[49 Pa.B. 5943]
[Saturday, October 12, 2019]
[Continued from previous Web Page]
Annex A
TITLE 55. HUMAN SERVICES
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1153. OUTPATIENT BEHAVIORAL HEALTH SERVICES
GENERAL PROVISIONS § 1153.1. Policy.
The MA Program provides payment for specific medically necessary psychiatric outpatient clinic services, MMHT services and psychiatric outpatient partial hospitalization services rendered to eligible MA beneficiaries by psychiatric outpatient clinics and psychiatric outpatient partial hospitalization facilities enrolled as providers under the program. Payment for behavioral health services is subject to the provisions of this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program Fee Schedule.
§ 1153.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Adult partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals 15 years of age or older.
Advanced practice professional—A person who holds a current Pennsylvania license as a certified registered nurse practitioner or a physician assistant and:
(1) Holds a mental health certification, or
(2) Obtains a mental health certification within 2 years of being hired by the psychiatric outpatient clinic or by July 30, 2020, whichever is later.
Children and youth partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals under 15 years of age.
Clinical staff—A psychiatrist or a mental health professional or mental health worker under the direct supervision of a psychiatrist.
Collateral family psychotherapy—Psychotherapy provided to the family members of an individual receiving psychiatric outpatient clinic services in the absence of the individual.
Department—The Department of Human Services.
Facility—A mental health establishment, hospital, clinic, institution, center or other organizational unit or part thereof, the primary function of which is the diagnosis, treatment, care and rehabilitation of individuals with mental illness or emotional disturbance.
Family—A person living alone or the following persons: spouses; parents and their unemancipated minor children and other unemancipated minor children who are related by blood or marriage; or other adults or emancipated minor children living in the household who are dependent upon the head of the household.
Family psychotherapy—Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental illness or emotional disturbance. Sessions shall be conducted by a clinical staff person.
Group psychotherapy—Psychotherapy provided to no less than 2 and no more than 12 persons with diagnosed mental illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.
Individual psychotherapy—Psychotherapy provided to one person with a diagnosed mental illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.
Inpatient services—Treatment provided to an individual who has been admitted to a treatment institution or an acute care hospital or psychiatric hospital on the recommendation of a physician and is receiving room, board and professional services in the facility on a continuous 24-hour-a-day basis.
Intake—The first contact with an individual for the initiation of or re-admission to outpatient behavioral health services covered by this chapter.
Interactive audio and video—Real-time two-way or multiple-way communication.
LPHA—Licensed Practitioner of the Healing Arts—A person who is licensed by the Commonwealth to practice the healing arts. This term is limited to a physician, physician's assistant, certified registered nurse practitioner, licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor or psychologist.
MMHT—Mobile Mental Health Treatment—One or more of the following services provided in an individual's residence or approved community site:
(i) Assessment.
(ii) Individual, group or family therapy.
(iii) Medication visits.
Mental health professional—A person who meets one of the following:
(i) Has a graduate degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation (CHEA) in a generally recognized clinical discipline in which the degree program includes a clinical practicum.
(ii) Has an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. (AICE) or the National Association of Credential Evaluation Services (NACES). The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
(iii) Is licensed in a generally recognized clinical discipline that includes mental health clinical experience.
Mental health worker—A person acting under the supervision of a mental health professional to provide services who meets one of the following:
(i) Has a bachelor's degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the CHEA in a recognized clinical discipline including social work, psychology, nursing, rehabilitation or activity therapies.
(ii) Has a graduate degree in a clinical discipline with 12 graduate-level credits in mental health or counseling from a program that is accredited by an agency recognized by the United States Department of Education or the CHEA.
(iii) Has an equivalent degree from a foreign college or university that has been evaluated by the AICE or the NACES. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
Mental illness or emotional disturbance—A mental disorder that meets the diagnostic criteria within the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases (ICD).
Outpatient services—Medical or behavioral health services provided to an individual by a psychiatric outpatient clinic or partial hospitalization outpatient facility that does not provide room, board and professional services on a continuous 24-hour-a-day basis.
Psychiatric clinic clozapine monitoring and evaluation visit—A visit for the monitoring and evaluation of an individual's physical and mental condition during the course of treatment with clozapine. The term includes only a visit provided to an eligible individual receiving clozapine therapy, and only by a psychiatrist, physician, certified registered nurse practitioner, registered nurse or physician assistant.
Psychiatric clinic medication visit—A visit only for administration of a drug and evaluation of an individual's physical or mental condition during the course of prescribed medication. This visit is provided to an eligible individual only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.
Psychiatric evaluation—An initial mental status examination and evaluation of an individual provided only by a psychiatrist in a face-to-face interview or through the use of interactive audio and video communication that conforms to industry-wide technology standards and is in compliance with State and Federal privacy and security laws. It must include a comprehensive history and evaluation of pertinent diagnostic information necessary to arrive at a diagnosis and recommendations for treatment or further diagnostic studies or consultation. The history must include individual, social, family, occupational, drug, medical and previous psychiatric diagnostic and treatment information.
Psychiatric outpatient clinic provider—A facility enrolled in the MA Program to provide psychiatric outpatient clinic services and licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide specific medical, psychiatric and psychological services for the diagnosis and treatment of mental illness or emotional disturbance.
Psychiatric outpatient clinic services—Outpatient medical, psychiatric and psychological services listed in the MA Program Fee Schedule furnished to an individual with mental illness or emotional disturbance while the individual is not a resident of a treatment institution, provided by or under the direction of a psychiatrist.
Psychiatric outpatient partial hospitalization provider—A facility enrolled in the MA Program to provide partial hospitalization outpatient services and licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide psychiatric, medical, psychological and psychosocial services as partial hospitalization for the diagnosis and treatment of mental illness or emotional disturbance.
Psychiatric partial hospitalization—An active outpatient psychiatric day or evening treatment session including medical, psychiatric, psychological and psychosocial treatment listed in the MA Program Fee Schedule. This service shall be provided to an individual with mental illness or emotional disturbance on a planned and regularly scheduled basis for a minimum of 3 hours but less than 24 hours in any 1 day. The session shall be provided by a psychiatrist or by psychiatric partial hospitalization personnel under the direction of a psychiatrist.
Psychologist in preparation for licensure—A person who has completed the educational requirements for licensure and is accruing the required postdegree experience for licensing.
Psychotherapy—The treatment, by psychological means, of the problems of an emotional nature in which a trained person deliberately establishes a professional relationship with an individual with the objective of removing, modifying or relieving existing symptoms of mediating disturbed patterns of behavior and of promoting positive personality growth and development.
Tele-behavioral health—
(i) The use of interactive audio and video communication to provide clinical services at a distance using technology that conforms to the industry-wide standards and is in compliance with State and Federal privacy and security laws.
(ii) Tele-behavioral health does not include telephone conversation, electronic mail message or facsimile transmission between a psychiatrist or an advanced practice professional and an individual receiving services or a consultation between two health care practitioners, although these activities may support the delivery of tele-behavioral health.
Treatment institution—A facility approved or licensed by the Department or its agents that provides full-time psychiatric treatment services for resident individuals with mental illness or emotional disturbance, residential facilities for individuals with intellectual disabilities or community residential rehabilitation services are not considered to be mental health treatment institutions.
Under the direction of a psychiatrist—Receiving oversight and consultation by a psychiatrist in the medical, psychiatric and psychological services provided to individuals by psychiatric outpatient clinic or partial hospitalization personnel.
COVERED AND NONCOVERED SERVICES § 1153.11. Types of services covered.
Medical Assistance Program coverage for psychiatric outpatient clinics, partial hospitalization outpatient facilities and MMHT services is limited to professional medical and psychiatric services for the diagnosis and treatment of mental illness or emotional disturbance, including a mental illness or emotional disturbance along with an intellectual disability, as specified in the MA Program Fee Schedule provided by psychiatric outpatient clinic providers and psychiatric outpatient partial hospitalization providers to MA beneficiaries.
§ 1153.12. Outpatient services.
The psychiatric outpatient clinic services specified in the MA Program Fee Schedule and the psychiatric partial hospitalization outpatient services specified in the MA Program Fee Schedule are covered only when provided by licensed psychiatric outpatient clinics or psychiatric partial hospitalization outpatient facilities under the direction of a psychiatrist. MMHT services specified in the MA Program Fee Schedule are covered only when provided by a licensed psychiatric outpatient clinic that has an approved service description for MMHT. Payment is subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).
§ 1153.14. Noncovered services.
Payment will not be made for the following types of services regardless of where or to whom they are provided:
(1) A covered psychiatric outpatient clinic, MMHT or partial hospitalization outpatient service conducted over the telephone.
* * * * * (4) An MA covered service, including psychiatric outpatient clinic, MMHT and partial hospitalization outpatient services, provided to inmates of State or county correctional institutions or committed residents of public institutions.
(5) Psychiatric outpatient clinic, MMHT or partial hospitalization outpatient services to residents of treatment institutions, such as individuals who are also being provided with room or board, or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program.
(6) Services delivered at locations other than licensed psychiatric outpatient clinics with the exception of MMHT under the conditions specified in § 1153.52(d) (relating to payment conditions for various services) or partial hospitalization outpatient facilities.
* * * * * (9) Psychiatric outpatient clinic services, MMHT services and psychiatric partial hospitalization outpatient services provided on the same day to the same individual, with the exception of clinical services not offered by the facility providing services to the individual.
(10) Covered psychiatric outpatient clinic services, MMHT services and psychiatric partial hospitalization outpatient services, with the exception of family psychotherapy, provided to persons without a mental diagnosis rendered by a psychiatrist in accordance with the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases—Chapter V, ''Mental, Behavioral, and Neurodevelopmental Disorders.''
(11) Psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization outpatient services provided to individuals with substance-related and addictive disorders, unless the individual has a primary diagnosis of a mental illness or emotional disturbance.
(12) Drugs, biologicals and supplies furnished to an individual receiving services at a psychiatric outpatient clinic or a partial hospitalization outpatient facility during a visit to the psychiatric outpatient clinic or partial hospitalization outpatient facility. These are included in the psychiatric outpatient clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided by the psychiatric outpatient clinic are noncompensable.
(13) Services not specifically included in the MA Program Fee Schedule are noncompensable.
(14) MMHT services not provided in accordance with the conditions specified in § 1153.52(d).
(15) Services provided beyond the 30th calendar day following intake, without review and approval of the initial assessment and treatment plan in accordance with § 1153.52(a)(7) and (8).
(16) The hours that the individual participates in an education program delivered in the same setting as a children and youth partial hospitalization outpatient program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the individual is in direct contact with a clinical staff person.
(17) Group psychotherapy provided in the individual's home.
(18) Psychiatric outpatient clinic and partial hospitalization outpatient services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.
(19) Electroconvulsive therapy and electroencephalogram provided through MMHT.
(20) MMHT services provided on the same day as other home and community-based behavioral health services to the same individual with the exception of clinical services not offered by the psychiatric outpatient clinic.
SCOPE OF BENEFITS § 1153.21. Scope of benefits for children under 21 years of age.
Children under 21 years of age are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.
§ 1153.22. Scope of benefits for adults 21 years of age or older.
Adults 21 years of age or older are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.
§ 1153.23. (Reserved).
§ 1153.24. (Reserved).
PROVIDER PARTICIPATION § 1153.41. Participation requirements.
In addition to the participation requirements established in Chapter 1101 (relating to general provisions), psychiatric outpatient clinics and partial hospitalization outpatient facilities shall meet the following participation requirements:
(1) Have current licensure as a psychiatric outpatient clinic or partial hospitalization outpatient facility by the Department's Office of Mental Health and Substance Abuse Services. To remain eligible for MA reimbursement, a psychiatric outpatient clinic or partial hospitalization outpatient facility shall be licensed at all times as a psychiatric outpatient clinic or partial hospitalization outpatient facility.
* * * * * (3) Have a written referral plan for individuals receiving services that provides for inpatient hospital care and follow-up treatment.
* * * * * (5) Appoint an administrator or director responsible for the internal operation of the psychiatric outpatient clinic or partial hospitalization outpatient facility. Appoint a psychiatrist or psychiatrists responsible for the supervision and direction of services rendered to eligible individuals.
(6) Notify immediately the Department, Office of Medical Assistance Programs, Bureau of Fee-for-Services, in the manner prescribed by the Department, of facility or clinic name, address and service changes prior to the effective date of change. Failure to do so may result in payment interruption or termination of the provider agreement.
* * * * * (8) Have each branch location or satellite of a licensed psychiatric outpatient clinic or partial hospitalization outpatient facility also licensed by the Office of Mental Health and Substance Abuse Services as a psychiatric outpatient clinic site or psychiatric hospitalization outpatient facility, whichever is applicable, and enrolled by the Office of Medical Assistance Programs before reimbursement can be made for services rendered at the branch or satellite. Licensure and enrollment of the parent organization does not constitute licensure and enrollment for any branches or satellites of the same organization.
(9) Be enrolled as a provider in the Medical Assistance Program.
(10) Have medications prescribed by a licensed psychiatrist, physician, certified registered nurse practitioner or physician assistant within the practitioner's scope of practice.
(11) Psychiatric outpatient clinics providing MMHT services shall have a service description approved by the Department under the conditions specified in § 5200.51 (relating to provider service description).
§ 1153.42. Ongoing responsibilities of providers.
(a) Responsibilities of providers. Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions). Psychiatric outpatient clinics and psychiatric partial hospitalization outpatient facilities shall also adhere to the additional requirements established in this section.
(b) Recordkeeping requirements. In addition to the requirements listed in § 1101.51(e) (relating to ongoing responsibilities of providers), the following items must be included in the records of MA beneficiaries receiving psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization outpatient services:
(1) The treatment plan must include:
(i) The treatment plan goals.
(ii) Services to be provided to the individual by the psychiatric outpatient clinic or partial hospitalization outpatient facility or through referral.
(iii) Persons to directly provide each service.
(2) As part of the progress notes, the frequency and duration of each service provided shall be included.
PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES § 1153.51. General payment policy.
(a) Payment is made for medically necessary professional medical and psychiatric services provided by or under the supervision and direction of a psychiatrist by participating psychiatric outpatient clinics and psychiatric partial hospitalization outpatient facilities subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule.
(b) The Department will publish procedures for the use of tele-behavioral health to provide compensable psychiatric outpatient clinic or psychiatric partial hospitalization services in the Pennsylvania Bulletin.
(c) Payment will not be made for a compensable psychiatric outpatient clinic, MMHT or psychiatric partial hospitalization outpatient service if payment is available from another public agency or another insurance or health program.
§ 1153.52. Payment conditions for various services.
(a) The following conditions shall be met by psychiatric outpatient clinics and partial hospitalization outpatient programs, as applicable, to be eligible for payment:
(1) A psychiatrist shall be present in the psychiatric outpatient clinic and partial hospitalization outpatient facility, as required by the Office of Mental Health and Substance Abuse Services licensing regulations, to perform or supervise the performance of all covered services provided to MA beneficiaries.
(2) Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview or using interactive audio and video communication that conforms to industry-wide technology standards with the individual and is in compliance with State and Federal privacy and security laws. Additional interviews with other staff may be included as part of the examination but shall be included in the psychiatric evaluation fee. Separate billings for these additional interviews are not compensable.
* * * * * (6) The psychiatric outpatient clinic medication visit shall be provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.
(7) Within 30 consecutive calendar days following intake for individuals who continue to participate in the treatment process, a mental health professional or mental health worker under the supervision of a mental health professional, shall:
(i) Interview and complete an assessment with each individual receiving services from the psychiatric outpatient clinic.
(ii) Develop the initial treatment plan based upon the assessment in collaboration with the individual.
(iii) Date and sign the initial treatment plan.
(iv) Request the individual to sign and date the treatment plan. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.
(8) The initial treatment plan shall be reviewed and approved in accordance with the following:
(i) If the individual is receiving psychotherapy and other clinic services, the psychiatrist or advanced practice professional shall review, approve, sign and date the initial treatment plan.
(ii) If the individual is receiving medication management services only, the psychiatrist, physician, certified registered nurse practitioner or physician assistant responsible for prescribing and monitoring the use of the medications shall sign and date the initial treatment plan.
(iii) The initial treatment plan shall be developed, reviewed, approved, dated and signed prior to the provision of any treatment services beyond the 30th day following intake.
(iv) The initial treatment plan shall be kept in the individual record.
(9) The treatment plan shall be reviewed and updated at least every 180 days or as may otherwise be required by law throughout the duration of treatment in accordance with the following:
(i) The treatment plan updates shall be based upon the assessment, diagnosis and input from the treatment team and individual receiving services.
(ii) The treatment plan update shall be signed and dated by the mental health professional, mental health worker under the supervision of the mental health professional, certified registered nurse practitioner or physician assistant providing treatment services to the individual.
(iii) The mental health professional or the mental health worker shall request the individual to sign and date the treatment plan update. In the event the individual does not sign the treatment plan, the mental health professional or mental health worker shall document the request in the record.
(iv) The treatment plan update shall be kept in the individual record.
(10) Treatment shall be provided in accordance with the identified goals in the treatment plan and updates.
(11) The treatment plan shall be reviewed on an annual basis by the psychiatrist or advanced practice professional throughout the course of treatment from the psychiatric outpatient clinic and the review documented in the individual record.
(12) The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for an individual receiving clozapine therapy.
(b) Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric partial hospitalization outpatient services provided to eligible individuals with mental illness or emotional disturbance in psychiatric partial hospitalization outpatient facilities under the following conditions:
(1) Individuals receiving partial hospitalization outpatient services shall meet the following criteria:
(i) Have a mental disorder diagnosis that has been verified by a psychiatrist.
(ii) Have a psychiatric condition requiring more intensive treatment than that provided by an outpatient clinic.
(iii) Be diagnosed with a mental illness or emotional disturbance and prescribed services for a period of at least 3 hours but less than 24 hours in any 1 day to prevent hospitalization or to support the transition from inpatient treatment to outpatient services.
(2) The following components shall be available in a psychiatric partial hospitalization outpatient facility and provided to an individual, if necessary, in accordance with the individualized treatment plan:
(i) Individual, group and family psychotherapy.
* * * * * (v) Medication administration and evaluation provided only by a psychiatrist, physician, certified registered nurse practitioner, physician assistant, registered nurse or licensed practical nurse.
* * * * * (c) Psychiatric outpatient clinic. Payment will only be made for psychiatric outpatient clinic services or MMHT services provided to eligible individuals with mental illness or emotional disturbance by psychiatric outpatient clinics under the following conditions:
(1) Medication visits shall be provided only for the purpose of administering medication and for evaluating the physical and mental condition of an individual during the course of prescribed medication.
(2) Individuals receiving psychiatric outpatient clinic services or MMHT services shall have a mental illness or emotional disturbance diagnosis verified by a psychiatrist or LPHA.
(3) Family psychotherapy is compensable only if one or more family members has a mental disorder diagnosis.
(4) Clozapine monitoring and evaluation visits shall be provided only for an individual receiving clozapine and for monitoring and evaluating the individual's absolute neutrophil count to determine whether clozapine therapy should be continued or modified.
(d) MMHT. MMHT services are subject to the conditions and limitations established in this chapter. MMHT services provided in the home or other approved community sites are compensable only if documentation in the individual record substantiates all of the following:
(1) The services are provided to an eligible individual with mental illness or emotional disturbance.
(2) There is a written recommendation for MMHT services from a LPHA acting within the scope of professional practice.
(3) The services if provided in a psychiatric outpatient clinic would be medically necessary.
(4) The assessment documents a mental or physical illness that impedes or precludes the individual's ability to participate in services at the psychiatric outpatient clinic.
(5) Treatment plan updates document the continued clinical need for MMHT services.
§ 1153.53. Limitations on payment.
Payment is subject to the following limitations:
(1) Psychiatric partial hospitalization outpatient service is provided for at least 3 hours per 24-hour period.
(2) The partial hospitalization outpatient service fees listed in the MA Program Fee Schedule include payment for all services rendered to the individual during a psychiatric partial hospitalization outpatient session. Separate billings for individual services are not compensable.
(3) Partial hospitalization outpatient facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the individual receiving treatment.
(4) Partial hospitalization outpatient facilities licensed as children and youth programs will be reimbursed at the child rate only when the individual receiving treatment is under 15 years of age.
(5) Family psychotherapy and collateral family psychotherapy are compensable for only one person per session, regardless of the number of family members who participate in the session or the number of participants who are eligible for psychotherapy.
(6) MMHT group therapy shall be provided only in an approved community-based site as specified in the treatment plan to individuals receiving MMHT services from the psychiatric outpatient clinic.
§ 1153.53a. (Reserved).
PART VII. MENTAL HEALTH MANUAL
Subpart D. NONRESIDENTIAL AGENCIES/FACILITIES/SERVICES
CHAPTER 5200. PSYCHIATRIC OUTPATIENT CLINICS
GENERAL PROVISIONS § 5200.1. Legal base.
The legal authority for this chapter is sections 105 and 112 of the Mental Health Procedures Act (50 P.S. §§ 7105 and 7112), section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)) and section 1021 of the Human Services Code (62 P.S. § 1021).
§ 5200.2. Scope.
(a) This chapter provides standards for the licensing of freestanding psychiatric outpatient clinics under section 1021 of the Human Services Code (62 P.S. § 1021), and approval of psychiatric outpatient clinics which are a part of a health care facility as defined in section 802.1 of the Health Care Facilities Act (35 P.S. § 448.802a), and under sections 105 and 112 of the Mental Health Procedures Act (50 P.S. §§ 7105 and 7112).
(b) This chapter applies to private, nonprofit or for-profit corporations and public entities which provide medical examination, diagnosis, care, treatment and support to individuals with mental illness or emotional disturbance on an outpatient basis and which participate in the public mental health program. This chapter does not apply to group or individual practice arrangements of private practitioners.
§ 5200.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Advanced practice professional—A person who holds a current Pennsylvania license as a certified registered nurse practitioner or a physician assistant and:
(1) Holds a mental health certification, or
(2) Obtains a mental health certification within 2 years of being hired by the psychiatric outpatient clinic or by July 30, 2020, whichever is later.
Assessment—A face-to-face interview that includes an evaluation of the behavioral health, medical, psychological, social, vocational and educational factors important to the individual.
Child psychiatrist—A physician who has completed a residency in psychiatry and who has a specialty in child psychiatry and is licensed to practice in this Commonwealth.
Department—The Department of Human Services.
FTE—Full-time equivalent—Thirty-seven and one half hours per week.
Facility—A mental health establishment, hospital, clinic, institution, center or other organizational unit or part thereof, the primary function of which is the diagnosis, treatment, care and rehabilitation of individuals with mental illness or emotional disturbance.
Interactive audio and video—Real-time two-way or multiple-way communication.
LPHA—Licensed Practitioner of the Healing Arts—A person who is licensed by the Commonwealth to practice the healing arts. The term is limited to a physician, physician assistant, certified registered nurse practitioner, licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor or psychologist.
MMHT—Mobile Mental Health Treatment—One or more of the following services provided in an individual's residence or approved community site:
(i) Assessment.
(ii) Individual, group or family therapy.
(iii) Medication visits.
Mental health professional—A person who meets one of the following:
(i) Has a graduate degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation (CHEA) in a generally recognized clinical discipline in which the degree program includes a clinical practicum.
(ii) Has an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. (AICE) or the National Association of Credential Evaluation Services (NACES). The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
(iii) Is licensed in a generally recognized clinical discipline that includes mental health clinical experience.
Mental health worker—A person acting under the supervision of a mental health professional to provide services who meets one of the following:
(i) Has a bachelor's degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the CHEA in a recognized clinical discipline including social work, psychology, nursing, rehabilitation or activity therapies.
(ii) Has a graduate degree in a clinical discipline with 12 graduate-level credits in mental health or counseling from a program that is accredited by an agency recognized by the United States Department of Education or the CHEA.
(iii) Has an equivalent degree from a foreign college or university that has been evaluated by the AICE or the NACES. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
Mental illness or emotional disturbance—A mental disorder that meets the diagnostic criteria within the current version of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases (ICD).
Psychiatric outpatient clinic—A nonresidential treatment setting in which psychiatric, psychological, social, educational and other related services are provided under medical supervision. It is designed for the evaluation and treatment of individuals with mental illness or emotional disturbance. Psychiatric outpatient services are provided on a planned and regularly scheduled basis.
Psychiatrist—A physician who has completed at least 3 years of a residency in psychiatry and is licensed to practice in this Commonwealth.
Psychologist—A person licensed to practice psychology in this Commonwealth.
Quality assurance program—A formal process to assure quality care and maximize program benefits to individuals receiving services.
Tele-behavioral health—
(i) The use of interactive audio and video communication to provide clinical services at a distance using technology that conforms to the industry-wide standards and is in compliance with State and Federal privacy and security laws.
(ii) Tele-behavioral health does not include telephone conversation, electronic mail message or facsimile transmission between a psychiatrist or an advanced practice professional and an individual receiving services, or a consultation between two health care practitioners, although these activities may support the delivery of tele-behavioral health.
§ 5200.4. Provider eligibility.
Psychiatric outpatient clinic services for individuals with mental illness or emotional disturbance shall be provided only by a facility which complies with this chapter and is licensed by the Department. Nothing in this chapter is intended to regulate the provision of mental health services in individual or group private practice.
§ 5200.5. Application and review process.
(a) A facility intending to provide psychiatric outpatient clinic services shall file an application for a certificate of compliance with the Department in accordance with Chapter 20 (relating to licensure or approval of facilities and agencies). Facilities shall meet both the requirements of Chapter 20 and this chapter to obtain a certificate. Submission of an application does not constitute a certificate to operate pending Departmental approval.
(b) Facilities will be inspected a minimum of once per year, and are subject to visits by the Department's designee at other times at the Department's discretion. The facility shall provide information concerning program and fiscal operation at the Department's request.
§ 5200.6. Objective.
The objective of the psychiatric outpatient clinic treatment services is to facilitate an individual's recovery to improve functioning, enhance resiliency and well-being, promote independence and maintain optimal functioning in the community consistent with the individual's preferences. The service may be provided to individuals with short-term or long-term treatment needs.
§ 5200.7. Program standards.
This chapter shall be met by a facility seeking licensure or approval.
ORGANIZATION § 5200.11. Organization and structure.
(a) The psychiatric outpatient clinic must be a separate, identifiable organizational unit with its own director, clinical supervisor and staffing pattern. When the psychiatric outpatient clinic is a portion of a larger organizational structure, the director and clinical supervisor of the psychiatric outpatient clinic shall be identified and their responsibilities clearly defined.
(b) The organizational structure of the unit must be described in an organizational chart.
(c) A written description of programs provided by the unit shall be available to the Department.
(d) The psychiatric outpatient clinic shall notify the Department within 10 days of a major change in the organizational structure or services.
§ 5200.12. Linkages with mental health service system.
(a) A psychiatric outpatient clinic requires a close relationship with an acute psychiatric inpatient service and a provider of emergency examination and treatment. A written statement describing the accessibility and availability of the services to individuals is required and shall be maintained on file at the psychiatric outpatient clinic and updated as needed.
(b) A psychiatric outpatient clinic shall maintain linkages with other treatment and rehabilitative services for a full continuum of care, including crisis services, partial hospitalization programs, peer support, psychiatric rehabilitation programs, intensive community services, community residential programs and community psychiatric hospitals. A written statement describing the accessibility and availability of the services to individuals is required and shall be maintained on file at the psychiatric outpatient clinics and updated as needed to accurately state the services currently available.
(c) When the psychiatric outpatient clinic serves children, linkages with the appropriate educational and social service agencies shall also be maintained. A written statement describing the accessibility and availability of the services to children is required and shall be maintained on file at the psychiatric outpatient clinic and updated as needed to accurately state the services currently available.
(d) A psychiatric outpatient clinic shall participate in the overall system of care as defined in the County Mental Health/Intellectual Disability (MH/ID) plan. A psychiatric outpatient clinic shall have an agreement regarding continuity of care and information exchange with the County MH/ID authority. A copy of an agreement must be included in the application package. Psychiatric outpatient clinics shall document the need for their services in their application for a certificate of compliance.
(e) New psychiatric outpatient clinics or new sites of existing psychiatric outpatient clinics established after the effective date of this chapter shall document the need in the proposed service area for the expansion of outpatient services. County MH/ID authorities shall review this documentation and make a recommendation to the Department. The Department may deny approval of the expansion where inadequate justification is provided.
STAFFING AND PERSONNEL § 5200.21. Qualifications and duties of the director/clinical supervisor.
(a) Each psychiatric outpatient clinic shall have a director and clinical supervisor, who may be the same individual. A clinical supervisor shall be a mental health professional with at least 2 years of supervisory experience.
(b) The director shall be responsible for the overall operation of the psychiatric outpatient clinic, including daily management, ensuring that clinical supervision is available during all operational hours, developing a quality improvement plan for the psychiatric outpatient clinic and monitoring adherence with this chapter.
(c) The clinical supervisor's responsibilities shall include all of the following:
(1) Supervision of clinical staff.
(2) Development or implementation of the policies and procedures for the operation of the psychiatric outpatient clinic.
(3) Regular meetings of clinical staff to discuss clinical cases, treatment plans, policies and procedures.
(4) Liaison with other portions of the service system.
(5) Employment, supervision and discharge of clinical staff according to established personnel policies.
(6) Supervision and documentation of clinical staff training and development.
§ 5200.22. Staffing pattern.
(a) There shall be qualified staff and supporting personnel in sufficient numbers to provide the services included in the psychiatric outpatient clinic's program as follows:
(1) At least 50% of the treatment staff providing psychotherapy services shall be mental health professionals.
(2) A psychiatric outpatient clinic is required to have 2 hours of psychiatric time per week for each FTE mental health professional and mental health worker providing clinical services.
(3) The psychiatrist must provide 50% of the required psychiatric time at the psychiatric outpatient clinic.
(4) The remaining 50% of the psychiatric time may be provided by:
(i) An advanced practice professional.
(ii) A psychiatrist off-site by the use of tele-behavioral health.
(iii) A combination of subparagraphs (i) and (ii).
(b) All clinical staff shall be supervised by the psychiatrist having the overall responsibility for clinical services provided by the psychiatric outpatient clinic as defined in § 5200.23 (relating to psychiatric supervision).
(c) There shall be sufficient clerical staff to keep correspondence, records and files current and in good order.
(d) The psychiatric outpatient clinic shall recruit and hire staff that is appropriate for the population to be served.
(e) If the psychiatric outpatient clinic serves children, specialized personnel are required, as appropriate, to deliver services to children.
(f) Each psychiatric outpatient clinic shall have a written comprehensive personnel policy.
(g) There shall be a written plan for regular, ongoing staff development and training.
(h) Graduate and undergraduate students in accredited training programs in various mental health disciplines may participate in the treatment of individuals receiving services when under the direct supervision of a mental health professional, but are not to be included for the purpose of defining staffing patterns.
(i) Psychiatric residents with an unrestricted license to practice medicine in this Commonwealth who are under the direct supervision of a psychiatrist are defined as mental health professionals for the purpose of defining staffing patterns.
(j) Volunteers may be used in various support and activity functions of the clinic, but are not considered for the purposes of defining staffing patterns.
§ 5200.23. Psychiatric supervision.
The supervision of a psychiatric outpatient clinic shall be by a psychiatrist and, at a minimum, include the following:
(a) Establishment of appropriate standards for treatment and prescribing practices.
(b) Involvement in the quality management process.
(c) Participation in clinical staff meetings 2 times per month. The psychiatric outpatient clinic shall maintain written documentation of clinical staff meetings, including attendance.
(d) Consultation to all clinical staff.
§ 5200.24. Criminal history and child abuse certification.
(a) A psychiatric outpatient clinic shall have documentation of the completed criminal history background check for staff, including volunteers that will have direct contact with an individual.
(b) A psychiatric outpatient clinic that serves children shall have documentation of the completed criminal history and child abuse certifications, and mandated reporter training in accordance with 23 Pa.C.S. §§ 6301—6386 (relating to the Child Protective Services Law) and Chapter 3490 (relating to protective services) for all staff, including volunteers that will have direct contact with children.
(c) A psychiatric outpatient clinic shall develop and implement written policies and procedures regarding personnel decisions based on the criminal history and child abuse certification, including volunteers.
TREATMENT STANDARDS § 5200.31. Treatment planning.
(a) For each individual receiving services, a mental health professional or mental health worker under the supervision of a mental health professional shall complete an assessment of the behavioral health, medical, psychological, social, vocational, educational and other factors important to the individual prior to the development of the initial comprehensive treatment plan.
(b) An initial comprehensive treatment plan shall be developed, reviewed and approved within 30 days of the intake and assessment with every individual who continues to participate in the treatment process in accordance with the following:
(1) The mental health professional or the mental health worker under the supervision of the mental health professional and the individual receiving services shall develop, sign and date the initial treatment plan.
(2) If the individual is receiving psychotherapy and other clinical services, the psychiatrist or advanced practice professional shall review, approve, sign and date the initial treatment plan.
(3) If the individual is receiving medication management services only, the psychiatrist, physician, certified registered nurse practitioner or physician assistant responsible for prescribing and monitoring the use of the medication shall review, approve, sign and date the initial treatment plan.
(4) For individuals under an involuntary outpatient commitment, the mental health professional or advanced practice professional providing services and the individual shall develop, review, sign and date the initial treatment plan. The treatment plan shall be reviewed and signed by the psychiatrist as part of the oversight of the treatment services provided.
(c) The treatment plan must be based upon the assessment and shall:
(1) Specify the goals and objectives of the plan, prescribe an integrated program of therapeutic activities and experiences, specify the modalities to be utilized and the expected duration of services and the person or persons responsible for carrying out the plan.
(2) Be directed at specific outcomes and connect these outcomes with the treatment modalities and activities proposed.
(3) Be developed with the active involvement of the individual receiving services and shall include strengths and needs. The treatment plan may also address individual preferences, resilience and functioning.
(4) For children and adolescents under 14 years of age, be developed and implemented with the consent of parents or guardians and include their participation in treatment as required by statute or regulation.
(5) Specify an individualized treatment program for each individual, which shall include clinically appropriate services such as psychiatric evaluation and diagnosis, psychological evaluation, individual, group and family psychotherapy, behavior therapy, crisis intervention services, medication evaluation and management, and similar services.
(d) The treatment plan shall be reviewed and updated throughout the duration of treatment as follows:
(1) For individuals under an involuntary outpatient commitment, the treatment plan shall be reviewed and updated every 30 days by the mental health professional or advanced practice professional providing treatment services and the individual receiving services. The treatment plan update shall be reviewed and signed by the psychiatrist as part of the oversight of treatment services provided.
(2) For individuals voluntarily receiving treatment, the treatment plan shall be reviewed and updated at a minimum of every 180 days by the mental health professional, mental health worker under the supervision of a mental health professional, certified registered nurse practitioner or physician assistant providing treatment services and the individual receiving services.
(3) The treatment plan update shall be signed and dated by the mental health professional, mental health worker under the supervision of a mental health professional, certified registered nurse practitioner or physician assistant providing treatment services.
(4) The mental health professional or mental health worker shall request the individual to sign and date the treatment plan update. In the event the individual does not sign the treatment plan update, the mental health professional or mental health worker shall document the request in the record.
(e) All treatment services shall be provided in accordance with the identified goals in the treatment plan and updates.
(f) The treatment plan and updates shall be kept in the individual record.
(g) The treatment plan shall be reviewed on an annual basis by the psychiatrist or advanced practice professional throughout the course of treatment from the psychiatric outpatient clinic and documented in the individual record.
§ 5200.32. Treatment policies and procedures.
Each psychiatric outpatient clinic shall have on file a written plan specifying the clinical policy and procedures of the facility and shall provide services in accordance with them. This plan must provide for the following:
(1) Intake and assessment policy and procedures.
(2) Admission policies including time frames for the following:
(i) Referrals from crisis intervention or emergency services.
(ii) Referrals from inpatient units.
(iii) Referrals for medication management services.
(iv) Other referrals.
(3) The services to be provided and the scope of these services.
(4) Discharge policies providing for continuity of care for individuals discharged from the program.
(5) Complaint policies and procedures.
(6) Statement of rights in accordance with 55 Pa. Code §§ 5100.51—5100.56 (relating to patient rights).
§ 5200.33. Discharge.
(a) A psychiatric outpatient clinic shall complete a discharge summary for each individual at least 45 days before discharge from services that includes the following:
(1) Summary of services provided and outcomes.
(2) Reason for discharge.
(3) Referral or recommendation for other services if needed.
(b) The psychiatric outpatient clinic shall provide the following information to individuals at discharge:
(1) Contact information for the local crisis intervention service.
(2) Contact information for any referrals.
MISCELLANEOUS PROVISIONS § 5200.41. Records.
(a) Under section 602 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4602), and in accordance with recognized and acceptable principles of recordkeeping, the facility shall maintain a record for each individual receiving services from a psychiatric outpatient clinic. The record must include the following:
(1) Identifying information.
(2) Referral source.
(3) Assessment including presenting problems.
(4) Appropriately signed consent forms.
(5) Medical, social and developmental history.
(6) Diagnosis and evaluation.
(7) Treatment plan and updates.
(8) Treatment progress notes for each contact.
(9) Medication orders.
(10) Discharge summary.
(11) Referrals to other agencies, when indicated.
(12) A written recommendation from a LPHA acting within the practitioner's scope of practice for any MMHT services provided.
(b) Records shall also be maintained as follows:
(1) Legible and permanent.
(2) Reviewed twice a year as to quality by the director, clinical supervisor or psychiatrist.
(3) Maintained in a uniform manner so that information can be provided in a prompt, efficient, accurate manner and so that data is accessible for administrative and professional purposes.
(4) Signed and dated by the staff member writing in the record.
(c) All protected individual records, written and electronic, shall be secured in accordance with all applicable Federal and State privacy and confidentiality statutes and regulations.
§ 5200.42. Medications.
(a) If medication is prescribed or dispensed by the psychiatric outpatient clinic, the requirements of all applicable Federal and State drug statutes and regulations shall be met. In addition, all of the following apply:
(1) Prescriptions shall be written only by a licensed psychiatrist, physician, certified registered nurse practitioner or physician assistant within the practitioner's scope of practice.
(2) The term ''written'' includes prescriptions that are handwritten or recorded and transmitted by electronic means.
(3) Written prescriptions transmitted by electronic means must be electronically encrypted or transmitted by other technological means designed to protect and prevent access, alteration, manipulation or use by an unauthorized person.
(4) A record of any medication prescribed shall be documented in the individual record.
(b) Written policies and procedures providing for the safe dispensing and administration of medication by the medical and nursing staff shall be in writing and on file. The policy must include all of the following:
(1) Medications shall be dispensed only on an order of a licensed psychiatrist, physician, certified registered nurse practitioner or physician assistant within the practitioner's scope of practice.
(2) All medication shall be kept in a secure place.
(3) Each dose of medication administered by the psychiatric outpatient clinic shall be properly recorded in the individual's record.§ 5200.43. Fee schedule.
Each psychiatric outpatient clinic shall maintain a schedule of uniform basic charges for services which are available to all individuals receiving services.
§ 5200.44. Quality assurance program.
All psychiatric outpatient clinics shall have a utilization review and clinical audit process designed to ensure that the most appropriate treatment is delivered to the individual receiving services and that treatment is indicated. Psychiatric outpatient clinics that provide MMHT services shall include MMHT services in the Quality Assurance plan. The Quality Assurance plan shall include the following:
(1) Process for the annual review of the quality, timeliness and appropriateness of the services provided, including feedback on satisfaction with services from individuals receiving services.
(2) Identification of the type of review and the methodology for the review.
(3) Documentation of the findings of the annual review.
(4) Utilization of the annual review findings to improve psychiatric outpatient clinic services.
§ 5200.45. Physical facility.
(a) Adequate space, equipment and supplies shall be provided in order that the outpatient services can be provided effectively and efficiently. Functional surroundings shall be readily accessible to the individual and community served.
(b) All space and equipment shall be well maintained and must meet applicable Federal, State and local requirements for safety, fire, accessibility and health.
(c) A waiting room which is clean, comfortable and sensitive to the culture of the population served shall be provided.
(d) There shall be office space for the clinical staff suitably equipped with chairs, desks, tables and other necessary equipment.
(e) There shall be an adequate number of suitably equipped conference rooms to provide for staff conferences and therapy.
(f) There shall be adequate provisions for privacy within the psychiatric outpatient clinic.
(g) A psychiatric outpatient clinic is defined by its staff and organizational structure rather than by a specific building or facility. It may operate at more than one site if the respective sites meet all physical facility standards and the sites operate as a portion of the psychiatric outpatient clinic. The staffing pattern at each site shall be based on the ratio of total individuals served at that site to the total individuals served in the psychiatric outpatient clinic as a whole. The Department will issue a single certificate of compliance to the parent organization which will list all operational sites.
§ 5200.46. Notice of nondiscrimination.
Programs may not discriminate against staff or individuals receiving services on the basis of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, national origin or age, and shall comply with all applicable State and Federal statutes and regulations.
§ 5200.48. Waiver of standards.
In instances where the development of specialty psychiatric outpatient clinic services is severely limited by these standards, such as rural clinics or specialty clinics, a waiver may be granted. Waivers may be applied only in areas where the need for these services and the attempts to meet the standards are adequately documented. Waivers are to be considered only in exceptional circumstances and are subject to approval by the Department.
MOBILE MENTAL HEALTH TREATMENT § 5200.51. Provider service description.
(a) Prior to the delivery of MMHT services, a psychiatric outpatient clinic shall submit to the Department for approval a MMHT service description that includes the information required under subsection (b). A psychiatric outpatient clinic shall submit a revised service description to the Department if there are changes to the information required under subsection (b).
(b) A service description must include all of the following:
(1) The population to be served, including all of the following:
(i) Expected number of individuals to be served.
(ii) The age ranges of the individuals to be served.
(iii) The presenting problems and other characteristics supporting the need for MMHT services.
(iv) The location of the provision of the services, whether in the home or community or both.
(v) The goals, objectives and expected outcomes of the MMHT services.
(2) Staffing pattern, including all of the following:
(i) Number of mental health professionals, licensed clinical psychologists, and psychiatrists providing MMHT services.
(ii) The qualifications of a staff person providing a MMHT service.
(iii) The specific clinical services to be provided by each staff.
(3) The policies and procedures for all of the following:
(i) The supervision of MMHT services.
(ii) Staff support in the provision of MMHT services.
(iii) Coordination of care with physical health services.
(c) A psychiatric outpatient clinic shall provide MMHT services only as set forth in its approved service description.
§ 5200.52. Treatment planning.
(a) Treatment planning shall be completed in accordance with § 5200.31 (relating to treatment planning) and shall include all of the following:
(1) Services to be provided.
(2) Treatment goals.
(3) Duration of service.
(4) Supports and interventions necessary to alleviate barriers to receiving services at a psychiatric outpatient clinic.
(5) Identification of the professional providing each service.
(6) Location of service provision.
(b) A MMHT services provider shall complete an assessment as required by § 5200.31(a) prior to developing the treatment plan. In addition, the following shall apply:
(1) The assessment shall include documentation of the disabling effects of a mental or physical illness that impedes or precludes the individual's ability to participate in services at the psychiatric outpatient clinic.
(2) The assessment shall be completed by a psychiatrist, mental health professional, or an advanced practice professional trained and qualified to provide services at a psychiatric outpatient clinic.
(c) Treatment plans shall be updated at a minimum every 180 days.
[Pa.B. Doc. No. 19-1510. Filed for public inspection October 11, 2019, 9:00 a.m.]
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