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(2) Can the services being provided be CHAMPUS benefits; not the type of provided more economically in another provider or condition of the benefacility or on an outpatient basis?
ficiary. (3) Are the charges reasonable?
(vi) Skilled nursing facility. A skilled (4) Is the care primarily custodial or nursing facility is an institution (or a domiciliary? (Custodial or domiciliary distinct part of an institution) that is care of the permanently mentally ill or engaged primarily in providing to inparetarded is not a benefit under the tients medically necessary skilled Basic Program.)
nursing care, which is other than a (D) Although psychiatric hospitals nursing home or intermediate facility, are accredited under the JCAHO AMH and which: standards, their medical records must (A) Has policies that are developed be maintained in accordance with the with the advice of (and with provisions JCAHO Consolidated Standard Manual
for review on a periodic basis by) a for Child, Adolescent, and Adult Psy
group of professionals, including one or chiatric, Alcoholism, and Drug Abuse more physicians and one or more regFacilities and Facilities Serving the istered nurses, to govern the skilled Mentally Retarded, along with the re- nursing care and related medical servquirements set forth in § 199.7(b)(3). The ices it provides. hospital is responsible for assuring (B) Has a physician, a registered that patient services and all treatment
nurse, or a medical staff responsible for are accurately documented and com- the execution of such policies. pleted in a timely manner.
(C) Has a requirement that the med(v) Hospitals, long-term (tuberculosis,
ical care of each patient must be under chronic care, or rehabilitation). To be
the supervision of a physician, and proconsidered a long-term hospital, an in
vides for having a physician available stitution for patients that have tuber
to furnish necessary medical care in culosis or chronic diseases must be an
case of an emergency. institution (or distinct part of an insti
(D) Maintains clinical records on all tution) primarily engaged in providing
patients. by or under the supervision of a physi
(E) Provides 24-hour skilled nursing cian appropriate medical or surgical
service that is sufficient to meet nursservices for the diagnosis and active
ing needs in accordance with the politreatment of the illness or condition in
cies developed as provided in paragraph which the institution specializes.
(b)(4)(iv)(A) of this section, and has at (A) In order for the service of long
least one registered professional nurse term hospitals to be covered, the hos
employed full-time. pital must comply with the provisions
(F) Provides appropriate methods and outlined in paragraph (b)(4)(i) of this
procedures for the dispensing and adsection. In addition, in order for serv
ministering of drugs and biologicals. ices provided by such hospitals to be
(G) Has in effect a utilization review covered by CHAMPUS, they must be primarily for the treatment of the pre
plan that is operational and func
tioning. senting illness. (B) Custodial or domiciliary care is
(H) In the case of an institution in a not coverable under CHAMPUS, even if
state in which state or applicable local rendered in an otherwise authorized
law provides for the licensing of this long-term hospital.
type facility, the institution: (C) The controlling factor in deter
(1) Is licensed pursuant to such law, mining whether a beneficiary's stay in a long-term hospital is coverable by
(2) Is approved by the agency of such CHAMPUS is the level of professional
state or locality responsible for licenscare, supervision, and skilled nursing
ing such institutions as meeting the care that the beneficiary requires, in
standards established for such licensaddition to the diagnosis, type of con
ing. dition, or degree of functional limita
(I) Has in effect an operating plan tions. The type and level of medical
and budget. services required or rendered is con
(J) Meets such provisions of the most trolling for purposes of extending
current edition of the Life Safety
Code 8 as are applicable to nursing facilities; except that if the Secretary of Health and Human Services has waived, for such periods, as deemed appropriate, specific provisions of such code which, if rigidly applied, would result in unreasonable hardship upon a nursing facility.
(vii) Residential treatment centers. This paragraph (b)(4)(vii) establishes standards and requirements for residential treatment centers (RTCs).
(A) Organization and administration.
(1) Definition. A Residential Treatment Center (RTC) is a facility or a distinct part of a facility that provides to beneficiaries under 21 years of age a medically supervised, interdisciplinary program of mental health treatment. An RTC is appropriate for patients whose predominant symptom presentation is essentially stabilized, although not resolved, and who have persistent dysfunction in major life areas. The extent and pervasiveness of the patient's problems require a protected and highly structured therapeutic environment. Residential treatment is differentiated from:
(i) Acute psychiatric care, which requires medical treatment and 24-hour availability of a full range of diagnostic and therapeutic services to establish and implement an effective plan of care which will reverse lifethreatening and/or severely incapacitating symptoms;
(ii) Partial hospitalization, which provides a less than 24-hour-per-day, seven-day-per-week treatment program for patients who continue to exhibit psychiatric problems but can function with support in some of the major life areas;
(iii) A group home, which is a professionally directed living arrangement with the availability of psychiatric consultation and treatment for patients with significant family dysfunction and/or chronic but stable psychiatric disturbances;
(iv) Therapeutic school, which is an educational program supplemented by psychological and psychiatric services;
(v) Facilities that treat patients with a primary diagnosis of chemical abuse or dependence; and
(vi) Facilities providing care for patients with a primary diagnosis of mental retardation or developmental disability.
(i) Every RTC must be certified pursuant to CHAMPUS certification standards. Such standards shall incorporate the basic standards set forth in paragraphs (b)(4)(vii) (A) through (D) of this section, and shall include such additional elaborative criteria and standards as the Director, OCHAMPUS determines are necessary to implement the basic standards.
(ii) To be eligible for CHAMPUS certification, the facility is required to be licensed and fully operational for six months (with a minimum average daily census of 30 percent of total bed capacity) and operate in substantial compliance with state and federal regulations.
(iii) The facility is currently accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) under the current edition of the Manual for Mental Health, Chemical Dependency, and Mental Retardation Developmental Disabilities Services which is available from JCAHO, P.O. Box 75751, Chicago, IL 60675.
(iv) The facility has a written participation agreement with OCHAMPUS. The RTC is not a CHAMPUS-authorized provider and CHAMPUS benefits are not paid for services provided until the date upon which a participation agreement is signed by the Director, OCHAMPUS.
(3) Governing body.
(i) The RTC shall have a governing body which is responsible for the policies, bylaws, and activities of the facility. If the RTC is owned by a partnership or single owner, the partners or single owner are regarded as the governing body. The facility will provide an up-to-date list of names, addresses, telephone numbers and titles of the members of the governing body.
(ii) The governing body ensures appropriate and adequate services for all patients and oversees continuing development and improvement of care.
8 Compiled and published by the National Fire Protection Association, Batterymarch Park, Quincy, Massachusetts 02269.
Where business relationships exist be- tion, and monitoring of all activities tween the governing body and facility, relating to medical treatment of paappropriate conflict-of-interest policies tients. If qualified, the Medical Direcare in place.
tor may also serve as Clinical Director. (iii) Board members are fully in- (7) Medical or professional staff organiformed about facility services and the zation. The governing body shall estabgoverning body conducts annual review lish a medical or professional staff orof its performance in meeting purposes, ganization to assure effective impleresponsibilities, goals and objectives. mentation of clinical privileging, pro
(4) Chief executive officer. The chief fessional conduct rules, and other acexecutive officer, appointed by and tivities directly affecting patient care. subject to the direction of the gov
(8) Personnel policies and records. The erning body, shall assume overall ad
RTC shall maintain written personnel ministrative responsibility for the op
policies, updated job descriptions and eration of the facility according to
personnel records to assure the selecgoverning body policies. The chief ex
tion of qualified personnel and successecutive officer shall have five years'
ful job performance of those personnel. administrative experience in the field
(9) Staff development. The facility of mental health. On October 1, 1997,
shall provide appropriate training and the CEO shall possess a degree in business administration, public health,
development programs for administrahospital administration, nursing, so
tive, professional support, and direct
care staff. cial work, or psychology, or meeting similar educational requirements as
(10) Fiscal accountability. The RTC prescribed by
shall assure fiscal accountability to apOCHAMPUS.
plicable government authorities and (5) Clinical Director. The clinical di
patients. rector, appointed by the governing
(11) Designated teaching facilities. Stubody, shall be a psychiatrist or doc
dents, residents, interns or fellows protoral level psychologist who meets ap
viding direct clinical care are under plicable CHAMPUS requirements for
the supervision of a qualified staff individual professional providers and is
member approved by an accredited unilicensed to practice in the state where
versity. The teaching program is apthe residential treatment center is lo
proved by the Director, OCHAMPUS. cated. The clinical director shall pos
(12) Emergency reports and records. The sess requisite education and experi- facility notifies OCHAMPUS of any seence, credentials applicable under state
rious occurrence involving CHAMPUS practice and licensing laws appropriate
beneficiaries. to the professional discipline, and a
(B) Treatment services. minimum of five years' clinical experi- (1) Staff composition. ence in the treatment of children and (i) The RTC shall follow written adolescents. The clinical director shall plans which assure that medical and be responsible for planning, develop- clinical patient needs will be approment, implementation, and monitoring priately addressed 24 hours a day, of all clinical activities.
seven days a week by a sufficient num(6) Medical director. The medical di- ber of fully qualified (including license, rector, appointed by the governing registration or certification requirebody, shall be licensed to practice med- ments, educational attainment, and icine in the state where the residential professional experience) health care treatment center is located and shall professionals and support staff in the possess requisite education and experi- respective disciplines. Clinicians proence, including graduation from an ac- viding individual, group, and family credited school of medicine or osteop- therapy meet CHAMPUS requirements athy, an approved residency in psychi- as qualified mental health providers atry and a minimum of five years clin- and operate within the scope of their ical experience in the treatment of licenses. The ultimate authority for children and adolescents. The Medical planning, development, implementaDirector shall be responsible for the tion, and monitoring of all clinical acplanning, development, implementa- tivities is vested in a psychiatrist or
doctoral level psychologist. The man- sion, a determination is made, and apagement of medical care is vested in a proved pursuant to CHAMPUS physician.
preauthorization requirements, that (ii) The RTC shall ensure adequate the admission is medically and/or psycoverage by fully qualified staff during chologically necessary and the proall hours of operation, including physi- gram is appropriate to meet the pacian availability, other professional tient's needs. Medical and/or psychostaff coverage, and support staff in the logical necessity determinations shall respective disciplines.
be rendered by qualified mental health (2) Staff qualifications. The RTC will professionals who meet CHAMPUS rehave a sufficient number of qualified quirements for individual professional mental health providers, administra- providers and who are permitted by law tive, and support staff to address pa- and by the facility to refer patients for tients' clinical needs and to coordinate admission. the services provided. RTCs which em- (6) Assessments. The professional staff ploy individuals with master's or doc- of the RTC shall complete a current toral level degrees in a mental health multidisciplinary assessment which indiscipline who do not meet the licen- cludes, but is not limited to physical, sure, certification and experience re- psychological, developmental, family, quirements for qualified mental educational, social, spiritual and skills health provider but are actively work- assessment of each patient admitted. ing toward licensure or certification, Unless otherwise specified, all required may provide services within the all-in- clinical assessments are completed clusive per diem rate, provided the in- prior to development of the multidiscidividual works under the clinical su- plinary treatment plan. pervision of a fully qualified mental (7) Clinical formulation. A qualified health provider employed by the RTC. mental health professional of the RTC All other program services shall be pro- will complete a clinical formulation on vided by trained, licensed staff.
all patients. The clinical formulation (3) Patient rights.
will be reviewed and approved by the (i) The RTC shall provide adequate responsible individual professional proprotection for all patient rights, in- vider and will incorporate significant cluding rights provided by law, pri- findings from each of the multidiscivacy, personnel rights, safety, con- plinary assessments. It will provide the fidentiality, informed consent, griev- basis for development of an interances, and personal dignity.
disciplinary treatment plan. (ii) The facility has a written policy (8) Treatment planning. A qualified regarding patient abuse and neglect. mental health professional shall be re
(iii) Facility marketing and adver- sponsible for the development, supertising meets professional standards. vision, implementation, and assess
(4) Behavioral management. The RTC ment of a written, individualized, shall adhere to a comprehensive, writ- interdisciplinary plan of treatment, ten plan of behavioral management, which shall be completed within 10 developed by the clinical director and days of admission and shall include inthe medical or professional staff and dividual, measurable, and observable approved by the governing body, in- goals for incremental progress and discluding strictly limited procedures to charge. A preliminary treatment plan assure that the restraint or seclusion is completed within 24 hours of admisare used only in extraordinary cir- sion and includes at least an admission cumstances, are carefully monitored, note and orders written by the admitand are fully documented. Only trained ting mental health professional. The and clinically privileged RNs or quali- master treatment plan is reviewed and fied mental health professionals may revised at least every 30 days, or when be responsible for the implementation major changes occur in treatment. of seclusion and restraint procedures in (9) Discharge and transition planning. an emergency situation.
The RTC shall maintain a transition (5) Admission process. The RTC shall planning process to address adequately maintain written policies and proce- the anticipated needs of the patient dures to ensure that, prior to an admis- prior to the time of discharge. The planning involves determining nec- gency services include policies and proessary modifications in the treatment cedures for handling emergencies with plan, facilitating the termination of qualified personnel and written agreetreatment, and identifying resources to ments with each facility providing the maintain therapeutic stability fol- service. Other ancillary services inlowing discharge.
clude physical health, pharmacy and (10) Clinical documentation. Clinical dietary services. records shall be maintained on each pa- (C) Standards for physical plant and tient to plan care and treatment and environment. provide ongoing evaluation of the pa- (1) Physical environment. The buildtient's progress. All care is documented ings and grounds of the RTC shall be and each clinical record contains at maintained so as to avoid health and least the following: demographic data, safety hazards, be supportive of the consent forms, pertinent legal docu- services provided to patients, and proments, all treatment plans and patient mote patient comfort, dignity, privacy, assessments, consultation and labora- personal hygiene, and personal safety. tory reports, physician orders, progress (2) Physical plant safety. The RTC notes, and a discharge summary. All shall be of permanent construction and documentation will adhere to applica- maintained in a manner that protects ble provisions of the JCAHO and re- the lives and ensures the physical safequirements set forth in § 199.7(b)(3). An ty of patients, staff, and visitors, inappropriately qualified records admin- cluding conformity with all applicable istrator or technician will supervise building, fire, health, and safety codes. and maintain the quality of the (3) Disaster planning. The RTC shall records. These requirements are in ad- maintain and rehearse written plan for dition to other records requirements of taking care of casualities and handling this part, and documentation require- other consequences arising from interments of the Joint Commission on Ac- nal and external disasters. creditation of Healthcare Organiza- (D) Standards for evaluation system. tions.
(1) Quality assessment and improve(11) Progress notes. RTC's shall docu- ment. The RTC shall develop and implement the course of treatment for pa- ment a comprehensive quality assurtients and families using progress ance and quality improvement program notes which provide information to re- that monitors the quality, efficiency, view, analyze, and modify the treat- appropriateness, and effectiveness of ment plans. Progress notes are legible, the care, treatments, and services it contemporaneous, sequential, signed provides for patients and their famiand dated and adhere to applicable pro- lies, primarily utilizing explicit clinvisions of the Manual of Mental ical indicators to evaluate all funcHealth, Chemical Dependency, and tions of the RTC and contribute to an Mental Retardation
Development Dis- ongoing process of program improveabilities Services and requirements set
ment. The clinical director is responforth in 199.7(b)(3).
sible for developing and implementing (12) Therapeutic services.
quality assessment and improvement (i) Individual, group, and family psy- activities throughout the facility. chotherapy are provided to all pa- (2) Utilization review. The RTC shall tients, consistent with each patient's implement a utilization review process, treatment plan, by qualified mental pursuant to a written plan approved by health providers.
the professional staff, the administra(ii) A range of therapeutic activities, tion, and the governing body, that asdirected and staffed by qualified per- sesses the appropriateness of admissonnel, are offered to help patients sion, continued stay, and timeliness of meet the goals of the treatment plan. discharge as part of an effort to provide
(iii) Therapeutic educational services quality patient care in a cost-effective are provided or arranged that are ap- manner. Findings of the utilization repropriate to the patients educational view process are used as a basis for reand therapeutic needs.
vising the plan of operation, including (13) Ancillary services. A full range of a review of staff qualifications and ancillary services is provided. Emer- staff composition.