Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-014 - Rehabilitative Services for Persons with Mental Illness (RSPMI) Update No. 3-13 and Inpatient Psychiatric Services for Under Age 21 Update No. 1-13

Current through Register Vol. 49, No. 6, June, 2024
Section II
Rehabilitative Services for Persons with Mental Illness
228.300
Record Reviews
The Division of Medical Services (DMS) of the Arkansas
				Department of Human Services (DHS) has contracted with ValueOptions to perform
				on-site inspections of care (IOC) and retrospective reviews of outpatient
				mental health services provided by RSPMI providers.
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ValueOptions contact information.
The reviews are
				conducted by licensed mental health professionals and are based on applicable
				federal and state laws, rules and professionally recognized standards of
				care.
228.311
Purpose
			 of the Review
The on-site inspections of care of RSPMI providers are intended
				to:
A. Promote RSPMI services being
			 provided in compliance with federal and state laws, rules and professionally
			 recognized standards of care;
B.
			 Identify and clearly define areas of deficiency where the provision of services
			 is not in compliance with federal and state laws, rules and professionally
			 recognized standards of care;
C.
			 Require provider facilities to develop and implement appropriate corrective
			 action plans to remediate all deficiencies identified;
D. Provide accountability that corrective
			 action plans are implemented and
E.
			 Determine the effectiveness of implemented corrective action plans.
The review tool, process and procedures are available on the
				contractor's website at
http://arkansas.valueoptions.com/provider/prv_forms.htm.
Any amendments to the review tool will be adopted under the Arkansas
				Administrative Procedures Act.
228.313
Information Available Upon
			 Arrival of the IOC Team
The provider shall make the following available upon the IOC
				Team's arrival at the site:
A. Medical
			 records of Arkansas Medicaid beneficiaries who are identified by the
			 reviewer;
B. One or more
			 knowledgeable administrative staff member(s) to assist the team;
C. The opportunity to assess direct patient
			 care in a manner least disruptive to the actual provision of care;
D. Staff personnel records, complete with
			 hire dates, dates of credentialing and copies of current licenses, credentials,
			 criminal background checks and similar or related records;
E. Written policies, procedures and quality
			 assurance committee minutes;
F.
			 Clinical Administration, Clinical Services, Quality Assurance, Quality
			 improvement, Utilization Review and Credentialing;
G. Program descriptions, manuals, schedules,
			 staffing plans and evaluation studies;
H. YOQ documentation and
I. If identified as necessary and as
			 requested, additional documents required by a provider's individual licensing
			 board, child maltreatment checks and adult maltreatment checks.
228.314
Cases Chosen for
			 Review
The contractor will review twenty (20) randomly selected cases
				during the IOC review. If a provider has fewer than 20 open cases, all cases
				shall be reviewed.
The review period shall be specified in the provider
				notification letter. The list of cases to be reviewed shall be given to the
				provider upon arrival or chosen by the IOC Team from a list for the provider
				site. The components of the records required for review include:
1. All required assessments, including
			 SED/SMI Certifications where applicable;
2. Master treatment plan and periodic reviews
			 of master treatment plan;
3.
			 Progress notes, including physician notes;
4. Physician orders and lab results
			 and
5. Copies of records. The
			 reviewer shall retain a copy of any record reviewed.
228.316
Beneficiary/Family
			 Interviews
The provider is required to arrange interviews of Medicaid
				beneficiaries and family members as requested by the IOC team, preferably with
				the beneficiaries whose records are selected for review. If a beneficiary whose
				records are chosen for review is not available, then the interviews shall be
				conducted with a beneficiary on-site whose records are not scheduled for
				review. Beneficiaries and family members may be interviewed on-site, by
				telephone conference or both.
228.318
Written Reports and Follow-Up
			 Procedures
The contractor shall provide a written report of the IOC team's
				findings to the provider, DMS Behavioral Health Unit and Arkansas Office of
				Medicaid Inspector General within 14 calendar days from the last day of on-site
				inspection. The written report shall clearly identify any area of deficiency
				and required submission of a corrective action plan.
The contractor shall provide a notification of either
				acceptance or requirement of directed correction to the provider, DMS
				Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within
				14 calendar days of receiving a proposed corrective action plan and shall
				monitor corrective actions to ensure the plan is implemented and results in
				compliance.
All IOC reviews are subject to policy regarding Administrative
				Remedies and Sanctions (Section 150.000), Administrative Reconsideration and
				Appeals (Section 160.000) and Provider Due Process (Section 190.000). DMS will
				not voluntarily publish the results of the IOC review until the provider has
				exhausted all administrative remedies. Administrative remedies are exhausted if
				the provider does not seek a review or appeal within the time period permitted
				by law or rule.
228.320
DMS/DBHS Work Group Reports and Recommendations
The DMS/DBHS Work Group (comprised of representatives from the
				Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the
				Division of Behavioral Health Services, the Office of Quality Assurance, the
				utilization review agency, as well as other units or divisions as required)
				will meet monthly to discuss IOC reports. When warranted by IOC results, the
				DMS/DBHS Work Group shall recommend to the DHS Review Team one or more actions
				in Section 228.322. Recommendations shall be in writing and shall include
				supporting documentation.
If a deficiency related to safety or potential risk to the
				beneficiary or others is found, then the utilization review agency shall
				immediately report this to the DMS Director (or the Director's
				designee).
228.321
Corrective Action Plans
The provider must submit a Corrective Action Plan designed to
				correct any deficiency noted in the written report of the IOC. The provider
				must submit the Corrective Action Plan to the contracted utilization review
				agency within 30 calendar days of the date of the written report. The
				contractor shall review the Corrective Action Plan and forward it, with
				recommendations, to the DMS Behavioral Health Unit, the Arkansas Office of
				Medicaid Inspector General and Division of Behavioral Health Services.
After acceptance of the Corrective Action Plan, the utilization
				review agency will monitor the implementation and effectiveness of the
				Corrective Action Plan via on-site review. DMS, its contractor(s) or both may
				conduct a desk review of beneficiary records. The desk review will be
				site-specific and not by organization. If it is determined that the provider
				has failed to meet the conditions of participation, DMS will determine if
				sanctions are warranted.
228.322
Actions
Actions that may be taken following an inspection of care
				review include, but are not limited to:
A. Decertification of any beneficiary
			 determined to not meet medical necessity criteria for outpatient mental health
			 services;
B. Decertification of any
			 provider determined to be noncompliant with the Division of Behavioral Health
			 Services provider certification rules;
C. On-site monitoring by the utilization
			 review agency to verify the implementation and effectiveness of corrective
			 actions;
D. The contractor may
			 recommend, and DMS may require, follow-up inspections of care and/or desk
			 reviews. Follow-up inspections may review the issues addressed by the
			 Corrective Action Plans or may be a complete re-inspection of care, at the sole
			 discretion of the Division of Medical Services;
E. Review and revision of the Corrective
			 Action Plan;
F. Review by the
			 Arkansas Office of Medicaid Inspector General;
G. Formulation of an emergency transition
			 plan for beneficiaries including those in custody of DCFS and DYS;
H. Suspension of provider
			 referrals;
I. Placement in high
			 priority monitoring;
J. Mandatory
			 monthly staff training by the utilization review agency;
K. Provider requirement for one of the
			 following staff members to attend a DMS/DBHS monthly work group meeting:
			 Clinical Director/Designee (at least a master's level mental health
			 professional) or Executive Officer;
L. Recoupment for services that are not
			 medically necessary or that fail to meet professionally recognized standards
			 for health care or
M. Any sanction
			 identified in Section 152.000.
Provider Manual Update Transmittal
				RSPMI-3-13
TOC required
221.600
Inspection of Care
			 (42 CFR Part 456, Subpart I)
All in-state inpatient psychiatric providers will receive an
				Inspection of Care (IOC) consistent with the Code of Federal Regulations,
				42 CFR
				§§
											456.600 through
				456.614.
				An IOC will be performed by an independent contractor or team annually, at a
				minimum. There must be a sufficient number of teams within the State that an
				on-site IOC can be made at appropriate intervals in each facility.
The inpatient psychiatric provider will be notified of the time
				of the inspection no more than forty-eight (48) hours before the scheduled
				arrival of the inspection team. The inspection must include:
A. Personal contact and observation of each
			 Medicaid recipient in the inpatient psychiatric facility and
B. Review of each beneficiary's medical
			 record.
See Section 241.000 for more information regarding inspections
				of care.
241.000
On-Site Inspection of Care (IOC)
The Department of Human Services (DHS) requires the contractor
				to conduct annual On-Site Inspections of Care for acute inpatient and
				residential services provided to Medicaid beneficiaries under age 21.
The inpatient psychiatric provider will be notified of the time
				of the inspection no more than forty-eight (48) hours before the schedule
				arrival of the inspection team.
241.100
Purpose of the Review
The on-site inspections of care of Inpatient Psychiatric
				Services for Under Age 21 providers are intended to:
A. Promote Inpatient Psychiatric Services for
			 Under Age 21 that are provided in compliance with federal and state laws, rules
			 and professionally recognized standards of care;
B. Identify and clearly define areas of
			 deficiency where the provision of services is not in compliance with federal
			 and state laws, rules and professionally recognized standards of
			 care;
C. Require provider
			 facilities to develop and implement appropriate corrective action plans to
			 remediate all deficiencies identified;
D. Provide accountability that corrective
			 action plans are implemented and
E.
			 Determine the effectiveness of implemented corrective action plans.
The review tool, process and procedures are available on the
				contractor's website at
http://arkansas.valueoptions.com/provider/prv_forms.htm.
Any amendments to the review tool will be adopted under the Arkansas
				Administrative Procedures Act.
241.200
Information Available Upon
			 Arrival of the IOC Team
The provider shall make the following available upon the IOC
				Team's arrival at the site:
A. Medical
			 records of all Arkansas Medicaid beneficiaries;
B. One or more knowledgeable administrative
			 staff member(s) to assist the team;
C. The opportunity to assess direct patient
			 care in a manner least disruptive to the actual provision of care;
D. Staff personnel records, complete with
			 hire dates, dates of credentialing and copies of current licenses, credentials,
			 criminal background checks, and similar or related records;
E. Written policies, procedures and quality
			 assurance committee minutes;
F.
			 Clinical Administrative, Clinical Services, Quality Assurance, Quality
			 improvement, Utilization Review and Credentialing;
G. Program descriptions, manuals, schedules,
			 staffing plans and evaluation studies and
H. If identified as necessary and as
			 requested, additional documents required by a provider's individual licensing
			 board, child maltreatment checks and adult maltreatment checks.
241.300
Written Reports and
			 Follow Up Procedures
The contractor shall provide a written report of the IOC team's
				findings to the provider, DMS Behavioral Health Unit and Arkansas Office of
				Medicaid Inspector General within 14 calendar days from the last day of on-site
				inspection. The written report shall clearly identify any area of deficiency
				and required submission of a corrective action plan.
The contractor shall provide a notification of either
				acceptance or requirement of directed correction to the provider, DMS
				Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within
				14 calendar days of receiving a proposed corrective action plan and shall
				monitor corrective actions to ensure the plan is implemented and results in
				compliance.
All IOC reviews are subject to policy regarding Administrative
				Remedies and Sanctions (Section
				150.000 ), Administrative
				Reconsideration and Appeals (Section
				160.000 ) and Provider Due
				Process (Section
				190.000 ). DMS will not
				voluntarily publish the results of the IOC review until the provider has
				exhausted all administrative remedies. Administrative remedies are exhausted if
				the provider does not seek a review or appeal within the time period permitted
				by law or rule.
241.400
Resident Interviews
Each resident who is a Medicaid beneficiary under age 21 must
				be interviewed by the IOC Team. It is the responsibility of the provider to
				devise a system that allows access to the residents in a way that is minimally
				disruptive to the treatment process.
If a Medicaid beneficiary will be discharged during the review,
				the provider is responsible for arranging for the resident to be interviewed
				prior to discharge.
Interviews should be conducted in a place and manner that
				respects the resident's right to privacy. The provider must provide private
				interview space for the interviews.
241.500
DMS/DBHS Work Group Reports and
			 Recommendations
The DMS/DBHS Work Group (comprised of representatives from the
				Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the
				Division of Behavioral Health Services, the Office of Quality Assurance, the
				utilization review agency, as well as other units or divisions as required)
				will meet monthly to discuss IOC reports. When warranted by IOC results, the
				DMS/DBHS Work Group shall recommend to the DHS Review Team one or more actions
				in Section 241.700. Recommendations shall be in writing and shall include
				supporting documentation.
If a deficiency related to safety or potential risk to the
				beneficiary or others is found, then the utilization review agency shall
				immediately report this to the DMS Director (or the Director's
				designee).
241.600
Corrective Action Plans
The provider must submit a Corrective Action Plan designed to
				correct any deficiency noted in the written report of the IOC. The provider
				must submit the Corrective Action Plan to the contracted utilization review
				agency within 14 calendar days of the date of the written report. The
				contractor shall review the Corrective Action Plan and forward it, with
				recommendations, to the DMS Behavioral Health Unit, the Arkansas Office of
				Medicaid Inspector General and Division of Behavioral Health Services.
After acceptance of the Corrective Action Plan, the utilization
				review agency will monitor the implementation and effectiveness of the
				Corrective Action Plan via on-site review. DMS, its contractor(s) or both may
				conduct a desk review of beneficiary records. The desk review will be
				site-specific and not by organization. If it is determined that the provider
				has failed to meet the conditions of participation, DMS will determine if
				sanctions are warranted.
241.700
Actions
Actions that may be taken following an inspection of care
				review include, but are not limited to:
A. Decertification of any beneficiary
			 determined to not meet medical necessity criteria for outpatient mental health
			 services;
B. Decertification of any
			 provider determined to be noncompliant with the Division of Behavioral Health
			 Services provider certification rules;
C. On-site monitoring by the utilization
			 review agency to verify the implementation and effectiveness of corrective
			 actions;
D. The contractor may
			 recommend, and DMS may require, follow-up inspections of care and/or desk
			 reviews. Follow-up inspections may review the issues addressed by the
			 Corrective Action Plans or may be a complete re-inspection of care, at the sole
			 discretion of the Division of Medical Services;
E. Review and revision of the Corrective
			 Action Plan;
F. Review by the
			 Arkansas Office of Medicaid Inspector General;
G. Formulation of an emergency transition
			 plan for beneficiaries including those in custody of DCFS and DYS;
H. Suspension of provider
			 referrals;
I. Placement in high
			 priority monitoring;
J. Mandatory
			 monthly staff training by the utilization review agency;
K. Provider requirement for one of the
			 following staff members to attend a DMS/DBHS monthly work group meeting:
			 Clinical Director/Designee (at least a master's level mental health
			 professional) or Executive Officer;
L. Recoupment for services that are not
			 medically necessary or that fail to meet professionally recognized standards
			 for health care or
M. Any sanction
			 identified in Section
			 152.000.
241.800
Reserved