PROVIDER CERTIFICATION MANUAL FOR COMMUNITY SUPPORT SERVICES PROGRAMS


Community Continuum of Care Program
Residential Rehabilitation Facility
Psychosocial Rehabilitation Center



DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF SOCIAL SERVICES


09-01-2004



TABLE OF CONTENTS

PAGE 
OVERVIEW	4

 1	CERTIFICATION FOR PROVIDER PARTICIPATION	5

	1.1	Authority	5
 
	1.2	Certification Criteria	5

	1.3	Procedure	5

 2 	CLINICAL STAFF AUTHORIZED TO PROVIDE SERVICES	6

 3	RECIPIENT ELIGIBILITY	7

 4	COVERED SERVICES	7

 5	SERVICE LIMITATIONS	8

 6	COMMUNITY CONTINUUM OF CARE PROGRAM STANDARDS	8

	6.1	Program Organization and Operation	8

	6.2	Program Staff	9

	6.3	Target Population	10

	6.4	Determination of Severity of Disability	10

6.5	Consumer Rights	11

	6.6	Intake	12

	6.7	Assessment	12

	6.8 	Determination of Consumer Service Intensity Level	14

	6.9	Treatment Planning	14

	6.10	Crisis Intervention Plan	16

	6.11	Clinical Supervision	17

6.12     Progress Notes	17

6.13     Summary of Monthly Client Activity	18

6.14      Discharge Summary	18

	6.15      Services	19

	6.16	Required Frequency of Contact	22

	6.17	Minimum Standards for Certifying Living
		Arrangements for Consumers	23

7	PSYCHOSOCIAL REHABILITATION CENTER (PRC) STANDARDS	24

8	RESIDENTIAL REHABILITATION CENTER (RRF) STANDARDS	29

9	ORGANIZATIONAL STANDARDS	29

10	ADMINISTRATIVE STANDARDS	30

	10.1	Consumer Records	30

	10.2	Procedure Manual	30

	10.3	Personnel Management	33

	10.4	Quality Assurance Program	36

11	WAIVER OF PROVISIONS	36


	


OVERVIEW

This manual contains the standards by which the Division of Substance Abuse and Mental Health 
certifies Community Support Services Programs for persons with psychiatric disabilities. 
Certification is required for provider enrollment with the Division of Social Services, Delaware 
Medical Assistance Program (DMAP) for Medicaid reimbursement through the rehabilitative 
services option of Title XIX of the Social Security Amendments.

Through an Inter-Divisional Agreement the Division of Substance Abuse and Mental Health has 
been delegated authority for administration of certain provisions of the Medicaid program 
pertaining to optional rehabilitative services. These provisions include the following: 1) 
certification of programs for provider enrollment; 2) rate setting; and 3) quality assurance. 
Delegated quality assurance functions include program monitoring, utilization control, training and 
technical assistance.

The Delaware Medical Assistance Program covers optional behavioral health rehabilitative services 
provided to eligible Medicaid recipients by certified providers. Behavioral Health rehabilitative 
services are medically related treatment, rehabilitative and support services for persons with 
disabilities caused by mental illness, alcoholism or drug addiction. The Community Continuum of 
Care Program (CCCP), Psychosocial Rehabilitation Center (PRC) and Residential Rehabilitation 
Facility (RRF) are categories of community support programs that the Division certifies for 
Medicaid provider enrollment. Services are provided for as long as medically necessary to assist 
service recipients to cope with the symptoms of their illnesses, minimize the effects of their 
disabilities on their capacity for independent living and prevent or limit periods of inpatient 
treatment.



1	CERTIFICATION FOR PROVIDER PARTICIPATION

	1.1	Authority - Through an Inter-Divisional Agreement, the Division of Social 
Services (DSS) Delaware Medical Assistance Program (DMAP) has delegated the 
function of certifying organizations for enrollment as providers of optional 
behavioral health community support services to the Division of Substance Abuse 
and Mental Health (Division or DSAMH).

	1.2	Certification Criteria - Eligibility for certification to provide community support 
services is determined according to the following criteria:

		1.2.1	Organizations eligible to apply for provider certification and enrollment with 
DSS for Medicaid reimbursement of Community Support Services include:

			1.2.1.1	Private non-profit human service corporations;

			1.2.1.2	Private for-profit human service corporations; 			

			1.2.1.3	State, county or municipal government-operated health and human 
services departments.

		1.2.2	The Division bases its certification of programs and enrollment 
recommendation to DSS upon the organization's compliance with state level 
organizational, administrative and program standards, and with federal 
requirements for the administration of Medicaid services as contained in 
federal statutes, regulations and guidelines.

			1.2.2.1	The Division may establish and apply minimum compliance 
guidelines to be used in making certification determinations.	
		
		1.2.3	The Division uses a certification survey to measure compliance with 
organizational, administrative and program standards. The determination 
with regard to a program's certification is based on:

			1.2.3.1	Statements of the organization's authorized representatives;

			1.2.3.2	Documents provided to the Division by the organization;

			1.2.3.3	Documented compliance with organizational, program and 
administrative standards;

			1.2.3.4	On-site observations by surveyors.

	1.3	Provider Certification

		1.3.1	Procedures for Certification, Recertification, Suspension, Revocation and 
Reinstatement of Certification may be found in the Medicaid Provider-
specific Policy Manual for Community Support Services (Behavioral Health 
Rehabilitative Services) available on the DMAP web site at 
http://www.dmap.state.de.us  or from EDS provider services (telephone 302-
454-7154 or 800-999-3371. 

2	CLINICAL STAFF AUTHORIZED TO PROVIDE SERVICES

	The provider may file claims for only those billable Community Support Services rendered 
by members of its clinical staff who hold the credentials required by each covered billable 
activity. 

2.1	The categories of clinical staff and their definitions for Community Support Services 
Programs for persons with psychiatric disabilities are as follows:

		2.1.1	Physician: a person with a Medical Degree or Doctor of Osteopathy degree, 
is licensed to practice medicine in Delaware and has completed (or is 
enrolled in) an accredited residency training program in psychiatry, internal 
medicine or family practice. 


2.1.2	Clinician: a person with a doctoral or master's degree in psychology, 
counseling, social work, nursing, rehabilitation or related field from an 
accredited college or university, (or a registered nurse with a certificate in 
mental health nursing from the American Nurses Association).

2.1.2.1	The Clinical Supervisor must meet the minimum criteria for 
Clinician.

2.1.3	Associate Clinician: a person with a bachelor's degree in a human service 
field or a registered nurse.

2.1.3.1	Case Managers must meet the minimum criteria for Associate 
Clinician.

2.1.4	Assistant Clinician: a person with an associate's degree in a human service 
field or a certified counselor who holds a certification from a nationally 
recognized certification body but lacks the academic credentials of an 
associate clinician.

2.1.5	Rehabilitative Services Assistant:  a person with a high school diploma or 
GED who has received documented training that shall, at a minimum, 
include:  1) a complete course in medications used in the treatment of mental 
illness including the side effects assigned; 2) a course in mental illness 
including symptoms of the major mental illnesses, mood and personality  
disorders; 3) a course in first aid including CPR training. 
 


3	RECIPIENT ELIGIBILITY

	Eligible recipients are certified by the program physician as being in medical need of 
program services in accordance with an assessment procedure approved by the Division for 
use in determining that persons are severely disabled according to criteria for severity of 
disability associated with mental illness. 
	
	3.1	The Division may require a full review of medical necessity in the event that a 
determination of medical necessity by the program physician does not appear to 
DSAMH to be supported by the assessment materials.

	3.2	Determination of consumer eligibility for Medicaid benefits is the sole responsibility 
of DSS.

4	COVERED SERVICES

		Covered Services are provided only within the context of an appropriately certified 
Community Support Services program.  Community Support Services may be billed to the 
Delaware Medical Assistance Program for eligible Medicaid recipients for the following 
activities.  [Definitions for all covered services may be found in the Medicaid Provider-
specific Policy Manual for Community Support Services (Behavioral Health Rehabilitative 
Services) available on the DMAP web site at http://www.dmap.state.de.us  or from EDS 
provider services (telephone 302-454-7154 or 800-999-3371.]. 

4.1	Comprehensive Medical/Psychosocial Evaluation 

	4.2	Physician Services 

4.3	Emergency Services

		4.3.1.	Emergency services are provided by a physician, clinician, associate 
clinician, assistant clinician or rehabilitative services assistant.
 
4.4	Counseling and Psychotherapy Services 

4.4.1.	Counseling is provided by physicians, clinicians, associate clinicians and 
assistant clinicians who are credentialed counselors or learning and 
practicing under direct supervision by a credentialed clinician.
	
4.5	Psychiatric Rehabilitative Services 

		4.5.1.	Psychiatric rehabilitative services are provided by a physician, clinician, 
associate clinician, assistant clinician or rehabilitative services assistant.


4.6	Psychosocial Rehabilitation Center Services  [Services limited to provision by a 
Certified Psychosocial Rehabilitation Center.]

4.6.1.	Services are provided by a physician, clinician, associate clinician, assistant 
clinician or rehabilitative services assistant.

4.7	Residential Rehabilitation Facility Services  [Services limited to provision by 
a Certified Residential Rehabilitation Facility.]

4.7.1.	Services are provided by a physician, clinician, associate clinician, assistant 
clinician or rehabilitative services assistant.


5	SERVICE LIMITATIONS

5.1	Limitations on optional Behavioral Health Community Support Services may be 
found in the Medicaid Provider-specific Policy Manual for Community Support 
Services (Behavioral Health Rehabilitative Services) available on the DMAP web 
site at http://www.dmap.state.de.us  or from EDS provider services (telephone 302-
454-7154 or 800-999-3371.

6	COMMUNITY CONTINUUM OF CARE (CCCP) STANDARDS

	6.1	Program Organization and Operation

6.1.1	A CCCP shall adhere to the following hours of operation: 

6.1.1.1	Highest Intensity Level: Seven days per week, a minimum of 12 
hours on weekdays and 8 hours on weekends and holidays.

6.1.1.2	Intermediate Intensity Level and Lower Intensity Level: No less 
than five (5) days a week, at least eight (8) hours per day. The 
schedule shall include at least eight hours per week outside the 
hours of 9:00 A.M. to 5:00 P.M. 

6.1.2	A clinician, associate clinician or assistant clinician shall be on-call and 
available to respond face-to-face immediately during non-operating hours. A 
second staff member shall be on back-up on-call.

6.1.3	A CCCP program shall be organized to provide a maximum clinical staff to 
consumer ratio of:

6.1.3.1	 1:12 with no individual staff member having a caseload of more 
than 20 for High Intensity Level consumer. 
6.1.3.2	1:20 with no individual staff member having a caseload of more 
than 30 for Intermediate Intensity Level consumers.
6.1.3.3	1:30 with no individual staff member having a caseload of more 
than 40 for Lower Intensity Level consumers.
6.1.3.4	AT LEAST 75% OF THE CLINICAL STAFF SHALL BE 
FULL-TIME.
6.1.4	Each consumer shall have a treatment team consisting of at least the staff 
members designated as the physician, registered nurse, clinician, and case 
manager who are primarily involved in his/her treatment plan. 

6.1.5	CCCP programs serving more than 100 consumers may break into smaller 
teams. 

6.1.6	Each consumer's team shall meet jointly:

6.1.6.1	Each day for High Intensity Level consumers to review the 
contacts with and status of each consumer during the previous 
day and to plan contacts for the current day.

6.1.6.2	Weekly for Intermediate Intensity Level and Lower Intensity 
Level consumers to review the contacts with and the status of 
each consumer during the previous week and to plan contacts for 
the following week.

6.1.7	The physician, clinical supervisor, case manager, at least one other member 
of the consumer's primary treatment team from the CCCP shall meet jointly 
at least weekly to conduct treatment planning and treatment plan reviews. 

6.1.8	 Program staff shall maintain regular, contact with consumers who are 
hospitalized for stabilization of psychiatric symptoms. Consumer contacts 
shall occur at least one time per hospitalization episode OR one time per 
week for hospital stays longer than 7 days.  Program staff shall collaborate 
with treatment teams providing care to hospitalized consumers.
	
	6.2	Program Staff

		6.2.1	There shall be an overall director of the CCCP who shall be a clinician with 
at least three years of clinical/administrative experience in providing 
community support services to adults with psychiatric disabilities.

6.2.2	Each CCCP shall have an overall clinical supervisor who shall supervise the 
provision of services to consumers and the quality assurance program. The 
clinical supervisor shall be a clinician with at least three years of post-
graduate experience in providing community support services to adults with 
psychiatric disabilities.

6.2.3	Associate clinicians and assistant clinicians shall have credentials/training 
for the treatment activities they engage in and shall be supervised by 
clinicians. 

6.2.4	Rehabilitative Services Assistants shall conduct activities only under the 
direction and supervision of a clinician in the implementation of specified 
treatment plan objectives.  

6.2.4.1	Rehabilitative Services Assistants shall have documented 
training and/or demonstrated competence in the conduct of 
assigned activities.

6.2.5	Rehabilitative Services Assistants shall provide services only when other 
clinical staff are on duty in the CCCP.  Rehabilitative Services Assistants 
shall not at any time be the only staff persons on duty in the CCCP.

6.2.6	The CCCP shall have among its staff individuals who are trained, skilled 
and experienced to conduct the following clinical activities: 
psychoeducational therapy; cognitive therapy; behavior therapy; symptom 
education and self-management; addictions therapy; vocational assessment 
and therapy; social skills training; daily living skills training; structured 
interviewing for completing rating scales, diagnostic interviews, mental 
status examinations, social security disability reports, etc. 

6.2.7	All clinical staff shall be trained and supervised to provide supportive 
counseling and case management.

6.2.8	When volunteers or student interns are used, they shall be supervised by a 
clinician. 

6.2.6.1	The CCCP shall have written procedures for the selection, 
orientation, in-service training and supervision of volunteers and 
students.

6.2.9	A CCCP program shall have a full or part-time physician who is available to 
provide direct service at CCCP sites. 

6.2.9.1	The physician shall have backup arrangements with other 
physicians for coverage when he/she is unavailable and shall 
provide them with an up-to-date listing of the medications and 
recommendations for each consumer in the event of a crisis.

6.2.10	For every 70 consumers, there shall be at least 1.0 Full Time Equivalent 
(FTE) Registered Nurse(s).
			
	6.3	Target Population

		Enrollment in a CCCP shall be limited to consumers who are certified by the 
program physician as being in medical need of the services provided in accordance 
with the Division's approved assessment procedure and meet the criteria for 
enrollment as community support consumers.

	6.4	Determination of Severity of Disability

		6.4.1	The Division uses the following criteria to make a determination of severity 
of disability; 

			6.4.1.1	An established history of rapid deterioration following previous 
interventions for psychiatric stabilization;

			6.4.1.2	The rating on Axis I through Axis V of the DSM IV TR Multiaxial 
System;
		 
			6.4.1.3 The degree of clinical risk evidenced by:

				6.4.1.3.1 	severity and interference of refractory symptoms;

				6.4.1.3.2	psychosocial dysfunction;

				6.4.1.3.3	impaired judgment;

				6.4.1.3.4	suicidal behavior;
	
				6.4.1.3.5	disruptive behavior.

	6.5	Consumer Rights

6.5.1	The provider shall establish a formal process for soliciting consumer 
complaints and for reviewing treatment decisions by staff with which 
consumers disagree.

6.5.1.1	The provider must identify a specific staff person responsible for 
unbiased assistance to consumers in following and understanding 
the complaints and grievance process and in appropriately 
presenting their complaint or grievance.

		6.5.2	The provider shall not establish any general conditions of program 
participation that limits a consumer's rights to self-determination. 

		6.5.3	The provider shall comply with DHSS Policy Memorandum 46 or (if not 
operating under contract to, or direct supervision of, DHSS) a similarly 
comprehensive written policy/procedure regarding the reporting of and 
responding to allegations of abuse and neglect, and to incidents resulting in 
injury or death. 

		6.5.4	Consumers shall be kept informed of their rights and responsibilities 
contained in written policies and procedures including reference to:

			6.5.4.1	Behavioral expectations and limitations;

			6.5.4.2	Consumer grievances;

6.5.4.3	Confidentiality including:

6.5.4.3.1	The Health Insurance Portability and Accountability Act 
(HIPAA), regulations 45 C.F.R. Parts 160 & 164;

	AND 

6.5.4.3.2	For substance abusing consumers, drug and alcohol 
confidentiality regulations 42 C.F.R. Part 2.

6.5.4.4	 Charges for which consumers or a third party may be billed;

			6.5.4.5	The process for appeal and review of problems which consumers 
experience in regard to the quality and responsiveness of services 
provided by program staff.

	6.6	Intake 

		6.6.1	During the intake process, there shall be documentation that the consumer 
has been informed of:

6.6.1.1	His/her rights as defined in 6.5;

6.6.1.2	The program's services and aims;

			6.6.1.3 The manner in which the program operates to ensure that consumers 
receive the services they need;

			6.6.1.4	How consumers can obtain assistance during an emergency or 
whenever the program offices are closed;

	6.7	Assessment

6.7.1	A Comprehensive Medical/Psychosocial Evaluation approved by the 
Division as a CCCP assessment procedure shall be started at the time of the 
consumer's admission to the Community Support Services Programs and 
shall be completed:

6.7.1.1	Within 30 days of admission; 

6.7.1.2	When consumers move from one level to another;

AND

		6.7.1.3	Annually for each consumer.

		6.7.2	A clinician shall conduct the evaluation. 

			6.7.2.1	The evaluation shall include a written summary of the assessment. 
The summary shall include:

6.7.2.1.1 	current psychiatric symptomatology and mental 
status to include multiaxial DSM IV TR diagnosis;

6.7.2.1.2	extent and effects of drug and/or alcohol use; 

6.7.2.1.3	 medical, dental, and optometric needs; 

6.7.2.1.4	 compliance with and response to prescribed 
medical/psychiatric treatment;

6.7.2.1.5	 recent key life events; 

6.7.2.1.6	vocational and educational functioning;

6.7.2.1.7	family history and social supports; 

6.7.2.1.8	current social functioning; 

6.7.2.1.9	legal history to include current legal issues;

6.7.2.1.10	financial status; 

6.7.2.1.11	conditions of daily living, including housing;

6.7.2.1.12	recommendations for treatment to include issues to 
be addressed.  

6.7.2.2	The Comprehensive Medical/Psychosocial Evaluation shall 
be signed, and dated by the clinician completing the 
evaluation. 

6.7.2.3	The Comprehensive Medical/Psychosocial Evaluation shall 
be reviewed, signed, and dated by the physician.

6.7.3	Clients who have not had a physical examination within one year (365 days) 
prior to admission shall have a physical examination within 60 days 
following admission to the program. 

6.7.3.1	Results of the current physical examination shall be documented 
in the consumer record.

6.7.3.2	The current physical examination shall be reviewed, signed, and 
dated by the physician or other qualified medical personnel 
whose license allows them conduct and/or review physical 
examinations without oversight from a physician.


6.8	Determination of Consumer Service Intensity Level

6.8.1	The CCCP shall utilize assessment information to determine the level of 
service intensity required to substantially address the treatment/rehabilitation 
needs of each consumer.

6.8.1.1	The level of service intensity required by each consumer shall be 
determined in a uniform manner for all consumers and shall 
substantiate the placement of the consumer into a program 
component conforming to one of the Levels specified in Section 6.1.

6.8.1.2	The CCCP shall determine level of service intensity using a clearly 
delineated process that is sufficiently documented and structured to 
allow review and understanding of the process by a clinician not 
experienced in its use [e.g.: the Level of Care Utilization System for 
Psychiatric and Addiction Services (LOCUS)].

6.9	Treatment Planning

6.9.1	An initial written treatment plan shall be developed on the day of admission. 

6.9.1.1	The initial treatment plan shall include:

6.9.1.1.1	Short-range goals, stated in measurable terms;

6.9.1.1.2	Long-range goals, stated in measurable terms; 

6.9.1.1.3	Specific staff interventions planned to achieve 
treatment goals;

6.9.1.1.4	Frequency of interventions. 

6.9.1.2	The initial treatment plan shall be reviewed, signed, and dated by: 

6.9.1.2.1	The case manager;

6.9.1.2.2	The physician 

		AND

6.9.1.2.3	The consumer.

6.9.2	Within 45 days of admission, following the completion of intake 
assessments, the consumer's primary case manager shall develop a 
comprehensive written treatment plan. 

6.9.2.1	The comprehensive treatment plan shall include:

6.9.2.1.1	Short-range goals, stated in measurable terms;

6.9.2.1.2	Long-range goals, stated in measurable terms;

6.9.2.1.3	Specific staff interventions planned to achieve 
treatment goals;

6.9.2.1.4	Frequency of interventions. 

6.9.2.2	The consumer's participation in the development of treatment 
goals shall be documented. 

6.9.2.3	The comprehensive treatment plan shall be reviewed, signed, and 
dated by:

6.9.2.3.1	The case manager;

6.9.2.3.2	The physician 

		AND

6.9.2.3.3	The consumer

6.9.3	The treatment plan shall be reviewed in full at least every six months at a 
treatment planning and review meeting. As a result of the review a new 
treatment plan shall be written. 

6.9.3.1	The treatment plan update shall include:

6.9.3.1.1	Short-range goals, stated in measurable terms;

6.9.3.1.2	Long-range goals, stated in measurable terms;

6.9.3.1.3	Specific staff interventions planned to achieve 
treatment goals;

6.9.3.1.4	Frequency of interventions. 

6.9.3.2	The consumer's participation in the development of treatment 
goals shall be documented. 

6.9.3.3	The clinical supervisor's participation in the development of 
treatment goals shall be documented. 

6.9.3.4	The treatment plan update shall be signed and dated by the case 
manager.

6.9.3.5	The treatment plan update shall be reviewed, signed, and dated by 
the physician.

6.9.3.6	The treatment plan update shall be reviewed, signed, and dated by 
the consumer.

6.9.4	Each time a consumer moves from a lower level of care to a higher level of 
care, or from a higher level of care to a lower level of care, a treatment plan 
update shall be completed in accordance with 6.9.3 of these standards.

6.10	Crisis Intervention Plan	

6.10.1	The Crisis Intervention Plan shall include:

6.10.1.1	Consumer-driven recommended procedures for crisis or 
emergency resolution;

6.10.1.2	Specific persons and/or programs to contact in times of 
crisis;

6.10.1.3	Signs and symptoms of decompensation or relapse for the 
consumer;

6.10.1.4	Methods for preventing crisis;

6.10.1.5	Advance directives for the use in crisis situation;

6.10.2	An initial written crisis intervention plan shall be developed on the date 
of admission.

6.10.2.1	The initial crisis intervention plan shall be reviewed, signed, 
and dated by:


6.10.2.1.1	The case manager;

6.10.2.1.2	The physician 

		AND

6.10.2.1.3	The consumer.

6.10.3	Within 45 days of admission, a comprehensive written crisis intervention 
plan shall be developed.

6.10.3.1	The comprehensive crisis intervention plan shall be 
reviewed, signed, and dated by:

6.9...1	The case manager;

6.10.3.1.2	The physician,

AND

6.10.3.1.3	The consumer.

6.10.4	The comprehensive written crisis intervention plan shall be reviewed in 
full at least every six months. As a result of the review, an updated 
comprehensive crisis intervention plan shall be written.

	6.10.4.1	The updated comprehensive crisis intervention plan shall be 
reviewed, signed, and dated by:

6.10.4.1.2	The case manager;

6.10.4.1.4	The physician,

 		AND

6.10.4.1.5	The consumer.

6.11	Clinical Supervision

6.11.1	Each consumer case shall receive at a minimum of:

6.11.1.1	Quarterly documentation of clinical supervision indicating:

6.11.1.1.1	A review of the consumer's progress;

6.11.1.1.2	 A review of the consumer's treatment plan;

6.11.1.1.3	Recommendations for treatment; 

6.11.1.1.4	Signature and date by the clinical supervisor.

6.11.2	When it is determined that a consumer must move from a higher level of 
care to a lower level of care, or from a lower level of care to a higher level of 
care, the clinical supervisor will document the reasons for the level change 
as outlined in 6.11.1.1 of these standards.



6.12	Progress Notes

6.12.1	A progress note shall be written for each clinical service provided to or on 
behalf of the consumer and include a summary of clinical service, clinical 
impressions and anticipated treatment in the following areas: 

6.12.1.1	Psychotherapy; 

6.12.1.2	Supportive Counseling; 

6.12.1.3	Crisis Intervention Services; 

6.12.1.4	Individual or Group Counseling; 

6.12.1.5	Physician/psychiatric services; 

6.12.1.6	Use of on-call services. 

6.12.1.7	Attempts to schedule and/or reschedule appointments. 

6.12.1.8	All other progress notes shall be written for each consumer 
record according to the policies and procedures of the CCCP 
but not less than once every 30 days.

6.13	Summary of Monthly Consumer Activity

6.13.1	The individual consumer record shall provide a monthly summary of all 
services provided to or on behalf of the consumer.

6.14	Discharge/Discharge Summary
	
6.14.1	The CCCP shall notify DSAMH a minimum of fourteen (14) days prior to 
the tentative discharge date of any consumer being considered for discharge 
by the CCCP.   

6.14.1.1	The CCCP shall consult and cooperate with DSAMH in the 
development and implementation of a mutually agreed upon 
consumer retention plan when retention is deemed by DSAMH 
as preferable to discharge.

6.14.1.2	The CCCP shall consult and cooperate with DSAMH in the 
development and implementation of a mutually agreed upon 
discharge plan, including referral/transfer to appropriate post-
discharge services.

6.14.3	Within 5 days of discharge from the program, a written discharge summary 
shall be completed for every consumer discharged.

6.14.4	The discharge summary shall include:

6.14.4.1	Date of discharge; 

6.14.4.2	Reason for discharge; 

6.14.4.3	Consumers status upon discharge; 

6.14.4.4	Multiaxial DSM IV TR diagnosis; 

6.14.4.5	Summary of progress toward treatment goals;  

6.14.4.6	Aftercare/follow-up plan;  

6.14.4.7	The consumer's forwarding address and/or telephone number.

6.14.5	The discharge summary shall be signed and dated by the physician.

6.14.6	The discharge summary shall be signed and dated by the case manager.

6.14.7	The discharge summary shall be signed and dated by the consumer, if 
available.

6.15	Services

6.15.1	The CCCP program shall provide the following services as deemed 
necessary by assessment and prescribed by the individual treatment plan:

6.15.1.1	Psychiatric and substance abuse treatment;

6.15.1.1.1	Psychiatrist assessment as follows: 

6.15.1.1.1.1	Face-to-face evaluation a minimum of every 
14 days for the first 90 days of treatment and 
then every 30 days after for High Intensity 
Level consumers; 

6.15.1.1.1.2	Face-to-face evaluation a minimum of every 
30 days for Intermediate Intensity Level 
consumers; 

6.15.1.1.1.3	Face-to-face evaluation a minimum of every 
30 days for Lower Intensity Level consumers 
prescribed psychotropic medication or a 
minimum of every 60 days when the 
physician determines contact less than every 
30 days is not needed. The physician must 
document the rational for reduced frequency 
in the consumer file. 

6.15.1.1.1.4	Face-to-face evaluation a minimum of every 
90 days for Lower Intensity Level consumers 
not prescribed psychotropic medication.

6.15.1.1.2	Medication monitoring as follows:

6.15.1.1.2.1	The psychiatrist will explain to the consumer 
the rationale for each medication prescribed 
as well as the medication's risks/benefits.

6.15.1.1.2.1.1	Informed consent shall be obtained 
for each medication prescribed at the 
time it is prescribed. 

6.15.1.1.2.1.2	Informed consent shall be updated, at 
a minimum, annually. 

6.15.1.1.2.2	Rationale for all changes in medication orders 
shall be documented in the physician's note. 

6.15.1.1.2.3	All medication orders in the consumer's case 
record shall specify:

6.15.1.1.2.3.1	Name of the medication; 

6.15.1.1.2.3.2	Dosage; 

6.15.1.1.2.3.3	Route of administration; 

6.15.1.1.2.3.4	Frequency of administration; 

6.15.1.1.2.3.5	Signature of the physician prescribing 
the medication; 

6.15.1.1.2.3.6	All known drug allergies.

6.15.1.1.2.4	Administration of medication by any method 
and/or the supervision of consumers in the 
self-administration of medication must be 
conducted and documented in conformance 
with the program's written policies and 
procedures for medication management. 

6.15.1.1.2.5	Medication administration records shall 
contain the following:

6.15.1.1.2.5.1	Name of the medication;

6.15.1.1.2.5.2	Dosage;

6.15.1.1.2.5.3	Route of administration;

6.15.1.1.2.5.4	Frequency of administration;

6.15.1.1.2.5.5	All known drug allergies;

6.15.1.1.2.5.6	Name of the person administering or 
assisting with the administration of 
medication.

6.15.1.1.2.5.7	Signature of the person administering 
or assisting with the administration of 
medication.

6.15.1.1.2.6	Staff shall monitor and document consumer 
compliance in following prescribed 
medication treatment and medication side 
effects to include the following:

6.15.1.1.2.6.1	Laboratory studies for all medications 
which require laboratory monitoring 
as recommended in the current 
Physician's Desk Reference; 

6.15.1.1.2.6.1.1	Laboratory reports shall
be reviewed and signed by 
the Physician or 
Registered Nurse within 
two (2) days of receipt.

6.15.1.1.2.6.2	Results of all laboratory studies shall 
be documented in the consumer's 
chart within 30 days. 

6.15.1.1.2.6.3	AIMS (Abnormal Involuntary 
Movement Scale) shall be performed 
no less than annually to assess clients 
at risk for developing Tardive 
Dyskinesia. 

6.15.1.1.2.6.4	Education of clients regarding side 
effects of prescribed psychotropic 
medications. 

6.15.1.1.2.6.5	Monitoring of vital signs to include 
temperature, blood pressure, pulse 
and respiration no less than monthly. 

6.15.1.1.3	Case management;

6.15.1.1.3.1	A qualified CCCP staff person shall be designated 
responsible for maintaining a primary case manager 
relationship with each consumer and provide direct 
assistance in finding and maintaining:

6.15.1.1.3.1.1	Medical Services to include:

6.15.1.1.3.1.1.1	Physical; 

6.15.1.1.3.1.1.2	Dental examinations; 

6.15.1.1.3.1.1.3	Eye examinations. 

6.15.1.1.3.1.2	Safe/decent/affordable housing; 

6.15.1.1.3.1.3	Entitlements; 

6.15.1.1.3.1.4	Educational/vocational services; 

6.15.1.1.3.1.5	Transportation; 

6.15.1.1.3.1.6	Social skills training; 

6.15.1.1.3.1.7	Training in activities of daily living, 
including personal hygiene tasks, 
housecleaning, cooking, shopping, 
laundry, and managing money within 
income limits.  

6.15.1.1.3.1.8	Provision of support to family and other 
members of the consumer's social 
network to assist them and the consumer 
to relate in a positive and supportive 
manner including: 

6.15.1.1.3.1.8.1	Education about the 
consumer's illness and their 
role in the therapeutic process;

6.15.1.1.3.1.8.2	Intervention to resolve 
conflict.		

6.16	Required Frequency of Contact

6.16.1	Staff shall attempt (providing it does not interfere with the establishment of 
a therapeutic relationship) to provide the consumer with a minimum level of 
contact based on the assessed level of need as follows:

6.16.1.1	High Intensity Level: 

6.16.1.1.1	Face-to-face contact with the staff psychiatrist a 
minimum of every 14 days in the first 90 days of 
treatment and a minimum of every 30 days there after. 

6.16.1.1.2	Face-to-face contact with a clinician or case manager 
once every 7 days. 

6.16.1.2	Intermediate Intensity Level :

6.16.1.2.1	Face-to-face with staff psychiatrist every 30 days. 

6.16.1.2.2	Face-to-face contact with a clinician or case manager 
every 14 days. 

6.16.1.3	Lower Intensity Level :

6.16.1.3.1	Face-to-face contact with a physician every 30 days if on 
psychotropic medication otherwise every 90 days.  (See 
also Section 6.15.1.1.1.3 as related.) 

6.16.1.3.2	Face-to-face contact with a clinician or case manager 
every 60 days.

6.16.2	The CCCP must make a good faith effort to reschedule missed appointments 
with consumers and the program physician during the same month the 
appointment is missed.


6.17	Minimum Standards for Certifying Living Arrangements for Consumers

6.17.1	Within the bounds of being safe, decent and affordable, housing shall be of 
the consumer's choice. 

6.17.2	Housing (building) shall have a certificate of occupancy. 


6.17.3	Housing shall contain smoke/heat detectors and conform to local fire safety 
codes. 

6.17.4	The Community Support Services program shall certify to the Division 
that housing meets the above standards.
 


7	PSYCHOSOCIAL REHABILITATION CENTER (PRC) STANDARDS

	7.1	PRC programs shall be operated only by providers of and in conjunction with a 
certified CCCP

	7.2	The PRC facility shall operate at least 5-days per week for provision of Medicaid 
covered rehabilitative services.  Medicaid covered rehabilitative services shall be 
provided at least from 8:30 a.m. to 1:30 p.m.
	
		7.2.1		A substantial period of consumer participation in the PRC program 
shall be required for the purpose of crediting the consumer with a 
full day of PRC Services.

			7.2.1.1	Partial days shall not be additive for the purpose of billing for PRC 
Services. 	

	7.3	The psychosocial rehabilitation center facility shall be organized to provide a 
maximum clinical staff to on-site consumer ratio of 1:10.

	7.4	Staff of both PRC and related CCCP shall meet jointly each morning to review the 
contacts with and status of each consumer during the previous day and to plan 
contacts for the current day.  A clinical supervisor shall lead the daily meeting.

	7.5	Staff of both the PRC and the CCCP shall meet jointly at least weekly to conduct 
treatment planning and treatment plan reviews.  A schedule of upcoming 
treatment plans and reviews shall be maintained.  A clinical supervisor shall lead 
treatment planning and review meetings.

	7.6	The PRC program shall have a program coordinator who supervises the operation 
of the center and the services provided by its staff.  The program coordinator shall 
be a clinician.

	7.7	The PRC program shall have among its staff individuals who are credentialed to 
conduct the following clinical skills: psychoeducational therapy; symptom 
education and self-management, vocational assessment and therapy; social skills 
training; and daily living skills training.

	7.8	When provision of PRC services is recommended, it shall be based on indications 
of the evaluation by the CCCP or the licensed Group Home for the mentally ill of 
deficits in symptom control, social skills and activities of daily living skills that 
are of sufficient severity to compromise the consumer's capacity for independent 
living and work.  For each deficit identified, the PRC will undertake a 
comprehensive identification of the consumer's strengths and needs in relation to 
his/her functional deficits and of the possible modification of the environments in 
which the consumer needs to function.

	7.9	For consumers enrolled in the PRC program, the treatment plan shall contain 
specific rehabilitation goals and interventions related to their participation in the 
center program.  The interventions, with their expected frequency and duration, 
shall be contained within the consumers' treatment plans.  The treatment plan shall 
be prepared on forms approved by the Division and shall be signed by the primary 
therapist, clinical supervisor and physician.

	7.10	The program shall nurture the consumer's control over the use of the PRC facility 
as a recreational and community resource.  The facility shall be available to 
consumers as a drop-in center, a location for self-help and mutual support 
meetings, and a resource to mount community service projects.  Such functions 
shall be cooperatively planned by program staff and consumers, with maximum 
opportunity for consumer involvement in decision making.  There shall be a clear 
separation between the rehabilitative function of the center and its role as a hub 
for CCCP consumers' social networks.

	7.11	In the PRC program, rehabilitative therapy will be based within the facility and 
focus on the acquisition or relearning of skills needed for the consumer to live 
more independently with the assistance of the Continuous Treatment Team 
program.

	7.12	The PRC shall provide the following services:

		7.12.1	Instrumental Life Skills Therapy Services - individual and/or group 
therapy to provide a transitional, individually time-limited, systematic 
treatment/training program which assists consumers toward their optimal 
level of community and vocational development.  Utilizing simulated 
work, the intent of the service is to assist consumers to understand the 
meaning, value, and demands of work and to learn or reestablish habits 
and behaviors prerequisite to holding a job.
				   
			7.12.1.1	Independent Living Assessment - Work units will be 
designed to allow the consumer to choose a work function. 
The primary goals are to help a consumer develop basic 
work skills, develop co-worker relationships, learn to deal 
with stress related to task performance activities and to feel 
a sense of accomplishment and reward to reinforce one's 
ability in productive activities.  The work units are also 
designed to provide basic acquisition of living skills in 
order to transfer this knowledge and experience to the 
independent community living environments.

			7.12.1.2	Work Adjustment Skills Training - treatment/training 
service utilizing individual and group work to provide 
work-related activities to assist individuals in developing 
functional capacities, as required, in order to assist 
individuals toward their optimum level of vocational 
development.

			7.12.1.3	Vocational Evaluation Services - will be provided in 
collaboration with Vocational Rehabilitation Services to 
provide a comprehensive process that systematically 
utilizes work, either real or simulated, as a focal point for 
assessment and vocational exploration, the purpose of 
which is to assist the person in vocational development and 
decision making.

			7.12.1.4	Job Placement Services - will provide assistance to 
consumers to identify, obtain and/or maintain employment 
commensurate with their vocational, social, psychological, 
and medical needs, and their abilities.  

7.12.2	Psychoeducational Therapy Services either in a group and/or individual 
format will provide consumers with knowledge of the biological, 
psychological and social elements of their illnesses; improve their ability 
to cope with and control their symptoms and teach skills associated with 
compliance with prescribed medical treatment.

			7.12.2.1	Control Symptoms - Supportive counseling or 
psychotherapy to assist the consumer to understand the 
nature and dynamics of his/her mental illness, to recognize 
symptoms, to follow prescribed medication therapy, and to 
exercise  self-control over symptoms and environmental 
factors that affect symptoms.

			7.12.2.2	Assess/Monitor Well Being - Determination of the 
individual's strengths and needs both at intake and 
continually throughout the treatment process.  Areas of 
assessment will include mental status, medication, general 
health, self-care, support network, family consultation, 
employment capabilities and training needs.

			7.12.2.3	Medication Education - individual and/or group contacts 
with the consumer to assess medication compliance by non-
medical staff according to DADAMH standards.  After 
medication counseling services, compliance assessment 
will include the documentation of compliance and 
medication effects and side-effects and as appropriate 
reported to prescribing physician.

			7.12.2.4	Alcohol/Drug Abuse Education - services provided by the 
interdisciplinary team on individual and group basis to 
provide appropriate assessment, referral, and treatment 
services as reflected in the program's capacity to meet the 
individual needs of the consumer.
					    
		7.12.3	Social Skills Training - direct service to the consumer, individually or in 
small groups, in the context of a planned and clinically relevant 
teaching/therapeutic structure to improve their capacity to establish social 
skills in the community.

			7.12.3.1	Personal and Social Adjustment Services-individual and/or 
group therapy in which functional skills are developed and 
maintained and which provide broad opportunities for 
valued adult roles in the community.  Treatment planning 
will be goal-oriented to maximize the consumer's 
independent functioning through the provision of therapy 
and training in such areas as self-care, physical and 
emotional maturation, socialization, communication, and 
cognitive, leisure, and pre-vocational skills.

			7.12.3.2	Interpersonal Skills Assessment and Development - direct 
service to the consumer, individually or in small groups, in 
the context of a planned and clinically relevant 
teaching/therapeutic structure to develop and maintain 
interpersonal relationships, to effectively represent one's 
needs and self-interests to others, to negotiate and resolve 
disagreements with others and to develop mutually 
supportive relationships with peers.

			7.12.3.3	Recreational Therapy Activities - social/recreational 
services designed to help consumers to strengthen 
interpersonal skills and have healthy leisure experiences 
which provide a sense of personal satisfaction.

		7.12.4	Activities of Daily Living Training - direct service to the consumer, 
individually or in small groups, in the context of a planned and clinically 
relevant teaching/therapeutic structure to build or improve capabilities for 
performing the instrumental tasks of independent living.

			7.12.4.1	Household Activities Training - training in activities of 
daily living including individual support, problem solving 
and supervision in home and community-based settings to 
assist clients in order to carry out personal hygiene tasks; 
carry out household activities including house cleaning, 
cooking, shopping and laundry; and manage money within 
income limits.

			7.12.4.2	Community Resources Training - use community resources 
such as transportation, social services, medical services; 
locate, finance and maintain decent, safe, and affordable 
housing/living arrangements; and relate to landlords, 
neighbors and others effectively.

			7.12.4.3	Adult Education - direct service to the consumer, 
individually or in small groups, in the context of a planned 
and clinically relevant teaching/therapeutic structure to 
improve general knowledge and qualifications for 
employment (e.g. GED preparation) or self-help (e.g. 
financial management and health maintenance).  Adult 
Educational Services may be provided in collaboration with 
the local Adult Continuing Education Service in order to 
promote and encourage continuation of adult education and
					completion of basic skill learning required to maintain 
community tenure.

		7.12.5	Community Social Support Services - will be provided by working with 
the consumer's family, friends, employer, and others with significant ties 
to the consumer in order to advocate with the consumer in the 
development of community supports related to locating, applying for, and 
using resources such as benefit programs; employment programs; housing 
options/resources; assistance with financial management; mental health 
services; medical, dental and other health care services; educational, 
recreational and social activities.

			7.12.5.1	Consumer Advocacy - Supportive counseling to assist the 
consumer to resolve interpersonal conflict, e.g. meeting 
jointly with consumer and family member to resolve a 
conflict disrupting the stability of the living arrangement; 
assisting the consumer to analyze and come to terms with 
					the reasons for termination from employment; 
accompanying the consumer to a meeting with the landlord 
to negotiate a settlement to a landlord tenant dispute.

			7.12.5.2	Service Linkage - direct assistance to or on behalf of the 
consumer in obtaining entitlement and health and social 
services.

			7.12.5.3	Resource Management - direct assistance to or on behalf of 
the consumer in obtaining necessities (e.g. clothing, 
appliances etc.) and managing funds (e.g. budgeting, bill 
paying, etc.).

	7.13	Required Frequency of Psychosocial Rehabilitation Center Home and 
Community-Based Contact

		7.13.1	Consumers of PRC services operated by or in conjunction with a CCCP 
shall attend the program a minimum of two days per week.  Attendance 
will count toward a requirement of five face-to-face contacts per week 
during the first six months following admission.  After the initial six 
months, like other CCCP consumers, those enrolled in PRC services shall 
be provided a minimum of one face-to-face contact in a home or 
community-based setting per week.  At least one contact per month shall 
be in the consumer's home.  Recurrent deviation from these minimum 
contact requirements must be clinically justified by the program physician 
in the consumer's treatment record.

8.	RESIDENTIAL REHABILITATION FACILITY (RRF) STANDARDS

8.1.    A Residential Rehabilitation Facility must be licensed as a Mental Health Group
          Home by the Delaware Division of Long Term Care Residents Protection (DLTCRP).

8.1.1.  The DSAMH conducts surveys in cooperation with DLTCRP for licensure
of Mental Health Group Homes.

8.1.2	Mental Health Group Home Licensing standards may be obtained from 
DLTCRP (telephone 302- 577-6661).

9.	ORGANIZATIONAL STANDARDS

9.1	Community Support Services programs shall establish an advisory committee, 
which meets at least quarterly and includes program consumers and family members 
of consumers within its membership. The function of the advisory committee shall 
be to ensure consumer and family participation in the process of setting and 
evaluating the values, mission, goals, objectives and service strategies of the 
program and to assist the program in representing its interest to the community in 
which it operates.

9.1.1	The advisory committee shall have written rules governing the conduct of its 
meetings which specify at least the following: 

9.1.1.1.       Its authority and duties; 

9.1.1.2.	      Officers and committees; 

9.1.1.3.	      Criteria, types, methods of membership;  

9.1.1.4.       Frequency of meetings; 

9.1.1.5.       Attendance requirements.

9.1.2	Minutes of advisory committee meetings shall be kept and shall include
the following:

9.1.2.1.       Date of meeting; 

9.1.2.2.	      Attendance; 

9.1.2.3.      Topics discussed; 

9.1.2.4.      Decisions reached; 

9.1.2.5.      Actions planned or taken; 

9.1.2.6.      Reports from sub-committees.

9.2	The facility(ies) within which the CCCP operates shall meet the following criteria:

9.2.1.	They shall maintain a Certificate of Occupancy;
 
9.2.2.	They shall meet all applicable fire and life safety codes; 

9.2.3.	They shall be maintained in a clean and safe condition; 

9.2.4.	They shall provide rest rooms maintained in a clean and safe condition 
available to consumers, visitors and staff;

9.2.5.	They shall be accessible to the consumer served; 

9.2.6.	They shall provide a smoke free environment.

10	ADMINISTRATIVE STANDARDS

	10.1 Consumer Records

10.1.1	There shall be a treatment record for each consumer that includes 
sufficient documentation of assessments, treatment plans and 
treatment to justify Medicaid participation and to permit a clinician 
not familiar with the consumer to evaluate the course of treatment.

10.1.2	There shall be a designated consumer record manager who shall be 
responsible for the maintenance and security of consumer records.

10.1.3	The record keeping format and system for purging shall provide for 
consistency, facilitate information retrieval and shall be approved by 
the Division.

10.1.4	Consumer treatment records shall be kept confidential and safe-
guarded in a manner consistent with the requirements of the Health 
Insurance Portability and Accountability Act on 1996, 45 C.F.R. 
Parts 160 and 164, and 42 C.F.R Part 2 governing the confidentiality 
of alcohol and drug patient records (if applicable).

10.1.5	The active consumer record shall contain the following:

10.1.5.1.	A minimum of the program's last 12 months
		treatment records for the consumer; 

10.1.5.2.	An up-to-date face sheet;

10.1.5.3.	Consent to treatment signed by the consumer;

10.1.5.4.	Consent to any occasion of release of information

10.1.5.5.	Documentation that the consumer has been informed 
      of his/her rights;

10.1.5.6.	Documentation that the consumer has been provided 
      with information regarding the process by which        
      grievances can be addressed;

10.1.5.7.	Copies of any grievances filed by the consumer; 

10.1.5.8.	Reports from all examinations, tests and clinical         
      consults;

10.1.5.9.	Hospital discharge summaries;

10.1.5.10.	Comprehensive medical psychosocial evaluation;

10.1.5.11.	Comprehensive treatment plan/treatment plan             
      updates;

10.1.5.12.	Crisis intervention plan and updates;

10.1.5.13.	Summary of monthly consumer activity;

10.1.5.14.	Progress notes;

10.1.5.15.	Documentation of clinical supervision;

10.1.5.16.	Medication records;

10.1.5.17.	Discharge documentation.

10.2	Procedure Manual

10.2.1	The Community Support Services program shall maintain a written 
procedure manual for its staff. A mechanism shall be in place to 
ensure that the procedure manual is updated continuously and that 
the staff of the program are notified promptly of changes. The 
manual shall include:

10.2.1.1.	A statement of the program's values, mission and       
      objectives;

10.2.1.2.	 Referral policies and procedures that facilitate         
       consumer referral;

10.2.1.3.	 Detailed instructions for assessment, service              
       planning and documentation procedures;

10.2.1.4.	Policies and procedures for medication management 
      In compliance with all applicable rules, regulations  
      and requirements of the Delaware Board of              
      Medical Practice, the Delaware Board of Nursing     
      and the Delaware Board of Pharmacy (if applicable) 
     to include policies and procedures for:

10.2.1.4.1	Prescribing medication;

10.2.1.4.2	Storage of medication;

10.2.1.4.3	Handling of medication;

10.2.1.4.4	Distribution of medication;

10.2.1.4.5	Dispensing of medication;

10.2.1.4.6	Disposing of medication;

10.2.1.4.7	Recording of medication used by 
consumers.

10.2.1.5	Policies and procedures for handling on-call 
responsibilities and consumer emergencies;

10.2.1.6	Detailed instructions for application to and 
communication with entitlement authorities;

10.2.1.7	Policies and procedures for sharing of 
information about consumers with family 
members or others;

10.2.1.8	Policies and procedures regarding committing 
and handling financial resources of the program;

10.2.1.9	Policies and procedures regarding the 
management of consumer's funds for whom the 
program has been designated payee;

10.2.1.10	Policies and procedures for the receipt, 
consideration and resolution of consumer 
complaints and/or grievances regarding treatment 
decisions and practices or other program 
activities.

10.2.1.11	Other policies and procedures as maybe 
promulgated or required by the Division and/or 
DSS/DMAP.


10.3    Personnel Management

10.3.1	The Community Support Services Programs or parent organization 
shall maintain an up-to-date Personnel Policies and Procedures 
Manual and make it readily available for reference by the program 
staff. The Manual will include:

10.3.1.1	Policies and procedures regarding equal employment 
opportunity and affirmative action to include 
compliance with:

10.3.1.1.1	The Americans with Disabilities Act and 
the Vocational Rehabilitation Act of 
1973, Sections 503 and 504 prohibiting 
discrimination against the handicapped;

10.3.1.1.2	Title VII of the Civil Rights Act of 1964 
prohibiting discrimination on the basis of 
race, color, creed, sex or national origin;

10.3.1.1.3	Age discrimination Act of 1975 
prohibiting discrimination based on age;

10.3.1.1.4	Section 402 of the Vietnam Era Veterans 
Readjustment Assistance Act of 1974 
prohibiting discrimination against 
disabled Vietnam Era veterans.

10.3.1.2.	Policies and procedures for interviews and selection   
      of candidates including verification of credentials and 
      references;

10.3.1.3.	 Policies and procedures for employee performance    
       appraisal;

10.3.1.4.	A code of ethics;

10.3.1.5.	Conditions and procedures for termination of              
      employment;

10.3.1.6.	Conditions and procedures for grievances and             
      appeals;

10.3.1.7.	An annual staff development plan which shall            
      include:


10.3.1.7.1.	Provisions for orientation of paid 
staff, student interns and volunteers. 
Orientation shall include:

10.3.1.7.1.1.	Review of these           
            standards;

10.3.1.7.1.2.	Review of the              
             program's procedures 
             and personnel              
             manuals;

10.3.1.7.1.3.	Review of DSSS         
             Policy Memorandum  
             #46;

10.3.1.7.1.4.	Review of section        
            5161 of Title 16;

10.3.1.7.1.5.	Review of the Health  
             Insurance Portability   
              and Accountability     
             Act of 1996, 45           
             C.F.R. Parts 160 and   
            164;

10.3.1.7.1.6.	Review of 42 C.F.R.   
            Part 2.


10.3.1.7.2.	      Provisions for continuing education of 
     staff;

10.3.1.7.3.	     Provisions for regularly scheduled        
     clinical supervision which teach and    
     enhance the clinical skills of staff         
     including:


10.3.1.7.3.3	Weekly team meetings 
             led by the clinical        
             supervisor during        
             which assessments,     
              treatment plans and    
              progress toward          
              treatment goals are     
              reviewed and staff      
              receive direction        
              regarding clinical       
              management of          
             treatment issues.

10.3.1.7.3.4	Individual face-to-face 
             sessions between the   
             clinical supervisor and 
             staff to review cases,   
             assess performance     
             and give feedback;

10.3.1.7.3.5	Individual, side-by-     
             side sessions during    
             which the clinical        
             supervisor attends       
             clinical sessions          
             conducted by staff to   
             assess performance,    
             teach clinical skills     
             and give feedback.


10.3.1.8.	Maintenance and access to personnel files which        
       shall contain employees' applications, credentials,      
       job descriptions, and performance appraisals, job       
       titles, training, orientation, salary, staff statement of   
       confidentiality.

10.3.1.9.	Work hours including hours of program operation,     
      shifts and overtime compensation.

10.3.1.10.	Agency policies regarding compensation including:

10.3.1.10.1	 salary ranges, salary increases, and           
 payroll procedures;

10.3.1.10.2	 Use of personal automobile for program  
 activities;

10.3.1.10.3	 Reimbursement for work related              
 expenses;

10.3.1.10.4	 Description of employee benefits.

10.4	Quality Assurance Program

10.4.1.	The Community Support Services Programs shall prepare an annual 
quality assurance plan, which shall be subject to approval by the -
Division. A clinician employed by the program or parent 
organization shall be designated quality assurance coordinator. The 
provider shall establish the following quality assurance mechanisms 
which shall be carried out in accordance with the quality assurance 
plan: a concurrent utilization review process; a retrospective quality 
assurance review process; a process for clinical care evaluation 
studies; and a process for self-survey for compliance with the 
certification standards.



11	WAIVER OF PROVISIONS

11.1	The Director of DSAMH, at his/her discretion, may issue a waiver of any of the 
discretionary requirements of these certification standards upon the good-cause-
shown request of a program seeking certification/re-certification. Such request for a 
waiver must demonstrate that the waiver will not in any substantial or material 
manner have a deleterious effect on the essential quality of services to the consumer.

11.1.1	Waivers issued by the Director shall be in writing and shall specify the 
maximum duration of the waiver's effect.

11.1.1.1.	Any waiver issued by the Director may be rescinded at any    
             time at the discretion of the Director and will be rescinded if 
             deleterious effect on the essential quality of service to the        
                  consumer is evidenced.

11.1.1.2.	Extensions and/or renewals of any waiver shall be made at    
            the Director's discretion.

 
 
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