[47 Pa.B. 4689]
[Saturday, August 12, 2017]
[Continued from previous Web Page]
PROVIDER PARTICIPATION § 1153.41. Participation requirements.
In addition to the participation requirements established in Chapter 1101 (relating to general provisions), [outpatient] psychiatric outpatient clinics and outpatient partial hospitalization facilities shall meet the following participation requirements:
(1) Have current full [licensure/approval] 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 facility shall be fully [licensed/approved] licensed at all times as a psychiatric outpatient clinic or partial hospitalization outpatient facility.
(2) Have medical personnel currently licensed, certified or registered in accordance with laws of the Commonwealth.
(3) Have a written [patient] referral plan for individuals receiving services that provides for inpatient hospital care and follow-up treatment.
(4) Post a current written fee schedule for billing third party and private payors.
(5) Appoint an administrator or director responsible for the internal operation of the psychiatric outpatient clinic or partial hospitalization facility. Appoint a psychiatrist or psychiatrists responsible for the supervision and direction of services rendered to eligible [recipients] individuals.
(6) Notify immediately the Department, Office of Medical Assistance[, Bureau of Provider Relations, in writing] Programs, Bureau of Fee-for-Services, in the manner prescribed by the Department, of [a] 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.
(7) Enter into a written provider agreement with the Department.
(8) Have each branch location or satellite of [an approved] a licensed psychiatric outpatient clinic or partial hospitalization facility also licensed [or approved] by the Office of Mental Health and Substance Abuse Services as a psychiatric outpatient clinic site or psychiatric partial hospitalization facility, whichever is applicable, and [approved] enrolled by the Office of Medical Assistance Programs before reimbursement can be made for services rendered at the branch or satellite. [Approval] Licensure and enrollment of the parent organization does not constitute [approval] licensure and enrollment for any branches or satellites of the same organization.
(9) [Be approved by the Department's Office of Medical Assistance.] Be enrolled as a provider in the Medical Assistance Program.
(10) Have medications prescribed by a licensed [physician] practitioner within his scope of practice.
(11) Psychiatric outpatient clinics providing MMHT 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). [Outpatient psychiatric] Psychiatric outpatient clinics and outpatient psychiatric partial hospitalization 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 [shall] must be included in medical records of [MA patients receiving outpatient psychiatric clinic] individuals receiving psychiatric outpatient clinic, MMHT and outpatient psychiatric partial hospitalization services:
(1) The treatment plan [shall] must include:
(i) The treatment plan goals.
(ii) Services to be provided to the [patient] individual in the clinic or partial hospitalization 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 [PSYCHIATRIC CLINIC AND OUTPATIENT PSYCHIATRIC PARTIAL HOSPITALIZATION] BEHAVIORAL HEALTH SERVICES § 1153.51. General payment policy.
Payment is made for medically necessary professional medical and psychiatric services provided by or under the supervision and direction of a psychiatrist [in participating outpatient psychiatric] by participating psychiatric outpatient clinics and outpatient psychiatric partial hospitalization 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. Payment will not be made for a compensable psychiatric [clinic] outpatient clinic, MMHT or psychiatric partial hospitalization 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 [outpatient] psychiatric outpatient clinics and partial hospitalization programs, as applicable, to be eligible for payment:
(1) A psychiatrist shall be present in the psychiatric outpatient clinic and psychiatric outpatient partial hospitalization facility, as required by the Office of Mental Health [approval/licensing] and Substance Abuse Services licensing regulations, to perform or supervise the performance of all covered services provided to [MA patients] individuals receiving MA benefits.
(2) Psychiatric evaluations shall be performed only by a psychiatrist in a face-to-face interview [with the patient] or using a real-time, two-way interactive audio-video transmission with prior written approval from the Department with the individual. 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.
(3) Psychotherapy—individual, family, collateral family or group—shall be provided only by a clinical staff person.
(4) Psychiatric partial hospitalization services shall be provided only by a clinical staff person.
(5) Diagnostic psychological and intellectual evaluations shall be administered and interpreted only by a licensed psychologist or by a psychologist in preparation for licensure under the direct supervision of a licensed psychologist.
(6) The psychiatric outpatient clinic medication visit shall be provided only by a psychiatrist, physician, certified registered nurse practitioner, physician's assistant, registered nurse or licensed practical nurse [who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing].
(7) Within [15] 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 [examine and initially assess each patient in the clinic; determine the patient's diagnosis and prepare an initial treatment plan] interview and initially assess each individual in the psychiatric outpatient clinic; determine the individual's diagnosis and prepare an initial treatment plan in collaboration with the individual; and date and sign the examination, diagnosis and treatment plan in the [patient's] medical record. The treatment plan shall be developed, maintained and periodically reviewed in accordance with the following criteria:
(i) The psychiatrist shall verify each [patient's] individual's diagnosis and approve the initial treatment plan prior to the provision of any treatment beyond the [15th] 30th day following intake. This review and approval shall be dated and signed in the [patient's] medical record.
(ii) [The psychiatrist and mental health professional, or mental health worker under the supervision of a mental health professional, shall review and update each patient's treatment plan at least every 120 days or 15 clinic visits, whichever is first, or, as may otherwise be required by law throughout the duration of treatment. Each review and update shall be dated, documented and signed in the patient's record by the psychiatrist and mental health professional.] The mental health professional or mental health worker under the supervision of a mental health professional and in collaboration with the individual receiving services shall review and update the treatment plan at least every 180 days or as may otherwise be required by law throughout the duration of treatment. Each update shall be dated, documented and signed in the medical record by the mental health professional and the individual receiving services.
(iii) The treatment plan and updates shall be based upon the evaluation and diagnosis. Treatment shall be provided in accordance with the identified goals in the treatment plan and updates. Psychiatrists' reviews and [reevaluations] re-evaluations of diagnoses, treatment plans and updates shall be done within 1 year of the previous psychiatric review with the mental health professional or mental health worker under the supervision of a mental health professional, [in the clinic and, whenever possible, with the patient] by the psychiatric outpatient clinic and with the individual receiving services. The review shall be dated and signed in the medical record.
(8) The psychiatric clinic clozapine monitoring and evaluation visit shall be used only for a person receiving clozapine therapy.
(b) Psychiatric outpatient partial hospitalization. Payment will only be made for psychiatric outpatient partial hospitalization provided to eligible [patients with mental disorders in approved] individuals with mental illness or emotional disturbance in licensed psychiatric outpatient partial hospitalization facilities under the following conditions:
(1) [Patients] Individuals receiving partial hospitalization 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) Have a psychiatric condition requiring provision of a supervised, protective setting for a prescribed time period to prevent institutionalization or ease the transition from inpatient care to more independent living.
(2) The following components shall be available in [an approved] a licensed psychiatric partial hospitalization facility and provided to [the patient] an individual, if necessary, in accordance with the [patient's] individualized treatment plan:
(i) Individual, group and family psychotherapy.
(ii) Health education—basic physical and mental health information; nutrition information and assistance in purchasing and preparing food, personal hygiene instruction; basic health care information, child care information and family planning information and referral; information on prescribed medications.
(iii) Instruction in basic care of the home or residence for daily living.
(iv) Instruction in basic personal financial management for daily living.
(v) Medication administration and evaluation provided only by a psychiatrist, physician, registered nurse or licensed practical nurse.
(vi) Guided social interaction supervised by psychiatric partial hospitalization personnel.
(vii) Crisis management provided by psychiatric partial hospitalization personnel.
(viii) Referral.
(c) Psychiatric outpatient clinic. Payment will only be made for psychiatric outpatient clinic services [provided to eligible patients with mental disorders in approved] or MMHT services provided to eligible individuals with mental illness or emotional disturbance by licensed psychiatric outpatient clinics under the following conditions:
(1) [Psychiatric clinic medication] Medication visits shall be a minimum duration of 15 minutes. They shall be provided only for the purpose of administering medication, and for evaluating the physical and mental condition of [the patient] an individual during the course of prescribed medication.
(2) [Patients receiving psychiatric clinic services shall have a mental disorder diagnosis verified by a psychiatrist.] Individuals receiving psychiatric outpatient clinic services or MMHT shall have a mental illness or emotional disturbance diagnosis verified by a psychiatrist.
(3) Family psychotherapy is compensable only if one or more family members has a mental disorder diagnosis.
(4) [Psychiatric clinic clozapine] Clozapine monitoring and evaluation visits shall be a minimum duration of 15 minutes. They shall be provided only for [a person receiving clozaril and for monitoring and evaluating the patient's white blood cell count] 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) Psychiatric clinic services provided in the home. Psychiatric clinic services delivered in the patient's home are subject to the conditions and limitations established in the chapter. Home visits, as defined in § 1153.2 (relating to definitions), are compensable as outpatient psychiatric services listed in the MA Program Fee Schedule only if the physician's documentation in the patient's records and progress notes fully substantiates that one of the following conditions exists:
(1) The client's disability requires specialized transportation which is not generally available.
(2) The client has a behavior disorder which disrupts the clinic environment.
(3) The client has a diagnosis of agoraphobia.
(e) Observation of the client in the home environment. Observation of the client in the home environment is considered to be an individual psychotherapy service and is compensable only when:
(1) The client is currently in therapy.
(2) Observation of the client in his home setting is a necessary component of the clients' psychotherapeutic regimen.]
(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 medical record substantiates all of the following:
(1) The services are provided to an eligible individual with mental illness or emotional disturbance.
(2) The services are ordered by an LPHA.
(3) The services if provided in a psychiatric outpatient clinic would be medically necessary.
(4) The evaluation documents 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.
(5) Treatment plan updates document the continued clinical need for MMHT services.
§ 1153.53. Limitations on payment.
[(a) Payment is subject to the following limitations:
(1) For recipients 21 years of age or older, 180 three-hour sessions, 540 total hours, of psychiatric partial hospitalization in a fiscal year per recipient, except for State Blind Pension recipients, for whom payment is limited to 240 3-hour sessions, 720 total hours, of psychiatric partial hospitalization in a consecutive 365-day period per recipient.
(2) At least 3 hours but no more than 6 hours of psychiatric partial hospitalization per 24-hour period.
(3) Two outpatient psychiatric evaluations in psychiatric clinics per patient per year.
(4) For recipients 21 years of age or older, a total of 5 hours or 10 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period, except for State Blind Pension recipients, for whom payment is limited to a total of 7 hours or 14 one-half hour sessions of psychotherapy per recipient per 30-consecutive day period. This period begins on the first day that an eligible recipient receives an outpatient psychiatric clinic service listed in the MA Program Fee Schedule. Psychotherapy includes the total of individual, group, family, collateral family psychotherapy services and home visits provided per eligible recipient per 30-consecutive day period.
(5) Three psychiatric clinic medication visits per patient per 30-consecutive days in psychiatric outpatient clinics.
(6) One outpatient comprehensive diagnostic psychological evaluation or no more than $80 worth of individual psychological or intellectual evaluations in psychiatric clinics per patient per 365 consecutive days.
(7) The partial hospitalization fees listed in the MA Program Fee Schedule include payment for all services rendered to the patient during a psychiatric partial hospitalization session. Separate billings for individual services are not compensable.
(8) Partial hospitalization facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the client receiving treatment.
(9) Partial hospitalization facilities licensed as children and youth programs will be reimbursed at the child rate only when the client receiving treatment is 14 years of age or younger.
(10) 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.
(11) Psychiatric clinic clozapine monitoring and evaluation visits are limited to five visits per patient per calendar month.
(12) Any combination of psychiatric clinic medication visits and psychiatric clinic clozapine monitoring and evaluation visits is limited to five per patient per calendar month.
(b) The Department is authorized to grant an exception to the limits specified in subsection (a)(1) and (4) as described in § 1101.31(f) (relating to scope).]
Payment is subject to the following limitations:
(1) At least 3 hours of psychiatric partial hospitalization per 24-hour period.
(2) The partial hospitalization fees listed in the MA Program Fee Schedule include payment for all services rendered to the individual during a psychiatric partial hospitalization session. Separate billings for individual services are not compensable.
(3) Partial hospitalization facilities licensed for adult programs will be reimbursed at the adult rate, regardless of the age of the individual receiving treatment.
(4) Partial hospitalization facilities licensed as children and youth programs will be reimbursed at the child rate only when the individual receiving treatment is 14 years of age or younger.
(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 from the psychiatric outpatient clinic.
§ 1153.53a. [Requests for waiver of hourly limits] (Reserved).
[(a) Clients who are 20 years of age or younger and who are diagnosed as having one of the medical conditions listed in this section, or conditions of equal severity, may request a waiver from the general limitation on the number of hours of covered services. The medical conditions are:
(1) Infantile autism.
(2) Atypical childhood psychosis.
(3) Borderline psychosis of childhood.
(4) Schizophrenia.
(5) Schizophrenic syndrome of childhood.
(6) Impulse control disorder.
(7) Early deprivation syndrome.
(8) Unsocialized aggressive reaction.
(9) Hyperkinetic conduct disorder.
(10) Over anxious disorder.
(11) Anorexia nervosa.
(12) Neurotic depression—with suicidal ideation.
(b) The request for a waiver shall be accompanied by supporting medical documentation and a second physician's certification as to the medical necessity of psychotherapy beyond the general limitation.
(c) The request for a waiver is reviewed by the Office of Mental Health, Bureau of Community Programs, and acted upon within 30 days of receipt. Failure to act within 30 days constitutes approval of the waiver.
(d) Waivers are granted for periods of up to 6 months. Requests for additional waivers shall be submitted 30 days prior to the expiration of an existing waiver and are reviewed under the same conditions as specified above.
(e) Requests for waivers must be submitted to: Department of Human Services, Office of Medical Assistance, Room 515 Health and Welfare Building, Harrisburg, Pennsylvania 17120.
(f) A denial of a waiver request may be appealed under the same terms and conditions as any denial of services. See Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). Notice of a decision of waiver request will be mailed to the MA recipient and to the provider of services.]
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 [Mental Retardation] Intellectual Disability Act of 1966 (50 P.S. § 4201(2))[;] and section 1021 of the [Public Welfare] Human Services Code (62 P.S. § 1021).
§ 5200.2. Scope.
(a) This chapter provides standards for the licensing of freestanding [outpatient] psychiatric outpatient clinics under section 1021 of the [Public Welfare] 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 [corporations] or for-profit corporations and public entities which provide medical examination, diagnosis, care [and treatment to the mentally ill or the emotionally disturbed], 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 one of the following:
(i) Certified registered nurse practitioner with a mental health certification.
(ii) Physician assistant with a mental health certification or at least 1 year of experience working in a behavioral health setting under the supervision of a psychiatrist.
Assessment—A face-to-face interview that includes an evaluation of the psychiatric, 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 [mentally disabled persons] individuals with mental illness or emotional disturbance.
[Full-time equivalent (FTE)—Thirty-seven and one half hours per week of staff time.]
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's assistant, certified registered nurse practitioner 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 trained in a generally recognized clinical discipline including, but not limited to, psychiatry, social work, psychology or nursing or rehabilitation or activity therapies who has a graduate degree and mental health clinical experience.] 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 which includes mental health clinical experience.
(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 which includes mental health clinical experience.
Mental health worker—[A person without a graduate degree who by training and experience has achieved recognition as a mental health worker.] A person acting under the direction 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 illness or emotional disturbance that meets the diagnostic criteria within the current version of the Diagnostic and Statistical Manual or the International Classification of Diseases. A mental illness or emotional disturbance is characterized by clinically significant disturbances in an individual's cognition, emotional regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning.
Psychiatric outpatient clinic [(outpatient)]—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 [patients with mental or emotional disorders] individuals with mental illness or emotional disturbance. [Outpatient] Psychiatric outpatient services are provided on a planned and regularly scheduled basis.
[Psychiatric nurse—A person who by years of study, training and experience has achieved professional recognition and standing in the field of psychiatric nursing and who is licensed by the State Board of Nursing to engage in the practice of professional nursing.
Psychiatric social worker—A person with a graduate degree in social work who by years of study, training and experience in mental health has achieved professional recognition and standing in the field of psychiatric social work.]
Psychiatrist—A physician who has completed [a 3 year] 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 [patients] individuals receiving services.
Telepsychiatry—
(i) Services provided by a psychiatrist licensed by the Commonwealth using real-time, two-way interactive audio-video transmission.
(ii) Telepsychiatry services do not include telephone conversation, e-mail message or facsimile transmission between a psychiatrist and an individual receiving services, or a consultation between two health care practitioners, although these activities may support telepsychiatry services.
§ 5200.4. Provider eligibility.
[Psychiatric clinic (outpatient) services for the mentally and emotionally disturbed shall be provided only by a facility which complies with this chapter and is certified by the Department to provide such a program. Nothing in this chapter is intended to regulate the practice of psychiatry or psychology in a solo or group practice.] 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. [Facilities shall be inspected a minimum of once per year, but are subject to visit by the Department's designee at other times at the Department's discretion. The Department may request the facility to provide information concerning program and fiscal operation at the Department's discretion.]
(b) [Programs currently operating under preexisting approval shall have 3 months after the effective date of this chapter to meet the requirements of this chapter.] 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 clinic treatment services is to increase the level of patient functioning and well being so that patients will require less intensive services. The service may be provided to persons with chronic or acute mental disorders who require active treatment.] 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. [For-profit facilities shall also have Joint Commission on Accreditation of Hospitals (JCAH) accreditation in order to be licensed or approved under this chapter.]
ORGANIZATION § 5200.11. Organization and structure.
[The psychiatric clinic shall be a separate, identifiable organizational unit with its own director, or supervisor, and staffing pattern. When the clinic is a portion of a larger organizational structure, the director or supervisor of the clinic shall be identified and his responsibilities clearly defined. The organizational structure of the unit shall be described in an organizational chart. A written description of programs provided by the unit shall be available to the Department. The Department will be notified of a major change in the organizational structure or services.]
(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 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 [patients] individuals is required and shall be maintained on file at the [clinic] psychiatric outpatient clinic and updated as needed.
(b) [A psychiatric clinic shall maintain linkages with other appropriate treatment and rehabilitative services including emergency services, partial hospitalization programs, vocational and social rehabilitation programs, and community residential programs and State psychiatric hospitals. A written statement documenting the linkages shall be maintained on file at the clinic.] 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 clinic 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 services agencies shall also be maintained. [A written statement documenting the linkages shall be maintained on file at the clinic.] 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/Mental Retardation (MH/MR)] 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/MR] MH/ID authority. A copy of an agreement [shall] 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/MR] 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/clinic] director/clinical supervisor.
[(a) Each mental health outpatient facility shall have a director/clinic supervisor. This person shall be a qualified mental health professional with at least 2 years of supervisory experience or a professional administrator with a graduate degree in administration and 2 years of experience. If the director/clinic supervisor is not a qualified mental health professional, a physician shall be appointed as clinical director in addition to the director.
(b) The director's/supervisor's duties shall include:
(1) Direction, administration and supervision of the clinic.
(2) Development or implementation of the policies and procedures for the operation of the clinic.
(3) Regular meetings of staff to discuss plans, policy, procedures and staff training.
(4) Liaison with other portions of the service system.
(5) Administrative supervision of personnel.
(6) Employment, supervision, and discharge of staff according to established personnel policies.
(7) Supervision of staff training and development.]
(a) Each psychiatric outpatient clinic shall have a director and clinical supervisor, who may be the same individual. A clinical supervisor shall be a qualified 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, policy 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 facility's program. At least 50% of the treatment staff shall be mental health professionals. Other treatment staff may be mental health workers as required by the patient load.
(b) Staff shall include at least four full-time equivalent (FTE) mental health professionals.
(c) A psychiatric clinic is required to have at least 16 hours of psychiatric time per week to ensure minimally adequate care and supervision for all patients. Psychiatric hours shall be expanded when treatment staff exceeds eight FTE. The ratio is two hours/week for each FTE treatment staff member.]
(a) There shall be qualified staff and supporting personnel in sufficient numbers to provide the services included in the psychiatric outpatient clinic's program. At least 50% of the treatment staff shall be mental health professionals.
(b) An outpatient psychiatric clinic is required to have 2 hours of psychiatric time per week for each FTE treatment staff member. The psychiatrist shall provide 50% of the required psychiatric time. The remaining time may be provided by advanced practice professionals specializing in behavioral health to ensure minimally adequate care or with prior written approval from the Department by the use of telepsychiatry.
[(d)] (c) At a minimum all clinical staff shall be supervised by the psychiatrist having the responsibility for diagnosis and treatment of the [patient] individual receiving services as defined in § 5200.31 (relating to treatment planning).
[(e)] (d) There shall be sufficient clerical staff to keep correspondence, records[,] and files current and in good order.
[(f)] (e) The psychiatric outpatient clinic shall recruit and hire staff that is appropriate for the population to be served.
[(g)] (f) If the psychiatric outpatient clinic serves children, specialized personnel are required, as appropriate, to deliver services to children.
[(h)] (g) Each psychiatric outpatient clinic shall have a written comprehensive personnel policy.
[(i)] (h) There shall be a [planned] written plan for regular, ongoing [program for] staff development and training.
[(j)] (i) Graduate and undergraduate students in accredited training programs in various mental health disciplines may participate in the treatment of [patients] 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 [pattern] patterns.
[(k)] (j) Psychiatric residents [licensed] 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.
[(l)] (k) 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.
At a minimum, the psychiatric supervision of a psychiatric outpatient clinic shall be by a psychiatrist who must monitor all treatment plans on a regular basis as defined by § 5200.31 (relating to treatment planning). Psychiatric supervision shall be expanded as necessary for the [patient] clinic population and services provided.
(Editor's Note: The following section is proposed to be added and printed in regular type to enhance readability.)
§ 5200.24. Criminal history and child abuse certification.
(a) A psychiatric outpatient clinic shall complete a 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 complete criminal history and child abuse certifications, and mandated reporter training in accordance with 23 Pa.C.S. §§ 6301—6386 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services).
(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) A qualified mental health professional or treatment planning team shall prepare an individual comprehensive treatment plan [for every patient] with every individual who participates beyond the intake process which shall be reviewed and approved by a psychiatrist. For [patients] individuals undergoing involuntary treatment, the treatment team shall be headed by a [physician or] psychiatrist or licensed clinical psychologist. [The treatment plan shall include the following:] The treatment plan must meet all of the following requirements:
(1) Be based on the results of the diagnostic evaluation described in paragraph (7).
(2) [Be developed within 15 days of intake, and for voluntary patients, be reviewed and updated every 120 days or 15 patient visits—whichever is first—by the mental health professional and the psychiatrist. For involuntary patients review shall be done every 30 days. Written documentation of this review in the case record is required.] Be developed within 30 days of intake when the individual continues participation in the treatment process. For individuals who voluntarily participate in the treatment process, the treatment plan shall be reviewed and signed by the mental health professional, psychiatrist and individual receiving services. Treatment plans shall be updated every 180 days by the mental health professional and the individual receiving services. The psychiatrist shall review and approve the treatment plan within 1 year of the previous psychiatric review as evidenced by the psychiatrist's signature. For an individual under an involuntary outpatient commitment, the review shall be done every 30 days by the psychiatrist. Written documentation of progress for the review period in the medical record is required.
(3) Specify the goals and objectives of the plan, prescribe an integrated program of therapeutic activities and experience, specify the modalities to be utilized and a time of expected duration and the person or persons responsible for carrying out the plan.
(4) Be directed at specific outcomes and connect these outcomes with the modalities and activities proposed.
(5) [Be formulated with the involvement of the patient.] Be developed with the active involvement of the individual receiving services and must include strengths and needs. The treatment plan may also address individual preferences, resilience and functioning.
(6) For children and adolescents, when required by law or regulations, be developed and implemented with the consent of parents or guardians and include their participation in treatment as required.
(7) Specify an individualized [active diagnostic and treatment program for each patient which shall include where] treatment program for each individual which must include clinically appropriate services such as diagnostic and evaluation services, individual, group and family psychotherapy, behavior therapy, crisis intervention services, medication and similar services. For each [patient the] individual receiving services, the psychiatric outpatient clinic shall provide diagnostic evaluation which shall include an assessment of the psychiatric, medical, psychological, social, vocational[,] and educational factors important to the [patient] individual.
(b) The treatment plan and updates must be based upon the evaluation and diagnosis. Treatment shall be provided in accordance with the identified goals in the treatment plan and updates.
§ 5200.32. Treatment policies and procedures.
Each [facility] psychiatric outpatient clinic shall have on file a written plan specifying the clinical policy and procedures of the facility. This plan [shall] must provide for the following:
(1) Intake policy and procedures.
(2) Admission and discharge policies.
(3) The services to be provided and the scope of these services.
(4) Policies providing for continuity of care for [patients] individuals discharged from the program.
MISCELLANEOUS PROVISIONS § 5200.41. Records.
(a) Under section 602 of the Mental Health and [Mental Retardation] Intellectual Disability Act of 1966 (50 P.S. § 4602), and in accordance with recognized and acceptable principles of [patient record keeping] medical recordkeeping, the facility shall maintain a record for each [person admitted to a psychiatric clinic] individual receiving services from a psychiatric outpatient clinic. The record [shall] must include the following:
(1) [Patient identifying] Identifying information.
(2) Referral source.
(3) 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 order for any MMHT provided.
(b) Records shall also be maintained as follows:
(1) Legible and permanent.
(2) [Reviewed periodically as to quality by the facility or clinical director as appropriate.] Reviewed biannually as to quality by the director or clinical supervisor as appropriate.
(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) The records must comply with §§ 5100.31—5100.39 (relating to confidentiality of mental health records).
(d) All case records shall be kept in locked and protected locations to which only authorized personnel shall be permitted access.]
(c) All protected medical and mental health records, written and electronic, shall be secured in accordance with all applicable Federal and State privacy and confidentiality statutes and regulations.
§ 5200.42. [Drugs and medications] Medications.
(a) If medication is prescribed or dispensed by the [facility] 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 practitioner within his 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 must be documented in the individual medical record.
(b) Written policies and procedures providing for the safe dispensing and administration of [drugs] medication by the medical and nursing staff shall be in writing and on file. [Such policy shall include the following:] The policy must include all of the following:
[(1) Prescriptions shall be written only by the physician.
(2) Drugs shall be dispensed only on the order of a physician.
(3) All drugs shall be kept in a secure place.
(4) Each dose of medication administered by the facility shall be properly recorded in the patient's medical record.]
(1) Medications shall be dispensed only on order of a licensed practitioner within his scope of practice.
(2) All medications 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 medical record.
§ 5200.43. Fee schedule.
Each outpatient psychiatric clinic shall maintain a schedule of uniform basic charges for services which are available to all [patients] individuals receiving services. [Fee schedules shall be submitted to the Department for information purposes.]
§ 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 [patient] individual receiving services and that treatment is indicated. [Patients shall be discharged when the identified benefit, as reflected in the initial evaluation, goals, objectives, and treatment plan, has been received.] Psychiatric outpatient clinics that provide MMHT shall include MMHT services in the quality assurance plan.
§ 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 [patient] individual and community served.
(b) All space and equipment shall be well maintained and [shall] must meet applicable Federal, State[,] and local requirements for safety, fire, accessibility and health.
(c) A waiting room which is [neat, cheerful, and comfortably furnished] 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 [the privacy of the patient in interview rooms] 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 [clinic patients seen at that site to the total patients seen in the psychiatric clinic as a whole] 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 shall not discriminate against staff or clients on the basis of age, race, sex, religion, ethnic origin, economic status, or sexual preference, and must observe all applicable State and Federal statutes and regulations.] 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 observe 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 [for staffing standards for a period of 6 months and may be renewed up to 3 times]. [Such waivers] Waivers may be applied only in areas where the need for [such] these services and the attempts to meet the standards are adequately documented. [Such waivers] Waivers are to be considered only in exceptional circumstances and are subject to approval by the [office of Mental Health] Department.
MOBILE MENTAL HEALTH TREATMENT (Editor's Note: Sections 5200.51—5200.53 are proposed to be added and printed in regular type to enhance readability.)
§ 5200.51. Provider service description.
(a) Prior to the delivery of MMHT services, a psychiatric outpatient clinic shall submit to the Department for approval an 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.
(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.
(ii) The qualifications of a staff person providing an 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.
(iii) Coordination of care with physical health services.
(c) A psychiatric outpatient clinic shall provide MMHT 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) An MMHT provider shall complete an assessment as required under § 5200.31(a)(7) prior to developing the treatment plan. In addition, all of the following 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 under the supervision of a psychiatrist.
(c) Treatment plans shall be updated every 180 days at a minimum.
§ 5200.53. Discharge.
(a) Discharge planning shall be discussed with the individual receiving MMHT services.
(b) Upon discharge, the psychiatric outpatient clinic providing MMHT shall complete a discharge summary that must include all of the following:
(1) MMHT services provided.
(2) Outcomes of MMHT service.
(3) Reason for discharge.
(4) Referral or recommendation for other services.
[Pa.B. Doc. No. 17-1339. Filed for public inspection August 11, 2017, 9:00 a.m.]
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