PROPOSED RULEMAKING
DEPARTMENT OF
HUMAN SERVICES
[55 PA. CODE CHS. 1330, 3800 AND 5330]
Psychiatric Residential Treatment Facilities
[54 Pa.B. 7156]
[Saturday, November 2, 2024]Statutory Authority
Notice is hereby given that the Department of Human Services (Department) under the authority of sections 201(2), 911 and 1021 of the Human Services Code (62 P.S. §§ 201(2), 911 and 1021) and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)) intends to adopt this proposed rulemaking as set forth in Annex A.
Purpose of Regulation
The Department licenses residential treatment facilities (RTF) that serve children, youth or young adults under the authority of Chapter 3800 (relating to child residential and day treatment facilities). A subset of the RTFs that provide medically necessary behavioral health treatment in a residential setting to children, youth or young adults under 21 years of age with a behavioral health diagnosis is also certified by the Department. These RTFs are referred to as psychiatric residential treatment facilities (PRTF) in this proposed rulemaking.
The Department proposes to codify the minimum licensing standards, Medical Assistance (MA) participation requirements and MA payment conditions for PRTFs that serve children, youth or young adults with a behavioral health diagnosis in Chapters 1330 and 5330 (relating to psychiatric residential treatment facility; and psychiatric residential treatment facility). Chapter 5330 establishes the Department's minimum program and operational standards for a provider to obtain a license as a PRTF. Chapter 1330 establishes the Department's MA payment conditions and MA participation requirements for PRTFs. All PRTFs will need to be licensed under and comply with Chapter 5330, but only those PRTFs that want to receive MA payment must comply with Chapter 1330. This proposed rulemaking will distinguish licensed PRTFs from other RTFs licensed by the Department and streamline the current licensure and certification process. Upon promulgation of the final-form rulemaking, PRTFs will be subject to Chapters 1330 and 5330.
This proposed rulemaking specifically addresses medically necessary behavioral health treatment for children, youth or young adults provided by a PRTF. It also includes requirements for PRTFs that are in line with the Federal requirements for PRTFs. Finally, this proposed rulemaking adds language to address specific health, safety and treatment needs of children, youth or young adults with a behavioral health diagnosis. This proposed rulemaking supports the goal of better services for children, youth or young adults with behavioral health needs and promotes the goal of children, youth or young adults returning to their home and community in the shortest time possible.
This proposed rulemaking will support children, youth or young adults who receive behavioral health treatment in a residential setting by adding requirements for minimum standards for treatment services, including the required frequency for individual therapy, group therapy and family therapy, and the qualifications for the individuals who provide therapy. This proposed rulemaking will also further delineate staff roles and responsibilities and enhance staff ratio requirements for direct supervision of children, youth or young adults.
This proposed rulemaking will update the current staff requirements to allow PRTFs to better meet the behavioral health needs of the children, youth or young adults served. While this proposed rulemaking maintains the current structure of a director, childcare worker and childcare worker supervisor, the minimum standards for these positions and the job titles are proposed to be updated. This proposed rulemaking also requires additional positions to meet Federal requirements and to better support the children, youth or young adults with behavioral health needs receiving treatment in a PRTF. The new positions include a medical director, treatment team leader, clinical director, mental health professional and registered nurse. This proposed rulemaking also includes minimum standards for additional positions, including an advanced practice professional and a licensed practical nurse. The fiscal impact of the changes to staff requirements is explained in detail as follows.
The current staff ratio requirements are also increased in this proposed rulemaking for both secure and nonsecure PRTFs, as described as follows. In addition, this proposed rulemaking increases certain types of reportable incidents. New incidents that are proposed to be reported include disruption of utilities, use of prohibited restrictive procedures and all medication errors. Because manual restraints have the potential to cause physical harm and can also have a traumatic impact on both the individual who is restrained and on the staff applying the restraint, this proposed rulemaking reduces the length of time for a manual restraint to be applied to a child, youth or young adult.
This proposed rulemaking also includes different admission requirements for secure PRTFs. Secure PRTFs prohibit egress from the facility or a portion thereof through internal locks, exterior locks or secure fencing around the facility. Generally, a child, youth or young adult needs to be alleged delinquent or adjudicated delinquent to receive care in a secure setting. This proposed rulemaking, however, deletes the delinquency requirement because MA can be used to pay for a child's, youth's or young adult's medically necessary behavioral health treatment in a secure PRTF if the secure PRTF does not exclusively treat children, youth or young adults who are alleged delinquent or adjudicated delinquent. As a result, admission of a child, youth or young adult whose treatment is funded by MA to a secure PRTF will depend on the child's, youth's or young adult's medically recommended treatment needs, rather than on the child's, youth's or young adult's delinquency status.
Finally, this proposed rulemaking codifies the payment requirements for treatment in a PRTF.
Requirements
As discussed previously, proposed Chapter 1330 contains the requirements PRTF providers will need to follow to receive MA payment for the services provided to a child, youth or young adult who receives medically necessary behavioral health services. Proposed Chapter 5330 identifies the minimum program and operational standards for a provider to obtain a license as a PRTF.
The following is a summary of the major provisions of each chapter included in this proposed rulemaking.
Chapter 1330. Psychiatric Residential Treatment Facility—Payment
General Provisions (§§ 1330.1 and 1330.2)
This proposed rulemaking requires a PRTF to be enrolled in the MA program to receive payment for medically necessary behavioral health services rendered to children, youth or young adults with a behavioral health diagnosis. This proposed rulemaking also establishes definitions of key terms used under Chapter 1330. Terms that are used in both Chapter 1330 and Chapter 5330 are defined consistently.
Scope of Benefits (§ 1330.11)
This proposed rulemaking establishes that children, youth or young adults who are MA recipients and have a behavioral health diagnosis are eligible to receive medically necessary services in a PRTF.
Provider Participation (§§ 1330.21—1330.23)
This proposed rulemaking includes both the initial and ongoing requirements for a PRTF to participate in the MA program. This proposed rulemaking also establishes requirements for when a PRTF changes ownership.
Payment (§§ 1330.31—1330.43)
This proposed rulemaking addresses MA payment for treatment in a PRTF, including a secure PRTF; the requirement that services be medically necessary; and the conditions for payment for admission and continued stay at a PRTF. This proposed rulemaking includes additional requirements for admission to a secure PRTF. This proposed rulemaking adds a requirement for approval by the Department prior to admission to a secure PRTF if a child's, youth's or young adult's treatment is being funded by MA. Further, this proposed rulemaking does not require that a child, youth or young adult be an alleged delinquent or adjudicated delinquent to be admitted to a secure RTF. Rather, admission to a secure PRTF is based on the clinical need for a secure PRTF. This proposed rulemaking also addresses limitations on payment, including payment for hospital-reserved bed days and during periods of elopement, visitation and days of care for which no payment will be made. This proposed rulemaking explains how the Department will set rates for treatment provided in a PRTF, including the Department's rate-setting policy, cost reporting procedures, allowable and nonallowable costs, income and offsets to allowable and nonallowable costs, and how costs should be allocated. It also includes requirements for related party transactions, billing requirements, financial records and third-party liability.
Utilization Review (§ 1330.51)
This proposed rulemaking requires claims submitted for MA payment to be subject to the utilization review procedures under Chapter 1101 (relating to general provisions).
Administrative Sanctions (§ 1330.61)
This proposed rulemaking addresses when sanctions will be imposed on a PRTF and when the Department will deny or recover payment for services or items.
Provider Right to Appeal (§ 1330.71)
This proposed rulemaking provides that appeals related to Chapter 1330 shall be made in accordance with Chapter 41 (relating to medical assistance provider appeal procedures).
Chapter 3800. Child Residential and Day Treatment Facilities
Exemptions (§ 3800.3)
This proposed rulemaking amends Chapter 3800 to specifically exclude PRTFs licensed under Chapter 5330. This provision will take effect 12 months after the effective date of the final-form rulemaking.
Chapter 5330. Psychiatric Residential Treatment Facility—Licensing
General Provisions (§§ 5330.1—5330.7)
This proposed rulemaking establishes the minimum requirements and treatment standards that must be met for a PRTF to obtain a license to serve children, youth or young adults with a behavioral health diagnosis. While this proposed rulemaking maintains much of the current licensing requirements for RTFs, it includes a new requirement that the facility be accredited to be licensed as a PRTF. The accreditation requirement is consistent with the Federal requirements to be a PRTF. See 42 CFR 441.151 (relating to general requirements). For a facility to be licensed as a PRTF under this proposed rulemaking, the facility must obtain a certificate of compliance from the Department; comply with Chapter 20 (relating to licensure or approval of facilities and agencies), Articles IX and X of the Human Services Code (62 P.S. §§ 901—1088) and 42 CFR Part 441, Subpart D (relating to inpatient psychiatric services for individuals under age 21 in psychiatric facilities or programs); and be accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA) or another accrediting body approved by the Department.
General Requirements (§§ 5330.11—5330.21)
This proposed rulemaking codifies the current minimum standards for a facility to be certified by the Department as an RTF, including the requirement that a PRTF have written agreements with other service providers to coordinate physical health care, educational services and other community-based behavioral health services and the requirement for a detailed service description. This proposed rulemaking also includes minimum standards for PRTFs that are required by Federal regulations, including the requirement to have an emergency preparedness plan. See 42 CFR 441.184 (relating to emergency preparedness). In addition, this proposed rulemaking includes new requirements that address visits with the child's, youth's or young adult's parents, legal guardians or caregivers, as well as a new requirement for a PRTF to have a written policy to designate awake and sleeping hours.
This proposed rulemaking addresses identification and reporting of abuse; complying with laws that prevent abuse of children, youth or young adults; safeguarding a child's, youth's or young adult's funds; obtaining consent for treatment and keeping records confidential. In addition, language is added to this proposed rulemaking requiring a plan of supervision for any PRTF staff implicated in abuse and a plan for protection of the child, youth or young adult who was subject to abuse.
This proposed rulemaking contains and expands the list of serious incidents that would need to be reported to the Department. Further, this proposed rulemaking requires notification to the child's, youth's or young adult's parents, legal guardians or caregivers. Additional incidents that need to be reported to the Department and require parental notification include disruption of water, heat or electricity; use of a prohibited restrictive procedure; and any medication error. This proposed requirement is to ensure that the child's, youth's or young adult's parents, legal guardians or caregivers and the Department are better informed about serious incidents occurring at a PRTF.
Current Federal regulations require that a child's, youth's or young adult's death, serious injury or suicide attempt be reported no later than the close of business the next business day. See 42 CFR 483.374(b)(1) (relating to facility reporting). Federal regulations also require that parents, legal guardians or caregivers be informed of their child's death, serious injury or suicide attempt no later than 24 hours after the occurrence. See 42 CFR 483.374(b)(2). This proposed rulemaking strengthens the Federal requirements by requiring that incidents involving a fire that results in children, youth or young adults being displaced and incidents involving the disruption of water, heat, cooling or power also be reported to the Department. In addition, this proposed rulemaking requires that all incidents be reported to the Department and parents, legal guardians and caregivers within 12 hours after the PRTF learns of the incident.
Rights (§§ 5330.31—5330.34)
This proposed rulemaking addresses children's, youth's and young adult's rights; the rights of their parents, legal guardians or caregivers; the grievance process that must be available for children, youth or young adults, parents, legal guardians or caregivers and prohibitions on discrimination. This proposed rulemaking also expands on rights by including rights under § 5100.53 (relating to bill of rights for patients). Further, this proposed rulemaking clarifies the requirements that must be met to conduct a search of a child, youth or young adult or the child's, youth's or young adult's property.
Staffing (§§ 5330.41—5330.53)
This proposed rulemaking maintains several existing requirements for several staff. However, staff titles and qualifications are proposed to be updated and staff may need to have additional years of experience and meet new educational requirements, which are proposed to enable staff to better serve children, youth or young adults with behavioral health needs.
In addition, staff positions are added to this proposed rulemaking to meet the treatment needs of children, youth or young adults in a PRTF setting and to incorporate requirements included in the Federal regulations for PRTFs. See 42 CFR 441.156 (relating to team developing individual plan of care). New required positions include a treatment team leader, mental health professional and a registered nurse.
This proposed rulemaking also includes new requirements for the supervision of clinical and direct care staff at a PRTF. Supervision requirements are added for registered nurses, clinical directors, advanced practice professionals, licensed practical nurses, mental health professionals, mental health worker supervisors and mental health workers, including requirements for direct observation, face-to-face supervision and documentation of the supervision. These requirements are added to increase oversight of the behavioral health treatment of children, youth or young adults.
The staffing ratios for a PRTF are also proposed to be enhanced. The staff-to-child, youth or young adult ratios are proposed to be increased to ensure that children, youth or young adults receive additional oversight based on their behavioral health needs. Under this proposed rulemaking, when there are less than 12 children, youth or young adults, at least 1 PRTF supervisory staff person shall be physically present or on call to consult with PRTF staff. When there are 12 or more children, youth or young adults, at least 1 PRTF supervisory staff person shall be physically present for every 12 children, youth or young adults. The proposed increased staff ratios also ensure that direct care staff have additional support if there is an incident at the PRTF. A mental health professional is also required to be at the PRTF during awake hours to provide children, youth or young adults in a PRTF additional time to meet with the mental health professional and allow parents, legal guardians or caregivers more time to contact the mental health professional or participate in family therapy.
The training requirements for staff in this proposed rulemaking include relevant behavioral health training areas that will better prepare staff to work with children, youth or young adults with behavioral health needs. New proposed behavioral health training areas include trauma-informed care principles; cultural competency and equity; principles of child development and behavioral health diagnosis; and conditions and needs that impact the child, youth or young adult.
Physical Site (§§ 5330.61—5330.86)
This proposed rulemaking maintains the current requirements for a physical site of a PRTF, such as equipment be operable, poisonous materials be secured, proper air temperature be maintained, first aid kits be available and there be adequate space for recreational and treatment activities. This proposed rulemaking also requires the PRTF to provide accommodations, equipment and furnishings needed to meet the health and safety needs of the children, youth or young adults served. It further requires the PRTF to ensure that heat sources are inaccessible to children, youth or young adults and sanitary conditions are maintained. The PRTF must also be properly lit and ventilated and free of hazards. The PRTF must have water that is safe to drink and a functioning communication system and post emergency telephone numbers by all telephones accessible to staff. These proposed facility requirements are to protect the health, safety and wellbeing of children, youth, young adults and PRTF staff.
Fire Safety (§§ 5330.91—5330.103)
This proposed rulemaking maintains existing fire safety requirements, such as the requirement to comply with fire safety statutes, regulations and ordinances; the need to develop evacuation procedures; the requirement that exit routes be available and clear of obstruction; and the minimum standards on the location and number of detectors, alarms and fire extinguishers. This proposed rulemaking also provides that a PRTF shall safely store flammable and combustible materials, have its furnace inspected, take other measures that will prevent a fire from starting and provide local first responders with information that will be needed in case of a fire. This proposed rulemaking also includes requirements for fire drills. Lastly, this proposed rulemaking requires that carbon monoxide alarms be installed in a PRTF to prevent carbon monoxide poisoning.
Health (§§ 5330.111—5330.119)
This proposed rulemaking maintains the existing standards for the provision of medical care to children, youth or young adults, such as the PRTF must arrange for or provide necessary physical or behavioral health treatment, that each child, youth or young adult undergo an initial medical assessment when admitted to a PRTF and, if the child, youth or young adult has not had a medical examination within 12 months prior to admission to the PRTF, the child, youth or young adult must have a medical examination. Under this proposed rulemaking, PRTFs are also required to ensure that children, youth or young adults receive dental, vision and hearing examinations. Further, this proposed rulemaking requires that if the child's, youth's or young adult's health or safety is at risk, a health and safety plan be developed and that the PRTF have a medical emergency plan.
This proposed rulemaking also addresses the use of drugs, alcohol, tobacco and e-cigarettes. Requirements for e-cigarettes are added due to the growth in the use of e-cigarettes. Under this proposed rulemaking, the use or possession of drugs, alcohol, tobacco and e-cigarette products by a child, youth or young adult is prohibited.
Staff Health (§§ 5330.121—5330.123)
This proposed rulemaking includes a requirement that each PRTF staff person have undergone a health assessment within 12 months of hire and every 24 months thereafter and have a tuberculosis screening upon employment. It also requires that each PRTF staff person show proof that they are free of any serious communicable diseases that may spread through casual contact.
Nutrition (§§ 5330.131—5330.133)
This proposed rulemaking maintains the existing requirements for nutrition. In addition, it proposes a new requirement that there cannot be more than 15 hours between an evening and morning meal the following day.
Treatment Services (§§ 5330.141—5330.148)
The requirements in this proposed rulemaking for treatment services comply with the Federal requirements specified in 42 CFR Part 441, Subpart D.
This rulemaking proposes that a child's, youth's or young adult's treatment be provided under the direction of a psychiatrist, including the development and updating of a child's, youth's or young adult's treatment plan. It also provides minimum standards for individual, family and group therapy and psychoeducation groups. This proposed rulemaking expands upon planning requirements for a child's, youth's or young adult's discharge from a PRTF. Finally, this rulemaking proposes new requirements on utilizing a level system for PRTFs that utilize such a system. Specifically, a PRTF is required to develop written policies and procedures that utilize trauma-informed care principles to provide incentives, structure, limit setting, encouragement and support to a child, youth or young adult. Further, the level system must be individualized, consistent with treatment objectives, and developmentally appropriate and cannot be punitive in nature.
Transportation (§ 5330.151)
This proposed rulemaking maintains existing requirements for safely transporting a child, youth or young adult, such as requiring compliance with applicable laws and regulations regarding the transportation of children, youth or young adults. It also proposes to increase the staff-to-child, youth or young adult ratio during transportation to allow for additional support in the event an incident occurs during transportation.
Medication (§§ 5330.161—5330.170)
This proposed rulemaking maintains existing requirements for the storage and labeling of medications, such as the use of and the administration of medications, maintenance of a medication log and documentation of medication errors. It also proposes, as a result of feedback from the stakeholder workgroup, to add requirements that address the right to refuse medication in accordance with Federal and State laws and regulations. Further, additional language is added prohibiting the use of pro re nata medication to control a child's, youth's or young adult's acute, episodic behavior in a PRTF.
Restrictive Procedures (§§ 5330.181—5330.190)
This proposed rulemaking differs significantly from existing requirements regarding restrictive procedures, including those in Federal regulations. Specifically, it proposes to prohibit the use of mechanical restraints and seclusion in both secure and nonsecure PRTFs. This rulemaking also proposes to prohibit the use of chemical restraints and exclusion in secure and nonsecure PRTFs. While it permits the use of manual restraints, this proposed rulemaking prohibits the application of a manual restraint for more than 30 minutes. The 30-minute time limit for the application of a manual restraint is more stringent than what is required by the Federal regulations (see 42 CFR 483.358(e)(2) (relating to orders for the use of restraint or seclusion)), which permit a manual restraint for no more than 4 hours if the individual being restrained is 18 years of age or older but under 21 years of age; for no more than 2 hours if the individual being restrained is 9 years of age or older but under 18 years of age; or for no more than 1 hour if the individual being restrained is under 9 years of age. These proposed additional requirements are included to eliminate the excessive use of restraints and minimize the trauma that can arise as a result of the use of a restraint.
Further, this rulemaking proposes to require that a restrictive procedure plan be developed for all children, youth or young adults. Also, it includes requirements on who can order a manual restraint that are consistent with Federal regulations. See 42 CFR 483.358. Additionally, it proposes to require PRTFs to document the use of a manual restraint and implement follow-up procedures to prevent the use of another manual restraint. These proposed additional requirements are intended to protect the health and safety of a child, youth or young adult on whom a manual restraint is used.
Finally, this proposed rulemaking includes requirements for the use of time outs that are consistent with Federal regulations (see 42 CFR 483.368 (relating to application of time out)) and incorporates the requirements in the Federal regulations for the submission of an initial and annual attestation that the PRTF is complying with the Centers for Medicare & Medicaid Services' standards on the use of restrictive procedures. See 42 CFR 483.374 (relating to facility reporting).
Secure PRTF (§§ 5330.201 and 5330.202)
This proposed rulemaking addresses the minimum standards for a secure PRTF, including the mechanisms that can be used to prohibit egress from a secure PRTF or a portion of a PRTF and the staffing requirements. The staff ratio requirements in this proposed rulemaking for secure PRTFs are to be increased because of the severe behavioral health needs of the children, youth or young adults that may be served in secure PRTFs.
Records (§§ 5330.211—5330.214)
This proposed rulemaking addresses the required content and retention of a child's, youth's or young adult's records and the requirements for PRTF records. In addition, it proposes additional content requirements that are specific to children, youth or young adults receiving behavioral health treatment in a PRTF, including the requirement that the certification of need for continued stay and the child's, youth's or young adult's psychiatric evaluations are included in the record. This rulemaking also proposes requirements for maintaining PRTF records and properly handling protected health information in accordance with Federal and State regulations, including the requirement to maintain licenses, emergency preparedness plans and policies.
Quality Assurance (§ 5330.221)
This proposed rulemaking requires PRTFs to establish and implement quality assurance practices that include evaluation of services provided to children, youth or young adults; review of manual restraints utilized and adherence to the parameters identified in the PRTF's service description. Quality assurance requirements are proposed to be consistent with the requirements for other behavioral health facilities licensed by the Department.
Waivers (§ 5330.231)
This proposed rulemaking contains requirements for a PRTF to obtain a waiver of a specific program requirement. It also addresses when the Department may revoke a waiver.
Affected Individuals and Organizations
RTFs that are currently licensed and certified by the Department to provide behavioral health treatment to children, youth or young adults will be affected by this proposed rulemaking. Currently, 22 providers with 76 licensed programs are accredited by TJC, CARF or COA. In addition, there are 6 providers with 27 licensed programs that are not accredited by TJC, CARF or COA. A new provider intending to provide PRTF services will have to meet the requirements proposed under Chapters 1330 and 5330.
Children, youth or young adults who receive treatment in a PRTF will be affected by this proposed rulemaking. Approximately 2,564 children, youth or young adults a year receive treatment funded by MA in an RTF certified by the Department. There may be additional children, youth or young adults affected by this proposed rulemaking whose services are funded by private insurance and other resources.
Staff employed by an RTF that seeks licensure as a PRTF may be affected by this proposed rulemaking because the minimum qualifications and responsibilities of positions have been changed to meet the behavioral health needs of children, youth or young adults in PRTFs.
The Department consulted with the Mental Health Planning Council in the development of this proposed rulemaking. The Mental Health Planning Council advises the Department on issues related to mental health, substance abuse, behavioral health disorders and cross-system disability. The Department also worked with a stakeholder workgroup to develop this proposed rulemaking. The stakeholder workgroup included representation from the following: RTF providers currently certified and licensed by the Department; family advocates; family members of children, youth or young adults who received RTF services; the Mental Health Association of Pennsylvania; Rehabilitation and Community Providers Association; Pennsylvania Council of Children, Youth & Family Services; Disability Rights of Pennsylvania; National Partnership for Juvenile Services; behavioral health managed care organizations; and county mental health representatives.
The stakeholder workgroup held an initial face-to-face meeting on February 11, 2020. After the onset of the novel coronavirus (COVID-19) pandemic, the workgroup held virtual meetings on June 11, 2020, June 17, 2020, and July 31, 2020. The stakeholder workgroup discussed staff qualifications and training, treatment planning, administering medication, ensuring health and safety and the use of restrictive procedures. A summary of each meeting was provided to workgroup members. Workgroup members were encouraged to ask questions, make suggestions or share concerns by means of e-mail.
The Department also consulted individually with family advocates; family members of children, youth or young adults who received RTF services; medical directors of behavioral health managed care organizations; psychiatrists; and other offices within the Department about whether there is a clinical need for secure treatment settings and determined that there are circumstances where there is a clinical need for children, youth or young adults to receive treatment in a secure PRTF. Because the Department is committed to ensuring active participation from family members whose children are currently receiving treatment in an RTF, the Department met with family members on March 19, 2021, June 25, 2021, September 1, 2021, and September 10, 2021.
The Department updated interested parties and organizations throughout the drafting of this proposed rulemaking to ensure a transparent process. Comments and feedback received from interested parties and organizations were considered in the drafting process.
Accomplishments and Benefits
This proposed rulemaking benefits children, youth or young adults receiving services in a PRTF by making changes that are intended to result in decreases in lengths of stay and reductions in readmissions. It encourages a robust commitment to trauma-informed principles; emphasizes active engagement of children, youth or young adults in their treatment; and promotes planning for discharge to begin upon admission.
This proposed rulemaking also benefits children, youth or young adults who receive treatment in a PRTF by increasing staff ratios, which will allow for increased supervision of children, youth or young adults and provides children, youth or young adults with additional access to mental health professionals during awake hours. Requiring mental health professionals to be present at the PRTF during all awake hours will increase the availability of clinicians to respond to immediate treatment needs and allow for more opportunities for family therapy. Increased staffing also provides families with additional opportunities to contact a staff member to discuss any treatment concerns that they may have regarding their child. In addition, there will be more clinical staff onsite to provide support and guidance to direct care staff.
Children, youth or young adults will also benefit because this proposed rulemaking establishes minimum standards for the frequency and duration of individual, group and family therapy and psychoeducation groups, which will improve the behavioral health treatment children, youth or young adults receive while in a PRTF. Furthermore, by setting minimum training standards and requiring staff training in trauma-informed care, child development, cultural competency, diversity, equity and inclusion, this proposed rulemaking will ensure that staff are appropriately trained. The increased staff qualifications proposed under this rulemaking will also help ensure that services are delivered by qualified staff, which will result in services that meet the clinical needs of the children, youth or young adults on a consistent and therapeutic basis.
This proposed rulemaking will also benefit children, youth or young adults and their parents, legal guardians and caregivers because it changes the requirements for admission to a secure PRTF. Specifically, it does not require that a child, youth or young adult be alleged delinquent or adjudicated delinquent to be admitted to a secure PRTF. Instead, admission to a secure PRTF will depend on the child's, youth's or young adult's medically recommended treatment needs. In addition, this rulemaking proposes more stringent staff ratios for secure PRTFs, which will protect the safety of children, youth and young adults who receive services in a secure PRTF.
Finally, this proposed rulemaking also benefits children, youth and youth adults by expanding upon the list of incidents to be reported and significantly reducing the length of time a manual restraint may be applied to a child, youth or young adult. In addition, it protects the health and safety of children, youth and young adults receiving services in a PRTF by prohibiting the use of seclusion, exclusion and prone, chemical and mechanical restraints.
This proposed rulemaking will benefit parents, legal guardians and caregivers of children, youth or young adults that receive treatment in a PRTF by setting a standard for family therapy and promoting the participation of parents, legal guardians and caregivers in treatment and discharge planning. It will also benefit PRTFs because it will allow for a more streamlined and codified approach to licensing.
Fiscal Impact
Because each RTF that is currently licensed and certified by the Department has a unique staffing, training and organizational structure, the Department does not have sufficient information to determine the fiscal impact this proposed rulemaking would have for each individual RTF. Therefore, the Department's fiscal analysis assumes that all RTFs are currently meeting, and not exceeding, the minimum licensure standards and the requirements to be certified by the Department to provide medically necessary behavioral health treatment. If providers incur additional costs as a result of the new requirements in this proposed rulemaking, allowable costs may be submitted for payment through the cost reporting process. The Department's behavioral health managed care organizations' capitation rates and MA provider rates are anticipated to be adjusted to reflect the increased PRTF costs.
This proposed rulemaking will result in an annual cost to the MA program of approximately $18,782,000 ($9,007,000 in State funds). Based on the anticipated time frame for this proposed rulemaking to be promulgated, the cost for the first fiscal year will be half of the total annual cost for subsequent years after promulgation. This will amount to approximately $9.42 million ($4.518 million in State funds) in the first year. These costs include MA payments for room and board expenses for children, youth or young adults residing at previously nonaccredited RTFs, payment for costs PRTFs incur to comply with new requirements in this proposed rulemaking, costs for increased staffing in secure PRTFs required as a result of this proposed rulemaking and the cost to the Department to hire additional staff to carry out the work associated with licensing PRTFs.
This rulemaking proposes to require accreditation to be licensed as a PRTF. Nonaccredited RTFs certified by the Department that seek to become PRTFs will incur the cost of becoming accredited. The cost to become accredited depends upon the accreditation body selected by the nonaccredited RTF as well as the size of the provider. The cost for accreditation can be up to $10,000.
In addition, if a child, youth or young adult who is eligible for MA receives medically necessary behavioral health treatment in an accredited RTF that is certified by the Department, MA will pay for the child's, youth's or young adult's behavioral health treatment and for room and board. However, if the child, youth or young adult is receiving medically necessary behavioral health treatment in a nonaccredited RTF certified by the Department, MA will only pay for the child's, youth's or young adult's medically necessary behavioral health treatment. The cost for the room and board is covered by another funding source, such as local governments. Because all PRTFs are proposed to be accredited under this rulemaking, it is anticipated that MA payment for room and board expenses for the six nonaccredited RTFs certified by the Department that are anticipated to convert to PRTFs will result in an annual cost to the MA program of approximately $10 million ($4.78 million in State funds). The annual cost was determined by breaking out the room and board component and averaging it to $95.22 per day. The room and board component is multiplied by the number of billed bed days for current nonaccredited RTFs certified by the Department, which was 103,321 billed bed days.
RTFs that seek to be licensed as PRTFs may also incur costs related to changes in staff qualifications, staff responsibilities, staff ratios and staff training. The exact cost for each RTF is dependent upon the RTF's current treatment modalities, organizational structure, staff qualifications and supervision and training requirements. Additionally, PRTFs may incur the cost of having an automated external defibrillator (AED) on grounds. Should a PRTF not currently have an AED on grounds, the cost to purchase one can range from $1,500 to $2,500 depending on the type of AED purchased. The Department anticipates that most of the RTFs that seek to be licensed as PRTFs already have an AED on the grounds.
This rulemaking proposes changes to the existing staff requirements to allow PRTFs to better meet the behavioral health needs of the children, youth or young adults served. While this proposed rulemaking maintains the structure of a director, childcare worker and childcare worker supervisor, the requirements for these positions are proposed to be updated.
The proposed requirements for the director position are less stringent under § 5330.46 (relating to program director) than existing requirements. Specifically, this proposed rulemaking allows a program director with a master's degree to have 1 year less work experience and a program director with a bachelor's degree to have 2 years less work experience. This proposed rulemaking also allows an individual with an associate's degree and 3 years of work experience or an individual with a high school diploma or equivalent and 5 years of work experience to become a program director.
Under this proposed rulemaking, the childcare worker, which is identified as a mental health worker in § 5330.49 (relating to mental health worker), has different qualifications. Specifically, this proposed rulemaking requires mental health workers to have a high school diploma or the equivalent of a high school diploma and 1 year of experience working directly with children, youth or young adults.
The education and experience requirements for a childcare supervisor, which is referred to as mental health worker supervisor under § 5330.50 (relating to additional staff positions), are also less stringent than current requirements. Specifically, this proposed rulemaking allows individuals with an associate's degree to have 1 year less work experience. This proposed rulemaking also allows individuals with a high school diploma or equivalent and 3 years of work experience to become mental health worker supervisors.
This proposed rulemaking also requires additional positions. The additional positions added under this proposed rulemaking meet Federal requirements for PRTFs and better support children, youth or young adults with behavioral health needs receiving medically necessary treatment in a PRTF. The new positions include a medical director, treatment team leader, clinical director, mental health professional and registered nurse.
A medical director may serve as the treatment team leader and clinical director as long as the requirements of each position are met. If an RTF needs to hire a medical director, treatment team leader, clinical director, mental health professional or registered nurse to meet the requirements of this proposed rulemaking, the approximate average annual cost for each position is as follows: $289,300 for a medical director or a treatment team leader; $66,450 for a clinical director, unless a physician assumes the role (which would increase the salary); $51,500 for a mental health professional, unless the individual is a licensed practitioner (which would increase the salary); and $66,500 for a registered nurse.
Finally, this proposed rulemaking allows a PRTF to also utilize a licensed practical nurse or an advanced practice professional. Should an RTF opt to employ a licensed practical nurse, the average annual salary is approximately $47,100.
An advanced practice professional may either be licensed as a physician assistant or a certified registered nurse practitioner. Should an RTF opt to employ a physician assistant or a certified registered nurse practitioner, the average annual salary is approximately $110,140 and $120,550, respectively.
The staff ratio requirements in this proposed rulemaking are more stringent than what is currently required. During the stakeholder workgroup meetings, many RTF providers stated that staff ratios exceed existing requirements and meet the staff ratio requirements in this proposed rulemaking. RTF providers that are not currently exceeding the minimum staff ratio requirements will incur costs under this proposed rulemaking.
Currently, 1 childcare worker is required for every 8 children, youth or young adults during awake hours and 1 childcare worker for every 16 children, youth or young adults during sleeping hours. This proposed rulemaking requires 1 mental health worker for every 6 children, youth or young adults during awake hours and 1 mental health worker for every 12 children, youth or young adults during awake hours.
Using a 16-bed provider as an example, a PRTF provider that is not currently exceeding the minimum staffing requirements will need to hire two additional mental health workers at an average salary of approximately $35,700. The total additional cost to the provider would be $71,400.
It is anticipated that RTFs that participate in the MA program will seek payment from the cost reporting process for the costs related to changes to staffing requirements identified previously, which will result in an annual cost to the MA program of approximately $7 million ($3.34 million in State funds).
While the number of hours of annual training staff must receive prior to working with children, youth or young adults is being maintained, this proposed rulemaking changes who must complete training and some of the training topics. Under this proposed rulemaking, all PRTF staff will be required to complete initial and annual training hours. In addition, additional training topics are proposed to be added. Some of the additional training topics include cultural competency and equity, child development, diagnosis and treatment, and trauma-informed care principles. These additional training topics are proposed as a result of feedback from workgroup members and to support the Commonwealth's initiative of becoming a trauma-informed and healing-centered state. If an RTF does not provide training on the additional topics and does not have the resources to provide training on the additional training topics, the cost for the additional trainings would be approximately $1,620. This cost was determined by factoring in the cost for training staff in the additional training topics and an assumption of 35% staff turnover.
This proposed rulemaking includes requirements for secure PRTFs. There are currently no secure PRTFs in this Commonwealth. An MA-enrolled provider that chooses to operate a secure PRTF will incur costs to meet the staffing requirements.
The staff ratio requirements for secure PRTFs are more stringent than the requirements for non-secure PRTFs. This proposed rulemaking requires that secure PRTFs have one mental health worker for every four children, youth or young adults during awake hours and one mental health worker for every eight children, youth or young adults during sleeping hours.
Existing RTFs that choose to transition to secure PRTFs and do not employ staff in excess of current requirements will need to hire additional mental health workers. Using a 16-bed provider as an example, an RTF will need to hire three additional mental health workers at an average salary of approximately $35,700. The total additional cost to the provider would be $107,100. Additional costs as a result of compliance with the staff-ratio requirements for a secure PRTF may be submitted for payment through the cost reporting process. MA provider rates and capitation rates are anticipated to be adjusted as needed to include the increased costs related to staff ratio requirements. The Department assumes that four facilities that are not currently providing an RTF level of care may develop secure PRTFs, which will result in an annual cost to the MA program of approximately $1 million ($480,000 in State funds).
This proposed rulemaking imposes additional paperwork requirements, which are discussed as follows. Should an RTF not meet the requirements of this proposed rulemaking, the one-time cost for the RTF to develop the documents will be approximately $2,763. The cost is based on an average hourly rate of $34.54 for a program director needing an estimated 80 hours to develop the documents.
As for quality assurance plans, RTFs accredited by entities such as TJC, CARF or COA are currently required by these entities to complete quality improvement plans. Given the common practice of utilizing quality assurance activities, increased costs to the MA program to implement this requirement are expected to be minimal.
As noted previously, additional costs incurred by an RTF to comply with this proposed rulemaking may be submitted for payment through the cost reporting process. Behavioral health managed care organizations' capitation rates and MA provider rates are anticipated to be adjusted to reflect the increased costs.
The Department will need to hire six additional human services program representative staff positions to carry out the work associated with licensing PRTFs. It is anticipated that these added positions will result in an annual cost to the MA program of approximately $782,000 ($407,000 in State funds).
The implementation of the requirements in this proposed rulemaking may result in improved outcomes, which may result in shorter lengths of stay at a PRTF and less utilization of more costly higher levels of care, such as hospitalizations. The Department, however, cannot estimate the amount of savings resulting from improved outcomes because the Department cannot determine the potential decrease in the utilization of higher levels of care or the length of stay as a result of the requirements in this proposed rulemaking.
In addition, there may be a decrease in costs to local governments of approximately $4.78 million as a result of this proposed rulemaking because they will no longer be paying for the cost of room and board for children, youth or young adults being served in nonaccredited RTFs certified by the Department.
Paperwork Requirements
While proposed Chapter 5330 maintains most of the current paperwork requirements for RTFs that are licensed and certified by the Department, it also includes new documentation requirements. This proposed rulemaking requires PRTFs to develop written policies and procedures on the following:
• Identification and reporting of abuse and plan of supervision for staff implicated in abuse.
• Reporting, investigating and management of reportable incidents.
• Reporting, investigating and management of recordable incidents.
• Management and disbursement of a child's, youth's or young adult's funds.
• Visits with legal guardians, parents or caregivers.
• Rights of children, youth or young adults and their parents, legal guardians or caregivers.
• Grievances.
• Searches of a child, youth or young adult or the child's, youth's or young adult's personal property.
• Designated awake and sleeping hours.
• Supervision of PRTF staff.
• Monitoring of initial and annual staff training.
• Use of hazardous equipment.
• Fire safety monitoring if a smoke detector, fire alarm or carbon monoxide detector becomes inoperative.
• Inclusion of the assessment of health and safety risks in the initial medical assessment.
• Use of a level system.
• Handling of discontinued and expired medication.
• Debriefing after a manual restraint.
In addition, this proposed rulemaking will require PRTFs to enter into written agreements to coordinate services with other service providers and to develop a written quality assurance plan and generate annual quality assurance reports.
Chapter 1330 will not result in additional paperwork for providers of PRTF services.
This proposed rulemaking will also not require children, youth or young adults who receive treatment in a PRTF or their parents, legal guardians or caregivers to complete additional reporting, recordkeeping or other paperwork requirements.
Effective Date
With the exception of the amendment to § 3800.3 (relating to exemptions), this proposed rulemaking will be effective upon publication of the final-form rulemaking in the Pennsylvania Bulletin. The amendment to § 3800.3 will be effective 12 months after publication of the final-form rulemaking.
The Department will require both accredited and nonaccredited RTFs certified by the Department to comply with this proposed rulemaking 12 months after promulgation.
The MA program will continue to pay for medically necessary behavioral health treatment and room and board for eligible children, youth or young adults provided by an accredited RTF certified by the Department for 12 months after promulgation of the final-form rulemaking.
RTFs currently licensed and certified by the Department must obtain a new license under Chapter 5330 within 12 months after promulgation of the final-form rulemaking. The Department will issue licenses in accordance with each RTF's license renewal date.
New facilities seeking to provide behavioral health residential treatment to children, youth or young adults shall obtain a license under Chapter 5330 prior to operating a PRTF.
Public Comment
Interested persons are invited to submit e-mail comments, suggestions or objections regarding this proposed rulemaking to the Department at ra-pwprtfregs@pa.gov.
If comments, suggestions or objections regarding this proposed rulemaking cannot be e-mailed, interested persons may submit written comments, suggestions or objections to Donald Hindmarsh, Bureau of Children's Behavioral Health Services, Commonwealth Towers, 11th Floor, P.O. Box 2675, Harrisburg PA 17105-2675.
Comments, suggestions or objections must be submitted within 30 calendar days after the date of publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference Regulation No. 14-555 when submitting comments.
Persons with a disability who require an auxiliary aid or service may submit comments by using the Pennsylvania Hamilton Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users), (844) 308-9292 (Speech-to-Speech) or (844) 308-9291 (Spanish).
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P.S. § 745.5(a)), on October 2, 2024, the Department submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the chairperson of the Health and Human Services Committee of the Senate and to the chairperson of the Human Services Committee of the House of Representatives. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey comments, recommendations or objections to the proposed rulemaking within 30 days after the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria in section 5.2 of the Regulatory Review Act (71 P.S. § 745.5b) that have not been met. The Regulatory Review Act specifies detailed procedures for review prior to final publication of the rulemaking by the Department, the General Assembly and the Governor.
VALERIE A. ARKOOSH,
SecretaryFiscal Note: 14-555. Under section 612 of The Administrative Code of 1929 (71 P.S. § 232), (1) General Fund;
(7) General Government Operations; (2) Implementing Year 2023-24 is $0; 1st Succeeding Year 2024-25 is $218,000; 2nd Succeeding Year 2025-26 through 5th Succeeding Year 2028-29 are $407,000; (4) 2022-23 Program—$120,016,000; 2021-22 Program—$120,570,000; 2020-21 Program—$106,235,000;
(7) MA—Capitation; (2) Implementing Year 2023-24 is $0; 1st Succeeding Year 2024-25 is $4,235,000; 2nd Succeeding Year 2025-26 through 5th Succeeding Year 2028-29 are $8,471,000; (4) 2022-23 Program—$3,481,000,000; 2021-22 Program—$4,557,000,000; 2020-21 Program—$3,060,000,000;
(7) MA—Fee For Service; (2) Implementing Year 2023-24 is $0; (3) 1st Succeeding Year 2024-25 is $64,000; 2nd Succeeding Year 2025-26 through 5th Succeeding Year 2028-29 are $129,000; (4) 2022-23 Program—$589,143,000; 2021-22 Program—$644,059,000; 2020-21 Program—$808,350,000;
(8) recommends adoption. Implementation and programmatic costs are expected to occur in the next fiscal year and thus funds will be included in the budget.
Annex A
TITLE 55. HUMAN SERVICES
PART III. MEDICAL ASSISTANCE MANUAL (Editor's Note: Chapter 1330 is proposed to be added and is printed in regular type to enhance readability.)
CHAPTER 1330. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY
GENERAL PROVISIONS Sec.
1330.1. Policy. 1330.2. Definitions.
SCOPE OF BENEFITS
1330.11. Scope of benefits.
PROVIDER PARTICIPATION
1330.21. Participation requirements for a PRTF. 1330.22. Ongoing responsibilities of a PRTF. 1330.23. Change of ownership.
PAYMENT
1330.31. General payment. 1330.32. Conditions for payment. 1330.33. Limitations on payment. 1330.34. Allowable costs. 1330.35. Income and offsets to allowable costs. 1330.36. Cost allocation for multiple programs. 1330.37. Related-party transactions. 1330.38. Nonallowable costs. 1330.39. Annual cost reporting and independent audit. 1330.40. Rate setting. 1330.41. Third-party liability. 1330.42. Billing requirements. 1330.43. Financial records.
UTILIZATION REVIEW
1330.51. Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS
1330.61. Sanctions, denied payments and overpayments.
PROVIDER RIGHT OF APPEAL
1330.71. Provider right of appeal.
GENERAL PROVISIONS § 1330.1. Policy.
The MA program provides payment for behavioral health treatment when the services are medically necessary and provided to children, youth or young adults with a behavioral health diagnosis by a licensed PRTF enrolled in the MA program.
§ 1330.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly demonstrates a different meaning:
Caregiver—An individual with the primary responsibility for the care and supervision of a child, youth or young adult.
Child—An individual under 14 years of age.
Cost center—A group of services or staff, or both, or another unit or type of activity into which functions of a PRTF are divided for purposes of expense assignment and allocations.
Cost report—A data collection tool issued by the Department to collect expense and utilization information from a PRTF that may include supplemental schedules or addenda as requested by the Department.
Day of care—Room, board and behavioral health services calculated on a 24-hour day basis using a midnight census hour.
Department—The Department of Human Services of the Commonwealth.
Elopement—When a child, youth or young adult leaves the premises of a PRTF or a location without staff approval.
Fiscal year—The period of time beginning July 1 and ending June 30 of the following year.
Hospital-reserved bed day—A day when a child, youth or young adult who is expected to return to the PRTF is approved for and admitted to an acute care general hospital or a psychiatric or rehabilitation hospital.
MA—Medical Assistance.
PRTF—psychiatric residential treatment facility—A residential facility that provides services to treat the behavioral health needs of children, youth or young adults under the direction of a psychiatrist.
Parent—The biological or adoptive father or mother of a child, youth or young adult.
Related party—An individual or organization that is associated or affiliated with or has control of or is controlled by a PRTF. Control includes the power to influence or direct the actions or policies of another. The term does not include a child, youth or young adult.
Secure PRTF—A PRTF from which egress is prohibited.
Staff—Individuals employed or contracted by a PRTF on a full-time or part-time basis. Staff includes temporary staff, volunteers and interns.
Treatment plan—An individualized and detailed written plan of treatment services specifically tailored to address a child's, youth's or young adult's needs.
Treatment team—A group of individuals who are led by a treatment team leader and includes the PRTF staff directly involved in the child's, youth's or young adult's treatment, and the child, youth or young adult. The treatment team may also include the child's, youth's or young adult's parent, legal guardian or caregiver; and any individuals chosen by the child, youth or young adult or the parent, legal guardian or caregiver.
Treatment team leader—A board-certified or board-eligible psychiatrist who has the overall responsibility of directing the child's, youth's or young adult's treatment.
Visit—When a child, youth or young adult is under the approved temporary supervision of an individual at the individual's residence or in the community and not under the supervision of PRTF staff.
Young adult—An individual 18 years of age or older but under 21 years of age or an individual who is 22 years of age but was admitted to the PRTF prior to turning 21 years of age.
Youth—An individual 14 years of age or older but under 18 years of age.
SCOPE OF BENEFITS § 1330.11. Scope of benefits.
Children, youth and young adults who are MA recipients with a behavioral health diagnosis may receive medically necessary services in a PRTF.
PROVIDER PARTICIPATION § 1330.21. Participation requirements for a PRTF.
To participate in the MA program, a PRTF shall:
(1) Comply with the special provisions applying to psychiatric hospitals set forth in 42 CFR 482.60 (relating to special provisions applying to psychiatric hospitals).
(2) Comply with the participation requirements in Chapter 1101 (relating to general provisions).
(3) Be licensed as a PRTF in accordance with Chapters 20 and 5330 (relating to licensure or approval of facilities and agencies; and psychiatric residential treatment facility).
(4) Enter into a written provider agreement with the Department to provide PRTF services.
(5) Be enrolled in the MA program by the Department.
§ 1330.22. Ongoing responsibilities of a PRTF.
(a) A PRTF shall comply with all of the following requirements:
(1) The record keeping and onsite access requirements in § 1101.51(e) (relating to ongoing responsibilities of providers).
(2) The record keeping requirements for child, youth or young adult records in § 5330.212 (relating to child, youth or young adult record).
(3) The record keeping requirements for PRTF records in § 5330.213 (relating to PRTF record).
(b) A PRTF shall retain complete, accurate, legible and auditable clinical, medical and fiscal records.
§ 1330.23. Change of ownership.
(a) If a PRTF changes ownership and the new owner wants to continue to participate in the MA program, the PRTF shall submit an application, on the form provided by the Department, and meet the requirements in § 1330.21 (relating to participation requirements for a PRTF).
(b) When a PRTF changes ownership, the Department will approve participation in the MA program by the new owner if the Department determines the new owner to be eligible to participate in the MA program under § 1330.21. The new ownership shall meet Federal and State laws and regulations prior to the Department approving participation in the MA program.
(c) When a PRTF changes ownership, the PRTF shall submit an attestation that complies with § 5330.190 (relating to attestation).
PAYMENT § 1330.31. General payment.
(a) Except as provided in subsection (b), the MA program will pay for medically necessary services provided by a PRTF to a child, youth or young adult who is an MA recipient subject to the conditions and limitations in this chapter and Chapter 1101 (relating to general provisions).
(b) The MA program will pay for medically necessary services provided to a child, youth or young adult who is an MA recipient by a residential treatment facility licensed under Chapter 3800 (relating to child residential and day treatment facilities) and certified by the Department as of [insert the effective date of the final-form rulemaking] for 12 months after [insert the effective date of the final-form rulemaking].
(c) If a PRTF is rendering services to a young adult before the young adult turns 21 years of age, the Department will continue to pay for services if they are medically necessary and the young adult is under 22 years of age.
(d) The MA program will not pay for services provided by a PRTF that exclusively serves children, youth or young adults who are alleged delinquent or adjudicated delinquent.
§ 1330.32. Conditions for payment.
(a) MA will pay a PRTF if all of the following conditions are met:
(1) A psychiatric evaluation of the child, youth or young adult that is a result of a comprehensive in-person diagnostic examination has been completed. The psychiatric evaluation shall:
(i) Include a behavioral health diagnosis.
(ii) Indicate that a PRTF is recommended and medically necessary.
(iii) Address all of the following:
(A) If ambulatory care provided in the community meets the service needs of the child, youth or young adult.
(B) If treatment of the child's, youth's or young adult's behavioral health needs requires services in a PRTF under the direction of a psychiatrist.
(C) If services in a PRTF are needed to improve the child's, youth's or young adult's behavioral health needs or prevent further regression.
(2) The psychiatric evaluation is reviewed by an independent team that includes a psychiatrist who meets all of the following requirements:
(i) Has competence in the diagnosis and treatment of mental illness, preferably in child psychiatry.
(ii) Has knowledge of the child's, youth's or young adult's treatment needs.
(3) The independent team is independent of the psychiatrist who completed the psychiatric evaluation and the PRTF that is being recommended.
(4) The independent team certifies all of the following:
(i) Ambulatory care provided in the community does not meet the service needs of the child, youth or young adult.
(ii) Treatment of the child's, youth's or young adult's behavioral health needs requires services in a PRTF under the direction of a psychiatrist.
(iii) Services in a PRTF are needed to improve the child's, youth's or young adult's behavioral health needs or prevent further regression.
(b) The child's, youth or young adult's treatment team leader shall review the need for continued PRTF level of care every 30 days and certify that the child, youth or young adult continues to meet the requirements in subsection (a)(4).
§ 1330.33. Limitations on payment.
(a) MA will pay for hospital-reserved bed days for a PRTF that is currently participating in MA as follows:
(1) Payment will only be made to a PRTF to reserve a bed when a child, youth or young adult is hospitalized if the child, youth or young adult is admitted to a licensed hospital or hospital unit accredited as a hospital, the hospitalization occurs during the child's, youth's or young adult's PRTF stay and the child, youth or young adult is expected to return to the PRTF upon discharge from the hospital.
(2) Payment for hospital-reserved bed days is limited to 15 cumulative days per calendar year for each child, youth or young adult, regardless of whether the child, youth or young adult was in continuous or intermittent treatment at one or more PRTFs during the calendar year.
(3) Payment for hospital-reserved bed days begins on the date of a child's, youth's or young adult's admission to the hospital and will be paid at the rate of 1/3 of the PRTF's approved per diem payment rate.
(b) MA will pay for up to 2 days of elopement from a PRTF per calendar year for each child, youth or young adult.
(c) MA will pay for a day of care if the child's, youth's or young adult's bed is reserved while the child, youth or young adult is on a visit.
(d) MA will not pay a PRTF for the following:
(1) A day of care during which a child, youth or young adult was absent from the PRTF for one of the following reasons:
(i) Elopement, unless the absence meets the criteria in subsection (b).
(ii) Leaving the PRTF against medical advice.
(iii) Hospitalization, unless the hospitalization meets the criteria in subsection (a).
(iv) Visits, unless the visit meets the criteria in subsection (c).
(2) Admissions and days of care that do not meet the requirements of this chapter.
(3) The day of discharge or transfer to another facility.
§ 1330.34. Allowable costs.
The Department uses Medicare principles as established by the Social Security Act (42 U.S.C. §§ 301—1397mm) and Federal regulations and instructions as a basis for determining what cost items are allowable for the purposes of MA reimbursement.
§ 1330.35. Income and offsets to allowable costs.
In an annual cost report, the PRTF shall report income from the following as sources to offset allowable costs in the determination of operating costs:
(1) Payments received from a youth or young adult or a child's, youth's or young adult's parent, legal guardian or caregiver.
(2) Gifts, donations, endowments, bequests and contributions restricted by the donor for allowable costs.
(3) Refunds and cash discounts.
(4) Grants designated for allowable costs.
(5) Income from the National School Lunch Program.
(6) Income from space rental, vending machines and similar items.
(7) Fundraising efforts restricted for allowable costs.
(8) Interest earned on items specified in paragraphs (1)—(7).
§ 1330.36. Cost allocation for multiple programs.
(a) If a provider operates a PRTF as well as other types of programs, the provider shall document how various costs are allocated between the multiple programs.
(b) The account of the cost allocation must include all of the following:
(1) Salary costs for individuals responsible for more than one program.
(2) Staff fringe benefits for individuals responsible for more than one program.
(3) Rental costs that apply to more than one program.
(4) Motor vehicles that are used by more than one program.
(5) Other related expenses shared by more than one program.
§ 1330.37. Related-party transactions.
(a) A PRTF shall include in its allowable costs, services and supplies furnished to the PRTF by a related party at an amount equal to the cost of such services and supplies to the related party.
(b) The cost of services and supplies procured by a PRTF through a related-party transaction may not exceed the cost of comparable services and supplies if purchased elsewhere.
(c) The related party's costs include reasonable costs incurred in the furnishing of services and supplies to the PRTF.
§ 1330.38. Nonallowable costs.
(a) The following costs are excluded from the operating costs described in § 1330.34 (relating to allowable costs) and are not included in a PRTF's per diem rate:
(1) Costs for legal services relating to litigation against the State, including administrative appeals, if the litigation is ultimately decided in favor of the State.
(2) Administrative costs of more than 13% of allowable MA costs.
(3) Costs for which Federal financial participation is prohibited by statute.
(4) Costs for services not provided by a PRTF to a child, youth or young adult residing in the PRTF.
(5) Education costs associated with a child's, youth's or young adult's individual educational plan, individual family service plan or treatment plan which are to be paid for by the child's, youth's or young adult's school district.
(6) Costs related to a PRTF staff's medical education, residency programs or education field placements.
(7) Costs for a service if payment is available from another public agency, insurance or health program or any other source.
(8) Expenses not related to providing services to MA recipients.
(9) Costs associated with the following:
(i) Advertising, excluding employment opportunities.
(ii) Charitable contributions.
(iii) Staff recognition, such as gifts, awards or dinners.
(iv) Staff social functions, such as picnics or athletic teams.
(v) Nonstandard fringe benefits.
(vi) Fundraising and marketing.
(vii) Life insurance for officers and directors of the governing board, including life insurance premiums necessary to obtain mortgages and other loans.
(viii) Membership fees for social, fraternal and other organizations involved in activities unrelated to the program or an organization defined as a lobbying group under 65 Pa.C.S. Chapter 13A (relating to lobbying disclosure).
(ix) Meals for visitors.
(x) Political activities.
(xi) Related-party rental, leases or other payments that exceed the provision outlined in § 1330.37 (relating to related-party transactions).
(xii) Reorganization costs.
(xiii) Federal, State or local income and excess profit taxes.
(xiv) Taxes from which exemptions are available to a PRTF.
(xv) Bad debts and contractual adjustments.
(xvi) Barber and beautician services.
(xvii) Children's, youth's or young adult's allowances.
(xviii) Clothing and shoes for children, youth or young adults receiving services in the PRTF.
(xix) Living expenses for live-in staff, including lodging, meals and personal laundry.
(xx) Meals for staff, except for meals provided during training activities documented in a child's, youth's or young adult's treatment plan.
(xxi) Penalties, fines or late charges assessed by any source, whether or not related to a PRTF.
(xxii) Personal hygiene items for children, youth or young adults receiving service in the PRTF.
(xxiii) Personal travel for staff, including personal use of a PRTF vehicle.
(xxiv) Transportation and living costs associated with onsite visits by parents, legal guardians or caregivers.
(xxv) Salaries for PRTF staff no longer employed by the PRTF.
(xxvi) Free care or discounted services.
(xxvii) Personal radio, television, Internet and telephone service.
(xxviii) Direct and indirect costs related to nonallowable cost centers including all of the following:
(A) Gift, flower and coffee shops.
(B) Homes for administrators or clergy.
(C) Convent areas.
(D) Nurses' quarters.
(xxix) Pennsylvania capital stock and franchise tax.
(xxx) Collection expenses associated with bad debts.
(xxxi) Travel expenses for members of the governing body unrelated to the PRTF's program.
(xxxii) Vocational rehabilitation services.
(xxxiii) Parties and social activities not related to providing care to children, youth or young adults receiving services in the PRTF.
(xxxiv) Recreation costs not related to providing care to children, youth or young adults receiving services in the PRTF.
(xxxv) Charity, in-kind and courtesy allowances.
(xxxvi) Extraordinary costs related to, or precipitated by, bankruptcy.
(b) The following services are not included in the per diem rate and may not be included as a cost for the PRTF:
(1) Health care, including dental, vision and hearing care, which is not related to the child's, youth's or young adult's behavioral health needs.
(2) Prescription drugs.
(3) Ambulance services.
(4) Methadone maintenance.
(5) Diagnostic procedures or laboratory tests.
(6) Inpatient hospitalization.
(7) Emergency room visits.
(8) Diagnostic or therapeutic procedures for experimental, research or educational purposes.
(9) Experimental or investigative procedures or clinical trial research and services that are not in accordance with customary standards of medical practice or are not commonly used.
(c) The Department will not contribute to a return on equity for proprietary programs.
(d) Costs that are not recognized as allowable costs in a fiscal year may not be carried forward or backward to other fiscal years for inclusion in allowable costs.
§ 1330.39. Annual cost reporting and independent audit.
(a) Residential treatment facilities that are licensed under Chapter 3800 (relating to child residential and day treatment facilities) and certified by the Department as of [insert the publication date of the final-form rulemaking] shall provide a projected cost report to the Department within 3 months of [insert the publication date of the final-form rulemaking].
(b) A PRTF shall submit to the Department an annual cost report and an independent audit performed by an independent public accountant.
(c) If costs have been allocated between programs and supporting services, disclosure shall be made in the independent audit and in accordance with generally accepted accounting principles.
(d) A PRTF shall disclose in the independent audit the existence of any affiliate and the affiliate's relationship to the PRTF, including the nature of any financial transaction between the affiliate and the PRTF.
(e) A provider that operates PRTFs in different locations but uses a consolidated financial report shall designate cost centers for each location in the independent audit. Information accompanying the independent audit shall include the basis used to allocate income and expenses to each location.
(f) A PRTF shall submit an annual cost report on a form specified by and in accordance with the instructions provided by the Department.
(g) The annual cost report submitted to the Department shall be prepared on an accrual basis.
(h) A PRTF shall identify allowable services, administration, ancillary and related organization costs based on financial and statistical records maintained by the PRTF. The cost information contained in the annual cost report shall be current and accurate.
(i) The annual cost report must cover a fiscal period of 12 consecutive months, from July 1 to June 30, except as noted in subsection (k).
(j) The annual cost report for the preceding fiscal year ending June 30 must be submitted to the Department by September 30 of that year.
(k) When a PRTF begins operating after the start of the fiscal year, the cost report must cover the period from the date of approval for participation in the MA program by the Department to June 30.
(l) The Department may adjust costs reported in the annual cost report as follows:
(1) Costs may be adjusted based upon the findings of current or closed audits, cost settlements, approved service descriptions or any information relevant to the costs being adjusted.
(2) The Department will inform the PRTF in writing if the annual cost report is adjusted.
(3) If the Department does not inform a PRTF of adjustments to the annual cost report in writing within 180 days of receiving the annual cost report, the annual cost report submitted by a PRTF will be accepted by the Department as submitted.
§ 1330.40. Rate setting.
(a) Per diem rates will be established as follows:
(1) A cost report submitted by a PRTF in accordance with § 1330.39 (relating to annual cost reporting and independent audit), as adjusted by the Department, if necessary, will be used for the calculation of the PRTF's per diem rate.
(2) A per diem rate for a PRTF will be established by dividing the total projected operating costs by the number of days of care reported in the annual cost report subject to a minimum of 85% of the maximum number of days based on the number of beds specified on the PRTF's certificate of compliance.
(3) The total actual days of care provided include all days of service provided plus hospital-reserve bed days as specified by § 1330.33 (relating to limitations on payment). Reserved beds counted as actual days of service may not be filled.
(4) The total projected operating cost will be calculated as follows:
(i) For a new PRTF, the total MA allowable costs from the budgeted annual cost report, including adjustments for income and nonallowable, limited and excluded costs, as determined by the Department are used to determine projected operating costs.
(ii) For an existing PRTF, an annual cost report filed September 30 as specified in § 1330.39, including adjustments for income and nonallowable, limited and excluded costs, as determined by the Department is used to determine projected operating costs.
(iii) Cost depreciation on capital assets, limited to buildings and fixed equipment, and interest on capital indebtedness is added to the total operating cost to obtain the total projected operating cost.
(5) Once established, a per diem rate will remain in place, unless the per diem rate is adjusted.
(b) The costs incurred in providing behavioral health treatment and room and board are included in the per diem payment for services in a PRTF and may not be billed separately or in addition to the per diem payment rate by the PRTF or any other entity with which the PRTF may have an agreement to provide these services.
(c) If there is more than one accounting method for handling a cost item, the method initially elected by the PRTF shall be followed consistently in subsequent annual cost reports, unless the PRTF submits prior written justification and receives approval from the Department for using a different accounting method.
§ 1330.41. Third-party liability.
(a) A PRTF shall utilize available third-party resources, including Medicare Part B, for services a child, youth or young adult receives while in the PRTF.
(b) If a PRTF receives reimbursement from a third party subsequent to payment from the Department, the PRTF shall repay the Department by submitting a replacement of prior claim according to the Department's instructions.
(c) If a child, youth or young adult or the legal guardian of a child, youth or young adult requests a copy of the record of payment or amounts due, the PRTF shall submit a copy of the invoice and the request to the Department.
(d) Except as specified in subsection (e), if a child, youth or young adult has third-party resource benefits, the MA program will pay the lesser of the following:
(1) A PRTF's per diem payment rate multiplied by the number of covered days, minus any payment from available third-party resources, including any Medicare Part B payment.
(2) The amount of the insurance plan's deductible and coinsurance minus any other payment from an available third-party resource, including any Medicare Part B payment.
(e) If payment from a child's, youth's or young adult's available third-party resources equals or exceeds a PRTF's per diem rate multiplied by the number of compensable days, the Department will not make payment to the PRTF.
§ 1330.42. Billing requirements.
(a) A PRTF shall submit invoices to the Department in accordance with the Department's instructions.
(b) Original and resubmitted claims, including replacement claims, must be received for final adjudication within 365 days following the last date of service on the invoice.
(c) If the service spans 2 fiscal years, a separate invoice must be prepared for each fiscal year.
(d) If the service spans two different per diem rates, a separate invoice must be prepared for each period covered by the different rates.
§ 1330.43. Financial records.
(a) A PRTF shall maintain adequate financial and statistical records for determination of costs payable under the MA program for a period of 5 years after the date of last payment.
(b) A PRTF shall maintain all of the following records:
(1) General financial ledgers, journals and books.
(2) Original evidence of cost, such as purchase requisitions, purchase orders, vouchers, vendor invoices, requisitions for supplies, inventories, timecards, payrolls and bases for apportioning costs, that are auditable and relate to the determination of reasonable costs.
(3) Records relating to allocated administrative costs.
(4) Records relating to each annual cost report.
(5) Cash disbursement journals.
(6) Cash receipts journals.
(7) Payroll journals or computer printouts.
(8) Fixed asset ledgers or equivalent records.
(9) Inventory control records.
(10) Charts of accounts that parallel or crosswalk to the annual cost report format issued by the Department.
(11) Statement listing all sources of a PRTF's revenue, including Federal, State, local and private sources.
(12) Accounting records.
(13) Documentation of staff compensation by PRTF positions.
UTILIZATION REVIEW § 1330.51. Scope of claims review procedures.
Claims submitted for payment under the MA program are subject to the utilization review procedures in Chapter 1101 (relating to general provisions).
ADMINISTRATIVE SANCTIONS § 1330.61. Sanctions, denied payments and overpayments.
(a) If the Department determines that a PRTF has billed for services inconsistent with the requirements of this chapter or Chapter 5330 (relating to psychiatric residential treatment facility) or provided services outside the scope of customary standards of medical practice or otherwise violated the standards set forth in a provider agreement, the PRTF will be subject to the sanctions in Chapter 1101 (relating to general provisions) up to and including termination from the MA program.
(b) If the Department determines that services or items provided by a PRTF were not provided according to standards of practice for the discipline providing the service, were not medically necessary, were inappropriate or were otherwise noncompensable, the Department will deny payment for the services and items and related services and items and recover payment already made for the services and items and related services and items.
(c) If the Department determines as a result of an audit or through other means that a PRTF received excess funds in the form of an overpayment from the Department, the funds must be returned to the Department within 6 months from the date the PRTF is notified.
PROVIDER RIGHT OF APPEAL § 1330.71. Provider right of appeal.
Appeals related to this chapter shall be made in accordance with Chapter 41 (relating to medical assistance provider appeal procedures).
PART V. CHILDREN, YOUTH AND FAMILIES MANUAL
Subpart E. RESIDENTIAL AGENCIES, FACILITIES AND SERVICES
ARTICLE I. LICENSING/APPROVAL
CHAPTER 3800. CHILD RESIDENTIAL AND DAY TREATMENT FACILITIES
GENERAL PROVISIONS § 3800.3. Exemptions.
This chapter does not apply to the following:
* * * * * (11) Private homes of persons providing care to a relative, except homes in which children live with their own children but no other relative, unless the home is a transitional living residence that is exempt from this chapter under paragraph (2).
(12) Psychiatric residential treatment facilities licensed under Chapter 5330 (relating to psychiatric residential treatment facility).
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