
adolescents who are psychologically or emotionally disturbed, or behaviorally
disordered, in a foster family setting, pursuant to these certification
requirements.
EH. TREATMENT FOSTER CARE SERVICES LEVEL
II means a program that provides therapeutic services to children or
adolescents who are psychologically or emotionally disturbed, or behaviorally
disordered, in a foster family setting, pursuant to these certification
requirements. It is distinct from
treatment foster care services level I in that it is provided to children and
adolescents who have successfully completed treatment foster care services
level I as determined by the treatment team, and are in the process of
returning to biological family and community, or who meet other established
criteria.
EI. TREATMENT FOSTER HOME means a
licensed residence overseen by a certified program and licensed child placement
agency in which treatment foster care services are being provided to agency
clients by licensed treatment foster parents.
EJ. TREATMENT PLAN means a written
document formulated on an ongoing basis by a treatment team that guides and
records for each client: individualized therapeutic goals and objectives;
individualized therapeutic services provided; individualized discharge plans
and aftercare plans.
EK. TREATMENT PLANNING means an ongoing
process, based on assessment and regular reassessment of a client’s needs, of
documenting those needs, the interventions intended to address those needs, and
the client’s behavioral responses to interventions. Treatment planning includes initial treatment
plans, comprehensive treatment plans, treatment plan reviews and discharge
plans.
EL. TREATMENT TEAM means the group of
individuals that assesses, plans, coordinates, implements, evaluates, reviews,
and adjusts all aspects of a client’s care over the course of treatment in a
certified program. The treatment team
includes the client, and as applicable, the client’s family or legal guardian(s),
therapist, direct service staff, treatment coordinators, treatment foster
parents, the department’s social worker or juvenile probation/parole officer,
case manager, a representative from an educational agency, or other significant
individuals in the client’s life.
EM. UNSUBSTANTIATED COMPLAINT means a
complaint or allegation that could not be verified by the LCA based on its
investigation.
EN. VARIANCE means a deviation from a
portion(s) of these certification requirements approved in writing at the sole
discretion of the LCA. It is based upon stipulated conditions to be met by the
agency, for an unlimited time period, provided that the health, safety, and
welfare of the clients and staff are not in danger.
EO. VOLUNTEER means an individual who
works without compensation at an agency in the physical presence or proximity
of clients.
EP. WRAPAROUND means a team-based activity
that helps groups of people involved in a family’s life work together toward a
common goal.
EQ. WAIVE/WAIVER means a deviation(s) from
any part of these certification requirements approved in writing by the LCA, at
the sole discretion of the LCA. It is
based on stipulated conditions to be met by the agency, for a limited period of
time, provided the health, safety, and welfare of clients and staff is not in
danger.
[7.20.11.7 NMAC - Rp 7 NMAC 20.11.7, 03/29/02; A, 04/14/05;
A, 01/01/08; A, 12/31/08]
7.20.11.8 RELATED REGULATIONS, LAWS AND
CODES: These certification
requirements supplement and apply in conjunction with the following regulations
laws and codes and any future amendments to such regulations or superseding
regulations.
A. Licensing Requirements for Child and
Adolescent Mental Health Facilities, 7.20.12 NMAC.
B. Health Facility Sanctions and Civil
Monetary Penalties, 7 NMAC 1.8 (1996).
C. New Mexico Children’s Code NMSA 1978
32A-1-1 et Seq. (1997).
[7.20.11.8 NMAC - Rp 7 NMAC 20.11.8, 03/29/02]
7.20.11.9 ISSUANCE OF CERTIFICATION:
A. Application for initial
certification:
(1) Applications for the
initial certification of a new program offering case management services,
behavior management skills development services, day treatment services, group
home services, all residential treatment services, or treatment foster care
services are submitted to the LCA for review and approval. The application for initial certification of
a program includes, but is not limited to, the following:
(a) a letter of intent naming
the service for which the agency is requesting initial certification and describing how and where the proposed
service will be delivered.
(b) policies and procedures
showing that the agency complies with both the general provisions and the
service-specific requirements of the program for which the agency is requesting
initial certification; and an index that references each policy and procedure
by the applicable certification requirement that the policy is designed to
meet.
(c) job descriptions, required
qualifications, resumes, current
licenses, proof of credentials, and criminal records clearances for
professional staff;
(d) job descriptions, required
qualifications and criminal records clearances for direct service staff; and
(e) a complete set of the forms that will be
used to document the services being provided.
(2) At the discretion of the
LCA, the application process may include interviews with staff, administrators,
or program directors.
(3) When applicant agencies
have an established in-state or out-of-state history of providing mental health
or substance abuse services for children and adolescents, whether or not the agency is currently providing such
services, the agency’s record with regulatory compliance will be considered
during review of the new application;
(4) Applications will be
reviewed by the LCA within 15 business days and
a written response will be sent to the agency.
The findings of the review will determine which of the following
responses will be issued by the LCA:
(a) Complete applications that
comply with all the requirements of these certification requirements will be
issued an initial certification for a period of up to 120 days.
(b) Incomplete applications
will be returned with a letter detailing what elements of the application are
missing. initial certification will not
be issued.
(c) When an application is complete, but fails
to show that the agency has fully or substantially complied with all of these
certification requirements, the LCA will issue a letter detailing the findings
of the review, with a list of the changes required to show the new program to
be in compliance with these certification requirements. An initial certification will not be issued.
(5) If, three months subsequent to the issuance of
an LCA letter detailing missing or insufficient elements of an application, the
agency has not responded with a completed application or has not achieved
compliance with these certification requirements sufficient to warrant initial
certification, the application will be considered void. The agency may reapply for certification of
the service, but will be required to begin a new application process.
(6) COA/CARF/JCAHO
Accreditation does not confer state certification status on a program.
B. Types of certification:
(1) FULL CERTIFICATION: Full
certification is granted to a program currently serving clients and found by
the LCA to be in substantial compliance with these certification requirements.
At the discretion of the LCA, the duration of full certification status is 12
to 24 months.
(2) EXEMPLARY STATUS is a type
of full certification that may be granted to a program that has no history of
temporary certification, sanctions
or loss of certification in the previous two years and that, based on a
determination made by the LCA, adheres to these certification requirements with
only minor deficiencies, which pose no health and safety risks to clients. Exemplary status may be granted for up to 24
months.
(3) FULL CERTIFICATION: This certification is
granted to a program currently serving clients and found to be in substantial
compliance with these certification requirements, when only minor and few
deficiencies, none of which compromise client health and safety, are identified
in the LCA certification report. The program submits an action plan for the
LCA’s approval within the time frame specified by the LCA, detailing the
measures that will be used to correct the deficiencies. At the discretion of the LCA, the program may
also be required to implement a directed action(s) within specified time
frames; or may be required to comply with monitoring as specified by the LCA
during the period of certification. Based on a determination made by the LCA,
the program produces proof of correction of deficiencies and/or compliance with
directed action(s) and/or monitoring through submission of relevant
documentation and/or by subsequent on-site review. The terms and the timeframes for monitoring
are established in writing in the certification report.
(a) The LCA provides written
notification indicating whether the program’s action plan is approved. Action plans may be approved with amendments
recommended and/or required within a time frame specified by the LCA. If an action plan is not approved, the LCA
will specify items that require revision or supplementation in order to receive
LCA approval.
(b) If another survey reveals
additional deficiencies, the LCA may require amendment of the action plan,
and/or issue new written directed actions, and/or implement a revised
monitoring plan, and/or sanction the program based on new deficiencies
identified.
(4) TEMPORARY CERTIFICATION:
Temporary certification is granted to a program currently serving clients that
is found by the LCA to be in partial compliance with the certification
requirements, or to a program that has been on inactive status and is returning
to active status.
(a) The LCA determines the
duration of a temporary certification. Temporary certification may be granted
for a period of up to 180 days. The LCA
determines the duration of temporary certification based on factors that may
include severity of deficiencies and the program’s history of compliance with
certification requirements.
(b) The program submits an
action plan for the LCA’s approval within 14 days of receipt of the LCA
certification report detailing its findings of deficiencies, unless otherwise
specified by the LCA. At the discretion
of the LCA, the program may also be required to implement directed action(s)
within specified time frames. The
program may be required to comply with terms of monitoring specified by the LCA
during the period of temporary certification, based on a determination made by
the LCA.
(c) Items 9.B(3)(a) and (b)
above are applicable for action plans that accompany temporary certification.
(d) For programs returning to
active status, an action plan, directed action, and/or monitoring are not
required unless specified by the LCA.
(e) If the program does not
achieve substantial compliance with these certification requirements at the end
of a temporary certification period, a sanction(s) may be imposed including
non-renewal of certification.
(f) At the discretion of the
LCA, a second consecutive temporary
certificate may be issued for a
period of up to 180 days, or
certification may be allowed to expire without renewal.
(5) INITIAL CERTIFICATION:
This certification is granted for a period of 120 days to a program that has
met the minimum requirements to provide child and adolescent mental health or
substance abuse services as determined by the application process described in
certification requirement 9.A above. If
the program has no clients at the end of 120 days, a second 120-day initial
certification may be granted. If the
program remains without clients beyond 240 days, the program’s initial
certificate expires and re-application for certification is required; or, at
the discretion of the LCA, inactive status may be granted.
(6) INACTIVE STATUS: This
certification is granted to a program not presently serving clients, but which has served clients within the current
period of certification. A certificate
of inactive status covers a period of time not to exceed 180 days from the date
of issue. If the program continues
without clients beyond 180 days, a second 180-Day certificate of inactive
status may be granted upon request. If
the program remains without clients beyond 365 days, the program’s inactive
status expires and re-application for initial certification is required.
(a) To return to active status
from inactive status for a certified service, the program must notify the LCA
in writing at least two weeks prior to its intended admission of
clients. In addition to the written
notice, the agency must submit the following to the LCA: information on any
changes in personnel or agency policies and procedures during inactive status;
proof of criminal records clearances, qualifications, and, as applicable,
licensure for new supervisory and direct service staff of the certified
program.
(b) Upon review of the
submitted information, the LCA may grant temporary certification. The agency will not admit any client(s) until
the LCA issues and the program receives temporary certification.
(7) AMENDED CERTIFICATE: This
certification is granted to a program currently serving clients that has had a change
of ownership or licensee, or that chooses to change its name. The agency submits a written request for an
amended certificate to the LCA ten business
days prior to the change.
(8) DEEMED CERTIFICATION: The LCA has
discretion to grant deemed certification when a program is
accredited by the council on accreditation (COA), the council on accreditation
of rehabilitation facilities (CARF), or for residential treatment services, by
the joint commission on accreditation of health care organizations (JCAHO), and
the LCA determines that the standards of the accrediting body apply
substantially to the program for which deemed certification is being
considered. A certified program that is
accredited by one of these organizations and wishes to request deemed
certification must provide a copy of the accreditation report to the LCA within
30 days of receipt of the report, and must provide any other
accreditation-related documentation to the LCA upon request. Upon receipt and review of the COA, CARF or
JCAHO survey reports, the LCA, at its discretion, may issue deemed
certification status effective for up to 24 months. For those
intervening years that the above-mentioned accrediting bodies do not conduct
on-site visits, the LCA may conduct annual or biennial
certification on-site surveys.
(a) EXCEPTION: The deemed certification may
not apply when COA, CARF or JCAHO identify any condition that the LCA, at its
sole discretion, determines to be a significant violation of certification or accreditation
standards, or that requires follow-up by the accrediting body; or when any
condition reported to the LCA appears to pose a threat to health and/or safety;
or when there is any other information indicating the existence of such a
threat.
(b) All agencies and programs that receive
deemed certification must comply with all applicable provisions of the
Children’s Health Act of 2000 and these certification requirements.
C. AUTOMATIC EXPIRATIONS OF A
CERTIFICATION:
(1) A certificate
automatically expires at midnight on the day a certified program discontinues
or suspends operation or changes location.
(2) A certificate
automatically expires at midnight on the tenth day after a certified program is
sold, leased, or otherwise changes ownership and/or licensee, unless the agency
has made a timely written request for amended certification. In such a case, the automatic expiration is
stayed, and previous certification remains in effect if the agency has until
the LCA acts on the application or takes other certification action.
D. WAIVERS AND/OR VARIANCES: Upon
written request of the agency and at
the discretion of the LCA, the LCA may issue a waiver and/or variance
E. CERTIFICATION REVIEWS: When
possible, the LCA schedules on-site program reviews prior to expiration of
certification. If the LCA does not
perform a certification on-site review
of a program prior to the expiration of its certification, and the program has
not received a written report from the LCA recommending that the program’s
certification be allowed to expire, the certification continues in effect until
the LCA performs a certification review.
F. The LCA, at its sole discretion,
may extend any certification for a period of up to 12 months.
G. In the event that a program’s
certification is revoked, suspended, denied, or not renewed, the medicaid
provider agreement terminates on the date of the revocation, suspension or
denial.
[7.20.11.9 NMAC - Rp 7 NMAC 20.11.9, 03/29/02; A, 04/14/05]
7.20.11.10 EMERGENCY REVOCATION, SUSPENSION,
NON-RENEWAL OF CERTIFICATION OR IMPOSITION OF EMERGENCY SANCTIONS, WITHOUT
PRIOR HEARING: If immediate action
is required to protect human health and/or safety, the LCA may immediately
revoke, suspend, not renew, or impose an emergency sanction(s) against the
certification status of a program
pending a hearing, provided that such hearing is held within five business days of the above-mentioned action and/or
sanction(s), unless the program waives its right to a hearing. The medicaid provider agreement terminates on
the date of the revocation, suspension, or non-renewal of certification.
[7.20.11.10 NMAC - Rp 7 NMAC 20.11.10, 03/29/02]
7.20.11.11 GROUNDS FOR IMPOSITION OF
SANCTIONS: Sanctions may be imposed by the LCA
based on its specific findings, including but not limited to any of the
following:
A. failure to comply with any
provision(s) of these certification requirements;
B. failure to allow surveys by
authorized representatives of the LCA;
employment of any person convicted of a felony or
misdemeanor without clearance by the department, including a misdemeanor
involving moral turpitude;
C. allowing any agency personnel to work under the influence of alcohol
or mood-altering drugs (if after employment, a staff member is charged and/or
convicted of a felony or misdemeanor involving moral turpitude and this fact is known to the agency, it must be
immediately reported to the LCA);
D. purposeful, deliberate or
intentional misrepresentation(s) or falsification(s) of any information on
application forms or other documents provided to the LCA;
E. repeated violations of
these certification requirements, or failure to correct deficiencies of survey
findings in current or past contiguous or noncontiguous certification periods;
F. presence of, and/or a history of,
certification/licensure revocation, suspension, non-renewal, or denial of
certification, sanction(s) or penalties or other similar disciplinary actions
taken by regulatory bodies in other states or countries and/or within New
Mexico regardless of whether any of these actions resulted in a settlement in
lieu of a sanction;
G. failure to provide a client in the
program with care, supervision and services or to protect client rights as
outlined in these certification requirements;
H. any neglect as defined in these
certification requirements;
I. presence of, and/or a history of
health and/or safety deficiencies found in current or previous surveys or
on-site visits;
J. death or serious injury to a
client;
K. psychological harm or cruelty and
indifference to the welfare of a client;
L. incidents that include acts of
physical harm to a client(s) by staff;
M. regulatory deficiencies that
jeopardize the health and/or safety of a client;
N. numerous deficiencies, that in
combination, jeopardize the health and/or safety of a client; or
O. non-disclosure and/or deceit
regarding condition of a facility/program or the services it provides.
[7.20.11.11 NMAC - Rp 7 NMAC 20.11.11, 03/29/02]
7.20.11.12 SANCTIONS:
A. Sanctions, as follows, may be
imposed for the reasons listed in Section 11. The severity of the action taken
by the department depends upon the specific facts in each case, the seriousness
and history of the events prompting the department to take action, and the
ability and willingness of the agency to promptly take adequate corrective
action.
(1) REVOCATION: The LCA
cancels certification, making it void. The medicaid provider agreement
terminates on the date of revocation.
(2) SUSPENSION: The LCA
temporarily revokes certification until the identified deficiencies are
corrected and the LCA approves the corrections. The medicaid provider agreement
terminates on the date of suspension.
(3) NON-RENEWAL: The LCA refuses to renew certification and
issues a notice stating that the certification is void as of a specific date,
on or about the date of expiration. The medicaid provider agreement terminates
on the effective date of non-renewal.
(4) DENIAL: The LCA refuses to issue certification.
(5) ADMISSIONS HOLD: The LCA
restricts the program from accepting any new clients until the identified
deficiencies are corrected and the LCA approves the corrections.
(6) EXPANSION HOLD: The LCA restricts the program from expanding
into additional services until the identified deficiencies are corrected and
the LCA approves the corrections.
(7) MAINTENANCE OR REDUCTION
IN PROGRAM CAPACITY: The LCA directs the program to maintain or reduce the
capacity of the program to a designated client census until the LCA determines
that all of the deficiencies resulting
in the sanction have been corrected.
(8) COMPLIANCE MONITOR: The
LCA may select and assign a compliance monitor and assign it to an agency for a
specified period of time to oversee an agency’s compliance efforts. The compliance monitor has the authority to
review all applicable facility records, including financial records and policies,
and the authority to interview facility staff and clients. The compliance monitor may also advise the
program regarding steps to correct violations and improve overall clinical
programming. The compliance monitor reports to the LCA on a weekly basis or
more often when indicated. The agency
pays all costs of the compliance monitor.
(9) TEMPORARY MANAGEMENT: The
LCA appoints temporary professional management with expertise in the field of
the child and adolescent mental health and/or substance abuse services provided
by the program. The temporary management
assumes primary responsibility to oversee the operation of the program; to
protect the health and safety of its clients; to assess and direct the
correction of deficiencies; and/or to facilitate an orderly closure. The
temporary management reports to the LCA.
The agency pays all costs of temporary management.
B. EXTENUATING CIRCUMSTANCES: In assessing the appropriateness or severity
of sanctions, the LCA may consider any relevant factor(s) that may mitigate or
exacerbate the situation precipitating the sanction.
C. CORRECTION OF DEFICIENCIES: When the LCA determines that deficiencies
exist, the program must correct the deficiencies according to the following
time frames or further sanctions may be imposed:
(1) Health and/or safety
deficiencies are corrected immediately.
(2) Deficiencies that do not compromise health and/or safety are corrected within a period of time specified by the LCA.
D. SERVICE OF NOTICE: The department
provides notification, by fax and certified mail or personal service/delivery,
of its imposition of any emergency sanction against a program. A notice of contemplated action under these
certification requirements may be sent by fax and mail, personal service or
delivery, or by certified mail. Each
notice of emergency sanction or contemplated action will be forwarded by
fax to the medical assistance division immediately. (The medical assistance
division of the human services department is responsible for any notices
related to medicaid payments sent to the provider.)
E. NEW OWNERSHIP: In the event a
provider sells or otherwise transfers its interest in its certified program to
another entity, and a sanction or other corrective measure is pending, the sale
of the certified program does not stay or otherwise impact the pending
sanction. The new owner/entity must
comply with all areas of correction noted in the sanction or action plan. If a
sanction(s) is pending, the LCA will proceed with the appeals process and may
issue a notice of final action pursuant to these certification requirements.
[7.20.11.12 NMAC - Rp 7 NMAC 20.11.12, 03/29/02]
7.20.11.13 APPEALS AND HEARINGS:
A. HEARING OFFICER: The department
appoints an impartial hearing officer to conduct any administrative appeal.
B. PROCEDURES: Adjudicatory Hearing
procedures, 7.1.2 NMAC, apply in all administrative appeals.
C. ADDRESS FOR REQUESTING AN
ADMINISTRATIVE APPEAL: All requests for
appeal must be addressed to: Licensing and Certification Unit; Children’s
Behavioral Health and Community Services Bureau; Children, Youth and Families
Department; Post Office Drawer 5160; Santa Fe, New Mexico 87502-5160 (facsimile
505-827-4595).
D APPEALS OF EMERGENCY SANCTIONS:
(1) If an emergency sanction
is imposed, the LCA conducts a hearing within five business days of the Notice. The LCA notifies the agency of the name of
the hearing officer and the date and time of the hearing.
(2) The emergency sanction
takes effect immediately, and is not stayed by any request for administrative
hearing or for an informal resolution conference.
(3) Any informal resolution
conference, if requested, will be held within five business days of the date of
the notice of emergency sanction.
E. APPEALS OF ADVERSE ACTIONS OTHER
THAN EMERGENCY SANCTIONS:
(1) A program may appeal any
adverse action set forth in a notice of contemplated action. The notice of contemplated action will
include instructions and time frames for the program to request an appeal
and/or an informal resolution conference.
The program must request the appeal in writing within ten business days
of receipt of the notice of contemplated action.
(2) When an appeal has been
requested, the adverse action(s) is stayed until either of the following events
occurs:
(a) the administrative hearing
officer has conducted the hearing and issued an opinion; or
(b) the LCA and the program
reach agreement through an informal resolution process.
(3) The administrative hearing
will be held within 30 calendar days, unless both the LCA and the program agree
to an extension. The LCA will inform the
program of the date and location of the administrative hearing, and will
identify the hearing officer.
(4) After the appeal process
is concluded, or upon expiration of the time for appeal if no appeal is
requested, the LCA will issue a notice of final action which will state the
final decision of the LCA and the effective date of sanction(s) or any other
adverse action. The notice of final action is not appealable.
F. INFORMAL RESOLUTION CONFERENCE: The
department and the program may resolve any filed or potential administrative
appeal through an informal resolution conference. The informal resolution conference provides
an opportunity for the program to present new evidence or arguments regarding
the deficiencies cited by, or corrective action proposed by, the department,
and to present information regarding plans to remedy deficiencies and discuss
possible pre-hearing disposition. The
LCA has discretion to accept or reject any proposal made by the program. The informal resolution conference does not
postpone any deadlines for appeal unless the LCA and the program both
explicitly agree in writing to the extension.
[7.20.11.13 NMAC - Rp 7 NMAC 20.11.13, 03/29/02]
7.20.11.14 PROGRAM
SURVEYS, INVESTIGATIONS, AND REPORTS:
A. Application
for certification, whether initial or renewal, constitutes permission for entry
into, and surveys of a program by the authorized LCA representatives at
reasonable times while the application is pending.
B. LCA
surveyors may enter the premises of an agency at any time and review any and
all records of medicaid recipients, CYFD custody clients and agency staff; the
LCA may conduct interviews with staff and/or clients in programs that are
certified or required to be certified, whether or not an application for
certification has been made, for the purpose of determining compliance with
these certification requirements.
C. The LCA may conduct a survey(s) to
assess/monitor progress with correction of violations found on previous
surveys; or to investigate complaints or allegations of abuse, neglect or
exploitation. The LCA may also conduct
inquiry into matters of potential health and/or safety risk to clients as
identified in serious incident reports or other information received by the
LCA.
D. Findings made by the LCA during
on-site surveys or investigations described in these certification requirements
may result in changes of certification status, sanction(s), suspension,
revocation, non-renewal, or denial of certification in accordance with all of
the guidelines governing such actions as defined in these certification requirements.
E. When
certification on-site surveys are conducted concurrently with licensing on-site
surveys and there are violations found of both licensing and certification
requirements that do not directly overlap, the LCA may issue a single report
citing deficiencies with reference to both licensing and certification
requirements.
F. When,
during a certification survey, the LCA finds a violation(s) of these
certification requirements that also constitute(s) a violation(s) of the
licensing regulations of the department, the LCA may issue a single report
addressing the violation(s) with reference to certification requirements only.
G. REPORTS:
(1) The LCA issues a written report of the
findings for all required certification surveys within 30 business days of
completion of the survey.
(2) When a survey is conducted for purposes of
investigation, the LCA issues a report in instances of partial or fully
substantiated complaint(s)/allegation(s) within 30 business days of the completion of the investigation.
(3) When a survey is conducted for purposes of
investigation and the complaint(s)/allegation(s) are unsubstantiated, the LCA
issues a letter indicating that the complaint was not substantiated, but does
not issue a report.
(4) When a survey is conducted for the
purposes of inquiry into questions of compliance arising from incident reports
or other reports, the LCA may issue a report of any findings of noncompliance. If such a report is issued, it will be issued
within 30 calendar days after completion of the survey.
(5) When a survey is conducted for purposes of
following-up a monitoring plan, the LCA issues a follow up letter, but does not issue a report unless
information obtained during such a visit indicates the need for a full program
review and/or additional investigation(s).
(6) When a survey is conducted for purposes of
technical assistance, the LCA does not issue a report.
(7) A report of a survey or investigation may
be combined with a notice of contemplated action or notice of emergency
sanction.
[7.20.11.14 NMAC - Rp 7 NMAC
20.11.14, 03/29/02]
7.20.11.15 CRIMINAL RECORDS CHECKS AND CLEARANCES:
A. Every program that provides child/adolescent mental health and/or substance abuse services pursuant to these
certification requirements, operating in the state of New Mexico, must initiate
and provide to the department two completed state-and FBI-approved fingerprint
cards for each employee who will serve as direct services staff. The
agency must have received the
criminal records clearance from the prevention and intervention division of the
department prior to the employee’s direct, unsupervised contact with clients of
the program. Non-compliance with this
requirement may result in sanction up to loss of certification as referenced in
NMSA 1978 32A-15-3.
B. All agencies must comply with 8.8.3 NMAC Regulations governing criminal records
checks.
C. Student trainees in psychiatry,
psychology, social work and/or nursing, or other related health, social or
human-services disciplines who are
enrolled in a clinical training program of a New Mexico state accredited
institution of higher learning, and who are under the supervision of a cleared
licensed independent practitioner, may be allowed to work with children without
direct physical supervision during their enrolled student
tenure if the trainee signs a sworn affidavit attesting that he or she has
never been convicted of a crime that would disqualify him or her from providing
direct services to children.
D. The certification requirements
governing criminal records clearances remain in effect while a program is
accredited by COA, CARF or JCAHO.
E. If a prospective employee has not
lived in the United States continuously for the five years previous to hire,
the equivalent of a criminal records clearance is required from any country in
which he/she has lived within the last five years, for a period longer than one
year.
F. If the agency receives reliable
evidence that indicates that an employee or prospective employee poses a
potential risk of child abuse, sexual abuse, exploitation, moral turpitude,
cruelty, or indifference to children, the agency is in violation of these
certification requirements and subject to sanction up to loss of certification
if that individual is hired or retained.
G. Upon request by the LCA, the agency
will provide a list of employees who are not required to have a criminal
records clearance, and the reason why not.
H. Non-compliance with any
certification requirement relating to criminal
records checks and clearances may result in sanction or
loss of certification. In addition to
the foregoing, the following certification requirements relate to criminal
records checks and clearances:
(1) 16.G.1(f) concerning
prospective employee history verification and reference checks;
(2) 16.G.1(h) concerning
letters of attestation for employees pending clearances;
(3) 16.G. 2 concerning
disclosure of arrests/convictions;
(4) 16.H.1-5 concerning staff schedules.
[7.20.11.15 NMAC - Rp 7 NMAC 20.11.15, 03/29/02]
7.20.11.16 PERSONNEL:
A. The agency provides personnel who
are trained, supervised and in all respects qualified to perform the functions
for which they are responsible.
B. Each position, or group of like
positions, is detailed in a written job description that clearly states qualifications,
responsibilities and requirements.
C. Each agency employee meets all state
registration, licensing and/or certification requirements applicable to his or
her position and/or use of professional title(s) and the agency has copies of
such licenses, etc. on file.
D. Orientation of personnel:
(1) The agency orients its
personnel to the agency’s goals, services, policies and procedures, and to the
responsibilities of the staff member’s position. Initial and ongoing orientation is documented
in the personnel record.
(2) Orientation includes
training on the establishment and maintenance of appropriate and responsive
relationships and boundaries with clients.
E. Personnel training, development,
responsibilities and supervision:
(1) The agency provides a
training and development program to allow personnel to improve their knowledge,
skills and abilities and to promote awareness and appreciation of the cultural
background and need of persons served by the agency. This training will be documented in the
personnel file.
(2) The agency provides staff
development opportunities for personnel, including in-service training.
(3) Staff who require training
to qualify for a position in which they are responsible for the care of
children do not have sole responsibility for the care of children until after
the successful completion of the training.
(4) Staff designated as direct
service staff under service-specific certification requirements receive ongoing
training related to the age and/or emotional development of the children for
whom they are responsible.
(5) All certified services are
provided under supervision of a clinical director who provides clinical
oversight of the program, by way of documented supervision and consultation to
all agency staff. Supervision may be
direct, or may occur through a clinical supervisor who is directly supervised
by the clinical director.
(6) All clinical
supervision/consultation is documented and documentation includes the theme,
date, length of time of supervision and signatures of those participating.
(7) In the event that the
therapist and clinical supervisor are the same person, another properly
credentialed clinician, either from within the agency or from outside the
agency, provides supervision at least one time per month to the clinical
supervisor.
(8)
The responsibilities of the therapist include providing therapy and
participating in the development of a treatment plan. These activities are
documented.
(9) When the agency utilizes
the services of professionals on a per interview, hourly, part-time, or
independent contractor basis, the agency documents regular assessment of the
quality of services provided.
F. Accountability:
(1) The agency ensures that
the performance of all employees, consultants, contractors, and volunteers is
consistent with agency policy and these certification requirements.
(2) At least once a year,
written performance reviews are conducted jointly between each staff member,
including volunteers, and the person’s supervisor.
G. Personnel records:
(1) A personnel record is
maintained for each employee and volunteer.
Each personnel record is readily accessible to the LCA at each site
visit, and contains, at a minimum:
(a) documentation of all orientation and
training, including dates, hours or credits, names of trainer and trainee, and written confirmation by trainer or
training organization that the training has occurred;
(b) employee’s name, current address,
telephone number and emergency contact(s);
(c) job title and description;
(d) evidence of licensure for
those employees required to be licensed;
(e) date first employed and
dates of transfers or changes in position;
(f) documentation of a minimum
of three employment reference checks within three weeks prior to employment (if
this process yields fewer than three employment reference checks, additional
professional and/or personal references are obtained to achieve the required
minimum of three references);
(g) a copy of the employee’s current CPR and first aid certificates;
(h) for cleared staff, the
criminal records clearance letter, or for uncleared staff, a signed statement
by the administrator, director, or operator attesting to direct supervision of the uncleared
employee by a cleared employee until the clearance is received;
(i) application for employment
or resume consistent with agency policy;
(j) performance reviews, as
applicable.
(2) The agency’s written
policies and practices require that an applicant for employment disclose any
prior criminal convictions, and employees report any arrests and/or convictions
that occur while employed.
(3) The agency’s written policies provide
personnel with access to their records and a process to review the record and
to make additions and corrections to the record.
H. Schedules of direct service staff in
day treatment and residential facilities:
(1) Each facility or licensed unit maintains a
written, legible schedule clearly identifying direct service staff responsible
for care of clients.
(2) Each uncleared employee is
identified on the staff schedule.
(3) The staff schedule is
updated daily to reflect actual hours staff are present and changes in
attendance as they occur.
(4) Original updated staff
schedules are kept on file for at least 12 months.
(5) The updated schedule documents the client
census for each unit of a residential treatment services center or group home
service on a daily basis.
[7.20.11.16 NMAC - Rp 7 NMAC 20.11.16, 03/29/02; A,
10/29/04]
7.20.11.17 ALLEGATIONS OF ABUSE/NEGLECT,
COMPLAINTS, AND SERIOUS INCIDENT REPORTING:
A. The agency maintains and follows
policies and procedures consistent with these certification requirements for
timely reporting of any serious incidents and allegations of abuse or neglect.
The agency immediately reports allegations of abuse or neglect to all
appropriate entities, including but not limited to the protective services
division of the department via statewide ventral intake/tribal social services
agency, the client’s legal guardian, the jurisdictional law enforcement agency,
and the LCA.
B. The agency reports all serious
incidents to the LCA by fax within 24 hours of any staff member becoming aware
of the incident or allegation of incident. Incidents involving minor illnesses
or injuries not requiring emergency services do not need to be reported to the
LCA. Day treatment services, case management services, and behavioral
management skills development services are not required to report serious
incidents that do not occur during program hours, with the exception that all
deaths must be reported.
C. Additional reporting requirements
for deaths: Deaths are reported to the
LCA immediately by telephone and followed by fax within 24 hours, whether or
not the death occurs during program hours.
Agencies are required to report any client death to the regional office
of the federal centers for medicare and medicaid services by no later than by
the close of business the next business day after the client’s death, and must
document in the client’s record that the death was reported to the centers for
medicare and medicaid services.
D. Each serious incident report is
written by the staff who have personal or firsthand knowledge of the
incident/allegation, and is signed and dated by that person(s). Once written,
the report is not altered, but may be amended.
Any amendment is signed and dated by its author and filed with the
original report. The report clearly distinguishes between events witnessed by
the reporter and statements made to the reporter. The report contains, but is not limited to the following information regarding the
incident: date, time, and location of the incident, behavioral description(s)
of relevant event(s), descriptions of health/safety risk(s) relevant to the
incident, identification of person(s) present, birth date(s) of client(s)
involved, level of care of the client(s) involved, initial actions in response
to the incident, names of persons providing information to the reporter, and
identification of other entities receiving the report.
E. Each serious incident for which a
report to the LCA is required herein and that involves possible criminal
activity is reported immediately to the appropriate law enforcement
agency.
F. The agency responds in a timely
manner to protect its clients from physical or psychological risks of which it
is or reasonably should be aware, in order to reduce and prevent future risks.
G. Outcomes, dispositions, and
descriptions of any voluntary corrective action(s) taken by the agency in
response to serious incidents are faxed or
mailed to the LCA in a timely
manner.
H. The program will not rely on the
fact that it has made a serious incident report to the LCA, or the fact that it
may not have received a response from the LCA, to delay appropriate corrective
or protective action in response to an incident.
I. The agency maintains and follows
policies and procedures for investigating and responding to allegations of
abuse or neglect in a confidential and timely
manner.
J. The agency maintains and follows
policies and procedures for investigating and responding to complaints in a
timely manner.
K. The agency provides a written
response, in a timely manner, to the complaining party and, as
applicable, the parent, legal or treatment guardian, regarding the resolution
of each complaint or allegation.
[7.20.11.17 NMAC - N, 03/29/02; A, 04/14/05]
7.20.11.18 AGENCY IN THE COMMUNITY:
A. The agency identifies a defined
purpose, uses a multi-disciplinary approach in which services are coordinated
within the agency and within the provider community, and collaborates with
other agencies in provision of services for its clients.
B. Agency purpose: The agency’s
statement of purpose includes a description of its primary function as
providing services that:
(1) serve those clients in need of treatment who are most
vulnerable or at risk;
(2) are habilitative in focus;
and
(3) are consistent with the
least restrictive means principle.
C. Community access to services:
(1) The agency provides
culturally competent services and serves the needs of those clients who are
bicultural and/or who are non-English speaking through the use of:
(a) bilingual/bicultural
professional and qualified paraprofessional personnel;
(b) translators to meet the
clients’ communication needs.
(2) The agency provides public
information concerning its services to persons in the community who are
non-English-speaking. This information is designed to encourage full
participation of non-English speaking clients.
[7.20.11.18 NMAC - Rp 7 NMAC 20.11.18, 03/29/02]
7.20.11.19 AGENCY GOVERNANCE AND
ADMINISTRATION:
A. The agency is legally authorized to
operate, identifies the members of its governing body, and administers its
program in accordance with its own policies, which support compliance with
these certification requirements.
B. The agency’s governing body is responsible
for adopting bylaws and policies and defining the scope of its services. The agency is legally authorized to operate
as one of the following:
(1) Not-profit agency,
incorporated in the state in which it operates, with a charter, constitution,
and by laws;
(2) Not-profit agency operated
by its own independent governing body, under the aegis of a religious body or
other organization recognized under the laws of the state;
(3) Public agency authorized
and established by statute, or a sub-unit of a public agency with which clear
administrative relationship exists;
(4) Proprietary agency
organized as a legal entity as a corporation, partnership, or association, but
excluding therefrom sole proprietors; or
(5) Agency of a tribal
government, or subdivision thereof.
C. Policies and procedures: The agency maintains a manual containing
current policies and procedures for agency administration, service delivery,
and protection of consumer rights.
(1) The agency makes a copy of
its policies and procedures manual available to new personnel upon employment.
(2) The agency documents that
it keeps all personnel advised regularly of revisions to its policies and
procedures manual as revisions occur.
(3) The agency conducts annual
reviews of its policies and procedures and makes revisions as necessary to
maintain compliance with applicable laws, regulations, and these certification
requirements.
[7.20.11.19 NMAC - Rp 7 NMAC 20.11.19, 03/29/02]
7.20.11.20 QUALITY IMPROVEMENT AND UTILIZATION
REVIEW:
A. The agency has a continuous quality
improvement process, reviewed annually, through which the agency systematically
evaluates the effectiveness of services provided by determining whether its
services meet pre-determined quality improvement expectations and outcomes, and
corrects any observed deficiencies identified through the quality improvement
process.
B. The agency explicitly details the
desired expectations and service outcomes for each of its programs and has a
written plan to achieve them.
C. The agency establishes a committee
or other mechanism for the timely and regular evaluation of serious incidents,
complaints, grievances, and related investigations. Committee evaluations include identification
of events, trends and patterns that may affect client health, safety,
and/or treatment efficacy. Committee
evaluation findings and recommendations are documented and submitted to agency
management for corrective action.
Actions implemented and outcomes are documented, and trends are analyzed
over time. The agency has a well-defined
plan for correcting problems. When
problems (or potential problems) are identified, the facility acts as soon as
possible to avoid any risks to clients by taking corrective steps that may
include, but are not limited to:
(1) changes in policies and/or
procedures;
(2)
staffing and assignment changes;
(3) additional education or
training for staff;
(4) addition or deletion of
services.
D. The agency develops a system to
utilize its collected data regarding the outcome of its activities for
delivering continuously improving services.
E. Formal and informal feedback from
consumers of services and other collateral sources is aggregated and used to
improve management strategies and service delivery practices.
F. The agency collects and maintains
information necessary to plan, manage, and evaluate its programs
effectively. The outcomes are evaluated
on a quarterly basis, the results of which are used continuously to improve performance.
G. The agency implements and maintains
ongoing utilization review processes.
[7.20.11.20 NMAC - Rp 7 NMAC 20.11.20, 03/29/02]
7.20.11.21 LEGAL,
REGULATORY, AND ACCREDITATION COMPLIANCE FOR PROGRAM OPERATION, INCLUDING
HEALTH, SAFETY AND PHYSICAL PLANT REQUIREMENTS:
A. The agency promotes and protects the
health and safety of its clients, demonstrates compliance with all applicable
laws and regulations, adheres to the requirements of its accrediting bodies, if
any, and possesses all applicable licenses required by law and departmental
policy.
(1) License(s) required: The agency possesses a license(s) and
complies with applicable licensing requirements for each service required by
state and local law and departmental regulation including, but not limited to the following:
(a) Each treatment foster care
child placement agency is licensed by the protective services division of the
department as a child placement agency.
(b) All residential facilities
are licensed by the department. Each maintains a separate license.
(c) Day treatment services are
licensed as day treatment centers by the department. Each day treatment services facility
maintains a separate license. Exception:
day treatment services provided in a
public school facility do not require licensure by the department.
(2) Residential treatment
services and group home services are certified only when provided in a facility
licensed by the LCA for 16 beds or fewer per unit.
B. An agency accredited by an
accrediting organization recognized by the LCA complies with the current
requirements of the accrediting organization.
The accrediting organizations recognized by the LCA are:
(1) Council on accreditation
for children and family services (COA);
(2) Joint commission on
accreditation of healthcare organizations (JCAHO); and
(3) Council on accreditation
of rehabilitation facilities (CARF).
[7.20.11.21 NMAC - Rp 7 NMAC 20.11.21, 03/29/02]
7.20.11.22 CLIENT PARTICIPATION, PROTECTION,
AND CASE REVIEW:
A. The agency takes all reasonable
action(s) to protect the health, safety, confidentiality, and rights of its clients. The agency informs the client of his or her
rights and responsibilities and develops and implements policies and procedures
that support and facilitate the client’s full participation in treatment and
related agency activities. The agency protects the confidentiality of client
records through adherence to its own set of policies and procedures governing
access to, and release of, confidential information.
B. Materials describing services
offered, eligibility requirements and client rights and responsibilities are
provided in a form understandable to the client and client’s legal guardian(s)
with consideration of the client’s/guardian’s primary language, and the mode of
communication best understood by persons with visual or hearing impairments.
(1) If the client is unable to understand the
materials for any reason, every effort is made to explain his or her rights and
responsibilities in a manner understandable to the client. These efforts will
be documented in the client’s record.
(2) Materials are available or
posted in the agency’s reception area and/or handed to potential clients during
their initial contact with the agency.
C. The agency explains to each client
what his or her legal rights are in a manner consistent with the client’s
ability to understand and makes this information available to the client in
writing, or in any other medium appropriate to the client’s level of
development. A written explanation of
these rights is given to the parent/legal guardian upon admission.
(1) A client who receives
residential treatment services has the rights enumerated in the New Mexico
children’s mental health and developmental disabilities Code, NMSA 1978,
Sections 32A-6-1 et seq. (1995).
Explanation of rights to the client and parents/legal guardian is
documented in the client’s record.
(2) The agency maintains and
follows written policy affirming that clients may refuse any treatment or
medication, unless the right to refuse treatment(s) has been limited by law or
court order. The agency informs the individual of the risks of such refusal. Client
refusal of treatment and advisement of risks of the refusal is documented in
the client’s record.
(3)
The agency specifies in written policies and procedures the conditions
under which it serves minors without parental/legal guardian consent, and when
parental/legal guardian consent is not possible, designates who is authorized to
give consent to treat the minor.
(a) The client record contains
all applicable consents for treatment, including consent for emergency medical
treatment and informed consent for prescription medication.
(b) Exception: Day treatment
services, behavioral management skills development services and case management
services programs are not required to file consents for prescription
medications that are not taken during program hours unless the medications are
prescribed by a program physician.
(c) Consent forms must contain the information identifying the
specific treatment, prescription medication, information release, or event for
which consent is being given prior to being signed by a client or guardian.
(4) Upon admission, each
client receives an orientation to the agency’s services that includes the basic
expectations of the clients, the hours during which services are available, and
any rules established by the agency regarding client conduct, with specific
reference to behavior that could result in discontinuation of a service. Orientation of the client and parents/legal
guardians is documented in the client’s record.
(5) The agency maintains a written
grievance/complaint procedure that is reviewed with the client and parent/legal
guardian upon admission. The client’s record contains documentation of the
agency’s explanation of the grievance procedure to the client and the
parent/legal guardian.
(6) Financial arrangements are
fully explained to the client and/or his or her parent/legal guardian upon
admission, and at the time of any change in the financial arrangements.
(7) Procedures for protecting
client assets: The agency establishes
and follows written policies and procedures to identify how it manages,
protects, and maintains accountability for client assets, including the segregation
of client funds when an agency assumes fiduciary responsibility for a client’s assets and/or disburses
funds such as maintenance or allowance funds to clients.
(8) The agency establishes
written procedures for providing client access to emergency medical services.
(9) Written agency policy specifies clinically
appropriate and legally permissible methods of behavior management and
discipline and provides training in their use to all direct service staff.
The agency prohibits in policy and practice the following:
(a) degrading punishment;
(b) corporal or other physical
punishment;
(c) group punishment for one
individual’s behavior;
(d) deprivation of an individual’s rights and
needs (e.g., food, phone contacts, etc.) when not based on documented clinical rationale;
(e) aversive stimuli used in
behavior modification;
(f) punitive work assignments;
(g) isolation or seclusion,
except as delineated in Section 24;
(h) harassment; and
(i) chemical or mechanical
restraints, except as delineated in Section 24.I.
(10) The agency establishes
and follows written policies and procedures for the use of therapeutic time-out
in accordance with these
certification requirements, including the following directives:
(a) therapeutic time-out can
only be used for the length of time necessary for the client to resume
self-control and/or to prevent harm to the client or others;
(b) therapeutic time-out is not used as a means
of punishment;
(c) therapeutic time-out is
not used for the convenience of staff; and
(d) therapeutic time-out is
monitored closely and frequently to ensure the client’s safety.
D. The agency prohibits the use or
depiction of individuals (residents, clients, etc.), either personally or by
name or likeness (e.g., photograph), in material (photographs, videotape or
audiotape), presented in a context that is either commercial or public-service
oriented in nature. An exception to this
prohibition applies to children presented on the “Wednesday’s child” television
program, Los Ninos or other
adoption exchange publications, in which case any participation and
presentation is in accordance with the department’s rules and regulations and
with the knowledge, consent and active participation of the department.
E. Client information and case review:
The agency maintains records and follows policies and procedures governing the
access to, and release of, confidential information. The agency provides
adequate facilities for the storage, processing and handling of clinical
records, including suitably locked and secured rooms.
(1) The agency’s written
policies govern the retention, maintenance, and destruction of board
administrative records, and records of former clients and personnel. These policies address:
(a) protection of the privacy
of former clients and personnel; and
(b) legitimate future requests
by former personnel or clients for information, particularly information that may not be available elsewhere.
(2) The agency has policies
governing the disposition of records, security of records and timely access and retrieval of
records in case of the agency’s dissolution. The retention of records is
required for the later of:
(a) four years after the
client is released from treatment; or
(b) two years after the client
reaches age 18; or
(c) two years after a client
has been released from most recent legal guardianship, and is no
longer under legal guardianship.
(3) The agency specifies in
written policies and procedures how it releases information. Any release is in accordance with applicable
state and federal laws. The agency does
not request or use any information release form that has been signed by a
client, parent, guardian or other party prior to pertinent information being
completed on the form.
(4) In the event of a medical
emergency that warrants immediate intervention in order to protect the life or
safety of the client, access to information regarding the client’s diagnoses
and treatment plan/service plan may be provided to medical personnel.
F. Contents of the client record:
(1) Agency policy defines
information to be contained in the client record. At the time of admission, the client’s date
of admission to each and any certified service is documented in a consistent
location in the client record.
(2) Agency policy and practice
provide that entries in the client record are made in an accurate, objective,
factual, legible, timely, and clinically-based manner.
(a) Entries made in the client
record pursuant to these certification requirements clearly identify the person
completing the entry and his or her credentials.
(b) Late entries are
identified as such; late entries include the actual date of the entry and the
signature of the person completing the entry.
G. When prescribing medication or other
treatments, the prescribing professional documents the indication for any
medical procedures and/or prescription medications.
(1) When a client is seen by
the prescribing professional, subsequent to a medical prescription or
treatment, the professional documents the response to the prescription or
treatment and any observed side
effects.
(2) Medication, including
non-prescription medication that is administered by a nurse or is self-administered,
is documented by the agency staff with the date and time of administration, the
name and dosage and any side effects observed.
H. A written discharge summary is
placed in the client’s record within 15 days of termination of services and
includes:
(1) clinical and safety
status;
(2) medications being taken at
discharge;
(3) documentation of
notification to primary care physician;
(4) specification of
referrals/appointments made with specific names;
(5) target behaviors
addressed;
(6) services provided;
(7) progress attained, or lack
thereof;
(8) description of
interventions to which the client did and did not respond, including
medications;
(9) recommendations for
continued treatment and services.
I. Client review of case record:
(1) An individual may review
his or her case record in the presence of a therapist or licensed independent
practitioner of the agency on the agency’s premises unless to do so would not
be clinically indicated. The reasons
why review is not clinically indicated are documented in the client’s record.
The confidentiality of other individuals is protected.
(2) The agency’s policies and
procedures allow the client to insert a statement into the record about his or
her needs or about services he or she is receiving or may wish to receive. Any agency statements or responses are
documented with evidence that the client was informed of insertion of such
responses.
[7.20.11.22 NMAC - Rp 7 NMAC 20.11.22, 03/29/02; A,
04/14/05]
7.20.11.23 INTAKE, ASSESSMENT, TREATMENT PLANNING, DISCHARGE PLANNING, AND DISCHARGE:
A. The agency establishes criteria for
admission, conducts ongoing clinical assessments, and develops, reviews,
revises treatment plans and provides ongoing discharge planning with the full
participation of the treatment team.
B. Clinical decisions are made only by
qualified clinical personnel.
C. Intake and screening:
(1) The agency establishes and
follows written criteria for admission to its program(s) and service(s),
including exclusionary criteria.
(2) The agency establishes and
follows written intake procedures to address clinical appropriateness for
admission.
(3) The agency’s eligibility
criteria are consistent with EPSDT requirements and Licensing Requirements for
Child and Adolescent Mental Health Facilities, 7.20.12 NMAC.
D. Assessments: The following applies
to all certified services, except case management services. Each client is
assessed at admission and reassessed at regularly specified times to evaluate
his or her response to treatment, and specifically when significant changes
occur in his or her condition or diagnosis. The assessment process is
multidisciplinary, involves active participation of the family or guardian, whenever
possible, and includes documented consideration of the client's and family's
perceptions of treatment needs and priorities. Assessment processes
include consideration of the client’s physical, emotional, cognitive,
educational, nutritional, and social development, as applicable. At a minimum, the
following assessments are conducted and documented:
(1) An
initial screening, conducted at admission, of physical, psychological, and
social functioning, to determine the client's need for treatment, care, or
services, and the need for further assessment; and assessment of risk of
behavior that is life-threatening or otherwise dangerous to the client or
others, including the need for special supervision or intervention.
(2)
A full EPSDT screen (tot-to-teen health check) within 30 days of the
initiation of services, unless such an examination has taken place and is
documented within the 12 months prior to admission. The documented content of
the history and physical examination must meet EPSDT requirements.
(3) The agency conducts a
comprehensive assessment of each client’s clinical needs. The comprehensive assessment is completed
prior to writing the comprehensive treatment plan, and includes the following:
(a) Assessment of the client’s
personal, family, medical and social history, including:
(i) relevant previous records
and collateral information;
(ii) relevant family and custodial history,
including non-familial custody and guardianship;
(iii) client and family abuse
of substances;
(iv) medical history, including medications;
(v) history, if available, as a victim of physical abuse, sexual abuse, neglect, or other
trauma;
(vi) history as a perpetrator
of physical or sexual abuse;
(vii) the individual’s and
family’s perception of his or her
current need for services;
(viii) identification of the
individual’s and family’s strengths and resources; and
(ix) evaluation of current
mental status.
(b) A psychosocial evaluation
of the client’s status and needs relevant to the following areas, as
applicable:
(i) psychological functioning;
(ii) intellectual functioning;
(iii) educational/vocational
functioning;
(iv) social functioning;
(v) developmental functioning;
(vi)
substance abuse;
(vii) culture; and
(viii) leisure and recreation.
(c) Evaluation of high risk
behaviors or potential for such;
(d) A summary of information
gathered in the clinical assessment process, in a clinical formulation
that includes identification of underlying dynamics that contribute to
identified problems and service needs.
(4) If the comprehensive
assessment is completed prior to admission, it is updated at the time of
admission to each certified service.
(5) Assessment processes
include the following:
(a) within 30 days of
admission, an educational evaluation or current, age-appropriate individualized
educational plan (IEP), or documented evidence that the client is performing
satisfactorily at school;
(b) when indicated by clinical
severity, a psychiatric evaluation;
(c) a psychological evaluation, when
specialized psychological testing is indicated;
(d) monthly updates on mental status and current level of
functioning, performed by a New
Mexico licensed master’s or doctoral level
behavioral health practitioner.
(6) Assessment information is
reviewed and updated as clinically indicated, and is documented in the client’s
record. For clients who have been in the service for one year or longer, an
annual mental status exam and psychosocial assessment are conducted and
documented in the client’s record as an addendum to previous
assessment(s). The agency makes every
effort to obtain all significant collateral information and documents its
efforts to do so. As collateral
information becomes available, the comprehensive assessment is amended.
E. Treatment planning and discharge
planning: The treatment planning process is
individualized and ongoing, and
includes initial treatment planning, comprehensive treatment planning,
discharge planning, and regular re-evaluation of treatment plans and discharge
criteria.
(1) For certified services
other than case management services and
behavior management skills development services, an initial treatment plan is
developed and documented within 72 hours of admission to each service. Based on
information available at the time, the initial treatment plan contains the
treatment planning elements identified above in 23.E (3) (a) through (j) below,
with the exception that individualized treatment goals and objectives are
targeted the first 14 days of treatment.
(2) For certified services
other than case management and
behavior management skills development services, a comprehensive treatment plan
based on the comprehensive assessment is developed within 14 days of admission.
The comprehensive treatment plan contains the treatment planning elements
identified above in 23.E (3) (a) through (j) below.
(3) Each initial and
comprehensive treatment plans fulfill the following functions:
(a) involves the full
participation of treatment team members, including the client and his or her parents/legal
guardian, who are involved to the maximum extent possible; reasons for
nonparticipation of client and/or family/legal guardian are documented in the
client’s record;
(b) is conducted in a language
the client and/or family members can understand, or is explained to the client
in language that invites full participation;
(c) is designed to improve the
client’s motivation and progress, and strengthen appropriate family
relationships;
(d) is designed to improve the
client’s self-determination and personal responsibility;
(e) utilizes the client’s strengths;
(f) is conducted under the
direction of a person who has the authority to effect change and who possesses
the experience and qualifications to enable him/her to conduct treatment
planning; treatment plans meet the provisions of the Children’s Code, NMSA
1978, Sections 32A-6-10, as amended, and are otherwise implemented in accordance
with the provisions of Article 6 of the Children’s Code;
(g) documents in measurable
terms the specific behavioral changes targeted, including potential high-risk
behaviors; corresponding time-limited intermediate and long-range treatment
goals and objectives; frequency and duration of program-specific
intervention(s) to be used, including medications,
behavior management practices, and specific safety measures; the staff
responsible for each intervention; projected timetables for the attainment of
each treatment goal; a statement of the nature of the specific problem(s) and
needs of the client; and a statement and rationale for the plan for achieving
treatment goals;
(h) specifies and incorporates
the client’s permanency plan, for clients in the custody of the department;
(i) provides that clients with
known or alleged history of sexually inappropriate behavior, sexual aggression
or sexual perpetration are adequately supervised so as to ensure their safety
and that of others; and
(j) documents a discharge plan
that:
(i) requires that the client
has achieved the objectives of the treatment plan;
(ii) requires that the
discharge is safe and clinically appropriate for the client;
(iii) evaluates high risk
behaviors or the potential for such;
(iv) explores options for alternative or
additional services that may better meet the client’s needs;
(v) establishes specific
criteria for discharge to a less restrictive setting; and
(vi) establishes a projected
discharge date, which is updated as clinically indicated.
(4) For residential treatment
services and group home services, the comprehensive treatment plan also
includes the following elements: a statement of the least restrictive
conditions necessary to achieve the purposes of treatment, and an evaluation of
the client’s cultural needs and provision for access to cultural practices,
including culturally traditional treatment.
(5) For case management
services, a service plan is developed and written within 30 days of the
initiation of services (see 26.F.1).
(6) For behavior management
skills development services, a service plan is developed within 14 days of
initiation of services (see 28.C (1) (c).
F. The
treatment plan is reviewed by the treatment team at intervals not to exceed 30
days and is revised as indicated by changes in the child’s behavior or situation,
the child’s progress, or lack thereof.
(1) Each treatment plan review
documents assessment of the following, in measurable terms:
(a) progress, or lack thereof,
toward each treatment goal and objective;
(b) progress toward and/or
identification of barriers to discharge;
(c) the client’s response to
all interventions, including specific
behavioral interventions;
(d) the client’s response to medications;
(e) consideration of
significant events, incidents, and/or safety issues occurring in the period
under review;
(f) revisions of goals, objectives, and interventions, if
applicable;
(g) any change(s) or updates
in diagnosis, mental status or level
of functioning;
(h) the results of any
referrals and/or the need for
additional consultation;
(i) the effectiveness of
behavior-management techniques used in the period under review.
(2) Some or all of the
required elements of a treatment planning document may be recorded in a
document other than the treatment plan/review, such as a clinical review form
or format provided by, or to a payor, when the following conditions are met:
(a) all required elements are
performed and documented in a timely manner by qualified clinical personnel;
(b) the client’s record
contains evidence of participation of treatment team members in each phase of
the treatment planning process.
G. When aftercare is indicated at the
time of non-emergency discharge, the agency involves the client, case manager
(if applicable), the parent, legal guardian, or guardian ad litem, if
applicable; and assists the client, family, or guardian in arranging
appointments, obtaining medication (if applicable), transportation and meeting
other identified needs as documented in the treatment/discharge plan.
H. Prevention, planning, and processing
of emergency discharge:
(1) The agency establishes
policies and procedures for management of a child who is a danger to
him/herself or others or presents a likelihood of serious harm to him/herself
or others. The agency acts immediately
to prevent such harm. At a minimum, the policies and procedures provide that
the following be documented in the client’s file:
(a) that the agency makes all
appropriate efforts to manage the
child’s behavior prior to proposing emergency discharge;
(b) that the agency takes all appropriate
action to protect the health and safety of other children and staff who are
endangered.
(2) In the event of a proposed
emergency discharge, the agency provides, at a minimum, procedural due process
including written notice to the family/legal guardian, guardian ad litem and
department, if applicable, and provision to stop the discharge action until the
parent/legal guardian, guardian ad litem and/or the department exhausts any
other legal remedy they wish to pursue.
The agency documents the following in the client record:
(a) provision for
participation of the parent/legal guardian, and guardian ad litem in the
discharge process, whenever possible; and
(b) arrangement for a conference to be held
including all interested persons or parties to discuss the proposed discharge,
whenever possible.
(3) If the child’s
parent/legal guardian is unavailable to take custody of the child and immediate
discharge of the child endangers the child, the agency does not discharge the
child until a safe and orderly discharge is effected. If the child’s family refuses to take
physical custody of the child, the agency refers the case to the department.
I. Discharge: Non-emergency discharge
occurs in accordance with the client's discharge plan, unless precipitated by a
client's or guardian's refusal to consent to further treatment, or other
unforeseen circumstances. Prior to
discharge, the agency:
(1) evaluates the appropriateness of release
of the client to the parent/legal guardian;
(2) provides that any discharge of the client
occurs in a manner that provides for a safe and orderly transition; and
(3) provides for adequate pre-discharge
notice, including specific reason for discharge.
[7.20.11.23 NMAC - Rp 7 NMAC 20.11.23, 03/29/02]
7.20.11.24 BEHAVIOR MANAGEMENT, PERSONAL
RESTRAINT, AND SECLUSION PRACTICES:
Certain provisions of this section are included to implement regulations
of the federal centers for medicare and medicaid services (CMS) and may be
amended when appropriate to reflect subsequent changes in the federal CMS
regulations. These provisions are
intended to implement, and to be consistent with the Child Health Act of 2000
and the CMS Interim Final Rule issued May 22, 2001, and are subject to further
modifications as dictated by CMS.
A. The agency protects and promotes the
rights of each client in the program, including the right to be free from
physical or mental abuse, corporal punishment, and any personal restraint or
seclusion imposed for purposes of discipline or convenience. The agency establishes and follows policies
and procedures governing the use of behavior management practices including
therapeutic hold, personal restraint and seclusion (when allowed as delineated
below). This will include documentation of each therapeutic hold, personal
restraint and seclusion in the client’s record.
B. For those behavior management
practices that are allowed for each type of program and are described above,
the program supports their limited
and justified use through:
(1) staff orientation and
education that create a culture emphasizing prevention of the need for
therapeutic hold, personal restraint and seclusion and their appropriate use;
(2) assessment processes that
identify and prevent potential behavioral risk factors; and
(3) the development and promotion
of preventive strategies and use of less restrictive alternatives.
C. Agency policy and procedures
identify qualified staff authorized to approve the protocols and apply the
criteria for use of therapeutic hold, personal restraint and seclusion.
D. Performance-improvement processes
identify opportunities to reduce or eliminate the use of personal restraint or
seclusion.
E. The agency establishes and follows
policies and procedures for the safe, effective, limited, and least restrictive
use of behavior management practices.
The policies and procedures include measures to ensure that treatment
planning includes regular review of the necessity for, type and frequency of
behavior management practices used in individual cases.
F. When behavior management practices
are used, the agency protects the safety, dignity, and privacy of clients to
the maximum extent possible at all times during each procedure.
G. Treatment plans document the
use of seclusion, personal restraint and therapeutic holds and include:
consideration of the client’s medical condition(s); the role of the client’s
history of trauma in his/her behavioral patterns; the treatment team’s
solicitation and consideration of specific suggestions from the client regarding prevention of future physical
interventions.
H. Seclusion, personal restraint
and therapeutic holds are implemented only by staff who have been trained and
certified by a state recognized body in the prevention and use of therapeutic
holds, personal restraint and seclusion. This training emphasizes de-escalation
techniques and alternatives to physical contact with clients as a means of
managing behavior. Clients do not
participate in the therapeutic holding, personal restraint or seclusion of
other clients.
I. Mechanical and chemical restraints
are prohibited in all programs except the program created under the Adolescent
Treatment Hospital Act, which has been mandated by NMSA 1978 Sections 23-9-1
et.seq., to serve adolescents who are violent or have a history of violence, and
which provides 24-hour on-site professional medical services in accordance with
Section 3207 of the Children’s Health Act of 2000.
J. Personal restraint and seclusion,
as defined in these certification requirements, are used in JCAHO-accredited or
non-JCAHO-accredited residential treatment centers and group homes; in
emergency circumstances to ensure the immediate physical safety of the client,
other clients, staff member(s) or others; and when less restrictive
interventions have been determined to be ineffective. Personal restraint and
seclusion are used in accordance with these provisions and with federal law,
rule or regulation which may supersede state or accreditation regulations. Personal restraint and seclusion are imposed
only by an individual trained and certified by a state-recognized body in the
prevention and use of personal restraint and seclusion and in the curriculum
that may be set forth in federal regulations to be promulgated under Title V of
the Public Health Service Act (42 U.S.C. 290aa et seq. as amended by section
3208, Part I, section 595). When federal
regulations are promulgated under Title V as described above, the curriculum
set forth there shall be included in the training.
K. Physical escort is allowed as a safe
means of moving a client to a safe location.
L. Personal restraint or seclusion are
not to be used for staff convenience and/or as coercion, discipline, or
retaliation by staff.
M. This sub-section (M) applies, for
personal restraint, to facilities accredited by JCAHO, and to all residential
treatment centers for seclusion. These
entities require orders that are consistent with Department regulation, agency
policy, and regulations of the centers for medicare and medicaid services (CMS)
42 CFR, Parts 441 and 483. These orders
are issued by a restraint/seclusion clinician within one hour of initiation of
personal restraint or seclusion, and include documented clinical justification
for the use of personal restraint or seclusion.
(1) If the client has a
treatment team physician and he or she is available, only he or she can order
personal restraint or seclusion.
(2) If personal restraint or
seclusion is ordered by someone other than the client’s treatment team
physician, the restraint/seclusion clinician will consult with the client’s
treatment team physician as soon as possible and inform him or her of the
situation requiring the client to be restrained or placed in seclusion and
document in the client’s record the date and time the treatment team physician
was consulted and the information imparted.
(3) The restraint/seclusion
clinician must order the least restrictive emergency safety intervention that
is most likely to be effective in resolving the situation.
(4) If the order for personal
restraint is verbal, the verbal order must be received by a restraint/seclusion
clinician or a New Mexico licensed registered nurse (RN) or practical nurse
(LPN). The restraint/seclusion clinician
must verify the verbal order in a signed, written form placed in the client’s
record within 24 hours after the order is issued.
(5) A restraint/seclusion
clinician’s order must be obtained by a restraint/seclusion clinician or New
Mexico licensed RN or LPN prior to or while the personal restraint or seclusion
is being initiated by staff, or immediately after the situation ends.
(6) Each order for personal
restraint or seclusion must be documented in the client’s record and will
include:
(a) the name of the
restraint/seclusion clinician ordering the personal restraint or seclusion;
(b) the date and time the
order was obtained;
(c) the emergency safety intervention ordered,
including the length of time;
(d) the time the emergency
safety intervention actually began and ended;
(e) the time and results of
any one-hour assessment(s) required; and
(f) the emergency safety
situation that required the client to be restrained or put in seclusion; and
(g) the name, title, and credentials
of staff involved in the emergency safety intervention.
(7) Supervision and assessment
of personal restraint or seclusion
(a) The restraint/seclusion
clinician must be available to staff for consultation, at least by telephone,
throughout the period of the emergency safety intervention.
(b) A New Mexico registered
nurse or a restraint/seclusion clinician other than a doctoral level
psychologist, must conduct a face-to-face assessment of the physical well being
of the client within one hour of the initiation of the emergency safety
intervention and immediately after the personal restraint is removed or the
client is removed from seclusion. A
restraint/seclusion clinician or a New Mexico registered nurse must conduct a
face-to-face assessment of the psychological well being of the client within
one hour of the initiation of the emergency safety intervention and immediately
after the personal restraint is removed or the client is removed from
seclusion. When the personal restraint or seclusion is less than one hour in
duration, and the restraint/seclusion clinician is not immediately available at
the end of the period of restraint or seclusion, the restraint/seclusion
clinician will evaluate the client’s well-being as soon as possible after the
conclusion of the restraint/seclusion, but in no case later than one hour after
its initiation.
(c) If the situation requiring
emergency safety intervention continues beyond the time limit of the order for
the use of personal restraint or seclusion, the New Mexico RN or LPN must
immediately contact the ordering restraint/seclusion clinician or the client’s
treatment team physician to receive further instructions. If clinical circumstances justify renewal of
personal restraint or seclusion, then the renewal order must be obtained within
the time frames outlined in 24.O (1) below.
N. This sub-section (N) applies to
personal restraint in residential treatment services not accredited by
JCAHO. In these residential treatment
services, personal restraint requires the following, which is consistent with
department regulation and agency policy.
(1) A New Mexico licensed
independent practitioner, licensed professional mental health counselor (LPC),
licensed master social worker (LMSW), or registered nurse must be available to
staff for consultation, at least by telephone, throughout the period of the
emergency safety intervention.
(2) A New Mexico licensed
independent practitioner, or a licensed professional mental health counselor
(LPC), licensed master social worker (LMSW), in consultation with a licensed
independent practitioner, or a registered nurse trained in the use of emergency
safety interventions must conduct a face-to-face assessment of the well-being
of the client within one hour of the initiation of the emergency safety
intervention and immediately after the personal restraint is removed or the
client is removed from seclusion. When the personal restraint or seclusion is
less than one hour in duration, and the restraint/seclusion clinician is not
immediately available at the end of the period of restraint or seclusion, the
restraint/seclusion clinician will evaluate the client’s well-being as soon as
possible after the conclusion of the restraint/seclusion, bu in no case later
than one hour after its initiation.
O. The
following sub-section (O) applies to all residential treatment centers and group
homes.
(1) The personal restraint or
seclusion is limited to a maximum of two hours for clients age of 17 and one
hour for clients under nine years of age.
(2) Post-intervention
debriefings with the client will take place after each emergency safety
intervention and the staff will document in the client’s record that the
debriefing sessions took place.
(3) The agency will have
affiliations or written transfer agreements in effect with one or more
hospitals approved for participation under the medicaid program that reasonably
ensure that:
(a) A client will be
transferred from the facility to the hospital and admitted in a timely manner
when a transfer is medically necessary for medical care or acute psychiatric
care;
(b) Medical and other
information needed for care of the client in light of such transfer will be
exchanged between the organizations in accordance with state medical privacy
law, including any information needed to determine whether the appropriate care
can be provided in a less restrictive setting; and
(c) Services will be available
to each client 24 hours a day, seven days a week.
(4) The agency will document
in the client’s record all client injuries that occur as a result of an
emergency safety intervention.
(5) All agencies will attest
in writing that the facility is in compliance with CMS standards governing the
use of personal restraint and seclusion.
This attestation will be signed by the agency director.
(6) If the client is a minor,
the agency will notify the parent(s) or legal guardian(s) that personal
restraint or seclusion has been ordered as soon as possible after the
initiation of each emergency safety intervention. This will be documented in
the client’s record, including the date and time of notification, the name of
the staff person providing the notification, and who was notified.
(7) Agencies will provide for
client health and safety by requiring direct service staff to demonstrate
competencies related to the use of emergency safety interventions on a
semiannual basis. Direct service staff
will demonstrate, on an annual basis, their competency in the use of
cardiopulmonary resuscitation. The
agency will document in the staff personnel records that the training required
was successfully completed.
(8)
The agency must maintain an aggregate record of all situations requiring
emergency safety intervention, the interventions used and their outcomes.
(9) Programs must report the
death of any client to the CMS regional office by no later than close of
business the next business day after the client’s death. The report must include the name of the
client and the name, street address and telephone number of the agency. The parent or legal guardian will also be
notified. Staff must document in the
client’s record that the death was reported to the CMS regional office.
[7.20.11.24 NMAC - N, 03/29/02]
7.20.11.25 MEDICATIONS:
A The agency establishes and follows
policies and procedures governing the storage, handling, use, administration
and disposal of all medications that are consistent with applicable laws,
regulations, and accepted professional practices.
B. Prescription orders are verified and
individuals are identified before medications are administered or self-administered.
C. Medications are administered only by
qualified, licensed medical staff, or are self-administered by the client with
supervision of staff who have been trained in assisting with
self-administration.
D. Policies and procedures support
self-administration of medications. Staff trained in these procedures provide
supervision of self-administration of medications and document the time
the medications are taken, the side effects observed, and client response, as well as any medications refused or
held. When medications are
self-administered by clients, a staff member may hold the container for the
client and/or assist with opening the container, but may not place the
medication in the client’s hand or mouth.
E. The agency has controls in place
for locked storage of medication and for access by authorized personnel.
F. The agency has controls in place to
ensure that medications are properly labeled with name of person served,
dosage, name of medication, name of prescribing physician, and number or code
identifying the written order.
G. The agency has controls in place for
the destruction of out-of-date medications and proper disposal of unused
medication and syringes.
H. When adverse or unusual conditions
are observed, appropriate consultation and/or medical response must be sought
in a timely manner.
I. Medication monitoring may include
input from various disciplines and the client and family. This information is used to maintain and
improve the outcomes of medication therapy while minimizing any drug-related
problems or adverse effects.
J. When medications that
require periodic testing of drug levels are used, such laboratory test results
are accurately recorded in the client record, as applicable.
K. The physician documents in
the client record the indication for, response to, and the potential and
observed side effects of any prescription medication(s).
[7.20.11.25 NMAC - Rp 7 NMAC 20.11.30.2, 03/29/02]
7.20.11.26 COMPREHENSIVE COMMUNITY SUPPORT SERVICES:
A. Comprehensive community support services
(CCSS) shall coordinate and provide necessary services and resources to
eligible clients and families to promote recovery, rehabilitation and
resiliency.
B. These culturally sensitive services
shall identify and address the barriers that impede the development of skills
necessary for independent functioning in the community as well as strengths,
goals and measurable objectives, which may aid the client or family in the
recovery or resiliency process.
C. CCSS shall address goals as
identified by the client or family specifically to meet recovery and resilience
based outcomes in the areas of independent living, learning, working,
socializing and recreation.
D. CCSS shall be provided to children,
youth and adults with significant behavioral health disorders and who meet
other criteria as identified by the collaborative.
E. CCSS shall be provided in
compliance with the medical assistance division (MAD) definition of medical
necessity and shall be furnished within the MAD benefits.
F. CCSS shall be furnished within the
scope and practice of the provider’s respective profession as defined by state
law, and in accordance with applicable federal, state and local laws and
regulations.
G. An assessment of baseline
functioning shall be performed within 10 working days of the client’s admission
into CCSS services. The assessment shall evaluate and document the client’s
specific functional effectiveness in multiple skill domains based on the
desired outcomes of the client or family.
(1) Functional level
determination shall identify domains in
which functional limitations precipitated by the behavioral health disorder are
present. The diagnoses and assessments shall be the basis for the comprehensive
client or family driven goal directed, measurable service plan
(2) CCSS eligible clients
shall have one designated agency that will have the primary responsibility of
partnering with the client and family for the purpose of implementing the
comprehensive service plan.
H. Within the CCSS agency, a primary
community support worker (CSW), under the documented supervision of the CCSS
supervisor, shall be identified on the comprehensive service plan and shall
partner with the client and family for the purpose of coordinating and
facilitating recovery and resiliency directed team meetings. The CCSS
supervisor shall sign, with name, credentials, and date, the initial service
plan indicating that he has reviewed and approved the comprehensive service
plan and each revision as it occurs.
I. Community support activities and
relevant providers shall be clearly identified in the comprehensive service
plan. The primary CSW shall coordinate the service plan without duplication by
the other service providers. The CCSS comprehensive service plan shall be
completed no later than 30 calendar days of the client’s admission into CCSS
services and specify recovery and resiliency strategies to include:
(1) the community support(s)
and any other rehabilitative and treatment interventions needed for the client
to achieve his specified service goals and to meet recovery and resiliency
outcomes;
(2) the CCSS staff responsible
for each recovery and resiliency intervention and the frequency of the planned
interventions;
(3) the client’s relevant
diagnoses and other risk factors that place him at risk of further diagnoses;
(4) measurable goals and
objectives identified by the client and family as their comprehensive service
plan priorities to meet desired recovery and resiliency outcomes;
(5) a recovery/ resiliency
management plan;
(6) a crisis management plan
to address after-hours crisis situations including actions to be taken by
client, family and natural supports;
(7) potential service plan
barriers and applicable strategies; and
(8) if requested, advanced
directives related to client’s behavioral healthcare.
J. CCSS shall include the development of crisis plan
interventions, as defined in an individual crisis plan, as a component of
overall CCSS comprehensive service plan.
If the client has or requests an advance directive, the crisis plan may
be incorporated into the advance directive. The individualized crisis plan
shall support the client and family in the management of crisis situations
outside of regular business hours to develop or enhance the client’s ability to
make informed and independent choices.
(1) the crisis plan shall
include the following requirements, which shall be formulated on admission to
CCSS by the CCSS team, client, family, legal guardian and other interested
parties.
(a) Risk assessment: Specify a
process to assess potential risk and specify an algorithm of community
resources to address by risk level that ranges from immediate (i.e. 911 or
first responders) to intermediate (e.g. call to crisis line) to moderate (call
for a clinic appointment).Specify a process to identify benchmarks that
indicate when a crisis is appropriate reconciled.
(b) Client/family education:
Provide the client and family education on community resources to be accessed
during crisis situations. Each family
and client shall be provided basic verbal communication techniques to help
de-escalate a potential crisis situation.
(c) Internal
communication: Crisis events are
discussed in the CCSS team meeting to ensure all risk factors are identified
and known by all team members.
(d) Face-to-face assessment:
CCSS team member shall make a face-to-face visit as soon as possible, but no
more than 48 hours after notification of a crisis, and complete an updated
assessment for presentation to the team.
(e) Research past crisis
situations for antecedent, precipitant, and consequent behaviors and discuss
with the client or family to identify strategies or objectives likely to
prevent crises.
(f) Identify alternative
interventions that may be initiated during crisis situations, including
pre-crisis or crisis instructions identified by the client or family.
(g) Incorporate client and
family outcomes as benchmarks or measures of when the crisis is over.
(h) Revise crisis plan over
time based on newly identified triggers and what is known to be effective.
(i) Document behavioral
benchmarks (e.g., number of runs, self-injury, assaults, etc., and what
worked).
(2) The negotiated crisis plan
shall triage for differing levels of intensity and severity of crisis events
and may identify other types of interventions that may include:
(a) residential services for
stabilization;
(b) crisis respite services;
(c) wrap around services;
(d) increased family and
community support specialist capacity to manage crisis situations;
(e) activation of advance
directive instruction; and
(f) utilization of emergency room (ER) and
other emergency response supports.
K. Every 90 days after implementation
of the comprehensive service plan, the CCSS team, in partnership with the
client and family, shall track and provide detailed documentation demonstrating
progress made over time relating to the CCSS service goals, objectives and
client/family designated recovery or resiliency outcomes. These shall be
documented in the service plan updates with modifications made based upon
barriers identified or redefined goals and objectives and future needs.
L. The follow up assessment shall
document the current status of the client and family designated measurable
recovery or resiliency functional outcomes.
M. Individualized CCSS interventions
shall address the following objectives, as indicated in the assessment and
comprehensive service plan:
(1) community services and
resources available to support the client’s achievement of his functional CCSS
service goals and objectives;
(2) assistance in the
development of interpersonal, community coping and functional skills (i.e.,
adaptation to home, school and work environments), utilizing evidence-based
practices to support the skills development in the following domains:
(a) socialization skills;
(b) developmental issues as
identified in the assessment;
(c) daily living skills;
(d) school and work readiness activities; and
(e) education and management
of co-occurring illness;
(3) facilitating the
development and eventual succession of natural supports in the workplace,
housing/home, and social and school environments;
(4) provision of client and
family education as appropriate regarding:
(a) self-management of symptom
monitoring, illness management, and recovery and resiliency skills;
(b) relapse prevention skills;
(c) knowledge of medication
and potential side effects;
(d) motivational and skill development
in taking medication as prescribed;
(e) ability to identify and
minimize the negative effects of symptoms which potentially interfere with the
client’s activities of daily living; and
(f) as indicated, supports to the client to
maintain employment and school or community tenure;
(5) facilitating the client’s
abilities to obtain and maintain stable housing;
(6) any necessary follow-up by
the CSW to determine if the services accessed have adequately met the client’s
needs.
N. Cultural competence shall be
demonstrated by the CCSS provider through the agency’s policies, procedures,
training, outreach and advocacy efforts, and throughout the array of service
delivery framework.
O. The CCSS provider shall demonstrate
through a documented internal quality monitoring process that on average (60%
or more) of CCSS services are delivered face-to-face and in vivo (where client
is in the community).
P. The CSW shall provide routine
follow-up to determine if the services accessed have adequately met the
client’s rehabilitative, recovery, resiliency, and treatment needs and document
findings.
Q. CCSS shall be offered at convenient
times and locations to meet the needs of the client and family; the CCSS
provider will actively work to eliminate language, financial, and other
barriers to service.
R. For clients and their families: The
CSW shall make every effort to engage and partner with the client and family in
achieving rehabilitative, recovery, and resiliency goals. Barriers to engaging
the client or achievement of the service goals will be identified and utilized
to amend the service plan interventions.
S. When CCSS is provided by a
certified peer or family specialist, CCSS functions shall be performed with a
special emphasis on recovery and resiliency values and process, such as:
(1) empowering the client to
have hope for, and participate in, his own recovery;
(2)
assisting the client to identify strengths and needs related to
attainment of independence in terms of skills, resources and supports, and to
use available strengths, resources and supports to achieve independence;
(3) assisting the client to identify and achieve
his personalized recovery and resiliency goals; and
(4) promoting the client’s
responsibility related to illness self-management.
T. CCSS shall be subject to the
limitations and coverage restrictions as defined by 8.315.6 NMAC, Comprehensive
Community Support Services.
U. Behavior management skills
development service (BMS) interventions are distinct and different from CCSS
and shall not be considered to be CCSS.
V. Eligible
providers: CCSS shall be delivered by a certified mental health agency.
(1) The agency shall be a
legally recognized entity in the United States, qualified to do business in New
Mexico, and shall meet standards established by the state of New Mexico or its
designee, and requirements of the funding source.
(2) CCSS shall be provided in
the following type of entities:
(a) federally qualified health
center (FQHC);
(b) Indian health service (IHS) hospital or
clinic;
(c) tribal-638 hospital or
clinic;
(d) community mental health
center
(e) core service agency (CSA);
or
(f) an agency otherwise
certified as a CCSS agency by New Mexico children, youth and families
department (CYFD) or New Mexico department of health (DOH)
(3) Eligible clients who are 18
through 20 years of age may be served by an agency certified for CCSS by CYFD
or DOH, as indicated.
W. Staff
qualifications: Clinical services and supervision by licensed behavioral
health practitioners shall be in accordance with their respective licensing board
regulations.
(1) Minimum staff
qualifications for the CSW:
(a) shall be a minimum of 18
years of age; and
(b) shall hold a bachelor’s
degree in a human service field from an accredited university and one (1) year
relevant experience working with the target population; or
(c) shall hold an associate’s
degree in a human service field from an accredited college and have a minimum
of two (2) years of experience working with the target population; or
(d) shall be a high school
graduate or have a general education development (GED) and shall have a minimum
of three years of experience working with the target population; or
(e) shall be certified as a
certified peer specialist (CPS) or certified family specialist (CFS).
(2) Minimum staff
qualifications for the CCSS program supervisor:
(a) shall hold a bachelor’s degree in human
services field from an a accredited university;
(b) shall have a four (4)
years relevant experience working with the target population; and
(c) shall have one year demonstrated
supervisory experience.
(3) Minimum staff
qualifications for the clinical supervisor (The clinical supervisor and the
CCSS program supervisor may be the same individual):
(a) shall be a licensed independent
practitioner (i.e., psychiatrist, psychologist, LISW LPCC, LMFT,
psychiatrically certified CNS) practicing within the scope of their New Mexico
licensure;
(b) shall have one year
documented supervisory experience; and
(c) shall provide documented
clinical supervision on a regular basis to the CSW, CPS and CFS.
(4) Minimum staff
qualifications for CPS:
(a) shall be a minimum of 18 years of age;
(b) shall have a minimum of high school diploma or GED;
(c) shall be self-identified
as a current or former consumer of mental health or substance abuse services
and have at least one year of mental health or substance abuse recovery; and
(d) shall have received
certification as CPS.
(5) Minimum staff qualifications
for CFS:
(a) shall be a minimum of 18
years of age;
(b) shall have a minimum of high school diploma or GED;
(c) shall have personal
experience navigating any of the child-family-serving systems or advocating for
family members who are involved with the behavioral health systems; shall have
an understanding of how these systems operate in New Mexico;
(d) if the individual is a
current or former consumer, he shall be well- grounded in his symptom
self-management; and
(e) shall have received
certification as a CFS.
X. Staff
training requirements:
(1) The minimum CCSS staff
training completed for all CSWs shall be documented in the personnel record and
include:
(a) an initial training
comprised of 20 hours of documented training or education drawn from an array
of the following areas, to be completed within the first 90 days of employment
as a CSW:
(i) clinical and psychosocial
needs of the target population, including cultural competency with regard to
race, religion, national origin, sex, physical disability and other community-
specific characteristics;
(ii) psychotropic medications
and possible side effects;
(iii) drugs of abuse and
related symptoms;
(iv) crisis management;
(v) principles of recovery,
resiliency and empowerment;
(vi) ethical and cultural
considerations;
(vii) community resources and
services, including pertinent referral criteria;
(viii) client and family
support networking;
(ix) mental health or developmental disabilities
code;
(x) children’s code;
(xi) client and family centered
practice;
(xii) behavioral management;
(xiii) treatment and discharge
planning with an emphasis on recovery and crisis planning.
(b) documentation of ongoing
training is required and maintained in the personnel record and comprised of 20
hours per year, commencing after the first year of hire, with content of the
education based upon agency assessment of staff’s needs. Such assessment shall
be monitored and documented through the agency’s continuous quality improvement
program and annual plan.
(2) Minimum staff training
requirements for supervisors shall be documented in the personnel record and
include:
(a) the same 20 hours of
documented training or continued education as required for the CCSS CSW;
(b) a minimum of eight hours
of training specific to supervisory activities; and
(c) documentation of ongoing
training comprised of 20 hours is required of a CCSS supervisor every year,
commencing after the first year of hire, with content of the education based
upon agency assessment of staff’s needs. Such assessment shall be monitored and
documented through the agency’s continuous quality improvement functions.
Y. Case
loads:
(1) Caseloads, on average,
shall not exceed a ratio of 1:20 (one CSW to 20 clients receiving CCSS).
(2) Clients participating in
medication management as the primary focus of service are not subject to the
client- staff ratio.
(3) CSW caseloads, of client
to staff ratio of 1:20 on average, shall be monitored and documented through
the agency’s internal continuous quality improvement program through defined
periodic review activities such as peer chart reviews to ensure the agency is
in caseload compliance. The agency will implement timely corrective action when
it is identified that staff ratio averages are not in compliance.
(4)
Detailed case notes document all CCSS service intervention activities
and locations of services provided for each service span delivered and include
the CCSS worker’s name, credential and date of the service delivery.
Z. Documentation
requirement:
(1) The CCSS provider shall be
responsible for consistent documentation of all service delivery. Each service
delivery case note shall include but not be limited to:
(a) date of service;
(b) service location;
(c) duration of service span
(e.g., 1:00-2:00pm);
(d) description of the service
provided with reference to the comprehensive service plan and related service
goal and objective; and
(e) the client’s name, and
signature and credential of the individual delivering the service.
(i) All CCSS file documentation
shall be legible.
(ii) All CCSS service delivery
shall be consistent with the service definition requirements.
(2) CCSS comprehensive service
plan and service delivery documentation shall be internally monitored through
the agency’s continuous quality improvement functions at least quarterly to
ensure compliance with all of the certification requirements.
[7.20.11.26 NMAC - Rp 7 NMAC 20.11.25, 03/29/02; A,
12/31/08]
7.20.11.27 DAY TREATMENT SERVICES:
A. Day treatment services as defined
herein are provided in a school or other community setting and are distinct
from partial hospitalization services provided
in a psychiatric hospital. Education
services are provided through the public school system or through a New Mexico
accredited private school in coordination with the day treatment services.
B. Personnel:
(1) Direct service staff may
be unlicensed or uncertified paraprofessionals such as teacher aides, mental
health workers, psychiatric technicians or similar direct service workers. At
least one staff member who has received all training required in 27.B (a)
through (f) is present during program hours. The direct service staff receives
documented clinical supervision for a minimum of two hours per month. The agency’s direct service staff must have
at least a high school education or GED and 20 hours of documented pre-service
training, including, but not limited to crisis management/intervention,
behavior management, and emergency procedures, that include current CPR and
first aid certificates. Within 90 days of hire, the staff will receive an
additional 20 hours of documented training, including but not be limited to:
(a) etiology and symptoms of
emotional disturbances and neurobiological disorders;
(b) family systems;
(c) basic communication and
problem solving skills;
(d) child and adolescent
development;
(e) issues related to ethnic and cultural considerations of
the clients served; and
(f) action and potential side
effects of medications.
(2) Clinical director:
(a) Clinical director
qualifications: The clinical director possesses one of the following New Mexico
licenses; physician (physicians must be board-certified in psychiatry or
eligible to attain such certification), psychologist, licensed independent
social worker (LISW), licensed master social worker (LMSW), clinical nurse
specialist in child psychiatric nursing, registered nurse (RN) with a master’s
degree in psychiatric nursing, licensed professional clinical mental health
counselor (LPCC), licensed marriage and family therapist (LMFT), or licensed
independent school psychologist.
(b) In addition to having one
of the above licenses, the clinical director is required to have a minimum of
two years of experience in clinical practice with children, adolescents and
families.
(c) Clinical director
responsibilities: The responsibilities of the clinical director are to provide
clinical oversight of the services, as well as to provide supervision, support,
and consultation to all agency direct service staff.
(3) Clinical supervisor:
(a) Clinical supervisor
qualifications: The clinical supervisor possesses one of the following New
Mexico licenses: physician (physicians must be board-certified in psychiatry or
eligible to attain such certification), psychologist, licensed independent
social worker (LISW), clinical nurse specialist in child psychiatric nursing,
registered nurse (RN) with a master’s degree in psychiatric nursing, licensed
professional clinical mental health counselor (LPCC), licensed marriage and
family therapist (LMFT), or licensed independent school psychologist.
(b) In addition to having one of the above
licenses, the clinical supervisor is required to have a minimum of two years of
experience in clinical practice with children, adolescents and families.
(4) Therapist: Therapist
qualifications: The therapist possesses one of the following New Mexico
licenses: Physician (physicians must be
board-certified in psychiatry or eligible to attain such certification), psychologist, licensed independent social
worker (LISW), licensed master social worker (LMSW), clinical nurse specialist
in child psychiatric nursing, registered nurse (RN) with a master’s degree in
psychiatric nursing, licensed professional clinical mental health counselor
(LPCC), licensed marriage and family therapist (LMFT), licensed independent
school psychologist, licensed professional mental health counselor (LPC),
licensed professional art therapist (LPAT), licensed entry level school
psychologist, or licensed mental health counselor (LMHC).
C. Services:
(1) Assessment and treatment planning conform
to Section 23 of these certification requirements.
(2) The agency provides
adequate care and continuous supervision of the client at all times in
accordance with the client’s developmental and clinical needs.
(3) The structured program of
care is scheduled for a minimum of four hours per day, two to five days per
week based on the acuity and the clinical needs of the client and family. The
agency provides the following, pursuant to the client’s treatment plan:
(a) individual, family, group
or other therapy, in whatever combination is appropriate to meet the needs of
the client;
(b) other services as provided in the treatment plan;
(c) development of life skills activities;
(d) crisis intervention;
(e) therapeutic recreation,
when indicated by the child’s needs;
(f) documentation of services
provided, and of the client’s progress or lack thereof on each day that service is
provided.
(4) The agency documents that:
(a) the child has access to the appropriate
educational services;
(b) the child has
opportunities for involvement in community, social, athletic and recreational
programs;
(c) the child has opportunities to pursue
personal, ethnic or cultural interests; and
(d) advance schedules are
posted for structured and supervised activities which include individual, group
and family therapy, and other planned activities appropriate to the age,
behavioral and emotional needs of the client
pursuant to the treatment plan.
(5) The agency maintains a
written agreement with the public school district or private school so that
appropriate educational services are provided to clients in the day treatment
services program.
[7.20.11.27 NMAC - Rp 7 NMAC 20.11.26, 03/29/02]
7.20.11.28 BEHAVIOR MANAGEMENT SKILLS
DEVELOPMENT SERVICES:
A. Behavior management skill
development services are delivered through an individualized behavior
management skills development service plan designed to develop,
restore, or maintain skills and behaviors that result in improved function or
which prevent deterioration of function.
Behavior management skills development services are delivered to clients
up to age 21 who:
(1) are in need of behavior
management skills development intervention to avoid inpatient
hospitalization, residential treatment or separation from his/her family; or
(2) require continued
intensive or supportive services following hospitalization or out-of-home
placement as a transition to maintain the client in the least restrictive
environment possible.
B. Personnel
(1) The behavior management skills development specialist
meets the following criteria:
(a) is at least 21 years of
age; and
(b) demonstrates the ability
to independently implement and document the outcome of the goals, measurable
objectives and interventions as defined in a behavioral management skills
development service plan.
(2) The behavior management
skills development specialist receives 20 hours of documented pre-service
training, to include, but not limited to:
(a) crisis
management/intervention;
(b) behavior management;
(c) emergency procedures,
which include current CPR and first aid certificates.
(3) Within 90 days of hire,
the behavior management skills development specialist receives an additional
20 documented hours of training, including but not limited to:
(a) etiology and symptoms of emotional
disturbances and neurobiological disorders;
(b) family systems;
(c) basic communication and
problem solving skills;
(d) child and adolescent development;
(e) issues related to ethnic
and cultural interests of the clients served;
(f) action and potential side
effects of medications.
(4) Behavior management skills development specialists
receive supervision by a New Mexico licensed practitioner with a doctoral or
master’s degree from an accredited institution in a human service related field
who has at least two years experience working with children, adolescents and families. Exception:
If a supervisor with the above qualifications cannot be recruited, the
supervisor must possess, at a minimum, a B.S.W., B.A., B.S., or B.U.S. in a
human service related field plus four years experience working with seriously
emotionally disturbed or neurobiological disordered children and adolescents.
(5) Supervision is provided
for a minimum of two hours per month depending upon the complexity of the needs
presented by clients and the supervisory needs of the behavior management
skills development specialist.
Supervision is documented with dates, times, and content of contacts.
C. Services:
(1) Behavior management skills
development services focus on acquisition of skills and improvement of the
client and/or family’s performance related to targeted behaviors. The agency:
(a) conducts a clinical
assessment, or acquires clinical information that guides the development of the
behavior management skills development services plan;
(b) documents clinical review
of information that enables the agency to complete the behavior management
skills development service plan;
(c) develops a behavior management skills
development service plan, including: client needs, measurable goals,
interventions, discharge criteria, and a discharge plan, within 14 days of
admission to the service;
(d)
reviews the behavior management skills development service plan every 30
days and revises as necessary; and
(e) works in partnership with
other agencies or individuals involved in the client’s care to implement the
discharge plan and link the client to aftercare, as indicated;
(f) provides services to one
or more child(ren) from the same or different home(s), provided that a
staff-to-client ratio of 1:1 is maintained at all times.
(2) The behavior management
skills development specialist provides the following services:
(a) participation in the
development, review and revision of the behavior management service plan;
(b) implementation of the behavior management
skills development service plan to include teaching of behavior enhancing
skills;
(c) documentation of each
client contact, including date, time, duration, and the client’s progress
and/or response to the interventions each day service is provided,
stated in terms of service plan goals and objectives; and
(d) coordinating with the
family and school personnel, if appropriate, to assist the client to achieve
and/or to maintain appropriate behavior management.
[7.20.11.28 NMAC - Rp 7 NMAC 20.11.27, 03/29/02]
7.20.11.29 TREATMENT FOSTER CARE SERVICES:
A. Treatment foster care services,
Level I and Level II, are specifically designed to accommodate the needs of
psychologically or emotionally disturbed and/or behaviorally disordered
clients. Eligible clients are those who are
at risk for failure or have failed in regular foster homes, are unable to live
with their own families, or are going through a transitional period from
residential care as part of the process of return to family and community.
(1) Treatment foster care
services, level I and II, are targeted to children who meet the following
criteria:
(a) are at risk for placement
in a higher level of care or are returning from a higher level of care and are
appropriate for a lower level of care; or
(b) have complex and difficult
psychiatric, psychological, neurobiological, behavioral, psychosocial problems;
and
(c) require, and would
optimally benefit from, the behavioral health services and supervision provided
in a treatment foster home setting.
(2) Treatment foster care
services level II (TFC II) Services are targeted to children who, besides,
meeting the criteria in 29.A.1. (A). (c), also meet one of the following
criteria:
(a) have successfully
completed treatment foster care services level I (TFC I), as indicated by the
treatment team; or
(b) require the initiation or
continuity of the treatment and support of the treatment foster family to
secure or maintain therapeutic gains; or
(c) require this treatment
modality as an appropriate entry level
service from which the client will optimally benefit.
(3) A client eligible for
treatment foster care services, level I or level II, may change treatment
foster homes only under the following circumstances:
(a) an effort is being made to
reunite siblings; or
(b) a change of treatment
foster home is clinically indicated, as documented in the client’s record by
the treatment team.
B. Personnel qualifications and
responsibilities:
(1) Treatment coordinator
qualifications: The treatment coordinator possesses one of the following: a
master’s degree from an accredited program in social work or another
human-services field; or a bachelor’s degree in social work or another related
human-service field and two years experience with this population.
(2) Treatment coordinator responsibilities:
(a) Treatment planning: Under
supervision, and in coordination with the rest of the treatment team, the
treatment coordinator:
(i) prepares the initial and
comprehensive treatment plans in accordance with the timelines established in
these certification requirements;
(ii) coordinates the
implementation of the treatment plan;
(iii) monitors the client and his/her situation
for events related to the treatment plan or otherwise significant to provision
of treatment;
(iv) documents revisions to
the treatment plan;
(v) assures that all members
of the treatment team, including the client as clinically indicated, participate in the treatment planning
process, as documented by the signatures of treatment team members on the
treatment planning documents; and
(vi) involves the client’s
parents or legal guardians in treatment team meetings and in all plans and
decisions affecting the client and keeps them informed of the client’s progress
in the program unless prohibited by the court or otherwise contraindicated
according to documentation in the client’s record.
(b) Contact with client: The
treatment coordinator has a private face-to-face visit with the client within
the first two weeks of placement, and at least twice monthly thereafter for TFC
I clients and once monthly for TFC II clients.
These contacts are conducted both in-home and out-of-home.
(c) Contact with treatment
foster parent(s): The treatment coordinator has a face-to-face interview with
the client’s treatment foster parents within the first two weeks of placement
and at least twice monthly thereafter TFC I clients and once monthly for TFC II
clients. The treatment coordinator has a
minimum of one phone contact with the treatment foster parent(s) weekly. Phone contact is not necessary in the same
week that face-to-face contact has been made.
(d) All contacts are documented
in the client’s record and include a summary related to the treatment plan,
significant events and the communications between treatment coordinator,
client, treatment parent(s) and the biological/adoptive family. All documentation includes the date, time,
location of the contact, and names of persons present.
(e) Support of the client’s
relationship with his or her biological/adoptive family: The treatment
coordinator supports and enhances the client’s relationship with his or her
family to the extent determined by the treatment team. The treatment team reviews any restrictions
at the time of the writing of the comprehensive treatment plan or at the time
the restriction is imposed. The
treatment coordinator documents in the client’s case record the reason(s) for
any restriction, and the treatment team’s involvement. Thereafter, the
restriction is reviewed at least every 30 days and documented in the treatment
plan review.
(f) Assistance to treatment
foster parents: The treatment coordinator assists the treatment foster parents
in the implementation and development of treatment
strategies, including goal-setting and planned interventions. This assistance is done through the
following:
(i) the provision of ongoing
client-specific training and problem solving;
(ii) facilitation of
professional development training for the treatment foster parents as described in Section 29.B(10) of
these certification requirements;
(iii) observation/assessment
of family interactions;
(iv) assessment of safety
issues involving the client(s) in the home.
(g) Community liaison and
advocacy: Based upon an assessment of
the client’s and biological/adaptive family’s
needs, the treatment coordinator advocates for and coordinates the provision of
community-based services, as related
to identified goals, and provides
technical assistance to community providers as needed to maximize the
utilization of services by the client and family.
(h) A treatment coordinator is
physically available within 60 minutes of a treatment foster home so that
quality of care, appropriate supervision and timely responsiveness to the
treatment foster family are possible.
(3) Clinical supervisor
qualifications: An individual providing supervision to the treatment
coordinator possesses one of the following New Mexico licenses: Physician (physicians must be board-certified
in psychiatry or eligible to attain such certification), psychologist, registered nurse (RN) with a masters degree in
psychiatric nursing, clinical nurse specialist in a related field, licensed
independent social worker (LISW), licensed professional clinical mental health
counselor (LPCC), licensed marriage and family therapist (LMFT) or other
licensed independent practitioner in a related field. In addition to having one
of the above licenses, the clinical supervisor is required to have a minimum of
three years experience in clinical practice with children, adolescents and families.
(4) Clinical supervisor
responsibilities: The role of the clinical supervisor is to provide support,
consultation and oversight to the treatment coordinator(s) and therapist(s) through a minimum of four hours of
supervision each month.
(a) The clinical supervisor is responsible for
supervising ongoing treatment planning and implementation of the treatment plan
for each client. The clinical supervisor evaluates progress in treatment and
signs the treatment plan documents.
(b) The clinical supervisor provides
coordination and back up coverage allowing for 24-hour on-call crisis
intervention services for treatment parents, clients and their families.
(c) The clinical supervisor
monitors the caseload of each treatment coordinator, and monitors each
treatment coordinator in fulfilling his/her responsibilities. The maximum number of treatment foster care
Services client(s) that maybe
assigned to a single treatment coordinator shall not exceed eight. Caseloads are reduced based on case complexity,
travel times and non-direct service times.
The actual number of clients in a single caseload is based upon the
ability of the treatment coordinator and/or agency to meet all applicable
regulations as well as on the following considerations:
(i) the difficulty of the
total client caseload; including the amount of time needed for support of,
contact with, and assistance to the treatment foster parent(s) based on the
complexity of client needs;
(ii) the availability of
paraprofessional support and assistance;
(iii) the skills and abilities
of the treatment foster parent(s);
(iv) geographical areas to be
served; and
(v) additional duties assigned
to the treatment coordinator.
(5) Therapist qualifications:
Therapists providing individual, family, and/or group therapy meet either the
necessary licensing qualifications as listed for clinical supervisor
or possess one of the following New Mexico licenses: Licensed master social
worker (LMSW), licensed professional mental health counselor (LPC), licensed
art therapist (LAT) or licensed mental health counselor (LMHC).
(6) Therapist
responsibilities: The therapist provides individual, family and/or group
psychotherapy to clients as described in the treatment plan. The therapist documents all therapeutic
contacts in the client’s record. Therapy notes will be kept current and
submitted to the treatment coordinator for inclusion in the client’s record
within one week of the session date. The
therapist is an active treatment team member and participates fully in the
treatment planning process.
(7) Supervision/consultation:
An independently-licensed therapist consults with the supervisor for a minimum
of two times per month. A
non-independently licensed therapist receives supervision from the supervisor
at a minimum of two times per month. All
consultation/supervision is documented with the date, time, duration, and
topics discussed.
(8) Staff training:
(a) Therapists, treatment
coordinators, and other professional staff participate in knowledge/skill based
pre-service training relevant to the services provided including:
(i) child and adolescent development;
(ii) prevention and
de-escalation of aggressive behavior and the use of therapeutic holds;
(iii) crisis management,
and intervention;
(iv) grief and loss issues for
client(s) in foster care;
(v) cultural competence and
knowledge of the means for obtaining and providing culturally responsive
services;
(vi) specific agency policies
and procedures including documentation;
(vii) recognition of
abuse/neglect symptoms and state abuse/neglect/exploitation reporting
requirements;
(viii) actions and potential
side-effects of medications;
(ix) certification in
emergency first aid and CPR; and
(x) behavior management.
(b) Professional staff who
can provide verifiable documentation of previous training in one or more of the
above areas are not required to repeat the training if the staff and the clinical
supervisor agree in writing as to which specific training is equivalent and
therefore not required. This exception
does not apply to training regarding an agency’s policies and procedures.
(c) All professional staff
attend annual, ongoing professional development/ training relevant to the
agency’s treatment foster care model and to their individual job
responsibilities.
(9) Treatment parent
qualifications/requirements: Prior to hiring or contracting with prospective
treatment foster parents, the agency documents that each prospective treatment
foster parent, including those who provide therapeutic leave,
meets and conforms to the certification requirements set forth in 8.27.3 NMAC
(Licensing Requirements for Treatment Foster Care Services), as well as the
following qualifications and requirements:
(a) hold a current and valid
license as treatment foster parent issued by an agency licensed by the
department as a child placement agency.
No home can be licensed for treatment foster care services until any previous foster care license
is surrendered to the issuing agency;
(b) have signed a release of
information that permits the department to share with the treatment foster care
services agency a summary of any substantiated complaints involving
abuse/neglect pertaining to the prospective treatment foster family;
(c) have signed a release to
allow the agency to read prior foster home and prior treatment foster home
records that exist through any previous foster home licensure or certification;
(d) understand the placement
in treatment foster care services as temporary, except when adoption by the
treatment foster parents has become the permanency plan;
(e) have access to reliable
transportation, and when driving a car have a valid New Mexico driver’s license
and liability insurance;
(f) have read, expressed
understanding of, and agreed in writing to fulfill the requirements and
responsibilities of a treatment foster parent;
(g) prior to hiring or
contracting with prospective treatment foster parent(s), the agency documents
that it has requested and reviewed the prospective parent(s)’ substantiated
reports of abuse/neglect, if any, and previous foster-parent records, if any,
and determined that such history does not disqualify the prospective parent(s)
from becoming treatment foster parent(s); the agency will inquire about any
previous treatment foster care services or regular foster care experience
applicant families may have had.
(10) Treatment parent
training: The training of treatment foster parents is systematic, planned,
documented and may include modalities other than didactic
instruction. Training is consistent with
the program’s treatment philosophy and methods and equips treatment foster
parents with the skills to carry out their responsibilities as agents of the
treatment process. Prospective treatment
foster parents are provided with a written list of duties clearly detailing
their responsibilities prior to their approval by the program. The written professional development plan is
placed in the treatment foster parent(s) record.
(a) All treatment foster
parents receive 40 hours of training, at least 30 hours of which are
completed prior to placement of client(s). Any remaining hours are completed
within two months of first placement. The training, at a minimum, includes:
(i) first aid and CPR
training, provided by a certified instructor before receiving a client for
placement;
(ii) child and adolescent
development;
(iii) behavioral management;
(iv) prevention and
de-escalation of aggressive behavior and the use of therapeutic holds;
(v) crisis
management/intervention;
(vi) grief and loss issues for
client(s) in foster care;
(vii) cultural competence and culturally
responsive services;
(viii) specific agency
policies and procedures including documentation,
(ix) recognition of
abuse/neglect symptoms, and State abuse/neglect/exploitation reporting
requirements;
(x) side-effects of
psychotropic medication; and
(xi) role of treatment foster
parent in treatment planning.
(b) Treatment foster parents
who can provide verifiable documentation of previous training in one or more of
the above areas are not required to repeat the training if the staff and the
clinical supervisor agree in writing which specific training is equivalent and
therefore not required. This exception
does not apply to training regarding an agency’s policies and procedures.
(c) Twenty-four hours of inservice training is required annually after receiving a client for
placement. The 24 hours may include:
(i) up to four hours of video
when supplemented by discussion in a classroom or clinical training setting;
(ii) up to four hours of
supplemental reading may be part of the 24-hour annual inservice training when
supplemented by by discussion in a classroom or clinical training setting.
(11) Treatment foster parent
responsibilities: The treatment foster parents works with the treatment team
and with agency supervision to develop and implement the treatment plan.
Treatment foster parents provide front-line
treatment interventions. The family living experience is the basic service to
which individualized treatment interventions are added. Treatment foster parents are responsible for
meeting the client’s basic needs, and providing daily care and supervision. In addition to their basic foster parenting
responsibilities, treatment foster parents perform the following tasks and
functions:
(a) Treatment planning:
Treatment foster parents actively participate in the treatment planning process
and implement specified provisions of the treatment plan.
(b) Treatment foster parents
work with the treatment team to maximize the likelihood that all services are
provided in a culturally competent and culturally proficient manner.
(c) Contact with the client’s family: Unless
contraindicated in the client’s treatment
plan, or by court order,
treatment foster parents assist the client in maintaining contact with
his or her family, and actively work to support and enhance those
relationships. When reunification with
the client’s family is planned, the treatment foster parents work in
conjunction with the treatment team toward the accomplishment of the
reunification objectives outlined in the treatment plan.
(d) Permanency planning assistance: The
treatment foster parents assist with efforts specified in the treatment plan to
meet the client’s permanency planning goal(s).
(e) Record keeping: The
treatment foster parents systematically record information and document client
behaviors/activities and significant events related to the treatment plan. Documentation occurs on a weekly basis at a
minimum, and more often in response to the occurrence of significant
events. Daily logging is preferable.
(f) Agency contact: The treatment foster parents keep the agency
informed of the occurrence of significant events. Daily logging is preferable.
(g) Confidentiality: Treatment foster parents maintain agency
standards of confidentiality.
(h) Incident reporting: Treatment foster parents report all serious
incidents to the agency, consistent with agency policy and certification
requirements.
(i) Availability: At least one
treatment foster parent is readily accessible at all times and is able to be
physically present, if necessary, to meet the client’s emotional and behavioral
needs; e.g., a treatment foster parents responds if the school requires
immediate parental attention. A single
treatment foster parent may not schedule work hours when a client is normally
at home.
(j) Care and supervision: Treatment
foster parents ensure that proper and adequate supervision is provided at all
times. Guardians ad litem, court-appointed special advocates, and CYFD
employees may meet privately with clients as necessary. Clients are not left in the care or unsupervised
presence of friends, relatives, neighbors, or others who have not received both
criminal records clearance and training.
Treatment teams determine that all out-of-home activities are
appropriate for the client’s level of need, including the need for supervision.
(k) Community-based
resources: The treatment foster parents
work with all appropriate and available community-based resources to secure
services for and/or advocate for the client(s).
B. Assessment, pre-placement, and
placement: Prior to placement of any
treatment foster care client in any home, including therapeutic leave or
interim placement, the agency will determine that the placement is
therapeutically appropriate. The
placement process includes documented consideration of the home and all
residents.
(1) The comprehensive
assessment includes face-to-face interviews with the client; with the client’s
biological or adoptive family whenever possible and when not contraindicated;
and contact with any previous care providers.
The comprehensive assessment meets the following requirements, in
addition to those listed in the general provisions:
(a) the client’s and his/her
family’s priorities and concerns, as appropriate, are documented; and
(b) if the client is in
department custody, the agency requests information from the client’s social
worker, including the permanency plan, collateral assessment(s), and any known
or suspected history of abuse/neglect.
(2) Placement does not occur
until
after a comprehensive assessment of how the prospective treatment
foster family can meet the client’s needs and preferences, and a
documented determination by the agency that the prospective placement is a
reasonable “match” for the client.
(3) A documented match
assessment includes, but is not limited to:
(a) the identified needs of
the client;
(b) the strengths of the treatment foster
parents to implement the client’s specific services and treatment plan;
(c) composition of the
treatment foster family; including the name, age, and gender of each person
residing in the home or visiting on a regular basis;
(d) treatment foster parents’
specific knowledge, skills, abilities and attitudes as related to the specific
needs of each client including high risk behaviors or the potential for
such;
(e) treatment foster family’s ability to speak
the primary language of the client;
(f) treatment foster family’s
willingness and ability to work with the client’s family;
(g) proximity of the treatment
foster parent to the client’s family, friends and school. If the client is placed more than an hour’s
driving time from the family, the justification is documented in the client’s
record;
(h) client and client’s
family’s (if applicable) preference for placement;
(i) availability of, and
access to, community resources required to meet the client’s needs; and
(j) a summary/rationale of the client’s
placement in the particular treatment foster home chosen; the clinical
rationale includes consideration of all residents of the home, including
anticipated effects of the placement on all clients present and potential
health and safety risks, and is documented in each client record prior to the
placement.
(4)
Pre-placement processes:
(a) Prior to placement, the client’s family of
origin meets with his or her child’s prospective treatment foster parent(s) unless
clinically contraindicated, prohibited by court order, or prevented by
refusal or unavailability. If
a pre-placement meeting does not occur, the reasons are documented in the
client’s record.
(b) Following completion of
the match assessment, the client visits with the treatment foster family for a
full 72 hours. The dates and times of
the visit are documented in the client’s record. At the end of the 72 hours, the treatment
coordinator documents an assessment of the visit and the therapeutic appropriateness
of the match, including the client’s reaction and the treatment foster
parent(s) response. When it is
clinically indicated, the client may remain in the placement at the end of the
72-hour visitation, provided that the clinically-based reasons are documented
in the client’s record.
(c) All information that the
treatment foster care services agency receives concerning a client waiting for
placement is explained to the prospective treatment foster family prior to
placement. Prospective treatment foster parents are responsible for maintaining
agency standards of confidentiality regarding such information.
(d) For all clients in the
custody of the department, the treatment foster care services agency shares the
home study of a prospective licensed treatment foster family with the client’s
department social worker and invites the social worker to meetings in which the
prospective placement is discussed.
(e) The treatment foster
parent(s) can refuse placement of any treatment foster client whom they
consider inappropriate for the home or to protect the safety of any children
currently in the home.
(f) Treatment home composition
and capacity, including capacity for therapeutic leave: Prior to any placement, the agency determines
that the match is consistent with the following limits:
(i) A Treatment foster family
is eligible to care for level I and level II treatment foster clients,
non-treatment siblings of treatment clients, and/or children who were
previously treatment foster clients in the same home, but are no longer
qualified for TFC. Non-treatment regular
foster or shelter care children may be temporarily placed in the home for
therapeutic leave or shelter care for up to 30 days, after the agency assesses
and documents that such a temporary placement will not compromise the treatment
of any current client. Regular foster
care children who were in the home previously or foster children who are
siblings or children of treatment foster clients currently in the treatment
foster home may be placed without the 30 day limit pertaining to therapeutic
leave or shelter care clients. Arrangements pertaining to placement of regular
foster children are made with the department social worker.
(ii)
The total number of children in a treatment foster care services home,
including treatment foster care clients, therapeutic leave children, and any
other children, may not exceed six,
except in rare circumstances such as placing sibling groups together. Such exceptions are approved in advance by
the treatment teams, guardians of all children, and by the agency’s clinical
director. The clinical rationale for the
exception is documented in each client’s record.
(iii) The total number of treatment foster
clients placed in a two-parent treatment foster care home is limited to
three. At no time may more than two TFC
I children be placed in the same home, except when they are siblings. In the
case of multiple treatment foster care children placements, at least one
treatment foster care parent will not be employed outside the home.
(iv) The total number of
treatment foster care clients placed in a single-parent treatment foster care
home cannot exceed two. No more than one
level I treatment foster care client may be placed in a single-parent treatment
foster care home, unless both are siblings.
(g) The agency obtains written
agreement of the treatment team, including Guardians ad Litem (GALs), and legal
guardians, for all placements.
(h) A client with a history of
more than one incident of substantiated sexual aggression may not be placed in
a home with any other client, including client(s) temporarily present for
therapeutic leave or shelter purposes, without prior written approval by the
treatment teams of all treatment clients in the home. In the case of non-treatment minors, written
permission must be obtained from the legal guardian(s) prior to such
placement. The rationale for such
placement will distinguish the sexually reactive from the sexually aggressive
client. The sexually reactive child may
have presented with a history of symptoms such as public masturbation, sex play
and/or developmentally incongruent preoccupation with sexual matters or
topics. This behavior by itself should
not present a barrier to the placement of other children. The sexually aggressive child has had more
than one incident of using force or intimidation to make another child comply
with a sexual activity. The treatment
team is responsible for evaluating all collateral information, evaluating
any high risk behaviors or the potential for such, regardless of when it
occurred or when an evaluation was performed, and the severity of the
force or intimidation, regardless of how recently it occurred, prior to placing
the child in a home where there are other children.
(i) The agency trains the
treatment foster family in cultural and physical care issues related to the
client’s race and culture prior to
the client’s placement.
(5) Therapeutic leave: Agency policy and practice provide for
treatment foster parent(s)’ access to therapeutic leave, both planned and
crisis-based.
(a) Treatment foster parents
providing therapeutic leave placements are licensed and trained by the agency,
are given a copy of the client’s treatment plan, and are supervised by the
treatment coordinator in the implementation of the
in-home strategies.
(b) Therapeutic leave
placements may be provided by a licensed and appropriately trained treatment
foster family from another licensed and certified treatment foster care
services agency, provided that the placing agency ensures the client’s
treatment plan is implemented appropriately.
(c) It is the treatment foster
care services agency’s responsibility to determine that treatment foster
parents into whose home a therapeutic leave client has been placed are
sufficiently skilled to work with the mix of treatment clients in their home,
and document this determination in their records prior to placement.
(d) If a treatment foster care
services agency cannot secure a trained and licensed treatment foster care
family to provide therapeutic leave for a client, the agency may place the
client in a licensed residential treatment services or licensed group home
services, if clinically appropriate and documented, for a period not to exceed
seven days. The residential treatment services or group home services program must
adhere to the client’s treatment plan and document the services provided and
the client’s behavior, consistent with these certification requirements for
treatment foster parent documentation.
(e) Therapeutic leave
placements comply with all certification requirements stated herein, including
capacity limits. The agency documents assessment of treatment home/family
composition, physical and sexual safety issues, and language(s) spoken, prior
to therapeutic leave placement.
D. Service planning and
provision:
(1) All treatment foster care services, as
described in these certification requirements, are the responsibility of the
treatment foster care services agency.
Services are furnished either through agency staff or contracted
persons.
(2)
The treatment foster care services agency provides intensive support,
technical assistance, and supervision of all
treatment foster parents.
(3) The agency provides
clinically appropriate therapy services to the client, and involves the
treatment foster parents and the client’s family to achieve the goals of the
treatment plan. Each treatment client
receives regularly scheduled therapy, including family therapy, as clinically
indicated and specified in the client’s treatment plan. Family involvement in treatment, including
family therapy is not required when contraindicated by court order,
or temporarily contraindicated by the clinical judgement of the department’s
legal guardian or treatment team.
(a) Therapy cannot be suspended or terminated
unless there is concurrence by the treatment team that therapy is not presently
indicated.
(b) All efforts are made to
place a client in close enough proximity to biological/adoptive family so that
family therapy will not be hindered.
(c) Family therapy is required
when reunification is the goal.
(d) In cases where family
involvement is contraindicated, the agency documents the clinical or legal
basis for that determination and documents regular review of the determination.
(4) The professional/clinical
staff provide or locate resources most suited to the individual needs of the
client in treatment foster care services
and helps the client, his or her parent(s) and the treatment foster
families to make effective use of them.
(5) Client’s access to agency
staff: An agency staff person, who is a member of the client’s treatment team,
is designated as a contact person for
each client. The client has direct access
to that staff member. The client is
informed of his or her designated staff person and how to reach that
person. The means for such communication
is available to the client for his or her use at all times. This is documented in the client’s record at
admission, and each time a change is made.
(6) Crisis on call: The treatment coordinator, or another professional
clinical staff member or contractor who meets the qualifications for treatment
coordinator, is on-call to treatment foster parents, client(s) and their
families on a 24-hour, seven-day-per-week basis.
(7) The agency works with the
local school district to access for the client the most appropriate educational
services in the least restrictive setting.
(8) The agency facilitates the
creation of formal and/or informal support networks for its treatment foster
parents through coordination of parent support groups and/or other systems.
(9) Documentation:
(a) All contacts between
agency staff and clients’ biological/adoptive parents, and/or treatment foster
parent(s) are documented in the client’s records.
(b) All therapy notes are
documented and placed in the client’s record within one week of the session
date.
(c) Therapy notes explicitly
address the goals/objectives identified in the treatment plan.
(10) The treatment foster care
services agency provides intensive support, technical assistance and supervision to all treatment
foster parents. The agency trains the treatment foster family in cultural and
physical care issues related to the client’s race and culture prior to
placement and throughout its duration, with the intention of the treatment
foster family becoming culturally competent.
(11) The agency is responsible
for determining that the treatment foster parent(s) effectively manage the
individual treatment needs, acuity-based safety needs, and cultural needs of
all clients placed in the home.
(12) The agency develops and
implements a plan to connect the treatment foster client with other children
and adults in the community who share the same culture, race and ethnicity.
(13) Services are provided to
each client as determined by the treatment team. No one member of the
treatment team has veto power except for those provision set forth in the
Children’s Code regarding change of placement notification. No services are terminated and/or suspended
without the review and concurrence of the team.
This certification requirement does not limit a managed care entity’s
right to determine, or the agency’s or legal guardian’s right to appeal, based
on medical necessity criteria, the authorization of continued placement of a
treatment foster care services client.
(14) The treatment plan is
developed through a process that utilizes a treatment team comprised of the
following individuals, as applicable and appropriate: the client, the client’s
family, treatment foster parent(s), treatment coordinator, department social
worker, juvenile probation/parole officer, education agency, guardian ad litem
and other significant individuals in the client’s life.
(15) The agency ensures that
all treatment plans adhere to the treatment planning requirements
contained in the general provisions section of these certification
requirements.
(16) The initial treatment
plan includes specific tasks to be carried out by the treatment team within the
first 14 days of placement.
(17) The initial and
comprehensive treatment plans address strategies to ease the
client’s adjustment to the treatment home and to assess directly the client’s
strengths, skills, interests and needs for treatment within the home.
(18) The treatment plan
reviews address discharge planning and strategies to prepare for the
client’s return to the biological, or adoptive, regular foster care home or
independent living as appropriate.
(19) The treatment plan is reviewed every 30
days by the treatment team, in accordance with the general provisions, and revised
when clinically indicated. The review
occurs face-to-face, telephonically or through teleconference.
E. Agency oversight:
(1) Except in emergencies, a client is removed
from a treatment foster care services home only after the treatment team has
documented that the move is in the client’s best interest. When such a move is necessary, the agency
complies with pre-placement, placement and treatment planning requirements.
(2) In the event that the
treatment foster parents request that a treatment foster client be removed from
their home, a treatment team meeting is held and there is agreement that a move
is in the best interest of the involved client.
Any treatment foster parent(s) who demands removal of a treatment foster
client from his or her home without first discussing with and obtaining
consensus of the treatment team will have their license revoked.
(3) If treatment foster
parent(s) wish to transfer between agencies, there must be written
documentation from both agencies that the transfer is in the best interest of
any client(s) currently in the home, including consideration of change of
treatment team members, and a written statement from the previous agency that
the transferring treatment foster family is in good standing.
(a) If any clients are
currently placed in the transferring treatment home, the receiving agency will
evaluate the appropriateness of the match and update the treatment plan.
(b) The receiving agency
completes a new home study, or an addendum to the original home
study reflecting any changes that have occurred in the composition of the home
since the date of the client’s admission.
(c) The receiving agency
notifies the previous agency that the treatment foster parent(s) has been hired,
and the previous agency, upon receipt of that notice, cancels its previous
license.
(4) At the time of new
licensure of a treatment foster care home, if non-treatment foster care
client(s) placed through prior licensing arrangements must be removed, the
process is conducted through an orderly and purposeful plan which is approved in
writing by the previous licensing agency as meeting the best interests of the
clients.
F. Property damage and liability:
(1) Written plan: The agency providing treatment foster care
services has a written policy concerning compensation for damages to a
treatment foster family’s property by client(s) placed in their care. A copy of the written plan is provided and
explained to the prospective treatment foster parents during the pre-service
training.
(2) Liability insurance: Treatment foster parent(s) document and
verify on a regular basis that they continuously maintain liability insurance for
automobiles, home and persons, including owner and occupants of the home.
(3) Property damage caused by
client(s) in CYFD custody may be reimbursed by the protective services division
of the department, consistent with protective services “maintenance payments to
substitute care providers” PR 8.10.22.10.9 Property Loss and Damage.
G. Transition to independent living:
(1) Older adolescents in
treatment foster care are provided with a series of developmental activities and
supportive services designed to enable them to prepare to lead self-sufficient
adult lives, in accord with their treatment plan. For those clients 16-20 years
old for whom family reunification, placement with extended family or with
previous caretakers, or adoption has been found to be infeasible or
inappropriate, the agency provides or arranges for a set of service components
to be delivered which are designed to enable the client to prepare for a
successful transition to independent
living.
(2)
The services provided or coordinated address the client’s identified
needs for:
(a) life skills training;
(b) education with regard to
health concerns including human sexuality;
(c) vocational and technical
training;
(d) housing needs during
transition and after discharge;
(e) legal services;
(f) arrangements for support
services, aftercare services and socialization, and
(g) cultural, religious and
recreational activities, as appropriate to the client’s needs.
[7.20.11.29 NMAC - Rp 7 NMAC 20.11.28, 03/29/02]
7.20.11.30 RESIDENTIAL TREATMENT SERVICES AND
GROUP HOME SERVICES:
A. Residential treatment services are
provided to children/adolescents with severe behavioral, psychological,
neurobiological, or emotional problems, who are in need of psychosocial rehabilitation
in a residential setting. They require
active residential psychotherapeutic intervention and a 24-hour therapeutic
group living setting to meet their developmental, psychological, social, and
emotional needs.
B. Group home services are provided to
children/adolescents with moderate behavioral, psychological, neurobiological,
or emotional problems, who are in need of active psychotherapeutic
intervention, who require a twenty-four hour therapeutic group living setting
to meet their developmental, social and emotional needs, and/or who are in
transition from a higher level of care to a lower level of care.
C. The agency maintains and follows
policies and procedures for emergency and non-emergency admissions. Admission policies and criteria are based on
the client’s identified need for residential treatment services or group home
services.
D. At the time of admission or transfer
to residential treatment services or group home services, the client is
informed of the reasons for the placement/transfer and his/her treatment
options. This discussion with the client
is documented in the client’s record by the admitting professional.
E. Personnel:
(1) Direct service staff
providing residential treatment services and/or group home services receive a
minimum of twenty hours of pre-service training, including training in:
(a) crisis
management/intervention, behavioral management, personal restraint and
seclusion;
(b) the agency’s emergency
procedures, which include CPR and first aid.
(2) The direct service staff
possess a high school diploma or G.E.D and one or more of the following:
(a) two years experience
working with clients and adolescents with severe psychological/ emotional disturbances/neurobiological disorders; or
(b) two years of post-secondary
education in a human service related field; or
(c) a minimum of 40 hours of documented
training, including the twenty hours of pre-service training described in E
above, and twenty additional hours including the following topics:
(i) etiology and symptoms of
emotional disturbances and neurobiological disorders;
(ii) family systems;
(iii) basic communication and
problem solving;
(iv)
child and adolescent development;
(v) ethnic and cultural
considerations related to the clients served; and
(vi) action and potential side
effects of medications.
(3) The training in (c) (i)
through (vi) above, when required, must be provided within three months of
hire.
(4) Those direct service staff who, prior to
beginning direct service work, can provide documentation of a current
certificate of training in one or more of these specified areas are not
required to repeat that training; their training requirements may be adjusted
as justified and documented by the clinical director or designee.
(5)
Clinical director:
(a) Clinical director
qualifications: The clinical director possesses one of the following New Mexico
licenses: physician (physicians must be board-certified in psychiatry or
eligible to attain such certification);
psychologist; licensed independent social worker (LISW); clinical nurse
specialist in child psychiatric nursing; registered nurse (RN) with a master’s
in psychiatric nursing; licensed professional clinical mental health counselor
(LPCC); and licensed marriage and family therapist (LMFT);
(b) In addition to having one
of the above licenses, the clinical director is required to have a minimum of
two years of experience in clinical practice with clients, adolescents, and
families.
(c) Clinical director
responsibilities: The responsibilities of the clinical director are to provide
clinical oversight of the services, as well as to provide supervision, support,
and consultation to all agency staff.
(6) Clinical supervisor
qualifications: The clinical supervisor possesses one of the following New
Mexico licenses: physician (physicians must be board-certified in psychiatry or
eligible to obtain such certification); psychologist; licensed independent
social worker (LISW) or other licensed independent practitioner in a related
field; clinical nurse specialist in child psychiatric nursing; registered nurse
(RN) with a master’s in psychiatric nursing; licensed professional clinical
mental health counselor (LPCC); or licensed marriage and family therapist
(LMFT). In addition to having one of the
above licenses, the clinical supervisor is required to have a minimum of two
years of experience in clinical practice with clients, adolescents and
families.
(7) Therapists qualifications:
Therapists providing individual, family and/or group therapy must meet either
the necessary licensed requirements as listed for clinical supervisor or
possess one of the following New Mexico licenses: licensed professional mental
health counselor (LPC); licensed master’s social worker (LMSW); licensed art
therapist (LAT); or licensed mental health counselor (LMHC).
F. Services:
(1) Residential treatment
services are provided through a treatment team approach and the roles,
responsibilities and leadership of the team are clearly defined.
(2) The agency provides a
daily structured program that meets clients’ needs as identified in the
comprehensive assessment and as prescribed in the treatment plan. The following
services are provided:
(a) individual, family, and
group therapy, at the level of frequency documented in the treatment plan;
(b) access to timely and
necessary medical care;
(c) supervision of
self-administered medication, if appropriate;
(d) crisis intervention;
(e) educational services;
(f) activities of daily
living;
(g) recreation, leisure time
and other planned therapeutic activities; and
(h) planning of discharge and
aftercare services; to facilitate timely and appropriate post discharge care,
regular assessments are conducted to support discharge planning and effect
successful discharge with clinically appropriate aftercare services; this
discharge planning begins when the client is admitted to residential treatment
services and is updated and documented in the client’s record at every
treatment plan review, or more frequently as needed.
(3) The agency provides services,
care, and supervision at all times, including:
(a) the provision of, or
access to, medical services on a 24-hour basis;
(b) maintenance of a
staff-to-client ratio appropriate to the level of care and needs of the
clients.
(i) for residential treatment
services, the minimum ratios are one to six during the day and evening shifts
and one awake staff to twelve clients during the night shift.
(ii) for group home services,
the minimum ratios are one to eight during the day and evening shifts and one
awake staff to twelve clients during the night shift.
(iii) additional staff must be
provided if the clinical needs of the client population are high.
(iv) a written schedule must
be maintained by the agency to document the staffing ratios.
(c) arrangements for, and
provision of, supervision for off-grounds activities, including transportation,
in accordance with minimum and need-based ratios; and
(d) arrangements for, and
provision of responses to significant life events that may affect the client’s
treatment when out of the facility.
(4) Services and activities
are appropriate to the age, behavioral, and emotional development level of the
client.
(5) When not therapeutically
or legally contraindicated, the agency encourages parent/client contact and
makes efforts at family reunification.
Such contacts and efforts are documented as they occur. If reunification is contraindicated, the
reason is documented in the client’s record at the time that determination is
made, and the issue is reconsidered
when indicated.
(6) The following factors will
be considered in determining the appropriate level of services and supervision.
(a) risk of victimizing others;
(b) risk of inappropriate
consensual activity;
(c) risk of being victimized
by others;
(7) The treatment plans contain
all the elements outlined in Section 23 of these certification requirements.
G. Residential treatment services and
group home services may be provided in the same licensed facility when the
agency ensures the health and safety of all clients present.
(1) A program certified for
residential treatment services may provide group home services in accordance
with these certification requirements without requesting or receiving a
separate certification for group home services.
(2) When residential treatment services and
group home services are provided in the same facility, the agency’s policies
and procedures specify clinically-based criteria under which the populations
may be mixed.
(3) When residential treatment services and group
home services populations are mixed, the agency documents that the
clinically-based criteria have been met to address safety issues.
(4) When residential treatment
services and group home services populations are mixed, the minimum staffing
ratios for residential treatment services apply.
[7.20.11.30 NMAC - Rp 7 NMAC 20.11.29, 03/29/02]
7.20.11.31 JCAHO
ACCREDITED RESIDENTIAL TREATMENT SERVICES: Residential treatment services programs that
are accredited by JCAHO comply with the general provisions and residential
treatment services sections of these requirements, and the following standards:
A. The
agency provides services, care, and supervision at all times, including
maintenance of a minimum staff-to-child ratio of one to five during the day and
evening shifts and one awake staff to ten clients during the night shift. Additional staff is provided when warranted
by client acuity or other conditions.
B. A physical
examination is completed by a licensed independent medical practitioner within
one week of admission, and includes medical history, physical examination,
assessment of pain, motor and sensorimotor functioning, speech, hearing, and
language functioning, vision, immunizations, oral health, history of
psychotropic medication use, and, when indicated an AIMS test. If a comprehensive medical history and
physical examination have been completed within 30 days before admission, a
durable, legible copy of this report may be used in the clinical record as a
physical examination, but any subsequent changes must be recorded at the time
of admission.
C. The agency
evaluates the need for the following assessments, and when such assessments are
indicated, they are completed in a thorough and timely manner: psychological,
psychiatric, educational, vocational, legal, nutritional, developmental
disabilities, and substance abuse.
D. The agency
has a written plan to provide all necessary medical histories, physical
examinations, and laboratory tests that the agency does not directly provide.
E. Infection
control
(1) The agency has a comprehensive and
functioning infection-control program based on proven epidemiological methods
for surveillance and prevention of adverse outcomes related to infection.
(2) The agency uses preventive processes such
as universal precautions to reduce risks for endemic and epidemic infections in
clients and staff.
(3) Infection control policies, procedures,
and practices include surveillance, identification, and control of infection,
and required reporting to staff and public health authorities.
(4) A current certification stating that the
employee is free from tuberculosis in a transmissible form, obtained prior to
the first date of direct service.
[7.20.11.31 NMAC - Rp 7 NMAC 20.11.30, 03/29/02; A,
10/29/04]
7.20.11.32 [Reserved]
[7.20.11.32 NMAC - N, 03/29/02; Repealed 04/14/05]
7.20.11.33 COMPREHENSIVE COMMUNITY SUPPORT
SERVICES:
A. Agencies certified for case
management under these regulations or agencies receiving children’s behavioral
health contract funding for case management services as of 01/01/08 will
receive provisional certification as a comprehensive community support services
provider.
B. The provisional certification will
be valid until the expiration of the agencies case management certification at
which time a survey will be completed by the licensing and certification
authority. Children’s behavioral health
contract agencies will have a survey completed within twelve (12) months of the
issuance of the provisional certification.
C. All comprehensive community support
services providers will have to meet the general provisions of these
requirements and requirements in medicaid regulation Title 8, Chapter 315, Part
6.
[7.20.11.33 NMAC - N, 01/01/08]
HISTORY OF 7.20.11 NMAC:
Pre-NMAC Filing History:
OMCI, Purpose and Definitions
Relating to Certification Regulations, 11-23-93.
A.O., Agency in the Community,
11-23-93.
B.O., Agency Governance and
Administration, 11-23-93.
C.O., Personnel, 11-23-93.
D.O., Client Rights and
Protection, 11-23-93.
H.O., Intake, Assessment and
Treatment Planning, 11-23-93;
I.O., Client Information,
Confidentiality and Case Review, 11-23-93.
AA.O., Group Home Services,
11-23-93.
BB.O., Residential Treatment
Centers, 11-23-93.
DD.O, Treatment Foster Care,
11-23-93.
EE.O., Day Treatment Centers,
11-23-93.
GG.O., Behavior Management
Skills Development Services, 8-16-94.
NMAC History:
7 NMAC 20.11, Certification
Requirements for Child and Adolescent Mental Health Services, 6-16-98.
7 NMAC 20.11, Certification
Requirements for Child and Adolescent Mental Health Services, 10-27-99.
History of Repealed Material:
7 NMAC 20.1, General Provisions
- Repealed 7-1-98.
7 NMAC 20.A, Agency in The
Community - Repealed 7-1-98.
7 NMAC 20.B, Agency Governance
and Administration - Repealed 7-1-98.
7 NMAC 20.C; Personnel -
Repealed 7-1-98.
7 NMAC 20.D, Quality Assurance
and Utilization Review - Repealed 7-1-98.
7 NMAC 20.E, Regulatory
Compliance for Program Operation Including Health, Safety and Physical Plant
Requirements - Repealed 7-1-98.
7 NMAC 20.F, Client Rights and
Protection - Repealed 7-1-98.
7 NMAC 20.G, Intake,
Assessment and Treatment Planning - Repealed 7-1-98.
7 NMAC 20.H, Client
Information, Confidentiality and Case Review - Repealed 7-1-98.
7 NMAC 20.AA, Case Management
- Repealed 7-1-98.
7 NMAC 20.BB, Day Treatment -
Repealed 7-1-98.
7 NMAC 20.CC, Behavior
Management Skills Development Services - Repealed 7-1-98.
7 NMAC 20.DD, Treatment Foster
Care - Repealed 7-1-98.
7 NMAC 20.EE, Residential
Treatment Centers - Repealed 7-1-98.
7 NMAC 20.11, Certification
Requirements for Child and Adolescent Mental Health Services - Repealed,
11-15-99.
7 NMAC 20.11, Certification
Requirements for Child and Adolescent Mental Health Services - Repealed,
3-29-02
7.20.11 NMAC, Section 32,
Home-Based Services - Repealed 04-15-05