Program Guidance for Managing Entity Contracts

Template 5

ALF-LMH Forms

Requirement: Sections 394.4574, and 429.075, F.S.

Attachment I, Section B.1.a.(3)(b)4)

Guidance Document 8

Frequency: Ongoing

Due Date: Data report from monitoring due annually with July data submission;

ALF-LMH Plan due December 1st annually

Effective: July 1, 2015

ALF-LMH Monitoring Tool

Mental Health Providers Serving Residents in Assisted Living Facilities with Limited Mental Health License

Date of Audit:

Mental Health Provider: Address:

Staff Conducting Audit:

Record 1 Compliance / Record 2 Compliance / Record 3 Compliance
CITATION / Yes / No / yes / No / Yes / No
ELIGIBILITY AND ASSESSMENT
394.4574 (1) / Documentation shows that the individual meets the definition of a mental health resident (the individual receives SSDI; or SSI and Optional State Supplementation (OSS).
394.4574(2)(d) / Is the documentation that the resident meets the definition of a mental health resident provided to the ALF administrator within 30 days of admission?
394.4574(2)(a) / Has an assessment been completed by the resident’s Mental Health Provider to document appropriateness for ALF placement?
394.4574(2)(a) / Was the above assessment conducted by a psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse (or an individual who is supervised by one of these professionals)?
394.4574(2)(e) / Has the provider assigned a case manager to the resident?
Note: If the resident refused case management services, there is documented evidence of refusal.
N/A / Does the case manager visit the resident at least monthly?
Note: During visits, the case manager should also meet with ALF administrator/ staff.
COOPERATIVE AGREEMENT
394.4574(2)(b) / The provider has a current copy of the Cooperative Agreement signed by the provider and the ALF-LMH administrator (Agreement may cover all residents; verify ALF-LMH licensure)
394.4574(2)(b) / The Cooperative Agreement specifies directions for accessing emergency and after-hours care for the mental health resident(s).
Record 1 Compliance / Record 2 Compliance / Record 3 Compliance
CITATION / Yes / No / yes / No / Yes / No
COMMUNITY LIVING SUPPORT PLAN (CLSP)
394.4574(2)(c) / The provider has a copy of the Community Living Support Plan for each mental health resident in ALF-LMH? (The CLSP and the Cooperative Agreement may be in one document)
394.4574(2)(c)
58A-5.029, FAC / CLSP was prepared with and signed by:
1. The mental health resident (if refusal, documentation of refusal is found)
2. The mental health case manager
3. The ALF administrator, or the administrator’s designee
394.4574(2)(c)
429.02(7)
429.075(3)
58A-5.029 FAC / The plan includes information about:
1. The specific needs of the resident
2. Specific services (including frequency and duration) to be provided by mental health provider
3. Other services/activities (including frequency and duration) to be provided by mental health provider
4. Obligations of the ALF to assist/facilitate resident attending appointments
5. Other services provided or arranged by ALF
6. Factors pertinent to the care, safety, and welfare including signs/symptoms that indicate immediate need for mental health services
394.4574(2)(c)
58A-5.029(2)(c)(3), FAC / Was the CLSP completed and given to the ALF administrator within 30 days of admission, or within 30 days after ALF received the placement assessment (whichever is later)?
394.4574(2)(e) / Is the CLSP updated annually?

2 Effective: FY 2012

Assisted Living Facility with Limited Mental Health License

Community Living Support Plan and Cooperative Agreement

Name of the Assisted Living Facility (ALF): ______

ALF Administrator’s Name: ______

ALF Address: ______Phone #: ______

Resident's Name: ______ALF Admission Date: ______

Resident’s current Health Plan: __________________

The resident is a recipient of Medicaid Medicare Other ______.

(check one)

Resident’s Power of Attorney/Legal Guardian, if applicable:______
Address: ______Phone #: ______
Resident’s Primary Care Physician: ______
Address: ______Phone #: ______
Resident’s Psychiatrist: ______
Address: ______Phone #: ______
Case Management Agency (CMA) or Community Mental Health Center (CMHC):
______
Address: ______Phone #: ______
Resident’s Case Manager: ______Phone #: ______
Managing Entity (ME) / Substance Abuse Mental Health (SAMH) Program Office Contact:
______Phone #: ______
Behavioral Health Care After-hours and Emergency Contacts:
u 911 for immediate assistance
u CMHC 24/7 Hotline: ______
u Health Plan’s Behavioral Health 24/7 Emergency contact #:______

In addition to the required health assessment completed within (30) thirty days of admission on AHCA’s 1823 Form, the below assessment was conducted to determine the appropriateness for placement:

q An Alternate Care Certification for Optional State Supplementation (OSS) Form, CF-ES Form1006 Form

q A discharge statement or form from a State Mental Hospital, completed (90) ninety days prior to admission

q A signed statement that the resident has been assessed and found appropriate for residency in an ALF that was conducted by a psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse, or a person (clinician) supervised by one of the these professionals (under FAC 58A-5.029(2))

The resident’s appropriateness for placement assessment was received by the ALF on ______.

Indicate the specific needs of the resident to enable the resident to live in the Assisted Living Facility.

1. Pursuant to 429.28(1)(j), list below the applicable clinical mental health services to be provided or arranged by the mental health provider in order to meet the resident's needs. (E.g., psychiatrist, ARNP, therapist, substance abuse treatment provider(s), etc.)

Agency / Service / Provider Name / Phone #

2. List below other non-clinical support services and activities to be provided by or arranged for by the mental health care provider, case manager or other State Agencies.

Agency/Provider / Service / Phone #

3. Pursuant to 429.41(3)(h)(4), the responsibilities of the facility are to assist the resident in attending appointments and activities. List below any services arranged for or provided by the ALF.

Type of Appointment
or Activity / Transportation Provider / Frequency

4. List additional services and activities currently available to the resident at the ALF:

______

5. List any special needs of the resident (e.g., related to head injuries, special medical, forensic issues, etc.) and any precipitating factors, which may indicate the need for professional services. Please include contact information, if applicable:

______

6. Please assist the resident with completing Sections I and II.

Section I - Triggers

Please ask the resident the following question: What are some of the things that make you angry or very upset?

Please check or *fill in the answers below:

Being touched / Other:
Loud noises / Other:
Taking my belongings without asking / Other:
Name calling / Other:
Other: / Other:

Section II - Calming Strategies

Please ask the resident the following question: Please share with us as many activities that you believe will be helpful when you are angry or very upset?

Please check or *fill in the answers below:

Listen to music / Exercise
Read a book / Do artwork (painting, drawing, etc.)
Wrap-up in a blanket / Hug an object of significance
Writing my feelings down / Drink a beverage
Watch television / Read spiritual material
Talk to staff / Go for a walk
Talk with peers / Other:
Call a friend or family member / Other:
Take time in a quiet room/comfort room voluntarily / Other:
Take a shower / Other:

7. The following people are peer supports for the ALF resident:

Name: ______Relationship: ______Phone #: ______

8. In accordance with 429.02(8) F.S., the below list of action steps should be used on behalf of the ALF resident to ensure he/she has accesses to emergency, after-hours and weekend behavioral health services:

1. ______

2. ______

3. ______

4. ______

5. ______

9. Identify any barriers that may prevent the resident from receiving services that are deemed necessary and how they will be addressed. (E.g., transportation, insurance coverage, elopement risks, resident’s refusal to sign the plan, etc.):

______

10. Date of the last Community Living Support Plan on record______

11. Other comments: ______

u Signatures: The signatures below affirm that this document serves as a written statement of understanding between the Mental Health Provider and the Assisted Living Facility (ALF) developed by the Mental Health Case Manager to ensure delivery of the appropriate services for the identified ALF Resident. Upon obtaining consent from the ALF Resident, the ALF Administrator may receive a copy of the Treatment Plan from the Mental Health Provider and a copy of the Service Plan from the Intensive or Targeted Case Manager.

______

ALF Resident Date

______

Power of Attorney/Legal Guardian, if applicable Date

______

ALF Administrator or Designee Date

______

Case Manager Date

______

Case Manager Supervisor or Designee Date

______

Mental Health Provider or Designee Date

ANNUAL PLAN for FY ______Managing Entity Region ______

ASSISTED LIVING FACILITIES-LIMITED MENTAL HEALTH (ALF-LMH) LICENSE ANNUAL PLAN

Section 394.4574, F.S., requires each Department of Children and Families region to submit an annual plan for ensuring services to residents in Assisted Living Facilities with Limited Mental Health licenses (ALF-LMH).

Section 429.075, F.S requires the Department to approve or provide mental health training to ALF-LMH staff. The Department has updated training materials July, 2012 and requires that they be used.

By December 1st annually, submit the Managing Entity regional plan for how the providers intend to ensure that these requirements will be met during the next fiscal year. Please enter the information in the sections below. All plans must include the following sections:

I. Public Input for regional ALF-LMH Plan as required per s. 394.4574 (3), F.S.

· Attach minutes of public meetings held within the last year related to: 1) Providing services to individuals residing in the ALF-LMH, 2) This Annual Plan, and 3) Other ALF issues. Please include a copy of the attendance roster for each meeting.

II. Describe how your region will ensure that the standards per s. 394.4574, F.S. are met.

· Demonstrate how the region will ensure the provision of state-funded substance abuse and mental health services to the ALF-LMH residents.

· Address case management services; access to consumer-operated drop-in centers; access to services during evenings, weekends, and holidays; supervision of the clinical needs of the residents; and access to emergency psychiatric care.

· Include frequency of mental health provider monitoring by the Managing Entity, method of monitoring, and sample size. The Managing Entity must first identify individuals living in ALFs and then of those, identify a minimum of 20% sample.

(See Monitoring Tool attached for standards)

III: Describe how your region will address the training requirements per s. 429.075, F.S.

· Each region is responsible for mental health training or arranging for training of the ALF-LMH direct service staff within the region. Note that the minimum required training materials are available from the Mental Health office at DCF headquarters. The training is designed to be 8 hours. Training events should be offered at least every 60 days, or as appropriate to the region.

· Attach agenda or list any training held within the last year including dates, locations, trainers, and a roster of those attending.

· Indicate schedule for trainings for the upcoming year, including proposed dates, locations, and trainers.

IV: Describe gaps or deficits in your region’s service capacity for individuals served in the ALF-LMH and plan for addressing them.

Completed by:

Contact information:
(Address/Phone/email)

09/30/14