Documentation Manual Specialty Mental Health Services€¦ · 2016-10-01 · Department of Health are Services (DHS) letters/notices, Tehama ounty Health Services Agency (TCHSA)

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Documentation Manual

Specialty Mental Health Services

Tehama County Health Services Agency Mental Health Division

October 01, 2016


TABLE OF CONTENTS

Overview….............................................................................................................................................. 4 A. Application ........................................................................................................................................ 4 B. Sources of Information ...................................................................................................................... 4 C. Technical Assistance .......................................................................................................................... 4 Sections …...................................................................................................................................... 5 I. Scope of Practice......................................................................................................................... 6 II. Informed Consent ...................................................................................................................... 9 III. Medical Necessity and Authorization of Services....................................................................... 10 IV. Assessment ............................................................................................…………….………………….. 12 A. Scheduling …………………………………………………………………………………………………………………….…….…….... 12 A. Documentation Timeline ................................................................................................................... 12 B. Assessment Components ……………………………………………………………………………………………….……….…… 13

1. Chief Complaint ……………………………………………………………………………………………………………………. 13 2. Cultural and Linguistic factors ………………………………………………………………………………………………. 13 3. Medical History …………………………………………………………………………………………………………………….. 13 4. Drug and Alcohol Use ……………………………………………………………………………………………………………. 13 5. History of Abuse/Neglect ……………………………………………………………………………………………………… 13 6. Developmental Milestones …………………………………………………………………………………………………… 13 7. Strengths ………………………………………………………………………………………………………………………………. 13 8. Mental Status ..……………………………………………………………………………………………………………………… 14 9. Functional Impairments ………………………………………………………………………………………………………… 14 10. Risk Assessment …………………………………………………………………………………………………………….…….. 14 11. Diagnosis ………………………………………………………………………………………………………………………….…… 12. Initial Recommendations ……………………………………………………………………………………………………...

14 15

13. Signatures ……………………………………………………………………………………………………………………..……… 15 14. Legibility ……………..………………………………………………………………………………………………………………… 15

V. Service Plan ............................................................................................................................... 16 A. Transformational Care Planning……………………………………………………………………………………………………. 16 B. Documentation Timeline ................................................................................................................... 16 C. Service Plan Components ..................................................................................................................

1. Identifying Information …………….…………………………………………………………………………………………… 2. Allergies ……………………………………………………………………………………………………………………………….. 3. Target Symptoms …………………………………………………………………………………………………………………. 4. DSM Diagnosis ………………………………………………………………………………………………………………………

17 17 17 17 17

5. Goals .......................................................................................................................................... 17 6. Anticipated Discharge Criteria ………………………………………………………………………………………………. 18 7. Functional Impairments ………………………………………………………………………………………………………… 18 8. Objectives ……………………….......................................................................................................... 18 9. Strengths ……………………………………………………………….……………………………………………………………… 19 10. Interventions …………………………................................................................................................. 19 11. Signatures .................................................................................................................................. 21 12. Progress Notes…………………….................................................................................................... 21


VI. Progress Notes.......................................................................................................................... 22 A. General Rules..……………………………………………………………………………………………………………………………… 22

1. Service Activities…………………………………………………………………………………………………………………… 2. Service Verification …………………………………………………………………………………………………………..….. 3. Content Requirements ……………………………………………………………………………………………….………… 4. Content Guidelines ………………………………………………………………………………………………….…….……… 5. Signatures …………………………………………………………………………………………………………………..………… 6. Professionalism …………………………………………………………………………………………………………..…………

22 22 22 23 24 24

VII. Service Activity Codes (SAC)...................................................................................................... 26 1. Assessment …………………………………………………………………………………………………………..…………… 26 2. Plan Development ………………………………………………………………………………………………..…………… 26 3. Collateral.………………………………………………………………………………………………………………...………… 27 4. Rehabilitation ..…………………………………………………………………………………………………….……………… 28 5. Therapy ……………………………………………………………………………………………………………..……………… 28 6. Targeted Case Management ……………………………………………………………………………………..………… 29 7. Crisis Intervention …………………………………………………………………………………………………..…………… 30 8. Medication Support ……………………………………………………………………………………………….…….……… 31 9. Katie A ………………………………………………………………………………………………………………………………… 10. TBS ………………………………………………………………………………………………………………………………………

31 33

VIII. Non-Reimbursable Services..................................................................................................... 34 IX. Lock–Outs ................................................................................................................................. 35 APPENDICES A. Medical Necessity Criteria – Diagnoses............................................................................................. 37 B. Documentation Timelines……………………………………………................................................................... 38 C. Service Activity Code Definitions………………………………………………...................................................... 39


OVERVIEW

The Documentation Manual is the Tehama County Health Services Agency – Mental Health Division’s (TCHSA-MH) official documentation guide for all clinical chart records. This manual serves as a guidance document to promote excellent, accurate, and timely documentation of the services we provide to our community. We strive to provide excellent care to our clients*, and accurate documentation is a crucial step in the process of delivering excellent care. *Note: A client is a person who accesses and receives outpatient mental health services; a client is also known as individual, patient, consumer, beneficiary, etc. A. Application: Managers and supervisors are encouraged to use the documentation manual as a reference and resource to train staff. The documentation manual defines key concepts and explains documentation requirements. All staff providing clinical services should refer to the manual whenever they need an answer to a documentation question. When situations arise where staff need clarification or further direction a supervisor or the Quality Assurance Manager should be consulted. B. Sources of Information: This Clinical Record Documentation Manual is to be used as a reference guide and is not a definitive single source of information regarding chart documentation requirements. This manual includes information based on the following sources: the California Code of Regulations (Title 9), the California Department of Health Care Service’s (DHCS) letters/notices, Tehama County Health Services Agency (TCHSA) policies & procedures, directives, and memos. C. Technical Assistance: The Quality Assurance Manager is available to answer questions about this documentation manual or documentation issues in general. You can reach the Quality Assurance Manager at (530)527-5631 ext.3971.


SECTIONS

I. SCOPE OF PRACTICE: Our guide on the scope of practice in answering the basic question: “Who can provide each service?”

II. INFORMED CONSENT: Provides information regarding informed consent

III. AUTHORIZATION OF SERVICES and MEDICAL NECESSITY: Addresses how all services must be properly authorized before being billed. Describes the requirements for establishing medical necessity for each client

IV. ASSESSMENT: Provides detail on how to complete a clinical assessment. Gives detailed information on what is expected to be included in each section of the form

V. SERVICE PLAN: Provides detail on how to complete a service plan and what is included

VI. PROGRESS NOTES: Presents general guidelines for writing progress notes

VII. SERVICE ACTIVITY CODES (SAC): Includes all SAC’s used to bill for services rendered.

VIII. NON-REIMBURSABLE SERVICES: Addresses activities that are not reimbursable.

IX. LOCK-OUTS: Provides information on the lockout rules


I. SCOPE OF PRACTICE

It is expected that staff will only provide services allowed in their job classification and by credentials (i.e. licensure, Board registration, education, training, and experience). Further limitations may be due to level of experience in a specific service category or by department restrictions.

STAFF ELIGIBLE TO PROVIDE SERVICES SERVICE ACTIVITIES

Physicians, Nurse Practitioners, Physician Assistants

• Assessment

• Plan Development

• Crisis Intervention

• Collateral

• Individual Therapy

• Family Therapy

• Group Therapy

• Rehabilitation (individual, group)/Intensive Home Based Services

• Brokerage / Targeted Case Management/Intensive Care Coordination

• Therapeutic Behavioral Services

• Medication Support (education, monitoring)

• Medication Administration

• Medication Evaluation

• Conservator Evaluation (not billable to Medi-Cal)*ONLY PSYCHIATRIST

RN with Master’s in Mental Health Nursing

• Assessment



• Collateral


• Family Therapy

• Group Therapy

• Rehabilitation (individual, group) /Intensive Home Based Services







Registered Nurse with ADN or BSN

• Nursing Assessment Only



• Collateral






Licensed Vocational Nurse & Licensed Psychiatric Technician

• Nursing Assessment Only (with co-signature)



• Collateral






Mental Health Clinicians (Board of Behavioral Science Registered Interns and

Licensed)

• Assessment



• Collateral


• Family Therapy

• Group Therapy




Case Resource Specialists I • Brokerage / Targeted Case

Management/Intensive Care Coordination

Mental Health Rehabilitation Specialists/Case Resource Specialists II


• Collateral

• Rehabilitation Services (individual, group) /Intensive Home Based Services




1st Year Graduate Student Intern 2nd Year Graduate Student Intern (ex. MSW 2nd year, MFT Trainee)

& One-year program Graduate Student

Interns (TCHSA does not bill services to Medi-Cal)

• Assessment*

• Plan Development*

• Crisis Intervention*

• Collateral*

• Individual Therapy*

• Group Therapy*

• Family Therapy*

• Rehabilitation Services (individual, group) /Intensive Home Based Services *

• Brokerage / Targeted Case Management/Intensive Care Coordination * *All services require a co-signature by licensed staff.

Undergraduate Student Interns (TCHSA does not bill services to Medi-Cal)

• Plan Development*

• Collateral*

• Rehabilitation Services/Intensive Home Based Services * (individual and group**)

• Brokerage / Targeted Case Management/Intensive Care Coordination * *All services require a co-signature by licensed staff. **Group Rehabilitation Services can only be provided with a TCHSA-MH co-leader.


II. INFORMED CONSENT A. Requirements

Informed Consent for Treatment must be obtained prior to providing the first face-to-face service to a client and is the first step to be completed between the clinician and the client or the client’s parent/guardian. Per Title 22, section 101, “informed consent means that a consumer grants, refuses or withdraws consent to treatment after the MH provider presents the consumer with information about the proposed mental health services, mental health supports, or treatment, in language and manner that the consumer can understand”.

B. Timeline

Informed consent is obtained during the initial assessment and at least annually thereafter. This consent covers outpatient services and is valid unless the client withdraws the consent. If a consumer is unwilling or unable to provide informed consent the reason, as well as attempts to obtain informed consent must be documented in the consumer’s clinical record.

C. Psychotropic Medications

For treatment with psychotropic medications there are additional documentation requirements for informed consent. Refer to policy # 03-07-1075 (Informed Consent for Psychotropic Drug Treatment F:\tchsa\mh\manualclinical\Informed Consent for Psychotropic Drug Treatment-Draft.doc). The Consent for Psychotropic Medication Therapy form (F:\tchsa\forms\mh\Informed Consent for Psychotropic Drug Tmt-ReV3.doc) must be completed by the prescriber (Psychiatrist, Physician Assistant, or Psychiatric Nurse Practitioner) and the consumer or the consumer’s parent/guardian. Prior to obtaining consent the provider must explain to the client the following:

• The reasons for taking the prescribed medications;

• Reasonable alternative treatments available, if any;

• The type, range of frequency and amount, method (oral or injection), and duration of taking the medication;

• Probable side effects;

• Possible additional side effects which may occur to consumers taking such medication beyond three months; and

• That consent, once given, may be withdrawn at any time by the consumer. Medication consent must be obtained prior to prescribing medication and whenever a new medication is prescribed.


III. AUTHORIZATION OF SERVICES and MEDICAL NECESSITY A. Authorization of Services

TCHSA-MH provides specialty mental health services to clients, including crisis stabilization, case management, outpatient services, medication support and rehabilitation. It is the policy of TCHSA-MH that all services, except crisis services, must be properly authorized prior to being provided (Authorization of Services Policy #03-01-1005 F:\tchsa\mh\manualadmin\authorization of services.doc). Proper authorization of mental health services is a critical process to ensure clients receive appropriate services focused on maximizing positive outcomes and to assure that no unauthorized services are inappropriately billed to Medi-Cal. Authorization is entered into CMHC via the Authorization Service Record (ASR). Authorization of services is done through triage F:\MH\QA\Procedure, Triage and RAM - Deferral Process and Procedure 2016-08-18.

B. Medical Necessity

In order to be eligible for outpatient specialty mental health services clients must meet medical necessity criteria. Medical necessity is formally evaluated at the time of the client’s initial and annual updated assessments and is reviewed by a Triage Team with the assessment. It is expected that TCHSA-MH staff are assessing clients’ continued medical necessity needs at the time clinical and medical services are provided.

Clinicians determine whether clients meet medical necessity for Specialty Mental Health Services using the following:

• Mental Health Screening Form: F:\MH\QA\Mental Health Screening Tool and Referral Instructions 2016-08-01 / F:\MH\QA\Child 0-5 BH Screen TCMH 2016-08-01 / F:\MH\QA\Child 6-17 BH Screen TCMH 2016-08-01 / F:\MH\QA\Adult BH Screen TCMH 2016-08-01

• Medical Necessity Severity (Mild-Moderate-Severe) is determined by the GAF for Children: F:\MH\QA\GAF Scale Mild-Mod-Sev 2016-08-01 and the WHODAS for Adults: F:\MH\QA\WHODAS 2016-08-01.

To meet medical necessity for Specialty Mental Health Services, clients must also meet the criteria described in Title 9 (§1830.205, 1830.210):

a. The client must have an included qualifying current Diagnostic and Statistical Manual (DSM) mental health diagnosis that is the focus of treatment. See APPENDIX A for a list of included and excluded diagnoses.

b. As a result of the mental health diagnosis, there must be one of the following criteria:

• A significant impairment in an important area of life functioning (e.g., health, daily activities, social relationships, living arrangement)

• A reasonable probability of significant deterioration in an important area of life functioning

• For a child (a person under the age of 21 years), a reasonable probability that the child will not progress developmentally as individually appropriate

c. Must meet each of the interventions criteria listed below:

• Focus of the proposed intervention must address the condition identified

• The proposed intervention will do, at least, one of the following: o Significantly diminish the impairment o Prevent significant deterioration in an important area of life functioning o Allow the child to progress developmentally as individually appropriate


• The conditions would not be responsive to physical health care based treatment (Primary Care Physician)

1. The Clinician who is assessing the client will determine if the client meets medical necessity for Specialty Mental Health Services during the Assessment/TCP session, based on the results of the Mental Health Screening Tool, and the score of the GAF (Children), or WHODAS (Adults). a. If the client does meet Medical Necessity criteria based on severe impairment, they will

continue the session and complete a TCP for MHOP services. b. If the client does not meet Medical Necessity criteria and has mild-moderate impairment,

the Clinician will refer the client to their Managed Care Plan (MCP), and indicate in their recommendations that the client does not meet the criteria for Specialty Mental Health services and that the client is being referred to their Managed Care Plan (MCP), for outpatient mental health services.

c. If the client does not have a qualifying diagnosis and does not have impairment in functioning, the Clinician will inform the client that they do not qualify for mental health services at this time and a NOA-A will be sent to the client after Triage Team review.

2. The Triage Team will review Clinician’s determination, confirm and authorize services based on medical necessity for Specialty Mental Health Services and identified client needs (functional impairments). a. The authorization is documented in a progress note in the client’s record and the

authorization log/sheet that is maintained by the Office Assistant (OA) III. b. The Licensed Clinical Supervisor for a Triage Team completes an Authorization Service

Record (ASR) and an OA III then enters the initial 60 day authorization period into CMHC. c. Initial authorizations are applicable for the sixty-day period following an initial assessment.

Services being requested beyond the initial sixty-day period must be authorized via a completed service plan.

d. Service authorizations automatically expire (lapse) on the anniversary date of the clinical assessment unless an annual reassessment is completed prior to that date. Refer to SECTIONS IV and for further instructions on assessment and service plan deadlines.

3. If the Triage Team determines that a client does not meet medical necessity for County Specialty

Mental Health Services based on the severe target population, or does not qualify for mental health services from a Managed Care Plan either, a NOA-A (F:\tchsa\forms\mh\NOA A FRONT.doc and F:\tchsa\forms\mh\NOA A back.doc) must be issued to the client if he/she is a Medi-Cal beneficiary. For additional information about NOAs please see Notice of Action process (F:\tchsa\forms\mh\Procedure, Notices of Action (NOA).doc). The assessment can be billed to Medi-Cal, but not the triage time.

4. No services will be billed without proper authorization.


IV. ASSESSMENT

The mental health assessment serves as the foundation for the client’s plan of care. The assessment reinforces eligibility to receive outpatient specialty mental health services, drives the service planning process, and provides the basis for ongoing changes in treatment delivery and discharge planning. The assessment form can be found at F:\tchsa\forms\mh\Assessment TCP Initial Screening Brief 9-10-14.xls A. Scheduling

It is TCHSA-MHS’s expectation that new clients can schedule an initial assessment within 14 days of contacting TCHSA-MH for an appointment. Walk-in assessment appointments are also available to clients daily (see the walk-in assessment process F:\tchsa\forms\mh\Procedure, Walk-in Assessments.doc).

B. Documentation Timeline Initial Assessment:

The initial mental health assessment is required for all clients who are not currently opened or are new to the outpatient mental health system (or are returning after not receiving services for more than 180 days).

1. Updated Assessment:

a. An updated assessment must be completed annually on or before the anniversary date of the initial assessment. An updated assessment will be considered current if it is completed in the same month the prior assessment occurred.

b. Updated assessments are required to be comprehensive and complete. The updated assessment must stand alone and cannot be the same as the initial assessment.

c. Updated assessments must clearly establish continued medical necessity in the “Chief Complaint/Presenting Problem” section – i.e. why the client continues to require services.

d. Updated assessments must contain a summary of the treatment provided in the past year and the response to that treatment in the mental health treatment history section of the assessment.

e. Clients who return after not receiving services for less than 180 days can be re-opened without having to re-do all opening paperwork. Consents, assessments, service plans, etc. can be defaulted from a previous program and updated as long as the information is current and was previously completed less than one year ago.

f. You must be able to justify why treatment shall continue, for example if a client has received individual therapy each week for a year and has not made significant progress why would we continue this same frequency, duration, and type of treatment? “Because client has made minimal progress in individual therapy client should be evaluated for different or additional services, as well as change of provider”.

2. Triage/RAM

a. Assessments are reviewed weekly at Triage during A-RAM (Adult Review and Monitoring)

and C-RAM (Child Review and Monitoring) F:\MH\QA\Procedure, Triage and RAM - Deferral

Process and Procedure 2016-08-18. All assessments are expected to be triaged within 14

days of completion.


C. Assessment Components 1. Chief Complaint/Presenting Problem

a. The beneficiary’s chief complaint - description of the client’s current symptoms and behaviors that supports the required DSM criteria for each diagnosis (including severity, frequency, duration)

b. History of presenting problem(s) c. Current level of functioning d. Relevant family history and current family information e. Relevant conditions and psychosocial factors affecting the beneficiary’s physical health and

mental health; including, as applicable, living situation, daily activities, and social support

2. Culture Considerations: a. A brief description of the client’s cultural/spiritual/linguistic factors.

i. With which cultural group does the client identify? ii. What language is spoken by client/family/support?

iii. How does the client’s cultural identification impact his/her experience of mental health and TCHSA-MH service preferences?

3. Medical History

a. Relevant physical health conditions reported by client or significant support person. b. Name and address of current source of medical treatment. c. Current medications d. Primary care provider e. Allergies

4. Mental Health History

a. Previous treatment b. Former providers c. Therapeutic modality (e.g., medications, psychosocial treatments) and response d. Inpatient admissions e. Relevant psychological testing or consultation

5. Drug/Alcohol Use/Treatment

a. Past and present use of tobacco, alcohol, caffeine, CAM (complementary and alternative medications) and over-the-counter drugs, and illicit drugs.

6. History of Abuse/Neglect

a. Abuse history: physical abuse, neglect, sexual abuse, domestic violence

7. Developmental Milestones a. For children and adolescents, the history must include prenatal and perinatal events and

relevant/significant developmental history.

8. Client Strengths a. Documentation of the beneficiary’s strengths related to the beneficiary’s mental health

needs and functional impairments as a result of the mental health diagnosis. b. What past accomplishments, current aspirations, motivations, personal attitudes, can help

client accomplish objective(s)?


c. Example: Client reports “I am a good cook”. Client reports when he cooks he feels calm and it helps him cope with disorganized thoughts and irritability. Client states that cooking is one way he can improve his independence and ability to maintain housing.

9. Mental Status

a. For items #12, 13, and 14 examples must be provided

• Example #12 (fund of knowledge): past/present president (adult), ABC song (children)

• Example #13 (abstract reasoning): “you can lead a horse to water, but you can’t make it drink”, “if you had 3 eyeballs, what would you do with the third?” (children)

• Example #14 (estimated intellectual level): did the client take special education classes?

10. Functional Impairments a. Barriers to client meeting goals as a result of mental illness. b. Based on mental health diagnosis. c. Symptoms, behaviors, and life functioning. d. Example: A client diagnosed with Schizophrenia – may have symptoms that impact

his/her life functioning such as: auditory hallucinations, delusions, disorganized thinking, poor hygiene, social withdrawal, or other issue that may interfere with securing stable housing and/or maintaining positive family relations (homelessness and verbal conflict with family members).

e. Example: A client diagnosed with Oppositional Defiant Disorder – arguing with adults, yelling and screaming, temper tantrums, blaming others, not taking responsibility; this behavior is interfering with school (removal from the classroom).

f. In some cases, there may be two diagnoses that are the focus of treatment (e.g. Bipolar Disorder & PTSD), so there could be two problems identified.

g. An excellent functional impairment section will include the client’s impairment in life functioning that is related to the diagnosis, i.e. maintaining housing. o Examples

▪ Client has depressive symptoms of insomnia, isolation, social withdrawal, decreased appetite, suicidal ideation, and poor concentration, which interferes with school (failure to complete homework), and interferes with social support (verbal conflict with peers).

• Client’s psychiatric symptoms of schizophrenia are evidenced by disorganized thoughts, irritability, paranoid ideations, and auditory hallucinations which lead to difficulties maintaining housing (homelessness).

11. Risk Assessment

a. Situations that present a risk to the beneficiary and/or others, including past or current trauma.

b. Document suicidal ideation, suicide attempts, talk of harm to others, attempts to harm others, family history of mental illness, family history of alcohol or substance abuse.

12. Diagnosis

A Diagnosis must be completed a. Numerical code and full clinical name from most current DSM. b. Alcohol and Drug Diagnosis must be Secondary Diagnosis (if primary client does not meet

medical necessity for mental health services). c. Updated diagnosis must be submitted to triage with progress note and grey sheet.


d. Clinical recommendations Primary diagnosis substance use – refer to Drug and Alcohol. e. Diagnosis needs to match current/recent psychiatrist diagnosis.

13. Initial Recommendations

a. Primary diagnosis substance use – refer to Drug and Alcohol. b. Medical Necessity – Determine if impairment is Mild-Moderate-Severe and refer to MCP. c. No PCP indicated - refer to TCHSA Clinic. d. If client meets medical necessity with severe impairment, then indicate recommended

MHOP/Med Support services.

14. Signatures a. The signature of the person providing the service (or electronic equivalent); the person’s

type of professional degree, licensure or job title. b. All staff signatures must be legible and correspond to the TCHSA-MH signature log. See

Signature policy and procedure (F:\mh\qa\Triennial 2014\Chart Documents\signatures .doc and F:\mh\qa\Triennial 2014\Chart Documents\signatures Appendix A.doc).

15. Legibility

a. All writing and signatures need to be legible. b. Document needs to be free of spelling and grammatical errors.

*All sections must be completed (use N/A if not applicable). It is not acceptable to leave questions or sections blank.


V. SERVICE PLANS Whereas the assessment documents the current mental health condition and functional impairments of the client, the service plan is the guiding force behind the delivery of care. The plan helps the client and the clinical staff to collaborate on the client’s recovery goals. The service plan consists of specific goals, objectives, and the treatment interventions that will be provided. It is the expectation of TCHSA-MH that all service plans are client centered and written with the involvement of the client, as well as other resource people identified by and agreed to by the client. There should be a flow from the DSM diagnosis and functional impairments in the assessment to the problem, goal, objectives, and interventions in the service plan. Treatment should result in services provided at the lowest level of care needed. Service plans are required for all billable services provided and are expected to be written in both the client’s preferred language (if preferred language is a threshold language) and English. Medication Support service plans: F:\tchsa\forms\mh\Service Plan Med Support Fillable.pdf Transformational Care Planning (TCP) service plans: F:\tchsa\forms\mh\service plan, TCP - Revised 10-20-14.xls and F:\tchsa\forms\mh\Service Plan, TCP-Span Revised 10-20-14.xls A. Documentation Timeline

Service plans are to be completed during the initial intake assessment appointment or completed before the expiration of the prior service plan. The 30-60-90 process was developed to assist staff in meeting service plan deadlines. The 30-60-90 process is available at F:\mh\admin\reports\30 60 90 ASR Reports - Aug 2014.doc. 1. Initial authorizations (IAs) are the mechanisms used by a triage team to authorize services for a

60-day period following the completion of an initial assessment (see Section IV – Assessment). This 60-day period gives service providers an opportunity to meet with clients and develop a service plan, in the event that the TCP is not completed at the time of the initial assessment/re-assessment appointment.

2. Once a service plan is written, signed, and triaged, it is approved for the following time period: a. Medication support service plans - for up to one year from the day the service plan was

signed by the client or one year from the expiration of the prior service plan, whichever is later. The authorization period cannot go beyond the anniversary date of the assessment.

b. Transformational Care Plans (TCPs) - Medi-Cal standards require updated services plan as least annually or when there are signification changes in the client’s condition. Agency practice is to update TCPs at least every 6 months. The authorization period cannot go beyond the anniversary date of the assessment.

3. An initial service plan can occur in two primary instances: new to services or being referred to different services. a. New to services: the initial service plan shall be completed at the time of the assessment or

within fifty-nine days of authorization for the specific service. This deadline applies to clients who are new to TCHSA-MH or are re-entering services after not receiving services for more than 180 days.

b. Different services: for existing clients who are referred to different services the plan needs be updated and triaged. The authorization end date will not change.

c. A new service plan must be completed and submitted to a Triage Team before the 6 month review date (see 30-60-90 process for service plan submission deadlines F:\mh\admin\reports\30 60 90 ASR Reports - Aug 2014.doc). All service plans sections are


required to be comprehensive and complete. All service plans should reflect clients’ current service needs (for example, if the previous plan did not help the client achieve his or her goals, the plan must change).

4. Late Submission - if the authorization period expires and the next service plan is completed late, there will be unauthorized days that shall not be claimed.

5. Service plans are reviewed and approved or deferred several times a week during A-RAM (Adult Review and Monitoring) and C-RAM (Child Review and Monitoring) triage meetings (F:\MH\QA\Procedure, Triage and RAM - Deferral Process and Procedure 2016-08-18.).

B. Transformational Care Planning (TCP) Service Plans

All services requiring client service plans are based on “Transformational Care Planning,” a recovery model introduced to TCHSA by California Institute for Mental Health (CiMH). This model is client centered and requires the involvement of the client in the entire treatment process, as well as other resource people identified by and agreed to by the client. See Client Involvement in Service planning Policy and Procedure, # 03-07-1015 F:\tchsa\mh\manualclinical\client involvement in service planning.doc

C. Service Plan Components

1. Identifying information: name, date of birth, medical record number

2. Allergies (applies only to Medication Support service plans) a. Document client’s medication allergies. b. Check the “NKDA” box if client has no known drug allergies.

3. Target Symptoms (applies only to Medication Support service plans)

a. Document client’s mental health symptoms and rank each from 1 to 10 (1 = no interference with social, occupational, or other important areas of life functioning, 10 = significant distress or impairment in social, occupational, or other important areas of life functioning).

4. DSM Diagnosis

a. Numerical code and full clinical name from most current DSM. b. Diagnosis needs to match most recent grey sheet.

5. Goals (Life Goals, Service Goals, Life Enhancement Goals)

a. The goal is the client’s desired outcome associated with their problem. What would life be like without the problem, or with better coping with the problem?

b. Goals should include statements of dreams, hopes, role functions and vision of life. For each individual and family and/or setting, completion of all three sub goals may not be necessary or appropriate.

c. Questions to ask:

• Describe “what would need to change so that you can manage on your own and not be in need of mental health services”

• Help clients reconnect with the past, if overwhelmed ask “what would be different,” or “imagine how different”, or ask about “earlier times without, the difficulty,” “what were your goals in high school”

d. Life goals are tied to discharge and transition


• Example: Diane desires to live independently. Or “I would like to live in my own apartment.”

• For more examples see F:\tchsa\forms\mh\service plan, TCP - Revised 6-20-14.xls e. Service treatment goals – what needs to happen to move toward life goals?

• Example: "Diane demonstrates the necessary skills to be able to live independently with minimal ongoing support from treatment team".

• For more examples see F:\tchsa\forms\mh\service plan, TCP - Revised 6-20-14.xls f. Life enhancement goals – life concerns for the client or family that are related to self-

actualization.

• Example: "I want to have a better relationship with my parents".

• For more examples see F:\tchsa\forms\mh\Service Plan TCP – DSM5 standards 2016-10-01.xls

6. Anticipated Discharge Criteria a. What will it look like when the client will no longer need the level of services he/she is

receiving now b. Changes in client’s current needs and circumstances that will need to occur for client to

succeed in meeting goal(s)/discharge. c. Describe changes in the individual's and family's current needs and circumstances that will

need to occur in order to succeed in discharge or transition. d. Example: “Sam has maintained independent housing for at least 6 months. Sam has not had

any behavioral or functional problems related to his mental illness.” e. For more examples see F:\tchsa\forms\mh\Service Plan TCP – DSM5 standards 2016-10-

01.xls

7. Functional Impairments a. Describe the challenges as a result of the mental illness that stand in the way of the

individual and family meeting their goals and/or achieving the discharge/transition criteria. Identifying these barriers is critical to specifying the objectives.

b. Related to mental health diagnosis c. Symptoms, behaviors, and life functioning. d. Clients may have multiple functional impairments. It is important to identify which

impairments will be the focus of the service plan. e. Example:

• Client’s depressive symptoms of insomnia, isolation, social withdrawal, decreased appetite, suicidal ideation, and poor concentration interfere with client’s ability to communicate with others (verbal conflict with family members), maintain intimate relationships (isolation from spouse), and parenting children (yelling and withdrawal).


8. Objective (Treatment Goal), with a Target Date

a. An objective is a description of what the client will do to show progress toward a goal. An objective will:

• Address a problem (functional impairment)

• Be observable and/or measurable


• Have baseline and target levels b. Objectives should not be absolutes, that is, we should not expect a person exhibiting a

behavior 8 times per day at baseline to go to 0 times per day to achieve the objective. Smaller and more reasonable steps can assist in successes in the client’s life and motivate towards goal achievement.

c. Objectives should be SMART (Simple, Measurable, Attainable, Realistic, Time-framed) d. Focus on positive changes that build on past accomplishments and existing resources e. Reflect an increase in functioning and ability, as well as the attainment of new skills (rather

than merely a decrease in symptoms) f. Remember, you can always update the plan when a goal is achieved, so a movement from 8

times per day to 5 times per day, for example, can be updated once achieved to assist that movement from 5 times per day to be 2 times per day etc…. Success breeds success.

g. It is important to track client progress on objectives closely. Update the service plan as needed or begin transitioning client to a lower level of treatment or discharge when objectives have been met or functioning returns.

h. Using action words, describe the specific changes expected in behavioral terms i. Expected changes must be observable measurable j. Must Include a baseline and a proposed target date for completion k. Should address the functional impairments l. Should be consistent with goals m. Should be consistent with the qualifying diagnoses n. Do not use percentages (%). They are difficult to track and measure. o. Template: OBJECTIVE to TARGET CLIENT NAME will INCREASE FUNCTIONAL IMPAIRMENT

from BASELINE p. Examples:

• Tom will be able to appropriately deal with frustrations in class through learning and using anger management skills (e.g. deep breathing, relaxation, time-outs, “I” statements), AEB decrease in removal from classroom from 3-0 times week for four consecutive weeks within six months, ARB Tom.

• Samantha will establish a regular time to go to bed, keep a sleep log, get regular exercise, and take a warm bath from 0-3 times weekly for four consecutive weeks within six months, ARB Samantha and parent.

• Mark will increase self-care skills (good hygiene and diet) and social skills (positive interactions with others), AEB attending the Vista Way Drop-In Center from 0-2 times weekly for 3 consecutive months within 6 months, ARB Mark.


9. Strengths

a. Documentation of the beneficiary’s strengths related to the beneficiary’s mental health needs and functional impairments as a result of the mental health diagnosis.

b. What past accomplishments, current aspirations, motivations, personal attitudes, can help client accomplish objective(s)?

c. Example: Client reports “I am a good cook”. Client reports when he cooks he feels calm and it helps him cope with disorganized thoughts and irritability. Client states that cooking is one way he can improve his independence and ability to maintain housing.


10. Interventions

a. Interventions are the therapeutic activities provided by staff to assist the client in attaining the objective. How can staff provide a clinical service to assist the client to meet his/her goals?

b. Interventions also include what the client or client’s support person is going to do to work towards the objective (i.e. therapeutic homework, attending a social skills group, wellness group, etc.).

c. Describe the specific activity, service, or treatment by all individuals on the treatment team (could include client, clinician, Case Resource Specialist, family members)

d. Describe the intended purpose or impact of the intervention as it relates to this objective e. For adults the interventions must significantly diminish impairment OR prevent significant

deterioration in an important area of life functioning f. For clients under 21 the interventions must allow appropriate developmental progression

OR correct condition g. State the frequency and duration of the intervention. It is appropriate to indicate how often

you plan on conducting the intervention(s) with the client initially (for a 6 month period) followed by what you would like to titrate it down to (e.g. “weekly to begin with, titrating down to bi-monthly for 6 months”). You could also say you want to see the client a minimum number of times (e.g. “bi-monthly at a minimum for 6 months”) or you could indicate that you will see the client at specific intervals or as needed (e.g. “weekly or as needed for 6 months”).

h. Template: TYPE OF SERVICE FREQUENCY & DURATION to ACTION WORD FUNCTIONAL IMPAIRMENT

q. Examples of client interventions:

• Sam will practice concentration skills three times weekly for twenty minutes each time and journal results to discuss in therapy for 6 months.

• Joan will research employment opportunities daily, pick up, complete, and submit applications, prepare for and attend interviews, and attend all medically necessary appointments for 6 months.


r. Example of a support person intervention:

• Joan’s mother will encourage her to practice what is learned in therapy and will provide transportation to appointments weekly for 6 months


s. Example of a clinician intervention:

• Susan will provide individual therapy and will use cognitive behavioral techniques to assist client in reducing symptoms of self-deprecating and suicidal ideation (weekly for 6 months).


t. Example of a Case Management intervention:

• Sandra will provide linkage and brokerage to Vista Way Drop-In Center, Shasta College, community groups, primary health care provider, local gym, Registered Dietician,


Department of Social Services, and medically necessary appointments and monitor progress weekly for 6 months.


u. Example of a Rehabilitation interventions:

• John will provide in-school support and skills building ½ hour a day for three days a week for up to six months to help client develop alternatives to aggressive behavior and appropriate responses to peers.


v. Example of a Medication Support intervention:

• Psychiatrist/Medication Support Provider will provide medication treatment (face-to-face sessions involving monitoring and assessment of client’s progress and psychotropic medication needs) to support adherence to medications and reduce psychiatric symptoms (disorganized thoughts, irritability, paranoid ideations, auditory and visual hallucinations) to increase client’s ability to live independently and maintain housing (1 time every 3 months for one year).

11. Signatures

a. The “signatures” section indicates the client’s participation and agreement with the Service plan (CCR Title 9 Division 1, §1810.440)

b. The client and identified participants must sign and date their signatures. All staff signatures must be legible and correspond to the TCHSA-MH signature log. See Signature policy and procedure (F:\mh\qa\Triennial 2014\Chart Documents\signatures .doc and F:\mh\qa\Triennial 2014\Chart Documents\signatures Appendix A.doc).

c. The client must be offered a copy of the service plan and acknowledge our offer of the copy by signing the plan as the signature states: “I agree with this plan and have received a copy”.

d. If there is another agency staff member that needs to sign, please write or type their name next to where the signature needs to be e.g.: Jane Doe, Social Services, etc.

e. All signatures need to have dates. f. All minors need to sign and need a parent/guardian signature/date and all conserved

persons need the Conservator and/or designate to sign/date.

• If the client does not or cannot sign the plan, then a progress note shall document the reason for the missing signature

• Minors must always sign the service plan in addition to the parent/guardian. If there is no signature there must be documentation as to why this was not possible (e.g. child was too young, child refused)

• Ongoing efforts should be made to obtain client’s missing signature and efforts documented

• Exception: If the client refuses to sign, then as best as possible, ascertain the reason. Renegotiate the goal, if that is the reason. If the client agrees with the goal and the treatment proposed, but still refuses to sign the service plan, then note that fact in the progress note


12. Progress Notes a. Service planning sessions shall always be documented in a progress note (as plan

development). An excellent progress note contains information about the client and the client’s significant support person’s participation in the service planning process and/or signing the plan.

VI. PROGRESS NOTES

A. General Rules for Progress Notes

1. Service Activity a. Every service activity must have a separate, corresponding note (i.e. if you provided two

different services to the same client in the same day, each service requires a separate note).

2. Service Verification a. All client-direct services must be accompanied by a service verification sticker on staff

Service Activity Logs (SALs) (see SAL Re-entry Review F:\tchsa\forms\mh\Procedure, sal re-entry review.doc)

b. Exception: Group services do NOT require a verification sticker because the service is verified by clients’ signatures on the roster.

3. Content Requirements

According to Medi-Cal protocol all progress notes must comply with the following requirements: a. Describe how services provided reduced impairment, restored functioning, or prevented

significant deterioration in an important area of life functioning outlined in the client plan. b. Document the following:

• Timely documentation of relevant aspects of client care, including documentation of medical necessity.

• Documentation of beneficiary encounters, including relevant clinical decisions, when decisions are made, alternative approaches for future interventions.

• Interventions applied related to the diagnosis and TCP.

• Beneficiary’s response to the interventions.

• Location of the interventions.

• The date the services were provided.

• Documentation of referrals to community resources and other agencies, when appropriate.

• Documentation of follow-up care, or as appropriate, a discharge summary

• The amount of time taken to provide services.

• The signature of the person providing the service (or electronic equivalent), the person’s type of professional degree, licensure or job title, and the relevant identification number if applicable.

• The date the service was documented in the medical record by the person providing the service.


4. Content Guidelines a. Progress notes for different services have different formats; however, a progress note

should contain the following D.I.R.T elements: Describe, Intervention, Response, Treatment.

• DESCRIBE Presenting Problem: o DESCRIBE the presenting problem, how the client presents him/herself, or the

reason for the service activity. o WHAT WAS THE REASON OR PURPOSE OF THE ENCOUNTER?

▪ Start by describing the type of service e.g. individual, collateral, etc. o WHAT WAS THE CONTENT OR TOPICS DISCUSSED?

▪ Factual, brief, and relevant to the goals and objectives if possible. o WHAT CLINICAL OBSERVATIONS WERE MADE?

▪ Should be objective, factual, and non-judgmental. o WHAT IS THE CURRENT MEDICAL NECESSITY FOR SERVICES?

▪ Please remember we need to demonstrate continued medical and service necessity for the level of services that are provided.

▪ Was the service provided appropriate to address the client’s service need?

o WHAT WAS SAID, DONE OR REQUESTED BY THE CONSUMER? ▪ This is a good place to address requests for linguistic services.

• INTERVENTION o INTERVENTION - What was attempted by the clinician? o WHAT DID YOU DO IN THE CONTEXT OF THE ENCOUNTER?

▪ Example: Address what was done about the request for linguistic services cited above.

o WHAT THERAPEUTIC INTERVENTIONS OR TECHNIQUES THAT WERE EMPLOYED? ▪ These hopefully reflect the ones listed in the client plan, if not address

why there was a deviation from the plan. o WHAT PROGRESS OR SETBACKS OCCURRED?

▪ Describe in measurable, behavioral terms progress toward the goal and address possible reason for lack of progress.

o WHAT REFERRALS WERE MADE? ▪ If any referrals were made, please address them here.

• RESPONSE o RESPONSE- What was the client’s response to the intervention? o WHAT WAS THE CONSUMER’S RESPONSE TO THE INTERVENTION?

▪ Address this in specific terms based on behavior or client report o HOW WAS THE INTERVENTION EFFECTIVE OR INEFFECTIVE?

▪ Describe in terms of measurable or observable changes in behavior whenever possible

o WHAT SIGNS OR SYMPTOMS OF THE DIAGNOSIS THAT IS PRESENT OR NO LONGER PRESENT?

▪ This goes to medical necessity and accuracy of current treatment. o WHAT WAS DONE OUTSIDE THE SESSION?

▪ If homework was given at the previous session this is a good place to address what the consumer did or did not accomplish.


▪ If the consumer self-initiated any interventions, report them as well (e.g. joining a self-help group)

o WHAT ARE THE CONSUMER’S CURRENT IMPAIRMENTS AND STRENGTHS? ▪ This addresses medical and service necessity and should describe

current levels of functional impairments and strengths to overcome them.

• TREATMENT SERVICE PLAN o HOW DID THE SESSION ADDRESS SERVICE PLAN OBJECTIVES?

▪ Based on what was described above, describe how you helped the consumer’s the recovery process.

o WHAT WILL BE DONE OUTSIDE THE SESSION? ▪ Describe any activities that will occur before the next contact, e.g.

planned, referrals, etc. o WAS THERE HOMEWORK ASSIGNED?

▪ Did you teach the consumer a new adaptive skill and is there an expectation that it will be practiced before the next session.

o WHAT TYPE OF FOLLOW UP WILL BE MADE? ▪ Similar to above, could consist of planned collateral contacts. State the

planned time for the next contact with the consumer

5. Signatures a. All staff signatures must be legible and correspond to the TCHSA-MH signature log. See

Signature policy and procedure (F:\mh\qa\Triennial 2014\Chart Documents\signatures .doc and F:\mh\qa\Triennial 2014\Chart Documents\signatures Appendix A.doc).

6. Professionalism

a. Documentation should be objective and contain observations that are factual and non-judgmental. If an opinion is documented it should be limited to a clinical opinion backed up by the recording of objective data or observations. The absence of recorded objective information limits a person’s capacity to later verify the reasonableness of a clinical decision made or treatment provided.

b. Clinical records are never an appropriate place for negative comments about a client or others.

c. A client can request his/her chart at any time and a court may subpoena a chart.

7. Legibility a. All writing and signatures need to be legible. b. Document needs to be free of spelling and grammatical errors.

8. Cloning a. "When documentation is worded exactly like or similar to previous entries, the

documentation is referred to as cloned documentation. Whether the cloned documentation is handwritten, the result of pre-printed template, or use of Electronic Health Records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made".


9. Timely Documentation

a. Every service is expected to be documented in a timely manner (see Late Entry Documentation Policy and Procedure (F:\tchsa\ad\manualemp\Late entry (out of sequence documentation)-Revised.doc)

b. Medi-Cal Timeliness/Frequency Requirements:

• Every service contact for: o Mental health services. o Medication support services. o Crisis intervention. o Targeted Case Management.

• Daily for: o Crisis residential. o Crisis stabilization (one per 23/hour period). o Day treatment intensive.

• Weekly for: o Day treatment intensive (clinical summary). o Day rehabilitation. o Adult residential.

c. As we move toward Electronic Health Records all staff will use concurrent documentation (write your note with the client present) to write notes in real time, eliminate post service documentation time, and increase the client’s involvement in his or her clinical record.

10. Multiple Staff a. When more than one staff member participates in a service for the same client, each staff

must write a note for the time they were present and billed for the service. b. Example: if two staff participate in a plan development meeting with a client, each staff

member writes his/her own note to represent their contribution to the meeting.

11. Risk a. If client is at risk for suicidal or homicidal ideation and/or hospitalization, document

potential risk in each progress note and safety plan/resources provided.

12. Golden Thread a. Progress notes should flow. b. There should be a clear connection between the client’s presenting problem, primary

symptoms, interventions, and plan of action.


VII. SERVICE ACTIVITY CODES (SAC)

*Note: TCHSA-MH staff working in different mental health programs (e.g. MHSA, CalWorks, etc) are expected to obtain written guidance on the specific coding requirements for their respective programs.

1. Assessment (SAC 301 (Initial) 302 (Other)

a. Activities

• A service activity designed to evaluate the current status of a beneficiary’s mental, emotional, or behavioral health. Assessment includes but is not limited to one or more of the following (CCR Title 9 Division 1, §1810.204):

• Mental status determination.

• Analysis of the beneficiary’s clinical history.

• Analysis of relevant cultural issues and history.

• Diagnosis.

• Use of testing procedures) (For information on how to complete an assessment document or option, please refer to the Assessment section).

b. Assessment activities are usually face-to-face or by telephone with or without the client or significant support persons and may be provided in the office or in the community. An assessment may also include gathering information from other professionals. Examples include the following:

• Interviewing the client and/or significant support persons to obtain information to assist in providing focused treatment.

• Administering, scoring, and analyzing psychological tests and outcome measures such as WHODAS, FIT, CANS and the MORS.

• In some instances, gathering information from other professionals (e.g., teachers, previous providers, etc.) and reviewing/analyzing clinical documents/ other relevant documents may be justified as contributing toward the assessment.

• Observing the client in a setting such as milieu, school, etc. may be indicated for clinical purposes.

2. Plan Development (SAC 330)

a. Activities

• A service activity which consists of development of client plans, approval of client plans, and/or monitoring of a beneficiary’s progress related to the client plan (CCR Title 9 Division 1, §1810.232).

• Plan Development activities may be face-to-face or by telephone with the client or significant support persons and may be provided in the office or in the community. Plan Development may also include contact with other professionals.

• Plan development activities can be conducted with or without the client, and include the five following items:

• Development of the service plan.

• Approval of the service plan.

• Updating of the service plan.

• Monitoring the client’s progress in relation to the service plan.

• Discharge (with client present).


b. Progress notes

• Plan Development progress notes are expected to refer to the service plan (i.e. development, approval, updating, or monitoring and/or discussing updating the client’s diagnosis).

• Discharge summaries document the termination and/or transition of services, and provide closure for a service episode and referrals as appropriate

• Administrative tasks such as “closing out the chart," “copying,” or “filing” cannot be claimed as billable services.

• Plan Development is expected to be provided during the development/approval of the initial Service plan and subsequent Service plans. However, Plan Development can be provided at other times, as clinically indicated. For example, the client’s status changes (i.e. significant improvement or decline) and there may be a need to update the Service plan.

• Plan Development may include activities without the client’s presence, such as collaborating with other professionals in the development or updating of the Service plan.

• Multiple Plan Development service activities for one event are at risk of disallowance, if inappropriately documented. For example, if several staff members are present at a team meeting in which a client’s Service plan is discussed or approved, the only staff that can bill are those who are actively involved in that client’s treatment, i.e. client’s doctor and therapist.

3. Collateral (SAC 310)

a. Activities (only billed after TCP has been authorized)

• A service activity to a significant support person in a beneficiary’s life for the purpose of meeting the needs of the beneficiary in terms of achieving the goals of the beneficiary’s client plan. Collateral may include but is not limited to: consultation and training of the significant support person(s) to assist in better utilization of specialty mental health services by the beneficiary, consultation and training of the significant support person(s) to assist in better understanding of mental illness, and family counseling with the significant support person(s). The beneficiary may or may not be present for this service activity. (CCR Title 9 Division 1, 1810.206).

• Collateral activities are usually face-to-face or by telephone with the significant support person, and may be provided in the office or in the community. The client may or may not be present. Examples include the following: o Educating the support person about the client’s mental illness. o Training the support person to better support or work with the client.

b. Progress Notes

• Collateral progress notes must include the staff intervention(s) identified on the client plan (examples include: educating, training, etc.).

• Collateral progress notes should include the role of the significant support person (e.g. parent, guardian, etc.).

• Documentation should substantiate that the support person is significant in the client’s life.

• An excellent collateral progress note should document the changes that occurred as a result of educating and training the significant other, e.g., show how parents learned and demonstrated new ways of dealing with their child’s symptoms or behaviors.


• If you are billing consultation with a significant other as a collateral service, documentation must include how the clinician educated or trained the significant other to better understand or support the client.

• Collateral groups (i.e. parenting groups) are billable with or without the client. The note must reflect how the interventions benefit the client.

4. Rehabilitation (SACs 340, 341, 342)


• A service activity which includes, but is not limited to assistance in improving, maintaining, or restoring a beneficiary’s or group of beneficiaries’ functional skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources; and /or medication education. (CCR Title 9 Division 1, 1810.243).

• It is important to distinguish “rehabilitation” versus “personal care activities.” Personal care activities are not reimbursable activities. Rehabilitation activities enable clients to overcome limitations due to mental disorder (e.g. teaching client to prepare his/her meals) whereas personal care activities are performing activities for the client who is unable to do for themselves (e.g. feeding client; preparing meals; general care).

• It should be noted that Rehabilitative Activities are designed to enable the client to overcome the limitations due to the mental disorder and to teach the client to function in an age appropriate manner without the need for redirection or intervention.

• Rehabilitation activities are usually face-to-face or by telephone with the client and may be provided in the office or in the community. Rehabilitation can be done as:

• Individual Rehabilitation.

• Group Rehabilitation (for two or more clients).

• Education, training, and counseling to the client in relation to the four following functional skills: ▪ Health – medication education and compliance, grooming and personal hygiene

skills, meal preparation skills. ▪ Daily Activities – money management, leisure skills. ▪ Social Relationships – social skills, developing and maintaining a support system. ▪ Living Arrangement – maintaining current housing situation.

b. Progress Notes

• Rehabilitation and TCM progress note must also include the reason for interaction (describe functional impairments/medical necessity and current issues/stressors)

o Example: “Client’s paranoid ideations and auditory hallucinations impair his ability to communicate and engage in social interactions. Current issues/stressors: client would like to participate in rehab activities at Vista Way, but reports he is concerned about ‘people talking about me behind my back’”.

• Progress notes that fail to provide adequate information about the intervention(s) are at risk of disallowance because it may be unclear if the ‘Rehabilitation Activity’ was provided.

5. Therapy (SACs 320, 321, 325, 328, 329) a. Activities (only billed after TCP has been authorized)

• A service activity which is a therapeutic intervention that focuses primarily on symptom reduction as a means to improve functional impairments. Therapy may be delivered to


an individual or group of beneficiaries and may include family therapy at which the beneficiary is present (CCR Title 9 Division 1, 1810.250).

• For documentation of a therapy note, the interventions must focus on amelioration or reduction of mental health symptoms.

• Therapy can be face-to-face, or over the telephone, or via telemedicine with the client(s) or family, and may be provided in the office or in the community.

• Individual Therapy.

• Group Therapy (for two or more clients).

• Family Therapy with the client present.

• Therapy can only be provided by an LPHA or a registered intern/trainee supervised by an LPHA. See the Scope of Practice section for more information.

b. Progress Notes

• Therapy progress notes must include presenting problems (stated in behavioral terms including med necessity, current stressors, functional impairments) and primary symptoms (stated in behavioral terms). o Example of presenting problem: “Client is failing to meet developmental milestones

and age appropriate academic achievements. Ability to make appropriate choices regarding friendships is impaired; client has difficulty communicating thoughts and feelings without emotional outbursts to have needs meet. Current issues/stressors: Confusion regarding no longer seeing biological mother; still worries about biological father ‘finding’ her”.

o Example of primary symptoms: “Client appears disheveled and distracted. Client reports he has recently experienced increased irritability and auditory hallucinations. Client states, ‘it’s hard for me to concentrate when people are talking to me’”.

• Progress notes that fail to provide adequate information about the intervention(s) are at risk of disallowance because it may be unclear if the Therapy activity was provided; i.e., each note must have the problem area/clinical focus, staff intervention and the client’s response. Each note must be unique to the client as well as to an intervention on their client plan.

6. Targeted Case Management (TCM) – Linkage and Brokerage (SAC 371)


• This category includes a broad array of services designed to assist and support clients, including life areas that fall outside of the mental health system.

• Definition of TCM – Linkage and Brokerage services are services that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities may include, but are not limited to, communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary’s progress; placement services; and plan development (CCR Title 9 Division 1, 1810.249).

• Linkage and Brokerage – Assist clients to access and maintain needed services such as psychiatric, medical, educational, social, prevocational, vocational, rehabilitative, or other community services.

• Placement – Assist clients to obtain and maintain adequate and appropriate living arrangements.


• Consultation – Exchange of information with others in support of client’s services

• TCM - Linkage and Brokerage activities are usually face-to-face or by telephone with the client or significant support persons and may be provided in the office or in the community. These services may also include contact with other professionals.

• Communicating, consulting, coordinating and corresponding with the client and/or others to establish the need for services and a plan for accessing these services

• Establishing and making referrals.

• Monitoring the client’s access to services.

• Monitoring the client’s progress once access to services has been established.

• Locating and securing an appropriate living arrangement, including linkage to resources; i.e., Board and Care, Section 8 Housing, or transitional living.

• Arranging and conducting pre-placement visits, including negotiating housing or placement contracts.

b. Progress Notes

• A TCM or Rehabilitation progress note must also include the reason for interaction (describe functional impairments/medical necessity and current issues/stressors)

o Example: “Client’s paranoid ideations and auditory hallucinations impair his ability to communicate and engage in social interactions. Current issues/stressors: client would like to participate in rehab activities at Vista Way, but reports he is concerned about ‘people talking about me behind my back’”

• A TCM Linkage and Brokerage progress note includes the focus of the assistance/intervention provided to the client (e.g., accessing medical services) and justifies the need for this service based on mental health symptoms/issues; i.e. who was spoken to, what was discussed with professional, what is the plan, is there a referral to an outside service and what is the next step needed to assist the client.

7. Crisis Intervention (SAC 375)

a. Activities (Can be provided without TCP authorized).

• An immediate emergency response that is intended to help the client cope with a crisis (e.g. potential danger to self or others; potentially life altering event; severe reaction that is above the client’s normal baseline, etc.).

• Definition – “Crisis Intervention” means a service, lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Crisis Intervention is distinguished from Crisis Stabilization by being delivered by providers who do not meet the Crisis Stabilization contact, site, and staffing requirements described in Sections 1840.338 and 1840.348 (CCR Title 9 Division 1, 1810.209).

• Crisis Intervention activities are usually face-to-face or by telephone with the client or significant support persons and may be provided in the office or in the community. These include:

o Assessment of the client’s mental status, acuity of symptoms and current need o Therapeutic services for the client. o Education, training, counseling, or therapy for significant support persons

involved.


b. Progress Notes

• An excellent Crisis Intervention progress note contains a clear description of the “crisis,” in order to distinguish the situation from a more routine event and the interventions used to help stabilize the client.

• All services provided (i.e., Crisis Assessment, safety plan, Collateral, Individual/Family Therapy, TCM - Linkage and Brokerage) shall be billed as Crisis Intervention.

• Once the crisis is resolved, any follow-up cannot be billed as Crisis.

• The maximum amount claimable to Medi–Cal for crisis intervention in a 24-hour period is 8 hours (480 minutes) per client.

8. Medication Support Services (361, 363, 365, 366, 367, 368)

a. Activities (Can be provided without TCP authorized).

• Services that include prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals necessary to alleviate the symptoms of mental illness (which should be related to client’s documented diagnosis). Service activities may include but are not limited to evaluation of the need for medication; evaluation of clinical effectiveness and side effects; the obtaining of informed consent; instruction in the use, risks and benefits of and alternatives for medication; and collateral and plan development related to development related to the delivery of the service and/or assessment of the beneficiary (CCR Title 9 Division 1, 1810.225).

• Medication Support Services activities are usually face-to-face or by telephone with the client or significant support persons and may be provided in the office or in the community. These services include:

o Evaluation of the need for psychiatric medication. o Evaluation of clinical effectiveness and side effects of psychiatric medication o Medication education, including discussing risks, benefits and alternatives with

the client or support persons. o Ongoing monitoring of the client’s progress in relation to the psychiatric

medication. o Prescribing, dispensing, and administering of psychiatric medications

• Medication Evaluation o For Prescribers only: this service is used when a psychiatric assessment is

performed by a Prescriber.

• Medication Management o For Prescribers only: includes clinic visits, refilling prescriptions , face-to-face or

telephone consults with other Medical Prescribers.

• Medication Support Non-Prescribers o For Medical Staff Non- Prescribers (Registered Nurses, Licensed Vocational

Nurses & Licensed Psychiatric Technicians). o Administering of medication per Prescribers orders. o Evaluation of clinical effectiveness and side effects of psychiatric medication. o Ongoing monitoring of the client’s progress in relation to the psychiatric

medication. o Medication education, including discussing risks, benefits and alternatives with

the client or support persons.

• Psychiatrist, Prescribers, and all Medical Staff Non-Prescribers (see above) can also provide:


o Medication Injection. o Prep report other Physicians/Agency (Preparation of report for other

physicians/agencies). o Review Hospital Records/Reports/Labs (Review of hospital records, reports and

labs).

• The maximum amount claimable to Medi-Cal for medication support services in a 24-hour period is 4 hours (240 minutes) per client.

• Aside from Medication Support Services, all Psychiatrists, Prescribers, Medical Staff Non- Prescriber Staff and most non-medical staff may also provide Plan Development, TCM- Linkage and Brokerage or Crisis Intervention as needed.

• If a Case Manager consults with a Psychiatrist (or Prescriber) about a client who has new stressors in their life and the Psychiatrist (or Prescriber) gives clinical advice, both the Psychiatrist (or Prescriber) and the Case Manager should bill TCM-Linkage and Brokerage.

9. Kaite A

a. Katie A. “Subclass” Intensive Care Coordination (SAC 370)

• Intensive Care Coordination services are provided to Katie A. “Subclass” members that are similar to the types of services provided with Linkage and Brokerage services. The difference between ICC and the more traditional Linkage and Brokerage services is that ICC must be used to facilitate the implementation of the cross-system/multi-agency collaborative services approach described in the Core Practice Model Guide for Katie A Subclass. ICC service components and activities are: o Assessing

▪ Assessing clients and family’s needs and strengths. ▪ Assessing the adequacy and availability of resources. ▪ Reviewing information from family and other sources. ▪ Evaluating effectiveness of previous interventions and activities.

o service planning and Implementation ▪ Developing a plan with specific goals, activities, and objectives. ▪ Ensuring the active participation of client and individuals involved and clarifying

the roles of individuals involved. ▪ Identifying the interventions/course of action targeted at the client’s and

family’s assessed goals. o Monitoring and Adapting

▪ Monitoring to ensure that identified services and activities are progressing appropriately.

▪ Changing and redirecting actions targeted at the client’s and family’s assessed needs, not less than every 90 days.

o Transition ▪ Developing a transition plan for the client and family to foster long term stability

including the effective use of natural supports and community resources.

• Medi-Cal Manual for Intensive Care Coordination (ICC), Intensive Home-based Services (IHBS) & Therapeutic Foster Care (TFC) for Katie A. Subclass Members. http://www.dhcs.ca.gov/Documents/KatieAMedi-CalManual3-1-13FinalWPREFACE.pdf

• Pathways to Mental Health Services – Core Practice Model (CPM) Guidehttp://www.dhcs.ca.gov/Documents/KACorePracticeModelGuideFINAL3-1-13.pdf.


b. Katie A. “Subclass” Intensive Home-Based Services (IHBS) (SACs 322, 326)

• Intensive, individualized and strength-based, needs-driven intervention activities that support the engagement and participation of a child/youth and his/her significant support persons and to help the child/youth develop skills and achieve the goals and objectives of the client plan. IHBS are not traditional therapeutic services. This service is targeted to the Katie A. Subclass (and their significant support persons). Services are expected to be of significant intensity to address the intensive mental health needs of the child/youth, consistent with the client plan and the Core Practice Model. Services may be delivered in the community, school, home or office settings. IHBS services includes, but not limited to:

• Medically necessary skill-based interventions for the remediation of behaviors or improvement of symptoms.

• Development of functional skills to improve self-regulation or self-care.

• Education of the child/youth/family/caregiver about how to manage the clients’ symptoms.

• Support of the development, maintenance and use of social networks and community resources.

• Support to address behaviors that interfere with the achievement of a stable and permanent family life and stable housing, obtain and maintain employment and achieving educational objectives.

10. Therapeutic Behavioral Services (TBS) (SACs 345, 346)

• Supplemental specialty mental health services under the EPSDT benefit. TBS is an intensive, individualized, one to one, short-term, outpatient treatment intervention for clients up to age 21 with Serious Emotional Disturbances (SED) who are experiencing a stressful transition or life crisis that is placing the individual at risk of an out of home placement in a RCL 12 or higher or are at risk of a psychiatric emergency.

• TBS activities are usually face-to-face with the client and can be provided in most settings. TBS-related activities can also be provided to significant support persons in collaboration with other professionals.

• One-to-one therapeutic contact typically models/teaches, trains or supports appropriate behavioral changes.

• TBS activities may also include assessment, collateral, and plan development, which are coded as TBS.

• TBS is provided only by qualified providers.


VIII. NON-REIMBURSABLE SERVICES For Medi-Cal, some services are not eligible for reimbursement even though they may be provided on behalf (and to the benefit) of the client. These services should have a service activity code of 106. These non- reimbursable services include, but are not limited to, the following:

1. Academic educational services. 2. Vocational services which have as a purpose actual work or work training 3. Recreation. 4. Personal care services provided to clients (e.g. grooming, personal hygiene, assisting with

medication, preparation of meals, etc.). 5. Socialization if it consists of generalized group activities which do not provide systematic

individualized feedback to the specific target behaviors of the clients involved. 6. Transportation of a client. 7. Service provided solely payee related. 8. Translation/interpretation services. 9. Missed appointments. 10. Travel time when no face-to-face contact with the client or significant support person was

provided, including leaving a note on the door for the client. 11. Leaving and/or listening to telephone messages. 12. Communication via e-mail unless clinically appropriate (e.g., therapeutic communication for

deaf and hard-of-hearing clients). 13. Completing mandatory reports: CSD, APS, Tarasoff, etc., including making associated phone calls 14. Completing Social Security reports, if there is no face-to-face contact with the client or

significant support person. 15. Clerical tasks: faxing, copying, mailing, etc. 16. After the death of a client, no services are billable. 17. Supervision in which the primary purpose is for the benefit of the clinician, which includes

trainees and student interns. Regularly scheduled supervision time would not be reimbursable, even though the client’s care may be discussed.

18. Staff development activities, including conferences, workshops, trainings, reading literature, Internet searches, etc.

19. Preparation for a service activity, such as collecting materials for a group session 20. Cleaning the office/play therapy room after client leaves.


IX. LOCK-OUTS

1. A “lockout” means that a service activity is not reimbursable through Medi-Cal because the client resides in and/or receives mental health services in one of the settings listed below. A clinician may provide the service (e.g. targeted case management for a client residing in an IMD), but it would be reimbursable only under certain circumstances.

a. Jail/Prison. b. Juvenile Hall (not adjudicated). c. IMD.

2. No service activities are reimbursable if the client resides in one of these settings (except for the

day of admission & discharge): a. Psychiatric Inpatient. b. Psychiatric Nursing Facility. c. Exception: Medication Support Services or TCM-Linkage and Brokerage (for placement

purposes only within 30 days of discharge) are reimbursable.

3. No other service activities are reimbursable during the same time period that the client is at the Crisis Stabilization Unit.

a. Exception: Targeted Case Management for placement purposes only is reimbursable while client is at the Crisis Stabilization Unit (CCR, Title 9, Section 1840.368).

4. Intensive Care Coordination (ICC)

a. For members of the target group who are transitioning to a community setting ICC services will be made available for up to 30 calendar days for a maximum of three non-consecutive periods of 30 calendar days 25 or less per hospitalization or inpatient stay prior to the discharge of a covered stay in a medical institution.

b. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions.

c. ICC may be provided solely for the purpose of coordinating placement of the child/youth on discharge from the hospital, psychiatric health facility, group home or psychiatric nursing facility, may be provided during the 30 calendar days immediately prior to the day of discharge, for a maximum of three nonconsecutive periods of 30 calendar days or less per continuous stay in the facility as part of discharge planning.

5. Intensive Home-Based Services (IHBS)

a. Mental health services (including IHBS) are not reimbursable when provided by day treatment intensive or day rehabilitation staff during the same time period that day treatment intensive or day rehabilitation services are being provided.

b. Authorization is required for mental health services if these services are provided on the same day that day treatment intensive or day rehabilitation services are provided. IHBS may not be provided to children/youth in Group Homes. IHBS can be provided to children/youth that are transitioning to a permanent home environment to facilitate the transition during single day and multiple day visits outside the Group Home setting. Certain services may be part of the child/youth’s course of treatment, but may not be provided during the same hours of the day that IHBS services are being provided to the child/youth. These services include:

a. Day Treatment Rehabilitative or Day Treatment Intensive


b. Group Therapy c. Therapeutic Behavioral Services (TBS) d. Targeted Case Management (TCM)

6. Standard Skilled Nursing Facility (SNF) is NOT a lock-out environment; only a Skilled Psychiatric

Nursing Facility would be a lock-out. A Skilled Nursing Psych Facility requires more than 50% of the beds to be “psych” beds.


APPENDIX A MEDICAL NECESSITY CRITERIA - DIAGNOSES

A. Included Diagnoses

The following DSM disorders qualify for a primary diagnosis: 1. Disruptive Behavior and Attention Deficit Disorders 2. Feeding and Eating Disorders of Infancy or Early Childhood 3. Elimination Disorders 4. Other Disorders of Infancy, Childhood, or Adolescence 5. Schizophrenia and Other Psychotic Disorders, except Psychotic Disorders due to a General

Medical Condition 6. Mood Disorders, except Mood Disorders due to a General Medical Condition 7. Anxiety Disorders, except Anxiety Disorders due to a General Medical Condition 8. Somatoform Disorders 9. Factitious Disorders 10. Dissociative Disorders 11. Paraphilic Disorders 12. Gender Identity Disorder 13. Eating Disorders 14. Impulse-Control Disorders Not Elsewhere Classified 15. Adjustment Disorders 16. Personality Disorders, excluding Antisocial Personality Disorder 17. Medication-Induced Movement Disorder related to other included diagnoses

B. Excluded Diagnoses

The following DSM disorders do not qualify for a primary diagnosis: 1. Autism Spectrum Disorders 2. Learning Disorders 3. Motor Skill Disorders 4. Communication Disorders 5. Tic Disorders 6. Delirium, Dementia, and Amnestic and Other Cognitive Disorders 7. Mental Disorders Due to a General Medical Condition 8. Substance-Related Disorders 9. Sexual Dysfunctions 10. Sleep Disorders 11. Other conditions that may be a focus of clinical attention, except Medication-Induced

Movement Disorders 12. Mental Retardation 13. Antisocial Personality Disorder 14. 799.9 / R69 Deferred Diagnosis 15. V71.09 / Z71.1 No Diagnosis


APPENDIX B DOCUMENTATION TIMELINES

NAME OF DOCUMENT INITIALLY COMPLETED UPDATED Informed Consent Initial contact – at time of

assessment. Annually

Advanced Directive (Adults Only)

Discuss with client (complete form if client requests Advanced Directive).

Not required

Member Information Brochure Initial contact – at time of assessment.

Not required

Acknowledgement of Receipt of Notice of Privacy Practices

Initial contact – at time of assessment.

Not required

Patients’ Rights Brochures Initial contact – at time of assessment.

Not required

Acknowledgment of Receipt of Medi-Cal Handbook


Not required

Acknowledgment of Receipt of CCRU Information


Annually

Pay or Financial Information Form (PFI)


Annually or if situation changes

Client CSI Data (CA State Info) Initial contact – at time of assessment.

Annually

Emergency Contact Initial contact – at time of assessment.

Annually

Release of Information Offered at initial contact – at time of assessment. Offered as needed to obtain, disclose, or exchange protected health information.

As needed (upon expiration of ROI or client’s preference)

Assessment Initial contact. Annually (see 30-60-90 process F:\mh\admin\reports\30 60 90 Caseload and Assessment Report (changes accepted).doc)

Client Service Plan Initial TCP due at the time of the assessment, and no later than 60 days from assessment date.

See 30-60-90 process (F:\mh\admin\reports\30 60 90 ASR Reports - Aug 2014.doc )

Progress Notes Same day of service. N/A

Consent for Psychotropic Medication Therapy

By Psychiatrist (or Prescriber) when medication is prescribed.

Completed when a new medication is added

Medication Order Sheet By Psychiatrist or (or Prescriber) when medications are prescribed.

Whenever meds are added, refilled, or discontinued

NOAs Complete NOA when client meets criteria (see NOA process)

N/A



APPENDIX C SERVICES ACTIVITY CODES DEFINITIONS

A. ASSESSMENT / TCP 301/302/330 - Can only be billed when there is no TCP signed and authorized. All other services require a current authorized TCP.

• 301 ASSESSMENT AND EVALUATION Formal assessment of a client that formulates a clinical analysis of the history and current status of the client’s mental, emotional, or behavioral disorder, including relevant cultural issues.

• 302 ASSESSMENT – OTHER This code is used for further assessment of a client’s mental diagnosis when more than one session with the client is required.

• 330 PLAN DEVELOPMENT Service activity, which consists of the development of client plans and the approval of client plans. Progress notes should state that the client plan goals and interventions were developed, updated, progress toward the goals, or how the interventions will be implemented.

NOTE: Only 301/302/330 SAC’s can be billed when there is no TCP signed and authorized. All other services require a current authorized TCP.

B. THERAPY

• 310 COLLATERAL Services to one or more significant support persons in the life of the client for the purpose of improving or maintaining the mental health of the client. Progress notes must address the goals and interventions on the client plan.

• 320 GROUP THERAPY Services provided to a group of clients that focus on symptom reduction as a means to improve functional impairment. Progress notes must include the number of clients in the group and address the goals and interventions on the client plan.

• 325 INDIVIDUAL THERAPY Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments. Progress notes must address the goals and interventions on the client plan.


C. REHABILITATION

• 340 REHABILITATION SERVICES Counseling and other services with a client which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must address the goals and interventions on the client plan.

• 341 GROUP REHABILITATION SERVICES Services provided to a group of clients which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must include the number of clients present and address the goals and interventions on the client plan.

• 342 REHABILITATION EVALUATION Formal evaluation of a client’s need for rehabilitation services.

D. CASE MANAGEMENT

• 371 BROKERAGE & LINKAGE/TARGETED CASE MANAGEMENT Services that assist a beneficiary to access needed medical, alcohol and drug treatment, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities include: communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and plan development.

E. CRISIS SERVICES

• 373 CONSERVATOR EVALUATION Psychiatrist evaluation of a client for LPS (Lanterman, Petris, and Short Act 1970) conservatorship (client is gravely disabled as a result of mental disorder as per Welfare and Institutions Code Section 5350-5372).

• 375 CRISIS INTERVENTION Face-to-face service time (client physically present). Unplanned services that require a more timely response than a regularly scheduled visit. Progress notes need not address the client plan goals and interventions; notes must document the nature and severity of the crisis, staff interventions to manage the crisis, and follow-up plans. Multiple contacts may be documented in a single note and contacts with collateral individuals may be included.


• 380 CRISIS STABILIZATION Crisis Stabilization” means a service lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis stabilization is distinguished from crisis intervention by being delivered by providers who do meet the crisis stabilization contact, site, and staffing requirements described in Sections 1840.338 and 1840.348.

NOTE: Authority: Section 14680, Welfare and Institutions Code. Reference: Sections 5777, 14021.4, and 14684, Welfare and Institutions Code.

F. MEDICAL SUPPORT SERVICES

• 361 MEDICATION SUPPORT-MD Face-to-face service time (client physically present). This code is to be used by psychiatrists and other individuals with prescriptive authority (Nurse Practitioner, Physician Assistant) for ongoing assessment, prescription, administration of medications, etc., but also includes a substantial psychotherapy component. Note: this code should not be used during routine 2F2 visits with clients that centers primarily on issues of medication.

• 363 MEDICATION SUPPORT A non face-to-face direct service activity (the client is not present). This code is used primarily for two Medi-Cal claimable activities: developing and writing a medication client plan (med support Plan Development); or medication monitoring services including review of recent lab reports, medication renewal orders, etc.

• 365 MEDICATION SUPPORT Face-to-face (client physically present). This code is to be used by any licensed medical staff without prescriptive authority (RN, LVN) where the primary purpose is ongoing assessment, monitoring, and dispensing of medications, etc.

• 366 MEDICATION SUPPORT GROUP Medication support services group (not Clozaril).

• 367 CLOZARIL MEDICATION SUPPORT GROUP-MD All Clozaril clients are seen weekly in a medication support group facilitated by a licensed nurse and MD. This is the code used by the MD. Group activities include assessment of clients, monitoring adherence to the medication regimen, observing for potential side-effects/adverse effects of the medication, providing medication education, and encouraging appropriate socialization.

• 368 CLOZARIL GROUP – NON-MD All Clozaril clients are seen weekly in a medication support group facilitated by a licensed nurse and MD. This is the code used by the nurse. Group activities include assessment of clients, monitoring adherence to the medication regimen, observing for potential side-effects/adverse


effects of the medication, providing medication education, and encouraging appropriate socialization.

G. KATIE A

• 322 (GRP) and 326 (INIDIVIDUAL) INTENSIVE HOME BASED SERVICES (IHBS) – KATIE A Intensive home-based mental health services (IHBS) are mental health rehabilitation services provided to members of the Katie A. Subclass. IHBS are individualized, strength-based interventions designed to ameliorate mental health conditions that interfere with a child/youth’s functioning and are aimed at helping the child/youth build skills necessary for successful functioning in the home and community and improving the child/youth’s family ability to help the child/youth successfully function in the home and community.

• 370 INTENSIVE CARE COORDINATION (ICC) – KATIE A Intensive care coordination (ICC) is a targeted case management (TCM) service that facilitates assessment of, care planning for and coordination of services, including urgent services for members of Katie A. Subclass.

H. THERAPEUTIC BEHAVIORAL SERVICES

• 345 THERAPEUTIC BEHAVIORAL SERVICES (TBS) – DIRECT This includes all direct services relating to TBS including direct service and collateral contacts with the family. Progress notes must address the goals and interventions on the TBS client plan. One note per shift.

• 346 THERAPEUTIC BEHAVIORAL SERVICES (TBS) PLANNING: This includes all plan development. Progress notes must address the goals and interventions on the TBS client plan. One note per shift.