Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-014 - Secure Psychiatric Residential Rehabilitation

Current through June 17, 2024
Secure Psychiatric Residential Rehabilitation is a secure
	 facility-based, non-hospital or non-nursing facility program for individuals
	 disabled by severe and persistent mental illness, who are unable to reside in a
	 less restrictive setting. These facilities are integrated into the community
	 and provide programming in an organized, structured setting, including
	 treatment and rehabilitation services and offer support to clients with a
	 severe and persistent mental illness and/or co-occurring substance abuse
	 disorders. These individuals demonstrate a moderate to high risk for harm to
	 self/others and are in need of recovery, treatment, and rehabilitation
	 services. The clients who are in need of this level of care have long standing
	 limitations with limited ability to live independently over an extended period
	 of time. These individuals have needed a high level of psychiatric intervention
	 and have limitations in all three functional areas, vocational/educational,
	 social skills and activities of daily living. See definitions in 471 NAC
	 35-001.01. The Secure Psychiatric Residential Rehabilitation program provides
	 skill building and other related recovery oriented psychiatric rehabilitation
	 services as needed to meet individual client needs. The Secure Psychiatric
	 Residential Rehabilitation Program is designed to:
1. Increase the client's functioning while
  improving psychiatric stability so that s/he can eventually live successfully
  and safely in a less restrictive residential setting of his/her choice and
  capabilities;
2. Decrease the
  frequency and duration of hospitalization;
3. Decrease and/or eliminate all high risk,
  unsafe behavior to self or others; and
4. Improve the ability to function
  independently by improving ability to function.
014.01 Program Components
A secure psychiatric residential rehabilitation program provides a
	 variety of on-site psychosocial rehabilitation and skill acquisition activities
	 and treatment each day. The program must facilitate client driven skills
	 training and activities as appropriate. A secure psychiatric residential
	 rehabilitation program must provide services identified on the client specific
	 Individual Treatment, Rehabilitation, and Recovery Plan, providing
	 culturally-sensitive and trauma-informed care. The activities must include, but
	 are not limited to:
1. Ongoing
  assessment;
2. Arrangement for
  general medical care including laboratory services, psychopharmacological
  services, psychological services, as necessary;
3. Provision of a minimum of 42 hours per
  week of on-site staff led psychosocial rehabilitation activities and skill
  acquisition;
4. Programming focused
  on relapse prevention, recovery, nutrition, daily living skills, social skill
  building, community living, substance abuse, education, medication education
  and self-administration, symptom management, and focus on improving the level
  of functioning to get to a less restrictive level of care;
5. Educational and vocational focus as
  appropriate; and
6. Access to
  community-based rehabilitation/social services to assist in transition to
  community as symptoms are managed and behaviors are stabilized.
35-014.01A
Assessments
: The following assessments must be
  completed:
1. A comprehensive mental health
  and substance abuse assessments by a licensed mental health practitioner must
  occur prior to admission;
2.
  Following admission and within 24 hours of stay, a assessment by the program's
  psychiatrist must be completed;
3.
  A history and physical must be completed by a physician or Advanced Practice
  Registered Nurse (APRN) within 24 hours of admission or one must be completed
  within 60 days of admission and available in the clinical record;
4. Comprehensive strength-based
  biopsychosocial assessment must be completed within 14 days of admission to
  assess the client according to the requirements described in 471 NAC
  35-014.01A
  1;
5. A nursing assessment must be
  completed by a Registered Nurse within 24 hours of admission; and
6. A functional assessment must be completed
  initially upon admission and annually with continued stay at this level of
  service.
35-014.01A1
Components of the Biopsychosocial Assessment
: The
  biopsychosocial assessment must be completed within the timeframe specified in
  the Secure Psychiatric Residential Rehabilitation program's policies and
  procedures, however, no more than 14 days after admission. Components 1 through
  9 of this assessment must be completed by a licensed mental health
  practitioner. Clinical impressions, including diagnosis and recommendations for
  treatment and rehabilitation, must be completed by the program's psychiatrist.
  The assessment must be in narrative form and include the following components:
1. Client name, Medicaid identification
  number, emergency contact (name, relationship, and contact information), and
  other information of the client that is relevant;
2. Provider demographics including: provider
  name, address, phone number, fax number, and e-mail address, and other contact
  information;
3. Presenting problem,
  primary complaint including:
a. Signs,
  symptoms, problems and dysfunctions relating to mental illness;
b. Reason for referral to Secure Psychiatric
  Residential Rehabilitation services and referral source;
c. Name and title of the referral
  professional (MD, psychologist, APRN, or LIMHP);
d. Presenting problem from the client's and
  provider's perspective; and
e.
  External leverage to seek evaluation (courts, family and other);
4. Medical History:
a. Dental history and current
  needs;
b. Current medication
  list;
c. Compliance with medication
  (historical and current);
d.
  Current primary care physician (name and contact information);
e. Date of last physical exam and physician
  providing that assessment;
f.
  Recent hospitalizations; and
g.
  Major health concerns (such as STD's, HIV, Tuberculosis, Hepatitis, and
  pregnancy);
5.
  Employment/Education/Military History:
a.
  History of employment;
b.
  Educational history;
c. Military
  involvement; and
d.
  Strengths;
6.
  Alcohol/Drug History:
a. Primary drug(s) of
  choice;
b. Amount, frequency and
  duration of use;
c. Prior
  treatment(s), location and length of stay;
d. Current compliance with relapse prevention
  plan;
e. Periods of abstinence
  (supports needed);
f. Tolerance
  level/withdrawal/history of complications from withdrawal;
g. Prior alcohol/drug
  evaluations/recommendations, including scores and results of screening
  tools;
h. Family history of
  alcohol/drug use; and
i. Other
  addictive behaviors (gambling, food, etc.);
7. Legal History (Information from Criminal
  Justice System):
a. Criminal history and
  consequences of criminal involvement;
b. Connection to alcohol/drug use;
c. Current legal charges/disposition of
  charges;
8.
  Family/Social/Peer:
a. Family members (age
  and level of involvement with client);
b. Adult or minor children (names, ages and
  level of involvement);
c. Parenting
  knowledge or skill level, history of system involvement (courts);
d. Social supports utilized by client
  (previous and current);
e. Housing
  (ability to maintain housing, type of current housing, need for
  assistance);
f. Recreational
  activities (client's preference);
g. Collateral information;
h. Client strengths as perceived by client
  and collateral contacts;
9. Psychiatric/Behavioral History:
a. Current diagnosis(s);
b. Previous treatment(s) and outcome(s) of
  treatment(s);
c. Current mental
  health and substance abuse providers and treatment currently
  provided;
d. Current psychiatric
  medication list;
e. Compliance with
  medication (historical and current);
f. History of self harm or threats to harm
  others;
g. Board of mental health
  commitments (reason and dates of commitment);
h. Abuse (to include sexual abuse, physical
  abuse, emotional abuse, neglect, witness domestic violence, victim/witness of
  community violence, physical assault; and
i. Trauma (serious accident/injury, sexual
  assault/rape, life-threatening medical illness, traumatic loss of a loved one,
  terrorist act, war/political violence/torture, disasters (tornado,
  earthquakes), sanctuary trauma (trauma while institutionalized),
  prostitution/sex trafficking;
10. Clinical Impressions: (must be completed
  by the licensed psychiatrist supervising the program and must be consistent
  with the psychiatrist's initial diagnostic interview):
a. Information that supports/justifies the
  recommendations; and
b. DSM
  diagnosis, Axis 1-5;
11.
  Recommendations by the program's psychiatrist:
a. Primary/ideal level of care;
b. Available level of care/barriers to ideal
  level of care; and
c.
  Client/family's response to recommendations;
12. Signature of psychiatrist and the
  licensed mental health practitioner completing the assessment; and
13. Date of signature.
35-014.01B
Individual
  Treatment, Rehabilitation, and Recovery Planning
: An initial
  Individual Treatment, Rehabilitation, and Recovery Plan must be completed
  within 24 hours of admission. Secure Psychiatric Residential Rehabilitation
  Service providers must develop an individual treatment, rehabilitation, and
  recovery plan with the client within 30 days following admission to the
  program. The plan must include substance abuse issues. The client's family
  and/or guardian must be included in all assessment and treatment,
  rehabilitation, and recovery planning. The provider must make every effort to
  be available and responsive to the client's family and/or guardian to assist
  their involvement in the client's recovery. The plan must be reviewed and
  revised with the client, discussing and documenting the discharge plan a
  minimum of every 7 days according the following requirements.
35-014.01B1
Individual Treatment,
  Rehabilitation, and Recovery Plan
: The master individual
  treatment, rehabilitation, and recovery plan must be based upon a comprehensive
  assessment and completed within 30 days of admission. This plan must:
1. Be oriented to the principles of recovery
  and meaningful client participation;
2. Apply the principles of recovery - to
  include meaningful client participation, and a life in the community of the
  client's choosing;
3. Incorporate
  and be consistent with best practices;
4. Include the client's individualized goals
  and expected outcomes;
5. Contain
  prioritized objectives that are measurable and time-limited;
6. Describe therapeutic interventions to be
  used in achieving the goals and objectives that are recovery-oriented,
  trauma-informed, and strength-based;
7. Identify staff responsible for
  implementing the therapeutic interventions;
8. Specify the planned frequency and duration
  of each therapeutic method;
9.
  Delineate the specific behavioral criteria to be met for discharge or
  transition to a lower level of care and reviewed weekly;
10. Include a plan developed with the client
  that includes strategies to avoid crisis or admission to a higher level of care
  using principles of recovery and wellness;
11. Include the signature of the client
  and/or parent/guardian;
12. Include
  health care proxy and trauma safety form when available and with client's
  consent;
13. Document that the
  individual treatment, rehabilitation, and recovery plan is completed within the
  timeframe specified in the program's policies and procedures;
14. Document that the plan has been reviewed,
  updated every 30 days, and revised according to client needs and progress;
  and
15. Document that the plan was
  reviewed by the program's treatment practitioners a minimum of every 30 days
  and that written revisions were approved, signed, and dated each 30 days by the
  program psychiatrist.
35-014.01C
Treatment
  Services
: The program must offer structured, planned treatment and
  rehabilitation services as prescribed by the individualized treatment,
  rehabilitation, and recovery plan. The following services must be available and
  offered to the client.
1. Individual
  Psychotherapy: An individual treatment and rehabilitation service between an
  identified client and a qualified licensed practitioner who focuses upon the
  identified goals of the individual treatment, rehabilitation, and recovery
  plan;
2. Group Psychotherapy: A
  service provided by a licensed clinician who is practicing within his/her scope
  of practice and provides a psychotherapy service in groups of no less than
  three and no more than twelve clients;
3. Family Therapy: Family therapy is a
  therapeutic service between the client and his/her family and a qualified
  licensed practitioner who provides intervention as identified by the
  family-focused goals of the individual treatment, rehabilitation, and recovery
  plan. Consent from the client must be documented prior to the involvement of
  the family and delivery of the service; and
4. Psychoeducational services, such as
  medical education by a registered nurse and skill development groups by a
  trained and skilled staff able to facilitate these groups supervised by a
  licensed mental health practitioner.
35-014.01D
Supportive
  Services
: The program must provide the following supportive
  services for all active clients: referrals as necessary, problem
  identification/solution, and coordination of the Secure Psychiatric Residential
  Rehabilitation program treatment and activities with other services the client
  may be receiving.