New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"Active treatment" means the implementation of a
				  professionally developed and supervised plan of care that is developed and
				  implemented no later than 14 days after admission and designed to achieve the
				  goal of the resident's appropriate discharge from the PRTF at the earliest
				  possible date. (See
				  42 C.F.R.
				  441.154.)
"Beneficiary or eligible beneficiary" means any person who is
				  a qualified applicant receiving benefits under the Medical Assistance and
				  Health Services Act,
				  30:4D-1 et seq.
"Care Management Organization (CMO)" means the
				  community-based Department of Children and Families/Division of the Children's
				  System of Care (DCF/DCSOC) contracted entity that is responsible for creating,
				  coordinating, and implementing an individualized plan of care for children with
				  emotional and behavioral disturbances that are in need of intensive care
				  coordination services.
"Centers for Medicare and Medicaid Services (CMS)" means the
				  agency of the Federal Department of Health and Human Services which is
				  responsible for the administration of the Medicaid program.
"Certification of need" means an evaluation made by an
				  interdisciplinary medical review team to determine the level of care required
				  to treat a resident with mental illness in the most effective manner in the
				  least restrictive environment.
"Certified nurse practitioner/clinical nurse specialists
				  (CNP/CNS)" means a person currently licensed as an advance practice nurse who
				  is currently certified by the New Jersey State Board of Nursing in accordance
				  with N.J.A.C. 13:37-7 and with N.J.S.A. 45:11-49a through d, or licensed
				  through a comparable agency of the state in which he or she practices.
"Contract pricing" means the facility-specific rate, based on
				  the rate determined in the contract negotiated with the DCF/DCSOC or the
				  Department of Human Services.
"Contracted System Administrator (CSA)" means the entity
				  contracted by the Department of Children and Families/DCSOC to provide
				  utilization management and care coordination activities for services to
				  children, including all mental health services provided to individuals as part
				  of the DCSOC, to monitor the quality of care, to prior authorize mental health
				  services, and approve continued lengths of stay in DCSOC's programs.
"Department (DHS)" means the New Jersey Department of Human
				  Services.
"Department of Children and Families (DCF)" means the New
				  Jersey Department of Children and Families, created by
				  P.L.
				  2006, c. 47.
"Division of Medical Assistance and Health Services (DMAHS)"
				  means the organizational component of the New Jersey Department of Human
				  Services which is responsible for the administration of the State's medical
				  assistance programs.
"Division of Mental Health and Addiction Services (DMHAS)"
				  means the organizational component of the New Jersey Department of Human
				  Services that is responsible for the administration of the State's mental
				  health and addiction programs.
"Division of Mental Health Services (DMHS)" means the
				  organizational component of the New Jersey Department of Human Services which
				  is responsible for the administration of the State's mental health
				  programs.
"Division of the Children's System of Care (DCSOC)" means the
				  Department of Children and Families' division that provides a comprehensive
				  system of care approach for the treatment of youth experiencing behavioral
				  health challenges, services for youth with intellectual/developmental
				  challenges, and services to youth with substance use challenges. DCSOC
				  beneficiaries are those individuals under the age of 21 that have been
				  determined by the Department of Children and Families/DCSOC to be eligible for
				  enrollment into the DCSOC, independent of their eligibility for Medicaid/NJ
				  FamilyCare coverage.
"Division of Youth and Family Services (DYFS)" means the
				  organizational component of the New Jersey Department of Human Services which
				  administers the Title IV-E program of the Social Security Act,
				  42
				  U.S.C. §§
										670 through
				  679b.
"Healthcare Common Procedure Coding System (HCPCS)" means a
				  nationwide two-level coding system. Level I codes are adapted from codes
				  published by the American Medical Association in the Common Procedure
				  Terminology (CPT) and are utilized primarily by physicians and independent
				  clinical laboratories. Level II codes are assigned by CMS for physician and
				  non-physician services that are not in the CPT.
"Hospital leave" means a temporary absence from the facility
				  for more than 24 consecutive hours due to the resident receiving inpatient
				  treatment in a hospital, including treatment in a psychiatric unit of a
				  hospital.
"Individual plan of care" means a written plan developed for
				  each resident to improve his condition to the extent that inpatient care is no
				  longer indicated.
"Interdisciplinary team," as described in Federal regulations
				  in 42 CFR 441.156,
				  is comprised of those employed by, or those who provide services to Medicaid/NJ
				  FamilyCare or DCF/DCSOC beneficiaries in the PRTF, and is responsible for the
				  review of the treatment needs of a resident receiving mental health services to
				  ensure that the most appropriate level of care is provided. The team shall
				  include, at a minimum, the professional staff listed at
				  10:75-2.5(b).
"Joint Commission on Accreditation of Healthcare
				  Organizations (JCAHO)" means the nationwide, independent, not-for-profit
				  organization that evaluates and accredits health care organizations and
				  programs, including, but not limited to, behavioral health care organizations
				  including, but not limited to, psychiatric residential treatment
				  facilities.
"New Jersey Medicaid Management Information System (NJMMIS)"
				  means the claims processing entity contracted by DMAHS to process claims for
				  Medicaid/NJ FamilyCare and other health programs that are administered in whole
				  or in part by the Division.
"Partnership for Children (PFC)" means the Department of
				  Human Services' initiative developed to provide a comprehensive approach to the
				  treatment of behavioral and mental disturbances in children, adolescents and
				  young adults. PFC beneficiaries are those individuals under the age of 21 that
				  have been determined by the Department of Human Services to be eligible for
				  enrollment into the PFC, independent of their eligibility for Medicaid/NJ
				  FamilyCare coverage.
"Physician" means a doctor of medicine (M.D.) or osteopathy
				  (D.O.) licensed to practice medicine and surgery by the New Jersey State Board
				  of Medical Examiners, or similarly licensed by comparable agencies of the State
				  in which he or she practices.
"Psychiatric residential treatment facility (PRTF)" means a
				  facility that is not licensed as a hospital, but which meets the requirements
				  in 42 C.F.R. part 441 subpart D, 42 C.F.R. 483 subpart G, and has a provider
				  agreement with the State Medicaid agency (the Division of Medical Assistance
				  and Health Services).
"Resident" means a beneficiary who has been admitted to a
				  PRTF on the recommendation of a physician and who receives services in the PRTF
				  for a 24-hour period or longer in accordance with this chapter.
"Restraint" means a personal hold of any duration, a
				  mechanical restraint, or a drug used as a restraint.
"Serious injury" means any significant impairment of the
				  physical condition of the resident as determined by qualified medical
				  personnel, including, but not limited to, burns, lacerations, bone fractures,
				  substantial hematoma(s), and injuries to internal organs, whether
				  self-inflicted or inflicted by someone else. (See 42
				  CFR 483.352.)
"Serious occurrence" means the death, suicide attempt or
				  serious injury of a resident. (See
				  42 C.F.R.
				  483.374(b).)
"The Joint Commission (TJC)" means the nationwide,
				  independent, not-for-profit organization that evaluates and accredits health
				  care organizations and programs, including, but not limited to, behavioral
				  health care organizations including, but not limited to, psychiatric
				  residential treatment facilities.
"Therapeutic leave" means a temporary absence from the
				  facility, greater than 24 consecutive hours, deemed therapeutic, approved by
				  the treatment team and included in the resident's plan of care. Reasons for
				  such absence include, but are not limited to, visits with parents, foster
				  parents, guardians, or other caregivers, attendance at a residential camp, or
				  residence in a temporary shelter.
"Utilization control" means an approved program instituted,
				  implemented and operated by or under the authorization of a utilization review
				  organization (URO) which effectively safeguards against unnecessary or
				  inappropriate Medicaid services and assesses the quality of those services to
				  Medicaid and NJ FamilyCare fee-for-service beneficiaries.