BPI MEDICAID Certification

1
BPI MEDICAID Certification

• Review Process and Federal Requirements

2
Federal Requirements

• BPI is responsible for PRTF MEDICAID
  Certification
• This Certification ensures that providers are in
  compliance with Federal Requirements
• Also monitored during site-visits are the state
  specific requirements and MA General Regulations

3
Federal Requirements

• PRTF physician involvement
• All services and treatment must be directed and
  ordered by the psychiatrist
• Psychiatrist heads treatment team

4
Federal Requirements

• 42 CFR 441.155(d)(1) and 456.160(b)
• Physicians Recertification of Need for Care

• A Physician, Physicians Assistant or Nurse
  Practioner acting within the scope of their
  practice, must recertify for each recipient that
  inpatient RTF level of care is still required.
  This recertification must be made at least every
  thirty (30) days and documented in the residents
  record

5
Federal Requirements

• 42 CFR 441.155 and 456.180
• Individual Plan of Care

• A individual plan of care must be written for
  each recipient. The plan of care must be based
  on a diagnostic evaluation and include the
  diagnosis, symptoms, complications, therapies,
  treatment objectives, social services and
  discharge planning.

6
Federal Requirements

• 42 CFR 441.154
• Active Treatment

• A Initial Psychiatric Evaluation and plan of care
  must be developed within fourteen (14) days of
  admission to the RTF.

7
Federal Requirements

• 42 CFR 441.154, 441.155, 441.156 and 456.180
• Treatment Team/Plan Reviews

• The plan of care must be reviewed and/or revised
  by the treatment team, as specified, at least
  every thirty (30) days.

8
Federal Requirements

• 42 CFR 441.155(b)(2) and 441.156
• Treatment Team/Members or Composition

• The team must include at a minimum 1) a board
  certified or board eligible psychiatrist 2) a
  clinical psychologist who has a doctoral degree
  and a physician licensed to practice medicine or
  osteopathy 3) a physician with specialized
  training in the treatment and diagnosis of mental
  health issues, and a clinical psychologist who
  has a masters degree in clinical psychology and
  one of the following (a) a clinical psychiatric
  social worker, (b) a registered nurse specialized
  with training or experience in treating mentally
  ill individuals, (c) a occupational therapist,
  (d) a clinical psychologist who has a masters
  degree.

9
Federal Requirements

• 42 CFR 441.155(b)(2), 441.156 and MA Bulletin
  1165-95-01

• All therapeutic leaves must be ordered by the
  physician and be used as a part of the
  recipients individual treatment program. Dates
  and times of the passes must be documented, as
  well as the therapeutic goals and results of the
  pass. MA payment for therapeutic passes in an
  RTF is limited to forty-eight (48) per calendar
  year.

10
Federal Requirements

• 42 CFR 441.155, 456.180 and 456.610
• Medications

• All medications must be ordered by the attending
  physician, to include the dosage, route and
  frequency. Diagnoses, symptoms and complications
  must be documented to justify the medication
  ordered, this includes over-the-counter
  medications. The attending physician must review
  and reorder the prescribed medications at least
  every thirty (30) days.

11
Federal Requirements

• 42 CFR 441.155, 456.180 and 456.610
• Treatments/Therapies

• All tests and treatments must be ordered by the
  attending physician. Diagnoses, symptoms and
  complaints must be documented to justify the
  orders. The attending physician must review
  prescribed treatments at least every thirty (30)
  days. (This can be done via the Treatment Plan
  Review process)

12
Federal Requirements

• 42 CFR 441.155, 456.180 and 456.610
• Dietary Needs

• All dietary needs must be ordered by the
  attending physician. The attending physician
  must review and reorder prescribed diet at least
  every thirty (30) days.

13
Federal Requirements

• 42 CFR 456.610
• Progress Notes

• The physician, nurse and all other professional
  progress notes must be consistent with the
  observed condition and progress of the recipient.
  

14
Federal Requirements

• 42 CFR 483 and MA Bulletin 53-01-01
• Restraint and Seclusion

• Restraints (holds) must be ordered by the
  physician or LIP Licensed Independent Practioner)
• Orders must include the type of hold to be used
  and the duration of the hold
• Orders must be signed by the physician, LIP
• If LIP is ordering the hold, documentation by the
  LIP must indicate that the physician was notified
  of the hold

15
Federal Requirements

• Restraint and Seclusion (Continued)

• Times must be documented as to when the hold
  began and ended
• If holds last over 10 minutes in duration the
  3800 Licensing Regulations must be followed as to
  documentation that physical assessments and
  adequate hydration and toileting needs are met

16
Federal Requirements

• Restraint and Seclusion (Continued)

• Within one hour of the duration of the hold, a
  physical and psychological assessment must be
  completed by a MD, PA, CRNP or RN and documented
  in the record. The documentation must include
  the time the assessment occurred

17
Federal Requirements

• Restraint and Seclusion (Continued)

• A client debriefing must take place with the
  client and staff involved in the physical hold
  within 24 hours of the safety intervention.
  Documentation of this debriefing must included
  all members who attended and the time and date
  the debriefing occurred

18
Federal Requirements

• Restraints and Seclusion (Continued)

• Within 24 hours of the release of the hold a
  staff debriefing consisting of all staff involved
  in the hold as well as appropriate treatment team
  members, and supervisory and administrative staff
  must occur. Documentation of this debriefing
  must include all members attending and the date
  and time of the meeting

19
Federal Requirements

• Restraint and Seclusion (Continued)

• The parents, guardians or custodians of the
  resident involved in the hold must be notified as
  soon as possible. The date, time, name of party
  contacted and name of staff member providing the
  notification must be documented in the residents
  record

20
Federal Requirements

• 42 CFR 456.180
• Multi-disciplinary Treatment Team (Inter-agency
  Team)

• The attending physician and all other personnel
  and agencies involved in the recipients
  immediate care and discharge care must meet to
  review and/or revise the recipients plan of care
  at least every ninety (90) days.

21
Federal Requirements

• 42 CFR 456.200 and 456.201
• Utilization Review

• Each mental health facility must have a written
  utilization review plan.