APPENDIX A

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF MENTAL HEALTH

DECEMBER 18, 2008

COMMUNITY BASED FLEXIBLE SUPPORTS STANDARDS

Introduction

These Standards are part of theCommunity Based Flexible Support Request For Response (RFR). The Standards must be read in conjunction with the service requirements set forth in Sections 2 and 3 of the RFR.

  1. SCREENING, ASSESSMENT, TREATMENT PLANNING, PROGRESS NOTES, CLIENT RECORDS

A.Screening & Enrollment

1.Screening is done by a Licensed Practitioner of the Healing Arts(LPHA) within 72 hours of the referral, including weekends and holidays.

2.Screening is conducted in the person’s preferred language by staff with native linguistic proficiency, staff fluent in the language, or through professional interpreters.

3.The documentation of the screening includesthe date, place, time, participants, and findings.

4.If as a result of the screening it is determined there are immediate health and safety issues,a critical needs plan is developed. Theplan is written and documents the interventions required to maintain the immediate health and safety of the client. The plan is signed by the LPHA and, if possible, the client or LAR.

5.The findings of the screening and the critical needs plan, if any, are used when completing the assessment.

6.Upon enrollment into CBFS, clients are provided with an orientation to the contractor and its CBFS services. The following written information, in the client’s and LAR’s primary language, if feasible, is presented to and reviewed with each clientandLAR:

  • A description of CBFS services
  • Hours of operation
  • Fee structure
  • Confidentiality policy
  • Informed consent policy and forms
  • Nondiscrimination provisions
  • Rights and responsibilities

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Department of Mental Health Community Based Flexible Supports Request For Response

December 18, 2008

Appendix A -Standards

  • Telephone number(s) of Emergency Services Program(s)
  • The name and responsibilities of the human rights officer
  • Grievance and appeal procedures, including how to file a human rights complaint with DMH and how to file a complaint of abuse with the Disabled Persons Protection Commission (DPPC).

If written information is not available in a client’s/LAR’s primary language, interpreters must be used.

B.Assessment

1.Each newly enrolled CBFS client is assessed within twenty (20) calendar days of enrollment and, at a minimum, annually thereafter.

2.Assessments are conducted in the client’s preferred language by staff with native linguistic proficiency, staff fluent in the language, or through professional interpreters.

3.Assessments are strength-based and person centered and use information obtained through interactions with the client and the client’s other treaters with the appropriate authorizations, as well as previous records as available.

  1. Assessments include an evaluation of risk of harm to self or others. The assessments indicate if these risks are related to symptoms or substance abuse and includefrequency and last occurrence of behaviors.

5.Assessmentsresult in clinical formulations which document the need for rehabilitative services as clinically appropriate. Formulations are used to inform the client’s Individualized Action Plans.

6.LPHAs are responsible for assessments.

7.Assessments are signed by LPHAsand if possible, the clients or LARs.

8.Copies of the assessments are given to the clients or LARs.

  1. Assessments are reviewed and modified as the clients’ needs or circumstances change.

C.Individualized Action Plan (IAP)

  1. IAPsare completed within 30 calendar days of enrollment.
  2. IAP planning is conducted in the client’s preferred language by staff with native linguistic proficiency, staff fluent in the language, or through professional interpreters.
  3. IAP meetings, to the extent reasonably possible, are scheduled to maximize attendance particularly of clients, LARs and the individuals of the clients’or LARs’choosing.
  4. Clients are encouraged to invite family members or other persons of their choice to be present during the development of their IAPs.
  5. Clients are engaged and supported to participate actively in the IAPprocess.
  6. IAPsare strength-based and guidedby the clients’ stated preferences.
  7. IAP goals, objectives, and interventions reflect the clinical formulation resulting from the assessment.
  8. LPHAsare responsible for the development of IAPs.
  9. IAPs are signed by LPHAs and the clients or LARs.
  10. Copies of the IAPs are given to the clients or LARsand the clients’ DMH operated and funded service providers.
  11. If a client receives DMH case management services, a copy of the client’s IAP issubmitted to his or hercase manager. The IAP is compatible with the client’s Individual Service Plan as required in 104 CMR 29.06. If a client is not receiving DMH case management services, his or her IAP is provided to DMH upon request.
  12. If during the development of an IAP, additional evaluations are determined necessary and are beyond the CBFS contractor’s capacity to perform, a request shall be brought to the Area Director, or designee, for authorization to have such evaluations performed by others.
  13. IAPs are in compliance with treatment planning regulations.
  14. When IAPs are modified, the assessmentsare reviewed and updated as needed to reflect the changes in the IAPs.
  15. IAPs are reviewed 3 months, 6 months and annually thereafter, and as needs change.
  1. Notes
  1. IAP progress notes are entered into aclient’s record each time a client receives an intervention as identified in the client’s IAP.
  2. IAP progress notes link the interventions delivered to the specific goals and objectives.
  3. IAP progress notes include the client’s response to the interventions and document outcomes and progress towards goals and objectives.
  4. Other notes are maintained regarding other significant life events which impact clients and in accordance with the contractor’s own protocols.
  1. Client Records
  1. Aconsolidated client record is maintained for each client at a centralized location for ready access to and review by the client, LAR, DMH, and the contractor.
  2. Client records include information that is sufficiently detailed to enable DMH to monitor and evaluate services.
  3. Confidentiality of records is maintained in accordance with 104 CMR 28.09 and the DMH CBFS Business Associate Terms and Conditions.

II.RECOVERY & SELF MANAGEMENT

  1. Clients are provided with information and options about recovery tools and techniques and self management strategies, and are given support by staff and, when desired, assistance in developing a self management plan. (e.g., WRAP)
  2. Clients’ self management plans and tools are incorporated into their crisis plans.
  3. Family members, friends and other individuals as chosen by the clients are incorporated in the development of self management plans and the recovery process.
  4. When self management plans include a crisis plan, they are used to inform the CBFS contractor’s crisis plan for the clients.

III.STAFFING

A.General Staff

  1. Staffing patterns are adequate to meet the needs of the client population.
  2. Staff has competencies in assessing and treating clients with serious mental illness and co-occurring addiction disorders to perform CBFS services.
  3. Identified staff isknowledgeable and current about Evidence Based Practices (EBPs), including, but not limited to, the SAMHSA identified EBPs. This includes being aware of the appropriateness of the EBP to the client population and/or individual clients, for which issues and clients it is effective; the staffing, credentialing and training required to implement the EBP; and the essential features of the model.
  4. 24-hour seven days a weekaccess to staff is available, including clinical staff.
  5. Staffisknowledgeable about tenant rights, subsidies, and resources available for housing maintenance and furnishing.
  6. Staff is knowledgeable about employment, Individualized Placement Support model, job readiness, skills development, and job placement and support.
  7. Staffing patterns allow for the ability to administer flexible services that are responsive to the individual needs of clients.
  8. LPHAsare responsible for the screening, assessment, development and review of IAPs.
  9. Consultation is available with registered nurses, nurse practitioners,or physician assistants in matters related to physical health, medication management and wellness.
  10. Credentials of professional staff are verified.
  11. Recruitment and employment practices promote the hiring and retention of people with lived experience. (Lived Experience is knowledge about mental illness that comes from the experience of being diagnosed and treated for his/her diagnosis, including for co-occurring disorders.)
  12. The staff with lived experience is supported by the provision of opportunities for peer supervision, consultation and support.
  13. Staffing patternsare diverse and culturally sensitive and reflect the cultural and linguistic needs of the clients.
  14. Services are culturally and linguistically competent.
  15. Staff fluent in the clients’ preferred language or professional interpreters are available to work with the client around engagement, re-engagement, developing a relationship sufficient to support treatment, providing assessments, reassessments, clinical rehabilitative and recovery based interventions; and to assess and respond to changes in acuity in a timely manner.
  16. To the extent feasible (clinically, economically, etc.), staff with whom a client is working shall continue to work with the client, regardless of possible or temporary changes in settings or changes in services needs.
  17. Each staff position has a written job description that clearly delineates roles and responsibilities.

B.Staff Supervision and Training

1.Staff receives ongoing training in assessing and treating individuals with serious mental illness and co-occurring addiction disorders and are knowledgeable about self help groups and peer counseling.

2.Staff providing direct services to clients receives regularly scheduled and ongoing supervision and consultation by licensed clinicians to promote achievement of client’s treatment goals. Supervision is provided by individuals with the appropriate credentials.

3.Staff receives appropriate training in the following competencies: psycho-social rehabilitation; principles and values of recovery-oriented and rehabilitative services including strength-based assessment, person centered treatment planning; wellness and culturally competent service delivery. Demonstration of competencies in these areas is verified annually.

4.Identified staff receives specialized training on motivational interviewing, trauma-informed care, harm reduction,Individual Placement and Support, and SAMHSA’s identified Evidence-Based Practices. These specially trained experts are available to consult actively and to mentor other staff to ensure treatment planning reflects current knowledge about effective interventions.

5.Staff receives mandatory orientation thatincludes initial job training and instruction on the contractor’s policies and procedures, particularly in regard to human rights and protected health information privacy and security.

6.Staff is trained on DMH mandated regulations and policies.

7.Staff is oriented and trained to work collaboratively with peer support staff and/or services.

8.Employee and subcontractor(s) job performanceis reviewed periodically in accordance with the contractor’s written protocol for such.

  1. SERVICE DELIVERY

A.Provider Linkages

1.Working relationships with community entities are maintainedthat may provide supports, services or opportunities to clients and their families and/or natural support system including, but not limited to, the following:

  • local community providers
  • educational institutions
  • places of worship
  • medical and emergency services
  • self-help groups
  • Recovery Learning Communities (RLC)
  • cultural and linguistic resources

B.Integration of Care

  1. Clients are assisted in the following transitions: as a new client to the CBFS contractor, as a CBFS client following hospitalization or other crisis placement, as a client is being discharged from CBFS.
  2. Clients are assisted with establishing linkages with community and other supports as necessary.
  3. Compatible with client preferences and authorization(s), CBFS services include working towards improving the quality of the client’s social network and family relationships.
  4. When a client is hospitalized or admitted to a detoxification or crisis stabilization program, CBFS staff participate in discharge/aftercare planning.
  5. When a client is being prepared for release from jail or a correctional facility, staff works with facility staff to assist in the client’s return to the community.
  6. If a client terminates without notice, documented efforts are made to contact the client and to provide assistance for follow-up services. DMH is informed of the termination.
  7. Rehabilitation interventions occur as often as possible in the community, rather than an office environment, for side-by-side teaching and social interaction.

C.Medication Education & Self Management

  1. Evaluations of the clients’ ability to self administer medications are conducted as part of the IAP process.
  2. Services are designed to provide the necessary support and training for clients to self administer and monitor their own medication whenever possible.
  3. Clients are supported in developing self advocacy skills regarding the effective use of medications with CBFS staff and prescribing practitioners.
  4. For clients unable to self administer medications, medication administration is consistent with the regulations and policies of DMH and the Department of Public Health that currently allow only staff certified under the Medication Administration Program (MAP), or appropriately licensed, to administer medication.
  1. Wellness
  1. Opportunities for physical activity for clients are provided.
  2. Nutritional offerings and broad-based nutritional education are provided.
  3. The treating of nicotine addiction and the reduction of cigarette smoking is promoted.
  1. HOUSING
  1. Housing and/or room and board provided by the contractor meets all applicable zoning, building and sanitation codes and comply with the Americans with Disability Act.
  2. Housing and/or room and board meets all licensing requirements set forth in 104 CMR 28.00.
  3. Clients have access to their residences 24 hours a day.

VI.CRISIS MANAGEMENT

1.Evaluation of the need to develop a crisis management plan shall be conducted during screening, assessment, and as part of the IAP process.

2.The plan is documented in writing, dated, signed in accordance with the CBFS contractor’s protocol.

3.The plan is distributed to all parties involved in the plan and readily accessible to appropriate CBFS staff.

4.The plan is reviewed minimally when the IAP is reviewed.

5.The plan is modified as necessary in the event of changes in the client’s clinical status, circumstances, protocols, signs/symptoms, and/or preferred interventions.

6.Crisis plans incorporate a client’s self management plan, if any.

  1. Affiliation agreements are established and maintained with, but not limited to, designated emergency services screening teams, hospitals, police department clinics.
  2. There are provisions for emergency medical services when needed.

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