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BPI MEDICAID Certification

BPI MEDICAID Certification. Review Process and Federal Requirements. Federal Requirements. BPI is responsible for PRTF MEDICAID Certification This Certification ensures that providers are in compliance with Federal Requirements

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BPI MEDICAID Certification

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  1. BPI MEDICAID Certification Review Process and Federal Requirements

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

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

  4. 42 CFR §§ 441.155(d)(1) and 456.160(b) Physician’s Recertification of Need for Care A Physician, Physician’s Assistant or Nurse Practioner acting within the scope of their practice, must recertify for each recipient that inpatient RTF level of care is still required. This recertification must be made at least every thirty (30) days and documented in the resident’s record Federal Requirements

  5. 42 CFR §§ 441.155 and 456.180 Individual Plan of Care A individual plan of care must be written for each recipient. The plan of care must be based on a diagnostic evaluation and include the diagnosis, symptoms, complications, therapies, treatment objectives, social services and discharge planning. Federal Requirements

  6. 42 CFR §441.154 Active Treatment A Initial Psychiatric Evaluation and plan of care must be developed within fourteen (14) days of admission to the RTF. Federal Requirements

  7. 42 CFR §§ 441.154, 441.155, 441.156 and 456.180 Treatment Team/Plan Reviews The plan of care must be reviewed and/or revised by the treatment team, as specified, at least every thirty (30) days. Federal Requirements

  8. 42 CFR §§ 441.155(b)(2) and 441.156 Treatment Team/Members or Composition The team must include at a minimum: 1) a board certified or board eligible psychiatrist; 2) a clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; 3) a physician with specialized training in the treatment and diagnosis of mental health issues, and a clinical psychologist who has a masters degree in clinical psychology and one of the following: (a) a clinical psychiatric social worker, (b) a registered nurse specialized with training or experience in treating mentally ill individuals, (c) a occupational therapist, (d) a clinical psychologist who has a master’s degree. Federal Requirements

  9. 42 CFR §§ 441.155(b)(2), 441.156 and MA Bulletin 1165-95-01 All therapeutic leaves must be ordered by the physician and be used as a part of the recipient’s individual treatment program. Dates and times of the passes must be documented, as well as the therapeutic goals and results of the pass. MA payment for therapeutic passes in an RTF is limited to forty-eight (48) per calendar year. Federal Requirements

  10. 42 CFR §§ 441.155, 456.180 and 456.610 Medications All medications must be ordered by the attending physician, to include the dosage, route and frequency. Diagnoses, symptoms and complications must be documented to justify the medication ordered, this includes over-the-counter medications. The attending physician must review and reorder the prescribed medications at least every thirty (30) days. Federal Requirements

  11. 42 CFR §§ 441.155, 456.180 and 456.610 Treatments/Therapies All tests and treatments must be ordered by the attending physician. Diagnoses, symptoms and complaints must be documented to justify the orders. The attending physician must review prescribed treatments at least every thirty (30) days. (This can be done via the Treatment Plan Review process) Federal Requirements

  12. 42 CFR §§ 441.155, 456.180 and 456.610 Dietary Needs All dietary needs must be ordered by the attending physician. The attending physician must review and reorder prescribed diet at least every thirty (30) days. Federal Requirements

  13. 42 CFR § 456.610 Progress Notes The physician, nurse and all other professional progress notes must be consistent with the observed condition and progress of the recipient. Federal Requirements

  14. 42 CFR § 483 and MA Bulletin 53-01-01 Restraint and Seclusion Restraints (holds) must be ordered by the physician or LIP Licensed Independent Practioner) Orders must include the type of hold to be used and the duration of the hold Orders must be signed by the physician, LIP If LIP is ordering the hold, documentation by the LIP must indicate that the physician was notified of the hold Federal Requirements

  15. Restraint and Seclusion (Continued) Times must be documented as to when the hold began and ended If holds last over 10 minutes in duration the 3800 Licensing Regulations must be followed as to documentation that physical assessments and adequate hydration and toileting needs are met Federal Requirements

  16. Restraint and Seclusion (Continued) Within one hour of the duration of the hold, a physical and psychological assessment must be completed by a MD, PA, CRNP or RN and documented in the record. The documentation must include the time the assessment occurred Federal Requirements

  17. Restraint and Seclusion (Continued) A client debriefing must take place with the client and staff involved in the physical hold within 24 hours of the safety intervention. Documentation of this debriefing must included all members who attended and the time and date the debriefing occurred Federal Requirements

  18. Restraints and Seclusion (Continued) Within 24 hours of the release of the hold a staff debriefing consisting of all staff involved in the hold as well as appropriate treatment team members, and supervisory and administrative staff must occur. Documentation of this debriefing must include all members attending and the date and time of the meeting Federal Requirements

  19. Restraint and Seclusion (Continued) The parents, guardians or custodians of the resident involved in the hold must be notified as soon as possible. The date, time, name of party contacted and name of staff member providing the notification must be documented in the resident’s record Federal Requirements

  20. 42 CFR § 456.180 Multi-disciplinary Treatment Team (Inter-agency Team) The attending physician and all other personnel and agencies involved in the recipient’s immediate care and discharge care must meet to review and/or revise the recipient’s plan of care at least every ninety (90) days. Federal Requirements

  21. 42 CFR §§ 456.200 and 456.201 Utilization Review Each mental health facility must have a written utilization review plan. Federal Requirements

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