Diadem Hearts INC,

The Department of State Health Services is seeking more information from your organization to verify you meet the requirements specified in the Home and Community Based Services-Adult Mental Health Open Enrollment (OE).
Our findings indicate your application remains incomplete. Applicant needs to ensure that they have both a policy and procedure in place for all the items notated in the Open Enrollment.

Below you will find some useful information to help you format the content of your policies and procedures. Also, please see attached template for an example of how to format your policies and procedures.

Policies are your rules and guidelines that ensure consistency and compliance with the HCBS-AMH program

– Your HCBS-AMH Policies should address:
· what the Policy is
· who is responsible for the execution and enforcement of the Policy, and
· why the Policy is required.

Procedures define the specific instructions necessary to perform a task or part of a Process.

– Your HCBS-AMH Procedures should detail:
· who performs the Procedure,
· what steps are performed,
· when the steps are performed, and
· how the Procedure is performed.

*DSHS has provided feedback and questions below outlining some of the deficits in your application:

Update on the HCBS-AMH program: The 84th Legislature directed DSHS to expand HCBS-AMH to divert populations with serious mental illness (SMI) from jails and emergency departments (ED) into community treatment programs. Providers that contract with DSHS are now able to choose which population(s) they serve.
} Long-term psychiatric hospitalization
} Jail Diversion
} Emergency Department Diversion

For an individual to qualify to receive a referral into the program they must meet 1 of the 3 criteria below:
1. For Jail Diversion:
– During the three years prior to their referral, an individual must have:
o two or more psychiatric crises (i.e., inpatient psychiatric hospitalizations and/or crisis episodes requiring outpatient mental health treatment), and
o repeated discharges from correctional facilities (i.e., three or more).
2. For Emergency Department Diversion:
– During the three years prior to their referral, an individual must have:
o a history of inpatient psychiatric hospitalizations or outpatient mental health crisis episodes, and
o a pattern of frequent utilization of the emergency department (ED) (i.e., fifteen or more total ED visits)
3. For Long-term Hospitalization
– During the five years prior to their referral, an individual must have:
o Spent three or more cumulative or consecutive years in an inpatient psychiatric setting

Questions for your response:
– Please identify the population(s) you intend on serving? (Extended tenure, Frequent arrests, Frequent ED visits)
– How long have you been a provider of mental health services?—-THIS IS MY FIRST CONTRACT, i HAVE NEVER BEEN A PROVIDER BUT HAVE WORKED IN MENTAL HOSPITAL
– What types of services do you currently provide?
– Tell me about your experience working with individuals with mental healthcare needs?
– Capacity to serve – How many individuals do you anticipate being able to serve? This can be determined based on the number of staff you employ or intend to employ for each service area, broken down by direct employees and sub-contractors.

This is the Link to the Provider Manual: provider manual

Please submit the following items:

– Please submit policy and procedures as outlined in the provider manual (Form L) for provision of services, utilization management, housing and placement
– Please submit detailed job descriptions for each position with required qualifications. Refer to the Provider Manual sections 9200 and 9300 Job descriptions should be provided for every service type included in our program services
– Please submit an updated organizational chart that includes direct care staff, contractors and subcontractors
– Please submit policy and procedures on provision of services/ coordination of care including routine and emergency availability, assurance that all services will be provided and notification to DSHS if services are unavailable
– Please expand on policy and procedures to include credentialing and staff training for both direct staff and subcontractors verification of staff licensure, qualifications, training requirements and certification records
– Provide policy for Personnel Recordkeeping Policy and Procedure needs to outline the applications/tools you will use to verify the following:
§ Review of Medicare/Medicaid Sanctions for staff members
§ Maintaining documentation verifying malpractice or liability insurance for professional staff.
§ Verify license of staff members
§ Review of state regulation sanctions of staff members (i.e. Employee Misconduct or Office of Inspector General)
§ Review disciplinary actions against staff members (i.e. State Board or other agency)
§ How you ensure criminal history and background checks are completed for all staff involved in the administration of HCBS-AMH services
§ Need to include your credentialing procedure including applications used to verify credentials.
– Provide policy and procedures for documenting training on policy and procedures for all staff and subcontractors
o Need to identify how you will document and monitor training to ensure all employees are trained according to HCBS-AMH standards.
– Provide Policy and Procedures that outline how you will document staff training is in compliance with HCBS-AMH requirements (see Appendix A in Provider Manual for an outline of required HCBS-AMH trainings)
o Need to identify in the document which trainings each service provider will need to receive.
o Identify how you will monitor that all staff trainings are up to date.
– Provide policy and procedures for maintaining client record keeping practices including the retention of records, updated and signed IRP, updated and signed progress notes (Provider Manual section 13400)
– Expand on and include in policy and procedures on confidentiality of client records and progress notes
o Expand your procedures for ensuring confidentiality of client records and progress notes.
§ More details needed so any employee reading the policy understands the specifics of HIPPA policy.
– Please provide policy and procedures for medication safety
– Provide policy and procedure on how to inform clients of rights and responsibilities and organizational grievance procedures
o Consumer grievances–Please clarify this section.
o Client complaints – how does your facility gather and address client complaints?
– Provide policy and procedures for Medicaid fair hearing
– Provide policy and procedures for personnel and client safety (examples include PMAB or CIT)
– Expand on critical incident reporting and reporting procedures for reporting abuse neglect and exploitation based on information in provider manual (Provider Manual section 13500)
– Provide separate contraband policy and procedures that outlines how discoveries of illicit drugs or weapons will be handled
– Elaborate on minimum standards identified in provider manual on procedures for seclusion and restraint and how staff will receive initial and ongoing training on the use of restraints
– Provide policy and procedures on how employees and subcontractors will receive payment for services rendered
o Payment of employees and subcontractors – A payroll policy defines the responsibilities and accountabilities of payroll staff and managers. Since payroll involves confidential information, the policy must specify access and security levels. The payroll procedures detail the process from when the employee is hired. They include payroll activities and forms required for processing new hires, employment changes, information updates, special payments, deductions, time reporting and termination
§ Payroll department responsibilities
§ Title of position that is in charge of managing payroll
§ Time Reporting – how do employees document time
§ How employees receive paychecks
§ Payroll schedules and deadlines for submission of payroll documents
– Provide policy and procedures for the transfer of individuals to another HCBS-AMH provider (Provider Manual section 10300)
– Provide policy and procedures for the discharge of individuals from HCBS-AMH (Provider Manual section 10000)
– Provide policy and procedures for a quality management plan including the formal process to diagnose problems and tracking resolution and monitoring for improvement
o Quality Management Plan
§ Formal procedures for diagnosis of problems – Note: This procedure should exist to help diagnose problems that exist within providing HCBS-AMH services, not diagnosing individual client problems.
§ Tracking resolution; and
§ Monitoring for improvement
– Provide policy and procedures for utilization management (Provider Manual section 12000)
– Provide policy and procedure for monitoring and tracking placement, expansion of community housing relationship plan. Reference form H of the OE
– Provide policy and procedures verifying provider owned and operated settings meet setting requirements. Policy should outline procedures for Form H (Provider Manual section 11000)