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February 15, 2000 In Consideration of Proposed Adoption of: OAR 309-032-1100 through 309-032-1230 - Standards for Children's Intensive Mental Health Treatment Services Prepared by:
The Mental Health and Developmental Disability Services Division (MHDDSD) of the Department of Human Services proposed adopting OAR 309-032-1100 through 309-032-1230 relating to Standards for Children's Intensive Mental Health Treatment Services (ITS). These rules would establish the standards and procedures for intensive mental health treatment services for children within a comprehensive system of care. The system of care shall be child and family-centered and community-based with the needs of the child and family determining the types and mix of services provided. The goal of these services is to maintain the child in the least restrictive treatment setting appropriate to the acuity of the child's disorder. These services may be as intensive, frequent and individualized as is medically appropriate to sustain the child in treatment in the community. These treatment services include treatment foster care, therapeutic group homes, psychiatric day treatment, partial hospitalization, residential psychiatric treatment and sub-acute psychiatric care. Hearings Procedure Persons testifying or providing written comments within
the required time line were:
Alex Vidal, L.C.S.W., Washington County Health and Human
Services
Barbara Trione, Executive Director, Accountable Behavioral Health Alliance
William Powers, Executive Director, The Christie School
Bob Lieberman, President, CHARPP
David Trump, M.D., SOASTC Board of Directors
Judith Selander, Parent, Lake Oswego, OR
Charles Younglove, Parent, Milwaukie, OR
Patricia Younglove, Parent, Milwaukie, OR
Carolyn Frey, Parent, Monmouth, OR
Callie Schlippert, Executive Director, Oregon Family Support Network
Yvonne Ballard, Parent, Family Development Council of Lane
County
Elizabeth Miller, Parent, Oregon Family Support Network
Group Submission, 15 individuals
Oregon Family Support Network, Lane
County Office
Tevina Benedict, Lane County
Coordinator, Oregon Family Support Network
Melvin Ferguson, Attorney, Oregon Association of Treatment
Ivan Frasier, Executive Director, Mid-Columbia Child and Family Center
Jeanne Scott, Board Chairperson, Mid-Columbia Child and Family Center
Sharon Frasier, Clinical Services
Coordinator, Mid-Columbia Child and Family Center
Richard Schuurman, Licensed Marriage
and Family Therapist, The Dalles, OR Group Submission, 17 individuals, Poyama Land Karla Langley, Merrill, OR
Nancy Winters, M.D., President, Oregon Council of Child and Adolescent
Psychiatry
Mark Lewinsohn, Director Child and
Family Services, Tualatin Valley Centers
Board of Directors Tualatin Valley Centers
Ruth Miller, President, Board of Directors
Southern Oregon Child Study and
Treatment Center
Richard Tovey, Executive Director, Cascade Child Center, Inc.
Janell Powell, Board President, Cascade Child Center, Inc.
Pat Kraby, Board President, Riverside Center
Bill Wellard, Executive Director, The Child Center
Karen Mounce, Program Manager, Family Friends
Rodent Birney, M.D., Family Friends
Darcy Strahan, Board President, Family Friends
George Longden, Executive Director, Family Friends
Toni Wyatt-Kirkeby, Family Services
Coordinator/Interim Executive Director, Pacific Child Center, Inc.
Richard Bossart, Board Chairperson, Pacific Child Center, Inc.
Jill Boyd, Board Member, Pacific Child Center, Inc.
R. Brady Scott, Vice-Chair, Pacific Child Center, Inc.
Lori Spray, Parent, North Bend, OR
Reverend David Torres, Board Member, Pacific Child Center, Inc. Lori Hanseth, Klamath Falls, OR
Nolle Rainbow, Learning Specialist, Olalla Center for Children and Families Charlene Butoff, parent
Joe Rozak, Executive Director,Riverside Center
Monica Ford, Morrison Center Review of Comments and Recommended Actions Comments relating to OAR 309-032-1100, Purpose and Statutory AuthorityTestimony: Judith Selander, parent, commented that the "appropriateness of services as related to intensity and frequency should be determined by all members of the interdisciplinary team, especially the parents." Recommendation 1: No change to OAR 309-032-1100. Operational aspects of the services are covered in other areas of the draft rule. Comments relating to OAR 309-032-1110, Definitions Testimony: Judith Selander, parent, commented on the definition of case management (7). She recommended adding that "case management services should be done in a timely fashion." Recommendation 2: No change to OAR 309-032-1110 (7). Case management is one of the services listed in OAR 309-032-1150 (1)(f) which states, "ITS providers shall ensure that the following services be available and accessible through direct service, contract or by referral." Treatment services should be driven by the individual plan of care and all services which may benefit the child should be done in a timely manner. However, since the ITS provider may not be the provider of case management, the rule cannot put a time frame on the provision of this service.
Testimony: Yvonne Ballard, Family Development Council of Lane County, commented on consent to treatment (17), stating she questions whether an emancipated child with mental illness can make an informed decision.
Recommendation 3: No change to
OAR 309-032-1110 (17). An emancipated child has equal protection and standing
in
statute as an adult.
Testimony: Tracy Brown, parent, commented on the definition of custody (23) and the requirement of a parent not needing to relinquish custody to access mental health treatment services. She stated that according to the SCF client service manual, if a parent has a history of abuse or neglect and/or if the child is an adjudicated delinquent in the juvenile correction system, the parent(s) would need to sign the "voluntary placement agreement" in order to obtain out of home mental health services.
Recommendation 4: No change to
OAR 309-032-1110 (23). The voluntary placement agreement does not relinquish
the
parent's custodial rights. This issue is covered in
SCF OAR 412-02-300 through 412-02-320.
Testimony: CHARPP commented on the definition of discharge criteria (27), stating in its written response that "this definition implies that the child and/or family will be moving to another level of service, which is not always the case." CHARPP recommended changing the definition language to "...and functional indicators the child and/or family will meet in order that the services at the specific level of care are no longer necessary."
Recommendation 5: No change to OAR 309-032-1110
(27). Preparing a child and family for another level of service should be part
of the discharge criteria and goal of
ITS providers. The focus in treatment should be the future, not just the current
level of
care. Testimony: CHARPP also commented on the definition of indicators of progress (39), stating the definition creates confusion between indicators of progress and objectives: "We believe that it is important that indicators of progress be required in program evaluation efforts, measuring functional improvements as a result of treatment, and be unlinked from inclusion in treatment plans." CHARPP recommended a language change to "...demonstrate the degree to which a child and family have made functional or behavioral improvement in the areas being measured."
Recommendation 6: Change OAR 309-032-1110
(39) to read "Indicators of progress,
means the diagnostic, behavioral, or functional measures used by the provider
to
demonstrate the degree to which a child and family have [advanced toward
achievement of treatment goals] made functional or behavioral
improvement in the
areas being measured."
Testimony: Judith Selander, parent, commented on the definition of interdisciplinary team (44), she indicated that parents presence on the interdisciplinary team is critical to the function and success of services provided. Parent or parents should definitely be included as full partners/participants in the decisions that team makes
Callie Schlippert, OFSN, commented on the definition of interdisciplinary team (44),
proposing that parents be made members of the interdisciplinary team. Yvonne Ballard, Family Development Council of Lane County, commented on the
definition of interdisciplinary team (44), proposing that the definition include family as
defined in (33). Elizabeth Miller, parent, commented on the definition of interdisciplinary team (44),
proposing that the parent of the child should be a member of the team. Tracy Brown, representing a group of 15 individuals from Lane County OFSN,
commented on the definition of interdisciplinary team (44), suggesting the following
language: "The team shall include family members or guardians who have been or will
be primary caregivers for the child and an advocate of their choosing." She explained,
"many parents have experienced inadequate discharge planning when dealing with
intensive care services. This will be a much stronger and clearer document if you say
up front that you recognize parents and guardians as critical members of the team for
discharge planning and all other aspects of planning, review and consultation." Chris Childress, parent, commented on the definition of interdisciplinary team (44),
recommending that this definition should include parents. Recommendation 7: Change OAR 309-032-1110 (44) to read: "Interdisciplinary team,
means a team of qualified treatment and education professionals including a child and
adolescent psychiatrist or LMP, and the child's parent or guardian, responsible for
assessment and evaluation, the development and oversight of individual plans of care,
and the provision of treatment for children admitted to an intensive treatment services
program."
Testimony: CHARPP commented on the definition of isolation (45) and also offered the following written responses: "As defined.... time in a bedroom with periodic contact by staff would trigger a documentation requirement following 15 minutes.... Such interventions, often called 'time-out', are perhaps the most critical element of most behavior management interventions. In intensive treatment, time in the bedroom is an intervention which is mid-range of a typical hierarchy of interventions for children who are not compliant, who are not responding, and who are beginning to escalate.... The additional report requirements which will result from 'time-out' or isolation as defined in this proposed definition will create a disincentive for front-line staff to utilize this intervention for more than 15 minute periods of time." CHARPP recommended a language change eliminating the second sentence of the definition, "periodic visual or verbal contact by staff does not prevent the child from being considered to be in isolation."
James Wrigley, Oregon Advocacy Center(OAC), supported the definition of isolation
(45). He proposed that the definition is adequate, stating in written testimony "most
importantly, it recognizes that the fact that the staff periodically check on a child does
not prevent the child from being in isolation. These brief visual or verbal contacts do
not realistically terminate the child's isolation, as long as the child is not given the
opportunity to leave the room or meaningfully communicate with others. Any other
conclusion would create a gigantic loophole in coverage." Bill Powers, The Christie School, questioned the definition of isolation (45), and
stated, "we believe very strongly that the sentence 'periodic visual or verbal contract
(sic) does not prevent the child from being considered to be in isolation' should be
removed. Not only is this illogical, in that one cannot be truly isolated if there is
contact, but more importantly it can elevate a natural and logical consequence (e.g.,
fifteen minutes in your room) to the status of a special treatment procedure (e.g.,
seclusion or physical restraint)." David Trump, SOASTC Board of Directors, wrote that the Board is "upset by the
definition of isolation in the rule (45), which creates a disincentive for the use of time-out in the bedroom, which is often a very useful intervention to defuse an escalating
situation." Recommendation 8: No
change to OAR 309-032-1110 (45). Isolation as defined and procedurally described
in OAR 309-032-1180 (3) will insure that when a child is
directed by staff to be in a space alone, without ongoing verbal or visual contact
with others for more than 15 minutes, this intervention will be noted in the
child's clinical
record. Notation required for isolation is different and less substantial than
documentation requirements for seclusion and restraint. Isolation interventions
do not reach the status of a special treatment procedure unless it is used
more than five hours
in five days, or for a single episode of two hours. Notation and reporting to
the child's interdisciplinary team regarding treatment interventions is critical
to treatment.
Without the qualifier that "periodic visual or verbal contact does not prevent
a child
from being considered to be in isolation," this provision would be meaningless.
All isolation interventions, even with periodic checks from staff, still prevent
a child from
engaging in other treatment activities. If isolation and movement restriction
for more than 15 minutes is the required treatment intervention, it should be
noted in the chart,
with data accumulated to recognize the extent of its use.
Testimony: Yvonne Ballard, Family Development Council of Lane County, commented on the definition of mental health assessment (54). She suggested that "copies of all written documentation of mental health assessments and changes in diagnosis be given to families. This should be a requirement not just by request."
Tracy Brown, parent, commented on the definition of mental health assessment (54).
She recommended adding: "Critical to a complete mental health assessment is
incorporating information from the primary care giver regarding the child's presenting
behavior and history." Recommendation 9: No
change to OAR 309-032-1110. Families should be aware of changes in assessments
and diagnoses as members of the interdisciplinary team and
through their participation in all phases of assessment, planning and treatment
(54). The comprehensive mental health assessment definition (16) requires
an interview with
the child, family and other relevant persons.
Testimony: David Trump, SOASTC Board of Directors, objected to the requirement that the psychiatrist (70) be board-eligible or board-certified in child and adolescent psychiatry. He stated, "The SOASTC Board protests this rule requirement and urges MHDDSD to adjust the provisions so as to require a 'board certified psychiatrist', rather than a 'board certified child psychiatrist.'"
Recommendation 10: No
change to OAR 309-032-1110 (70). Children receiving intensive levels of mental
health services need to be seen by a child psychiatrist. The
rule provides a "grandfather clause" for current provider psychiatrists and allows
for a variance to the rule in cases where providers are unable to acquire the
services of a
child psychiatrist.
Testimony: Tracy Brown, parent, recommended adding the words "and their families" at the end of the definition of system of care (83).
Recommendation 11: Change
OAR 309-032-1110 (83) to read, "System of care,
means the comprehensive array of mental health and other necessary services which
are organized to meet the multiple and changing needs of children with severe
emotional
disorders and their families." Comments relating to OAR 309-032-1120, General
Conditions of participation for Children's intensive Mental Health Treatment
Services Providers
Testimony: Charles Younglove, parent, commented on
providers demonstrating family involvement (6). He proposed "language should
be added to show how providers shall demonstrate the family involvement in
all phases of assessment, treatment planning and
the child's treatment." Patricia Younglove, parent, commented on(6), stating "language should be added to
show how providers shall demonstrate the family involvement in all phases of
assessment, treatment planning and the child's treatment." She also recommended "it
is imperative that the parents of that child be included in the decision making process
as part of the interdisciplinary team." Recommendation 12: No
change to OAR 309-032-1120 (6). This provision as written requires providers
to document participation and involvement in the clinical record.
Testimony: Yvonne Ballard, Family Development Council of Lane County, commented on (13)(a) and (c) regarding monitoring and evaluation. She suggested the term "periodically" have a maximum length of time defined.
Recommendation 13: No
change to OAR 309-032-1120 (13)(a) and (c). This provision is closely linked
to the Quality Management section which does include time
frame requirements. Comments relating to OAR 309-032-1130, General Treatment Requirements Testimony: Charles Younglove, parent, commented that admissions(1) to intensive treatment
services should be coordinated with the family so the family can attend. Patricia Younglove, parent, also commented that admissions (1) to intensive treatment
services should happen at times when the family can be present. Recommendation 14: No
change to OAR 309-032-1130 (1). See recommendation 88.
Testimony: Karin Mounce, Family Friends, commented on (3)(b), stating "a 30-day time line for a comprehensive assessment is too brief for a day treatment program. As we have the children at our facility only four hours per day, this would result in an assessment that would be limited in depth and inclusiveness."
Recommendation 15: No
change to OAR 309-032-1130 (3)(b). The required time line is 30 treatment days
after admission.
Testimony: Karin Mounce, Family Friends, commented on (3)(c), stating it seems unnecessary to
update the comprehensive assessment yearly, "as the majority of information in the
assessment relates to the history of the child's family and difficulties. As this is
historical information, it is not likely that it will change from year to year." Recommendation 16: No
change to OAR 309-032-1130 (3)(c). Assessments address current functioning
and symptomatology as well as child and family history. It is
reasonable to expect annual review and documentation of changes or continuity
in presenting mental health problem(s); mental status; substance use; and emotional,
cognitive, family, behavioral, social, physical, nutritional, school/vocational,
recreational and/or cultural functioning. Domains evidencing no change do not
require
re-documentation. While historical information will not likely change from
year to year, symptomatology and level of functioning should change during
the course of
treatment, as may the meaning and impact of one's history. These changes warrant
documentation.
Testimony: Karin Mounce, Family Friends, commented on (4)(b)(A), stating "the individual plan of care developed at 14 days is too brief a time period for an accurate report... this would cause more adjustments and changes as time went on in the individual care plan."
Rodent Birney, M..D., Family Friends, also commented on (4)(b)(A), stating "14 days
after admission may be inadequate especially when weekends and holidays are taken
into account. I believe phrasing this in terms of treatment days as you did in item
(3)(b) would be more consistent." Recommendation 17: Change
OAR 309-032-1130 (4)(b)(A) to read: "...Be developed
and implemented no later than 14 treatment days
after admission by an interdisciplinary team, in consultation with the child,
[and] the parent(s) or guardian,
[or] and the provider to which the child will be discharged." An individual plan of care should be a dynamic document that is continually updated
and revised when new information is discovered or treatment needs change.
Testimony: Patricia Younglove, parent, commented that treatment goals and objectives (4)(b)(C) should be written in language that a parent can easily understand.
Recommendation 18: No
change to OAR 309-032-1130 (4)(b)(C). (4)(a) specifies,
"providers shall fully inform the child in developmentally appropriate language
and obtain informed consent from the child's parent(s) or guardian about the
proposed
care." Also, recommendation #7 would mandate parent/guardian membership on the
interdisciplinary team. These provisions should facilitate a parent's full understanding
of the child's individual plan of care.
Testimony: CHARPP commented on the individual plan of care reviews (5), recommending clarifying the language to differentiate between the 30 day and 90 day reviews.
Rodent Birney, M..D., Family Friends, also commented on the individual plan of care
reviews (5): "The increase in reviews from every 90 to every 30, how will this do
anything but add paperwork? A good team is continually reviewing challenging or
difficult cases anyway." Karin Mounce, Family Friends, also commented on (5), stating "that difficulties exist
with 30-day plan of care reviews. As children are here a limited amount of time each
day, any changes noted are likely to be minor for such a brief time span, and therefore
less significant." Recommendation 19: Change
OAR 309-032-1130 (5) to read:
Testimony: CHARPP commented on (6)(a)(A), the inclusion of progress indicators in the discharge planning process: "Indicators of progress typically refer to separate program evaluation and outcome measurements. While specific indicators of progress are sometimes included as discharge criteria such is not always the case. Elimination of the specification for indicators of progress would be consistent with changes in the definition recommended above and with other changes which have been made pertaining to this language from previous drafts of the rule." CHARPP recommended removing the words "and the indicators of progress" from this provision.
Recommendation 20: Change OAR 309-032-1130 (6)(a)(A) to read, "Integrate
discharge planning into ongoing treatment planning and documentation from the time
of admission, and specify the discharge criteria [and the indicators of progress] that
will indicate resolution of the symptoms and behaviors that justif[y]ied the admission."
Testimony: Alex Vidal, Washington County Health and Human Services, commented that discharge instructions [(6)(b)] lack description of what is considered best practices in the discharge and after care planning process. All too often, our office receives concerns from parents in our county who have received discharge plans for their children returning to their home and community from a local acute psychiatric hospital or residential treatment facility which lack appropriate continuation of their psychiatric treatment and medication management.... when there is a disruption in the continuity of care, such as accessing treatment and medication services it may take weeks to establish relationships with appropriate community resources."
George Longden, Family Friends, commented on discharge planning and coordination
(6), stating "a critical component of discharge planning has been left out of this rule.
Programs should be required to assure that appropriate medical care and medication
management will be provided to all clients who leave through a planned discharge.
This requirement should be accomplished by the program identifying the medical
personnel who will provide that follow-up care and arranging a set up appointment
with the new provider. Nothing is a stronger predictor of an unsuccessful outcome
then that a child in need of psychiatric medication at discharge goes off it shortly after
leaving an intensive treatment service. This comment was suggested by a local group
of physicians and mental health providers that meet monthly.... to address the issue of
physical and behavioral health integration." Recommendation 21: Change
OAR 309-032-1130 (6)(a) by adding a new discharge planning and coordination
requirement that reads: "(E) Assure that appropriate
medical care and medication management will be provided to clients who leave
through a planned discharge. The discharging provider's interdisciplinary team
shall identify the medical personnel who will provide continuing care and shall
also arrange an initial appointment with that provider."
Testimony: Yvonne Ballard, Family Development Council of Lane County, suggested that discharge planning (6)(a) should include a detailed, workable crisis plan.
Recommendation 22: No
change to OAR 309-032-1130 (6)(a). Crisis requirements are specified in OAR
309-032-1120(3).
Testimony: Judith Selander, parent, commented on the discharge planning provisions in (6)(a)(C), (6)(b), (6)(d). She recommended changing the language to include parents or guardians and the providers of the next level of care.
Patricia Younglove, parent, also recommended changing the language of (6)(b) to
read, "...parents or guardian, and provider of care..." Recommendation 23a: Change
OAR 309-032-1130 (6)(a)(C), to read, " Include the
parent, guardian, [other person or aftercare resource in whose care the child
will be
placed when discharged] and provider to which the child will
be discharged in
discharge planning, and reflect their needs and desires to the extent clinically
indicated;
[and]"
Recommendation 23b: Change OAR 309-032-1130 (6)(c), to read; "Providers shall notify the child's parent(s), guardian, [or] and the provider to which the child will be discharged [of the next level of care] of the anticipated discharge dates at the time of admission and when the discharge plan is changed."
Testimony: Debra Depew, parent, recommended that the discharge process (6)(C) require the interdisciplinary team to make an effort to include relevant school personnel.
Recommendation 24: No
change to OAR 309-032-1130 (6)(C). Education professionals, members of the
interdisciplinary team, are responsible for discharge
planning and coordination related to educational performance and placement.
Testimony: Rodent Birney, MD, Family Friends, commented that the timeline for a completed discharge summary (6)(e) should be listed in terms of working days.
Recommendation 25: Change
OAR 309-032-1130 (6)(e) to read, "A discharge
summary reflecting the active course of treatment shall be completed and placed
in the
chart within 15 treatment days following discharge." Comments relating to OAR 309-032-1140,
General Staffing and Personnel Requirements
Recommendation 26: No
change to OAR 309-032-1140 (1)(a)(A). This provision allows for different levels
of medical involvement at different levels of care.
Consultation is a different level of involvement than medical oversight. In
levels of care requiring only consultation, coverage is determined by the needs
of the program.
Testimony: CHARPP commented on documentation in the personnel files(3), stating "this provision implies that only QMHP and QMHA qualified individuals are considered as clinical staff. In many intensive treatment service organizations, staff are regarded as clinical staff from the time of employment. . . including those who have not yet gained QMHA credentials. Removing the reference to 'clinical staff' and making this provision more specific would mitigate this semantic inference, which is dis-empowering." CHARPP recommended the following language change: "provider shall ensure through documentation and personal (sic) file that all individuals designated as QMHP and QMHA meet all applicable professional licensing, certification, and required competencies."
Recommendation 27: No
change to OAR 309-032-1140 (3). Comments relating to OAR 309-032-1150, System
of Care
Testimony: OATC commented
on the general requirements of providers to ensure listed services be available
and accessible through direct service, contract or by referral (1)(f) stating, "many
providers cannot afford to have a psychiatrist on staff and must therefore
contract for that medical service. If the literal language of the rule is followed
by the
Division in implementing the rule, then OATC has no strong objection -i.e. if
Providers
who cannot afford to provide psychiatric services need only "refer" a patient
to a psychiatrist and the patient or his/her family are then required to privately
pay, have
their own health insurance, or have coverage under the Oregon Health Plan. If
however, the Division intends to interpret this rule more broadly requiring the
provider to provide psychiatric and psychological assessments, and hire qualified
professionals
to evaluate and monitor medication of children clients, then there are added
cost to the
Provider." Recommendation 28: No change to OAR 309-032-1150 (1)(f). The provision was
written to ensure the provider has the necessary systems knowledge to minimally be
able to refer a child to a necessary service. This provision allows the service to be
provided elsewhere if it is not required in other provisions and/or it is systemically
more appropriate for the child and family.
Testimony: OATC commented that there is no definition of vocational or pre-vocational rehabilitation (1)(F).
Recommendation 29: No change to OAR 309-032-1150 (1)(f).
Testimony: CHARPP commented on (1)(i), stating "this provision addresses both measurement of treatment outcomes and provision of treatment and staffing interventions. These are two very important but separate activities...." CHARPP recommended removing the clause, "...and provide treatment and staffing interventions based on the child's individual plan of care."
Recommendation 30: Change OAR 309-032-1150 (1)(i) to read "Providers of ITS
shall measure individual active treatment outcomes for children in treatment with the
provider.[ and provide treatment and staffing based on the child's individual plan of
care.]" The requirement to provide staffing based on the acuity and severity of
admitted children is included in other provisions.
Testimony: OATC commented on measuring active treatment outcomes (1)(i), stating "Historically
the Division has defined 'measuring' to be 'testing.' OATC members have no
objection to a requirement that mental health providers be required to quantify
their use of State and Federal dollars, but if significant State testing is
expected then fewer
children and adolescents can be effectively served. The Division should also
be fair to providers and let providers know the actual tests to be used to
measure success, not
merely the standards that will be used in developing the tests." Recommendation 31: No
change to OAR 309-032-1150 (1)(f). It is not appropriate
for an OAR to identify "testing" instruments. Contracts and individual provider
plans
are more appropriate mechanisms to address this issue.
Testimony: George Longden, Family Friends, commented on an admitted child's special education status and the requirement that a child have or be screened for an Individualized Education Plan, Personal Education Plan, and/or an Individual Family Service Plan (3)(9). He suggested these should not be required either prior to admission or during treatment in an intensive treatment service. Mr. Longden stated, "the reality is that not all school districts are willing to identify children as emotionally disabled..... School districts often see that they are taking on a significant period of years where they would in cumber [sic] what they consider to be significant financial liability if they do this and it is a disincentive for them to do it. So we need clarity here so that children can be admitted."
Recommendation 32: No change to OAR 309-032-1150 (3) and (9). A representative
of the Department of Education has recommended retaining this provision.
Testimony: Alex Vidal, Washington County Health and Human Services, commented on the lack of mention of the Medicaid Authorization Specialist(MAS) function. Quoting (6)(a)(A) which states, "The referral information shall have been reviewed by an independent psychiatric review process established by the division to certify the need for services based on the following criteria...," he asked the Division to "please clarify what is the 'independent psychiatric review process' that the Division has established to certify the need for services? Does the county continue to be responsible for this responsibility?"
Recommendation 33: No
change to OAR 309-032-1150 (6)(a)(A). The Division currently uses the Oregon
Medical Professional Review Organization (OMPRO) for the
independent psychiatric review process. Counties are not responsible for this
service.
Testimony: OATC commented on the requirement that psychiatric day treatment programs must have 24-hour on-call availability of at least one QMHP during hours the program is not open(9)(a). OATC contended, "This is a direct additional cost to the provider either in additional pay to the professional or a reduction in service on a daily basis to compensate the professional for services after hours."
Recommendation 34: Change OAR 309-032-1150 (9)(a) by deleting the sentence,
"Providers shall have the 24-hour on-call availability of at least on Qualified Mental
Health Professional during the hours the program is not open."
Testimony: OATC also commented on the requirement that psychiatric day treatment programs develop admission policies (9)(b)(B)(ii), and stated, "a child's continued stay in treatment is however, subject to a review approved by the Division. What is the State approved review process that is contemplated and how does that review process differ from the current OMPRO review process currently used by the Division?" CHARPP commented on (9)(b)(A)(i) and (ii), stating "this citation refers
to a review process approved by the Division. It is not clear what this process
is or what it will
entail." CHARPP also commented on (9)(b)(B)(ii), stating "this citation similarly refers to a 90
day review process which is otherwise undefined." CHARPP suggested the Division
"specify the parameters of the review process, if only in the fiscal impact statement.
While the flexibility implicit in the language is important, these provisions will have a
time and cost impact on providers and the system both." Recommendation 35: No
change to OAR 309-032-1150 (9)(b)(A)(i) and (ii), or (9)(b)(B)(ii). The Division
does not intend to use the OMPRO review process for
psychiatric day treatment. Local community control and involvement in the admission,
review, and discharge decision of the admitted children is intended. This provision
allows the provider to develop a community based process that will be approved
by the
Division on an individual provider basis.
Testimony: CHARPP commented that the language regarding continued stay in therapeutic group or treatment foster care (10)(d)(B) is somewhat vague. CHARPP recommended changing the language to: "...shall be based upon determination by a LMP of the medical appropriateness of the setting treating the psychiatric condition(s)...identified in the child's individual plan of care."
Recommendation 36: Change
OAR 309-032-1150 (10)(d)(B) to read: "Continued stay
in a therapeutic group or treatment foster care home shall be based upon determination
[of medical appropriateness ] by a LMP [to treat the psychiatric
conditions(s)] of the
medical appropriateness of the setting treating the psychiatric condition(s)
identified in
the child's individual plan of care." Comments relating to OAR 309-032-1160, Establishing and Maintaining
Clinical Records
Testimony: Yvonne Ballard,
Family Development Council of Lane County, commented that this section should
include, "authors of documents shall include in documents their source
of information." Recommendation 37: No
change to OAR 309-032-1160
Testimony: Judith Selander, parent, offered the following suggestion regarding terminology: "Communicate in a consistent fashion the names of medications. Either always speak/write using the chemical name, or the commercial name."
Recommendation 38: No change to OAR 309-032-1160 (2) Comments relating to OAR 309-032-1170, Child and Family Rights Testimony: James Wrigley,
OAC, made a general comment concerning child and family rights.
He stated, "because of the significant power that intensive treatment settings
have over children in their care, and indirectly over the families of these children,
it is important
that children and families have meaningful, clearly stated rights. For the most
part, we
believe that the proposed rules are a major step in this direction." Gwen Gorbee, parent, articulated general support for strengthening child and family
rights. Speaking from experience with a son in residential treatment, she stated, "rights
that he had with me no longer existed when he went into care, he - I had no rights. I
was not informed of situations that took place, he was not protected as he should have
been." Recommendation 39: No
change to OAR 309-032-1170
Testimony: OATC commented that this section "which addresses rights of the Child and Family, allows a child and/or family the ability to refuse treatment and to object to a treatment plan. While OATC fully supports active involvement by parents and guardians of a child so that a treatment plan suitable to the particular needs of the child can be developed, if a family insists upon a plan that is not clinically recommended and/or will not, in the professional's opinion, resolve the needs of the child then the provider should have the discretion to discharge the child and family from treatment... The Providers' concern is that they not be mandated to provide services which are not supported by the family and which may ultimately be of little or no benefit to the child."
Recommendation 40: No change to OAR 309-032-1170. OAR 309-032-1120 (6)
requires providers to "demonstrate family involvement and participation in all phases
of assessment, treatment planning and the child's treatment by documentation in the
clinical record." OAR 309-032-1130 describes the providers and parent(s) or guardian
interface in treatment. This involvement is critical to a successful therapeutic
relationship. In the event of a lack of agreement between the parties good
documentation and sound discharge planning will be important. It is not appropriate in
rule to prescribe that a provider shall never discharge a child who has not met treatment
goals.
Testimony: George Longden, Family Friends, commented that "the section on Child and Family Rights misses the significant opportunity to address responsibilities... The section should be labeled 'Child and Family Rights and Responsibilities'. At a minimum those responsibilities should include protecting the identity and confidentiality of other program clients and require their attendance at scheduled family therapy, treatment planning, and treatment review sessions."
Joan Wayland, M.D., commented on the lack of client responsibilities in this section.
She stated, "I do not see anything about client responsibilities. In my 20 some years of
working in day treatment we have had situations where the kids family- the situation
became an untenable situation. Because of a lack of cooperation by the family. In the
DARTS Standards it is very clear that family involvement is mandated. If you don't
have it, you don't have a treatment situation and therefore, sometimes its unfortunate,
but you have to kind of let go." Recommendation 41: No
change to OAR 309-032-1170. The purpose of the rule is to provide standards
and procedures for the delivery of intensive treatment services, not to
specify the responsibilities of recipients of the service. The rule regulates
programs,
not the behaviors of program participants.
Testimony: Judith Selander, parent, commented that "the withdrawn, acting in child deserves treatment as much as the acting out, aggressive, easily noticed child. The withdrawn child should have the right NOT to be restricted or punished or put on segregation because of the offenses of more violent, acting out children... If a child misses out on a scheduled therapy or activity, because the staff have to respond to violence and safety concerns, that child must be guaranteed a make-up session."
Recommendation 42: No
change to OAR 309-032-1170.
Testimony: James Wrigley, OAC, strongly supported the right to participate in treatment planning as specified in 309-032-1170(7). He also stated OAC "approves of the other listed child and family rights, including the right to an education in the least restrictive environment, and to recreation and exercise."
Recommendation 43: No
change to OAR 309-032-1170 (7)
Testimony: Charles Younglove, parent, commented on (8) that providers should not be allowed to withhold parent phone calls from children as a disciplinary measure.
Patricia Younglove, parent, also commented on (8) that providers should not be
allowed to withhold parent phone calls from children as a disciplinary measure. James Wrigley, OAC, strongly supported 309-032-1170(8), which assures the right to
private and uncensored communication. He also supported the right to personal
possessions, as specified in 309-032-1170(9). Regarding the notices of restrictions
required by these two sections, he proposed that they should include information
concerning the right to file a grievance and how to do so. He stated that "the right is
much more meaningful if information about it is provided in the context of an actual
restriction of rights." Recommendation 44: No change to OAR 309-032-1170 (8) or (9). Provision (8)
states that communications can only be restricted if, in the absence of the restriction,
significant physical or clinical harm will result to the child or others. Comments relating to OAR 309-032-1180, Behavior Management Testimony: OATC commented, "OAR
309-032-1180 as proposed requires a provider to create a 'special treatment
procedures committee' to oversee and presumably administer a
written behavior management policy. OATC certainly supports a well written behavior
management policy that allows treatment to be given in a developmentally appropriate
manner. The proposed rules however, at least on their face, are much more restrictive,
and require more intensive participation by a provider's staff. Additional training
will be required of staff. Staff will need to participate in additional meetings,
more
documentation of behavior management will be required, etc. -all at the expense
of
providing direct services to children." Recommendation 45: No
change to OAR 309-032-1180. The special treatment procedures committee is mandated
to review special treatment procedures. This
section on behavior management was written to assure that each provider create
consistent policies, procedures, and practices based on the provider's philosophy
of
treatment.
Testimony: Isaabelle Littman, retired psychologist, stated, "I think the thing that troubled me more than anything else in these rules was the section on behavior management. Over the years I have seen the descriptions of such programs sound more and more punitive, as if such programs have only one objective: to eliminate problem behavior so the child learns to conform and stop causing trouble. Behavior management is a very powerful tool and in my opinion should always include the use of programs to improve self image and sense of competence-in other words some good things to go along with the bad."
Recommendation 46: No change to OAR 309-032-1180.
Testimony: CHARPP recommended a few minor adjustments in language, syntax and verb tense to make sub-section (1) read more clearly.
Recommendation 47: Change OAR 309-032-1180 (1) to read. "Providers shall have a
written behavior management policy specifying which behavior management practices
and restrictions may be used by staff and the circumstances under which they may be
used. The behavior management policy shall [describe how the provider will]:
Testimony: CHARPP commented on (1)(b), stating "this provision does not require the provider to explain the consequences of refusal to provide informed consent in the use of behavioral management practices or to document such refusal. The requirement is stated generically in the section on child and family rights. However, restating the requirement in this section would underscore its importance." CHARPP recommended additional language, stating "add to the provision, as recommended above, '...developmentally in the appropriate manner, explain the consequences of refusal to provide informed consent, and document such refusal in the child's record.'"
Recommendation 48: No
change to OAR 309-032-1180 (1)(b). See recommendation
40.
Testimony: Callie Schlippert, OFSN, commented on informed consent (1)(b), stating "in situations where parents/guardians do not agree with the usefulness of a provider's behavior management practices... a child should not be rejected from the program. Instead, the provider and parents (and child, if appropriate) should make every effort to develop an individualized plan for behavior management. Once in a program, a child should not be ejected from the program for bad behavior. An individualized behavior plan should be developed to help them deal with their unacceptable behaviors."
Recommendation 49: No change to OAR 309-032-1180 (1)(b). See recommendation
40.
Testimony: Elizabeth Miller, parent, commented that "a plan should be in place to deal with a child's behaviors that is acceptable to the parents and will also prevent the child from being dismissed if this plan is not necessarily in agreement with the provider."
Recommendation 50: No change to OAR 309-032-1180 (1)(b). See recommendation
40.
Testimony: James Wrigley, OAC, proposed that all incidents of isolation be documented, and expressed serious concerns about the requirement in 309-032-1180(3) that providers only document each staff-directed behavior management intervention that isolates a child for more than 15 minutes. He stated "we strongly believe that all incidents of isolation should be documented, regardless of length." He commented that unless all incidents are documented, "there will be harmful confusion regarding the other, very positive provisions of section 309-032-1180(3). Proper implementation of these requirements hinges upon the collection of data. With only some isolation being documented, the glaring flaws in the data will lead to arbitrary outcomes, and cynicism and confusion. In the long run, providers as well as children and families will benefit from the simplicity of our proposed requirement that all isolation be documented."
Recommendation 51: No
change to OAR 309-032-1180(3). See recommendation 8. The 15 minute threshold
for noting isolation in the child's clinical record will allow
providers to use the intervention briefly without added paperwork, but will assure
that
high utilizers of the intervention will be noted. Comments relating to OAR 309-032-1190, Special Treatment Procedures Testimony:Judith Selander,
parent, commented that "once placed in a setting, no child should be
suspended. Suspension is a denial of treatment. If the child is always in time-out
and not available for treatment, then another placement should be considered.
Being sent
home does not therapeutically assist anybody-child or family. Individualized
plans must be developed that address the unique disabilities/illnesses of the
child."
Testimony: Carolyn Frey, parent, commented on the negative impact that restraint has had on her daughter: "The impact that I have seen of the use of restraints on my daughter has been a terrible increase in the amount of fear and uncertainty with which she must now attempt to approach her life. On behalf of my daughter and for myself, I ask that OAR wording be arranged so that restraints are not used on children."
Recommendation 53: No
change to OAR 309-032-1190.
Testimony: Rodent Birney, M..D., Family Friends,
commented generally on seclusion and restraint, stating "the staff tries to
use what is clinically most efficient in protecting and calming a child, and
getting them to return to the milieu. What is the clinical
reasoning behind
the differences in times and frequencies you allot before review? Will this
difference shift focus from the one that is more clinically relevant to the
one with more time
allotted?"
Recommendation 54: No change to OAR 309-032-1190. The duration of manual
restraint or seclusion interventions is based individually on the child, lasting only long
enough for the child to resume self control and prevent harm to the child and others.
The thresholds and frequencies in this provision were established through significant
research and workgroup discussion.
Testimony: James Wrigley, OAC, approved of the prohibition of chemical restraints, (2) and the limitations in (3) on the use of mechanical restraints. (3) He stated, "in general, the proposed rules effectively provide safeguards against the misuse of seclusion and restraint and we believe that they should be enacted as written."
Recommendation 55: No change to OAR 309-032-1190 (2) or (3).
Testimony: CHARPP commented on (4)(d), special treatment procedures, stating, "the inclusion of the clause regarding improving the quality of care links a general imperative (improving quality) with a specific review process of a high risk procedure. Requirements regarding quality improvement are already in a special section in the Rule." CHARPP suggested the Division "delete the clause '...improving the quality of care for children receiving services...'."
Recommendation 56:No
change to OAR 309-032-1190 (4)(d)
Testimony: CHARPP commented on informed consent (5), suggesting "Add the following sentence: 'Explain the consequences of refusal to provide informed consent and document such refusal in the child's clinical record.' "
Recommendation 57: No
change to OAR 309-032-1190 (5) See recommendation 40.
Testimony: CHARPP commented on (6)(g) regarding including alternatives to seclusion and restraint as part of the individual plan of care: "This provision is unclear and suggests that restraint and seclusion shall be outlined in the individual plan of care. This would be contradictory to the earlier requirement that restraint and seclusion should occur only in an emergency." CHARPP recommended deleting this entire provision.
Recommendation 58: No
change to OAR 309-032-1190 (6)(g). The provision states
that "...alternatives to manual restraint and seclusion be identified and made
part of the
child's individual plan of care." If these interventions are based on a child's
safety needs, then the interdisciplinary team should be outlining therapeutic
alternatives and
interventions to reduce its use.
Testimony: CHARPP commented on provision (6)(h)(A)(i) regarding the assessment of physical injury, stating, "the documentation requirements as stated imply that a physical injury may be expected, thereby requiring 'an assessment of physical injury'. In fact in most episodes such injury does not occur." CHARPP recommended changing the clause to read, '...assessment of physical injury, if any...'"
Recommendation 59: No
change to OAR 309-032-1190 (6)(h)(A)(i). It is not possible to know if an injury
has occurred without an assessment, and this assessment should be
documented.
Testimony: CHARPP commented on provision (6)(h)(A)(ii), requiring a minimum of two staff to implement a manual restraint: "This requirement at first reading appears contradictory." CHARPP recommended "Change the second sentence to read: 'If in the event of an emergency of such imminence that a single-staff manual restraint has occurred, the providers or on call administrators shall immediately review the intervention.'"
Karin Mounce, Family Friends, commented that (6)(h)(A)(ii), is a contradictory
statement. Citing the proposed Rule, "A minimum of two staff shall implement a
manual restraint. In the event of a single staff manual restraint, the providers on-call
administrator shall immediately review the intervention." She then asked, "how can
one staff do a restraint if two staff were already specified as the minimum? Aside from
this, a two staff restraint is often unnecessary for certain children such as a pre-school
age child who is small enough to safely restrain by one person." Rodent Birney, M..D., Family Friends, also commented on (6)(h)(A)(ii), asking how do
you do a one person restraint when there have to be two people present?" Recommendation 60: Change
OAR 309-032-1190 (6)(h)(A)(ii) to read: "A minimum
of two staff shall implement a manual restraint. If in
the event of an emergency a
single-staff manual restraint has occurred, the
provider's on call administrator shall
immediately review the intervention." This provision does not prohibit single
person manual restraints, but requires the presence of two staff, for the protection
of both
children and staff. If in an emergency situation where one staff is alone with
a child and a manual restraint intervention is used then immediate review shall
occur. Again
this is for the protection of both the child and staff.
Testimony: OATC commented on (6)(h)(B) and (7) which identify the standards for the imposition of seclusion. OATC stated, "It should be clarified, however, that a disciplinary 'timeout', even if it is administered in a separate room that the child is prevented from leaving, should not be considered 'seclusion' as intended in the proposed rule."
Recommendation 61: No change to OAR 309-032-1190 (6)(h)(B)or (7). National
accreditation standards and numerous organizations' position papers on restraint and
seclusion clearly state that seclusion shall not be used as method of coercion, discipline
or punishment.
Testimony: CHARPP commented on (6)(h)(B)(vi), recommended changing the clause to read, "...assessment of physical injury, if any..."
Recommendatio 62: No
change to OAR 309-032-1190 (6)(h)(B)(vi). See
recommendation 59.
Testimony: David Trump, SOASTC Board of Directors, commented on their concern regarding the difference in the requirements for manual restraint and seclusion: "The Rule seems to view seclusion as a more serious intervention, requiring more immediate authorization and a far greater degree of treatment team review than manual restraint... The Board would urge that the baseline regulatory thresholds for the two interventions should be identical... They would also urge that the threshold for a special treatment procedure review for seclusion be made identical to that in the Rule for restraint and isolation, i.e., five hours in five days or a single episode of two hours."
CHARPP commented that in (6)(h)(B)(vii), "the threshold for a special review of the
plan of care for seclusion is far more stringent than that for manual restraint... This
provision positions seclusion as far more serious than restraint... Given the brief length
of the majority of seclusions, there is a significant fiscal impact also with this
provision." CHARPP recommended changing the threshold requirement to "...five
hours within five days..." Recommendation 63: Change
OAR 309-032-1190 (6)(h)(B)(vii) to read: "If incidents
of seclusion used with an individual child cumulatively exceed[s] five
[times] hours in
five days or a single episode of more than two hours for children
age nine and
older and more than one hour for children under age nine the psychiatrist
or designee shall within 24 hours convene by phone or in person individual(s)
in the
program with designated clinical leadership responsibilities to review the child's
individual plan of care and/or behavior management interventions and make
necessary adjustments." This new language will position the review process for seclusion to be equal with
manual restraint and it takes into account the guidelines for written orders established
in OAR 309-032-1190 (6)(h)(B)(ii). Recommendation 64: Change OAR 309-032-1190
(6)(h)(A)(v) to read, "If incidents
of manual restraint used with an individual child cumulatively exceed [more than]
five hours in five days or a single episode of one hour, the psychiatrist or designee shall
within 24 hours convene by phone or in person individual(s) in the program with
designated clinical leadership responsibilities to review the child's individual plan of
care and/or behavior management interventions and make necessary adjustments."
Testimony: CHARPP commented that the availability of a mattress or mat in quiet room (8)(d) can become unsafe and recommended that either the mattress be affixed to the floor or the provision be eliminated.
Recommendation 65: No
change to OAR 309-032-1190 (8)(d). The provision calls for the availability
of a mattress or mat; it does not dictate its use in all circumstances. Comments relating to OAR 309-032-1200, Quality Management Testimony: OATC commented that it "fully supports Provider organizations being able to assure the public that state and federal funds are being properly managed. While quantifying the success of mental health treatment is doable, it is done at the expense of direct service to kids in need... OATC is willing to partner with the State in developing measurable standards- but it is not acceptable for the State to simply mandate quality management and provide no funds to implement the monitoring, reporting and follow-up required by such a system."Recommendation 66: No change to OAR 309-032-1200. Original fiscal analysis led
to the recommendation of a 1% increase in cost for programs which are not nationally
accredited. See recommendation 94 for updated fiscal analysis information.
Testimony: Callie Schlippert, OFSN, commented that the quality management process should include a system whereby families can make anonymous suggestions.
Recommendation 67: No
change to OAR 309-032-1200
Testimony: Joe Rozak, Riverside Center, commented on the QA process, stating "it's a paper and pen process and community process and all that, but it's actually a weak process compared to the one that we currently enjoy, but the one we currently enjoy is going to be essentially eroded or cut out if the OAR is implemented as standard." He described the Board of Directors as "one of the finest and strongest QA components any program could have and to have an OAR that would want to eliminate or actually reduce that role down to a piece of where they have to approve a QA plan is serious design flaw and one that I believe should be corrected."
Recommendation 68: No
change to OAR 309-032-1200
Testimony: CHARPP commented on the standing quality management committee requirement (5), expressing confusion about whether the 'standing' committee is the same as the quality management committee described in other provisions. CHARPP commented that "clarification of the requirement would assist in implementation," and recommended the following language: "The provider shall have an external standing committee that meets at least quarterly to review the quality and appropriateness of the services being delivered. The standing committee shall be composed minimally of:..."
Recommendation 69: Change OAR 309-032-1200 (5) to read, "The provider shall
have a [standing] Quality Management Committee that meets at least quarterly. The
Quality Management Committee shall be composed of:..."
Testimony: Patricia Younglove, parent, suggested that quality management committee meetings (5) take place at a time parents can attend.
Recommendation 70:No
change to OAR 309-032-1200 (5)
Testimony: Judith Selander, parent, commented on the composition of the quality management committee (5)(b), stating: "The language here should be more explicit to say that the representative should be a parent or guardian."
Recommendation 71: No
change to OAR 309-032-1200 (5)(b).
Testimony: CHARPP commented on the role of the psychiatrist (9), stating "this provision does not specify what membership on the quality management committee means." CHARPP recommended the following language change: "The provider assures that the psychiatrist participates and is involved in quality management activities and is recognized within the staff organization as a member of the quality management committee with responsibilities described in the providers quality management plan."
Recommendation 72: Change OAR 309-032-1200 (9) to read, "The [process assures
for psychiatrist membership on the Quality Management Committee and provides for
involvement in Quality Management activities] provider assures that the psychiatrist
participates and is involved in quality management activities and is recognized
within the staff organization as a member of the quality management committee
with responsibilities described in the provider's quality management plan." Comments relating to OAR 309-032-1210, Formal Complaints
Testimony: OATC commented, "OAR 309-032-120 as proposed
requires that providers develop a system to handle formal complaints made by
a child or person consenting to a child's
treatment. OATC is supportive of a process to address consumer complaints but
this rule assumes that providers will not take consumer complaints seriously.
It is
reasonable to expect that a complaint by a child, parent/guardian or other authorized
person will be addressed professionally and appropriate notations made in the
child's file or addressed in provider's records which are discoverable if litigation
ensues. A
formal procedure however, may not address every situation and will result in
unnecessary bureaucratic paperwork which takes resources from direct treatment. Comments relating to OAR 309-032-1220, Certificate
of Approval
Recommendation 74: No change to OAR 309-032-1220. Comments relating to OAR 309-032-1230, Variance
General Comments Testimony: Alex Vidal, Washington County Health and
Human Services, commented on the absence of requirements for demonstrating
cultural competency, gender responsiveness
and language appropriateness in the delivery of services to clients. He suggested, "Though
federal and state statute require this, and the office of MHDDSD advocates for
this, the State of Oregon should reflect these priorities in its rules." Recommendation 75: Add language to OAR 309-032-1120, General Conditions, to
read: " (16) Demonstrate cultural competency, gender responsiveness and
language appropriateness in the delivery of services to clients."
Testimony: Mr. Vidal also commented that the Medicaid Authorization Specialist (MAS) function is not specified in the proposed rules.
Recommendation 76: No changes to OAR 309-032-1100 through 309-032-1230.
There are no functions for an MAS in intensive treatment services.
Testimony: Lane County OFSN's group submission commented that "the cumbersome legalistic way in which the document is written will reduce its effectiveness as a tool for administrators, workers and family members who want to ensure that children are well served. We strongly recommend that you contract with an editor to break apart overly long or complex phrases and to simplify without altering intent."
Recommendation 77: No changes to OAR 309-032-1100 through 309-032-1230. Testimony: CHARPP commented on the need for MHDDSD to develop a process for reviewing agencies' compliance with the Rule. CHARPP recommended that the review process involve peer participation, and be codified in appropriate rule or policy.
Recommendation 78: No changes to OAR 309-032-1100 through 309-032-1230. The
Division will certify providers based on OAR 309-12-130 through 309-12-220
"Certificates of Approval for Mental Health Services." The Division intends to utilize a
site review process which is led by Division staff. Other interested and necessary
persons will be invited and included in the review process. This process will include
other providers of like services, but may also include representatives of families, other
state agencies, county personnel, advocacy organizations, mental health organization
personnel, and/or others who may have a stake in the level of care being reviewed. It is
not appropriate in administrative rule to specifically describe an implementation
process which may evolve over time. The Division is committed to a collaborative
development of review protocols.
Testimony: Karin Mounce, Family Friends, commented "I find the added authorizations and reviews that would be required under the administrative rule to be cumbersome and unnecessary. Examples include: review of child's care plan within 24 hours when behavioral management thresholds are exceeded; reviewing discharge plans every 30 days, requiring authorization for restraints over 30 minutes, and having a special treatment procedure committee with the added data collection and meetings inherent in such a committee... Additionally... I find repeated vague statements such as 'approved by the Division' with no specific information following which causes additional concern for me over what exactly would be put in place."
Recommendation 79: No changes to OAR 309-032-1100 through 309-032-1230. See
recommendation 35, 45, and 54. Testimony: The Family Friends Board of Directors commented, "our primary concern regards the diminishing role for Boards of Directors, of psychiatric day treatment programs... Currently those boards have multiple responsibilities for oversight of program operations. Under the proposed OAR they would be limited to only a single role, that of a once per year review of 'the annual Quality Management report' and approval of 'the annual Quality Management plan'. This significant step backward for programs, that are meant to be community governed, also represents the unbalancing of a current healthy public/private partnership that is unacceptable to us."
Recommendation 80: Add language to OAR 309-032-1120, General Conditions to
read: "(17) Demonstrate operation by a governing body whose membership
reflects diverse community interests and whose organization and operation shall
be set out in writing."
Testimony: George Longden, Family Friends, commented, "in the crucial area of safeguarding clients the combined rules [ITS and SCF licensing] lack provisions that would require programs to have no firearms on premises or to keep poisons locked away from clients." Recommendation 81: Add language to OAR 309-032-1120 as follows: "(20)
Develop policies and procedures prohibiting firearms and outlining the management
of
other potentially dangerous objects." Management of hazardous substances is
specified in the SCF licensing rule, OAR 413-210-100(9)(e), which states, "Poisons,
chemicals. rodenticides, insecticides and other toxic materials which shall be properly
labeled, stored in the original container and kept in a locked storage area."
Testimony: George Longden, Family Friends, commented that "new requirements, in the OAR, clearly reflect MHD concerns about the length of stay (LOS) for clients in day treatment programs. MHD's concerns are reasonable and some programs have had clients remain for periods that are not clinically justified. Unfortunately, provisions in this rule take a howitzer to a problem that could be solved with a good fly swatter. First, quarterly reviews are changed to every 30 days. Second, provisions for a review every 90 days for continued stay approval 'by a review process determined by the Division' are new to this level of care. Third, a requirement for an annual comprehensive assessment also appears to be an attempt to get at LOS... These requirements along with increased documentation and review of special treatment procedures will insure that clinicians will spend more time in committee meetings and working with their computers and consequently less time in family meetings and working with their clients. Taken together, the unintended consequence could be an actual increase in LOS."
Recommendation 82: See
recommendations 16, 19, and 35.
Testimony: Bill Thomas, Multnomah County Department of Community and Family Services, expressed support for adoption of the rules. He stated, "the reality is that the document you are considering is the process of a long period of development and while they are far from perfect, I think they provide a better foundation for moving ahead in the integration of this level of care into a more community based continuum of care for children with high needs. I think that the approach that the Division has taken to encouraging the development of locally directed pilot projects for intensive treatment services is something that will move us further in a direction of involving funders and providers (child welfare, education, mental health and families) in a more responsive continuum rather than isolated programs."
Recommendation 83: No changes to OAR 309-032-1100 through 309-032-1230. Testimony: Monica Ford, Morrison Center, commented that the issue of treatment foster care weren't addressed. She explained that the current funding stream for treatment foster care is a blending of county and SCF money and also additional county money to get individual services. She stated, "I think you all know that but what happens is that it is splintered. It's difficult to provide comprehensive services, like you'd see in a day treatment setting."
Recommendation 84: No changes to OAR 309-032-1100 through 309-032-1230. DARTS Standards Testimony: Barbara Trione, Accountable Behavioral Health Alliance, commented that the proposed rules are general enough to allow for good oversight on the part of the Division, but flexible enough to allow for some creativity in the care. She stated she was glad to see that the reference to standards, particularly the DARTS standards, were eliminated from this final rule. She believes most of the pertinent aspects of these standards are included within the context of the rule. Ms. Trione commented on staffing levels, stating "it is my belief that levels should not be specified in rule, but staffing for these services should be based on an acuity-based system that is division approved."Recommendation 85: No additional changes to OAR 309-032-1100 through 309-032-1230. Testimony: CHARPP recommended that "psychiatric day treatment programs which are not part of nationally accredited agencies be required to adhere to DARTS standards or a set of similar standards approved by MHDDSD; that psychiatric day treatment services which are part of nationally accredited agencies continue to be regarded as adhering to the national standards by which those agencies are accredited and not be required to adhere to an additional set of standards; [and] that standards be designated by MHDDSD for therapeutic group and foster care."
Recommendation 86: No additional changes to OAR 309-032-1100 through 309-032-1230.
Testimony: OATC commented extensively on the issue
of the DARTS standards, stating "During
the two year period in which the rules were being formulated Division staff
have repeatedly and consistently indicated that their desire was to eliminate
the
established Community Child and Family Treatment Program Standards, commonly
known as the
DARTS Standards. These standards that were first implemented in 1972 with
the establishment of six programs was based upon the success of a pilot project
approved
by the 1967 Oregon Legislature and administered by the Oregon Mental Health
Division. The standards have of course over time been modified and updated
as necessary by professionals in the field and Division administrators who
understand
the treatment needs of these children. The standards enjoy broad acceptance
among professionals in the child mental health field. DARTS standards have
also been
nationally recognized as a model system of care for emotionally disturbed children,
adolescents and their families. In fact, this Division in its effort to improve
the
efficiency of providing Psychiatric Day Treatment Services to Oregon's children
commissioned OATC in State Contract No. 85032 to provide treatment and services
to children and their families 'in accordance with Community Child and Family
Treatment Program Standards (DARTS Standards).' Oregon's DARTS Standards are
codified in Chapter 309, Division 34 of Oregon's Administrative Rules. What
is truly
perplexing about the rules as currently proposed is that despite the Division's
stated intent to eliminate the DARTS Standards and replace these Standards
with something
new, the proposed rules do not, repeat, do not repeal the current DARTS Standards...
If the proposed rule should have repealed the DARTS Standards, and it was a
mere oversight by the Division in not including the proper language to authorize
a
repeal,
then we will be back - in full battle armor to defend those standards that
have served
Oregon's 'special' children and families so well these past 28 years."
Recommendation 87: No additional changes to OAR 309-032-1100 through 309-032-1230. The Division does intend on filing a notice to repeal OAR 309-034-0060
through 309-034-0140 titled "Psychiatric Day Treatment Services for Children," and
OAR 309-034-005 titled "Standards for Day and Residential Treatment Programs."
Testimony: Bill Wellard, on behalf of the Child Center and its Board of Directors, recommended that "the DART Standards be referenced by this rule and be made part of the contract expectations for any provider who offers psychiatric day treatment services. I would not expect the DART Standards to be applied to residential services, but to any day treatment service provider... The proposed rule has incorporated some aspects of the DART Standards, but does not nearly replace the standards nor act as a good substitute. The elimination of the DART Standards leaves this service with no other set of recognized standards to address such items such as the Governing Body, safety issues, fiscal accountability, facility or physical plant, treatment philosophy, staff performance appraisals, staff training activities, orientation of child and family, education component, child/youth daily activities while in the program, community integration, transportation, and the list goes on. One might argue that these items do not belong in an administrative rule. I would agree if there were a set of operating standards that were required by contract to assure that those items were being addressed by each program. I firmly believe that the Division must include the DART Standards to ensure program quality at a time when there are great pressures to cut corners, do without or minimize services."
Recommendation 88: See
recommendations 80, 81, and 93. Add new language to OAR 309-032-1120, General Conditions, to state: "(18) Develop
and publish a comprehensive document which describes the mission statement,
treatment philosophy, programmatic descriptions, admission criteria, and the
policies and procedures for operation of the program. (19) Develop policies and procedures for orientation of the incoming child and
family that consider pre-admission orientation times convenient for the family and
that facilitate adequate staff, program, and child and family preparation prior to
admission."
Testimony: Nancy Winters, M.D., OCCAP, commented that "the organization's main concern with the proposed rule is the omission of the DARTS Standards to cover programs not supported by other accrediting organizations." OCCAP considers "the DARTS Standards to be a very high quality set of guidelines, impressive for their comprehensiveness, their attention to the individual and developmental needs of children and their recognition of the importance of working with families." Dr. Winters further commented that "the standards for comprehensive assessments within specific time frames are very sound." She also noted that the DARTS requirement that "the consulting psychiatrist function as a member of the multi- disciplinary team has led to psychiatrists' fundamental involvement in the programs." Recommendation 89: No
additional changes to OAR 309-032-1100 through 309-032-1230.
Testimony: Joan Wayland, M.D., commented that one of the strengths of DARTS has been the OATC oversight of quality, based on site reviews in which the clinical quality of the program was assessed through direct observation by peer directors and a psychiatric consultant. She stated, "I have personally observed how their input has resulted in recognizing both quality and problems, with directors helping each other. If DARTS Standards are no longer required, there would be less reason for OATC to continue to monitor each other, and quality control becomes more of an internal operation and a paperwork assessment."
Recommendation 90: See
recommendation 78.
Testimony: Les Busch, OHSU Children's Psychiatric Day Treatment Center, explained that the DARTS standards were influential in securing federal approval for funding day treatment as a unit of service that encompassed a full day of service. "My concern," he stated, "is that we will end up with a piece meal funding process which for those of you who are familiar know how that works, it doesn't work well. What I am talking about is funding for individual therapy and group activities and not funding a unit of service that encompasses all the family work and all the other things that wouldn't necessarily be billable if you are just in outpatient service."
Recommendation 91: No
changes to OAR 309-032-1100 through 309-032-1230. This proposed rule does not
describe funding mechanisms.
Testimony: Cindy Stenard, Grande Rhonde Child Center, commented that she has seen day treatment as a cooperative arrangement historically funded through three different agencies (Health Division, the Department of Education, and Children's Services Division). She thinks that has worked well to provide integrated services for children. She stated, "When I read some of the things coming out of the Human Resources - Human Services, and Gary Weeks now emphasis on partnering that's what the DARTS has done for the day treatment program. It's encouraged, and forced us to partner with the schools, with our local mental health communities and with Children's Services Division. I think if you look at the children who are currently in day treatment programs I am willing to guess that you will find more of the children have been referred to our programs from Children's Services Division than from the community mental health programs. The children need services, not just mental health services, but they need the services of education and the whole community."
Recommendation 92: No
changes to OAR 309-032-1100 through 309-032-1230.
The Division received 69 testimonies from parents, staff, Boards and Board members, and other concerned citizens all voicing support for inclusion of the DARTS Standards into the proposed OAR. The testimony summarized herein highlights many of the commonalities in the testimony received. Generally these 69 testimonies described the DARTS standards as a long-standing mechanism that has contributed to assuring a high quality of care, community oversight and support, a peer review process, a detailed operational procedure, and community and family integration. Many expressed concern that without direct reference to the DARTS Standards in the proposed OAR, the psychiatric day treatment level of care would be in jeopardy.
The Office of Mental Health Services considered several options for responding to
these comments. One would simply not reference the DARTS Standards in OAR 309-032-1100 through 309-032-1230 because many of the recommendations in this report
add sections of the DARTS Standards to the Rule. With these additions, a significant
majority of the DARTS Standards are included in this proposed OAR and/or are
contained in the SCF licensing rule under which most ITS programs operate. Another option would reference the DARTS Standards as voluntary, alternative
standards which are superceded by the ITS rule in the event of conflicts. This option
would also codify the terminology and also reinforce in rule the Division's statutory
authority in relation to this level of care. To avoid confusion, the Division would need
to file a notice to repeal OAR 309-034-0060 through 309-034-0140 titled "Psychiatric
Day Treatment Services for Children," and OAR 309-034-005 titled "Standards for
Day and Residential Treatment Services Programs." These rules reference the DARTS
Standards in the definition sections and would not be necessary with the adoption of
this ITS rule. Recommendation 93: Add language reflecting the latter option to 309-032-1120 to
read, "(1) (b) Providers that are not required to have
accreditation approved by the Health Care Financing Administration
may use alternative standards
for the
organization of their services; The Division should review the appropriateness of filing notice repealing outdated
Rules referencing the DARTS Standards.
Comments Relating to Fiscal Impact Testimony: Bill Powers,
The Christie School, commented on the fiscal impact of additional psychiatric
time. He noted that it will be necessary to fund an additional hour of
psychiatric time for his program. Response 1: There are no direct mandates for additional psychiatric time. Providers
will have to analyze the job duties of the psychiatrist to ensure requirements of the rule
are met. Direct contracts have always mandated 60% of physician time be provided by
a psychiatrist. The proposed rule requires that a psychiatrist be board eligible or board
certified in child psychiatry but allows for a transition period for this requirement. For
example the rule allows for providers to "grandfather" current psychiatrists into
meeting the standards if needed. Tele-medicine technology and practice standards are
continually improving and are being shown to be an effective alternative for providers
in areas that do not have in-person access to board-certified child psychiatrists. The
Division is also willing to consider variances for programs in areas with child
psychiatric recruitment problems. Response 2: The rule does specify seclusion room physical requirements in order to
ensure that safe environments are provided for the children needing this level of
intervention. Current practice includes a great deal of process, oversight, and
documentation. The rule will require providers to analyze and update their processes,
which can be accomplished by adjusting administrative priorities; however, the
Division recognizes some additional costs may be incurred by specific programs
choosing to use seclusion rooms. These costs will be considered on a case-by-case
basis for one-time Division funding. The Division will absorb these costs within its
existing budget.
Testimony:CHARPP believes that the Fiscal Impact Statement, "is significantly understated, both in some of the assumptions made in the assessment and in the omission of other fiscal impacts inherent in the rule:"
CHARPP testimony is numbered (1) through (8) and is followed by the Division
Response. Response 3a to (1): A behavior management committee is not a requirement of the
rule, although it is a requirement of JCAHO. The rule requires that a special treatment
procedure committee be established; however, these duties may be assigned to an
already established quality management committee. There is not a specific requirement
for a review process after a "time-out (isolation)" unless the isolation is longer than two
hours or cumulatively exceeds five hours in five days. Time-out is not an intervention
defined in the rule; therefore, providers will be able to define this intervention and the
review threshold that is associated with its use. Children who are high users of
seclusion and restraint should be regularly reviewed by the interdisciplinary team.
JCAHO already requires a performance improvement process related to the use of
seclusion and restraint. The Division believes that JCAHO itself will be increasing
requirements in this area. (2) "Other meeting and documentation requirements. The requirement for 30 day treatment reviews in day treatment programs, there will be a cost both in meeting time and documentation time that has not been analyzed. Discharge instructions will require a small additional paperwork cost." Response 3b to (2): Day treatment providers have stated and the Division has observed
that in many programs both formal and informal individual plan of care reviews already
occur at least every 30 days. What is required in the rule is that these meetings be
documented in the clinical record. The discharge instruction requirement is a minimal
document which relays critical information about medication, diagnosis, and current
treatment intervention strategies that will allow the provider of the next level of care to
meet the short term needs of the child. This is considered to be a basic standard of care
that will require no additional resources since in most programs it is already the
practice.
(3) "Quality management. Given the necessity to integrate and account for two sets of quality management requirements a one percent increase for the nationally accredited programs would be a minimum cost; the increase for psychiatric day treatment programs may be greater."
Response 3c to (3): The quality management requirements do not conflict with JCAHO
requirements. This section was written to allow the provider a basic outline of quality
management and to develop an individualized plan. There may be some fiscal impact
for programs who are JCAHO-accredited. (See Recommendation 94 ) (4) "Child Psychiatry time. Increase cost of a child psychiatrist of $40 to $50 per hour. Requirements or implied requirements for psychiatrist participation in treatment planning meetings in excess of current practice. Additional psychiatrist time for quality management, one to two hours per week in some programs. Special treatment procedures will necessitate more frequent contact and oversight." Response 3d to (4): The rule was developed with awareness of the cost associated with
psychiatric time and it allows as much flexibility as possible. HCFA requires that
services be provided under the direction of a physician and that they are part of the
team that develops the individual plan of care; therefore, the rule assumes that directing
intensive treatment services already involves the psychiatrist as a participant in
treatment planning. An example of the rule's flexibility is that it allows the
psychiatrist to designate some responsibilities of special treatment procedures except
for seclusion interventions that exceed the original order time frames. The rule also
requires the psychiatrist membership on the quarterly quality management committee
but the provider is allowed to identify specific quality management activities for the
psychiatrist. The Rule requirements and identified concerns do not go beyond HCFA
or JCAHO requirements. Some providers may need to reallocate their current use of
psychiatry time and may need to redefine some duties to meet the rule requirements.
(5) "Measurement of treatment outcomes. Given the degree of planning and technical work involved in accurately and meaningfully measuring outcomes, this could be significant in some programs (as much as one FTE)."
Response 3e to (5): The DARTS Standards which all programs have met for years
include this provision. Principle A, Standard 4, Guideline 2, states, "outcome
measurements shall be developed which address the effectiveness, efficiency, and
appropriateness of the child and family treatment. Therefore, no additional fiscal
impact is anticipated.
(6) "Seclusion rooms. Cost for agencies in refurbishing and redesigning seclusion rooms to meet rule requirements. Cost for completion of the paperwork to apply and receive certification for seclusion rooms. There will be additional cost to the Division in processing this paperwork."
Response 3f to (6): See Response 2 above.
(7) "Day treatment review process. There is a new "review process to be determined by the Division" required for admission and continuing stay in the psychiatric day treatment programs. This process will involve additional cost for providers in preparing the necessary paperwork and attending meetings. There will be start-up cost in shifting to the new process."
Response 3g to (7): No additional fiscal impact is anticipated. There may need to be a
one-time adjustment of administrative functions for some programs but the Division
believes this can be accommodated under usual administrative reviews and practices.
(8) "General cost. Revising program policies, procedures and documentation as well as staff re-training to meet proposed requirements."
Response 3i to (8): Once again, the Division believes that program policies and
procedures are reviewed and revised on a regular basis using existing administrative
resources. The Division will use the first year following adoption of the new rules to
assist programs in adjusting and re-prioritizing to meet the new administrative
requirements.
Testimony: Oregon Association
of Treatment Centers (OATC) commented, "that the Division's
analysis fails to address numerous factors which increase costs to providers:" OATC testimony is numbered (1) through (7) and is followed by the Division
Response.
(1) "Cost associated with mandating psychiatrists be available for children and adolescents;"
Response 4a to (1): See Response 1. Historically direct service contracts have
required 60% of physician time be provided by a psychiatrist.
(2) "Facility remodeling costs for special treatment procedures;" Response 4b to (2): See Response 2. (3) "The estimate of two hours for an annual comprehensive assessment update is inadequate;"
Response 4c to (3): See Recommendation # 16. The Rule requires the comprehensive
assessment to be revised and updated annually. It is not anticipated that an update and
revision will exceed two hours.
(4) "Costs for meeting new behavioral management requirements have not been adequately addressed. Increased psychiatrist time is required and there are increased demands for QMHA and QMHP staffing;"
Response 4d to (4): The Rule allows for the psychiatrist to designate the authority for
authorizing special treatment procedures except for seclusion interventions that exceed
the original order time frame. The Division anticipates that Federal regulations for
authorization and oversight of seclusion and restraint may become more stringent than
those required in this Rule. The Division acknowledges that there may be additional
fiscal impact, see Recommendation #94.
(5) "Costs for revising program policies and procedures to comply with the proposed rules and costs associated with training staff have not been considered;"
Response 4e to (5): Program policies and procedures should be updated and revised on
a regular basis. Staff training is also provided on a regular basis. The Division will
sponsor regional training opportunities and provide individual technical assistance as
requested. The Division will use the first year following adoption of the new rules to
assist programs in adjusting and re-prioritizing to meet the new administrative
requirements. The first year will considered a transition period towards full
compliance to the new rules. (6) "Changes in time frames for clinical documentation and increased requirements for clinical record documentation have costs. Provider's staffs have more meetings to attend which means fewer staff to provide services and as a result higher service costs;"
Response 4f to (6): Day treatment providers are currently required to be operational four to five hours per day depending on the age of the population served. The direct service contract requires 230 days of service excluding weekends, holidays, and school vacation periods but requires the performance of necessary services at any time during the child's enrollment. There appears to enough flexibility built in the |