STATE OF ILLINOIS: Rule 132 Amendment Training

June 5, 2012


Cathy Cumpston

Kristy Herman

Lee Ann Reinert


Moderator: Ladies and gentlemen, thank you very much for standing by. Welcome to today's Rule 132 Amendment Training conference call. At this time, all participants are in a listen-only mode. Later, we will conduct a question and answer session with instructions given at that time. As a reminder, today's conference is being recorded.

 I would now like to turn the conference over to our host for today, Ms. Cathy Cumpston.

C. Cumpston: Thank you, Dave. Welcome, everybody. I'm so glad that you are able to participate with us today. We are going to spend today going through the PowerPoint that you were all sent with the announcement. So, I hope you do have it that you can follow along with us. We will do our best not to read it to you because we do believe you can all read. And so, we will just use it as our guide for what we want to talk about today and proceed through it.

 One of the things I want to share with you though is that we are really going to talk today about the bigger changes that are made, that are being proposed to be made to the rule so that when the rule finally is adopted, you'll understand the changes. I would encourage you all to get a copy of it and read it.

 Today, we are going to review the changes that are being proposed and then we will, as Dave said, respond to questions that you have. One of the first things that I want to do though is apologize to all of you. The public comment period on this proposed rule during the first filing period with JCAR ended back in February and we received a lot of wonderful comments and our group that we have to work on this rule did write responses to those comments. And in addition to that, we did propose changes to the original rule in response to those comments.

 Unfortunately, all of that is still with DHS legal, being reviewed for appropriateness and the legalness of what we suggested doing and you have not received responses to your comments. And again, I apologize for that. I personally follow-up with them about once a week or so, seeing what the status is and if they need any assistance, if they have any questions, and I will continue to do that. You will receive response to comments and the rule will ultimately be filed with JCAR for a second filing with the changes that were proposed that we accepted incorporated.

 So, we will do that and our group that writes this and monitors this and keeps working on this continues to be hopeful and we are right now hoping that we can adopt this within the next 60 days.

 When it is adopted, you will get notification that it has been adopted. You will get information about where it is published so that you can get a copy of it. The guidelines, instructions and checklist will be amended. That's the survey instrument that all of the reviewers use. That, too, will be published and you will be told where you can get a copy of that.

 So, with all of that said, let's just begin. On the PowerPoint, let's start really with page three. There are some policy changes and I'm not going to read to you. The rule as published for first filing is still out there and available to you, and I hope that you have had an opportunity to look at it.

 But, you can look at that to see what the actual language of these policy changes are, but the most important thing that I wanted to talk about in reference to policy changes is that we will give you a 30 day period of time from the adoption, not from today, from the adoption of the amendments to make the changes to your policy. These are not things that have to be implemented. These are changes that you have-we look at do you have a policy on, what does the policy say, and we would like for you to get those policy changes made within 30 days after the effective date of the amendment.

 On page four, in May of 2011, there was an amendment adopted to this rule that we have never really talked to you all about and it was an amendment to the definition of medical necessity. What it did was to expand the use of the Healthy Kids screen from HFS to get kids, as a result of an EPSDT screen, into services more quickly. So, we are treating that screen much as we do an admission note so that if a kid and family most likely come to you with a Healthy Kids mental health screen, which is the HFS version of the EPSDT screen for mental health needs - they come to you with that screen in place - you may use that to begin providing services to them immediately while you then conduct your mental health assessment and development your treatment plan.

 The screen itself is good for 60 days after the physician signs and dates it. So, if a physician does a Health Kids screen on June 1st, you have then approximately until August 1st to use that to initiate services. And then once you initiate services, it is good for 30 days for you while you develop the mental health assessment.

 We made some changes to our definitions. We changed the definition of mental health professional and we changed that in two ways. We clarified some of the acceptable fields that we would recognize for a bachelor's degree. We added a certified family partnership professional, a CFPP, as an MHP and then we specified that in addition to experience, one did have to have a high school diploma or a GED.

 However, we did include grandfather clause. So, any MHP you have working in your program prior to the adoption of these amendments can continue to work as an MHP even if they don't have the high school diploma, or the GED, but they've got the required experience.

 We did a similar thing with RSAs. We clarified that we wanted an RSA to have a high school diploma or a GED, but we also included a grandfather clause. And again, the grandfather clause does not kick in until the rule amendments are adopted.

 We defined both intervention and activity. Over the years, we'd had lots of questions about some of the documentation requirements that we had and all of you pointing out to us that some of the services were really activities. Some of the services were you just doing something and there really then wasn't a response of the consumer to what you had done, or really progress towards objectives. So, it was really just an activity rather than an intervention.

 So, we have clarified the difference between those two things and then further on, we will talk about the differences in documentation requirements based on whether it's an intervention or an activity. We added a definition of mental health setting and we added a definition of psychotropic medication.

 Page six of the PowerPoint presentation: we added a new section. However, most of the content is not new. We pulled pieces from 132.145 that really didn't seem to be appropriate in that section of that rule and we created this new section upfront of provider qualifying conditions; same requirements, different location in the rule. And then also we added to 132.27 the new section that accessibility standards, as they apply to a certified provider, apply to all subcontracted certified providers.

 Page seven. We gave ourselves more latitude in not renewing certification or in revoking certification. We have written into the rule that providers that consistently perform poorly, and we have defined what that means, can have their certification either revoked or not have it renewed following a second certification review. We also incorporated that another reason for revocation would be a provider who is suspended from billing because of a very poor post-payment review and not being able to get the needed improvements in place for more than a year.

 From our history, this is probably going to be used very seldom. Most providers may occasionally have a bad review, but we really don't even have very many of you that have bad reviews. And generally, those that do, get corrections made and move on and do just fine. So, this is not likely to be used often, but we felt very strongly that we did need to be able to ultimately penalize providers that were not making the effort to comply and do what the rule required.

 We made some changes to post-payment review, probably one of the bigger changes that we made in these amendments. When the rule amendments are adopted, there will no longer be an initial notice of unsubstantiated billing. The documentation requirements haven't changed. Providers will continue to be given advanced notice of post-payment reviews, providers will continue to have the right to appeal findings, and during the post-payment reviews, reviewers are going to make a concentrated effort to work with providers to gather any documentation that they're unable to find.

 So, there's going to be a lot of communication between the provider and the reviewer during post-payment reviews so that if there are notes that are missing or if there's a treatment plan that's missing or a mental health assessment that's missing, that that is shared with the provider during the review so that that documentation can be found and given to the reviewer.

 However, when the review is done, there will no longer be an initial notice that is provided with 30 days time to submit additional documentation. Following the post payment review, we will give the provider a preliminary report so that you know what the findings were and then within 30 days following that post-payment review, there will be a notice of unsubstantiated billing.

 Another change that we made in this section is that it gives the public payer the option of extrapolating findings. At this point in time, neither DCFS nor DMH have plans to begin extrapolating findings and if they should ever do that, they would have to be sure that the way that they select the records for review really do produce a sample that is representative of all records so that there is no question about being able to extrapolate.

 We have added some things in 132.65 and I think that it is important in opening what we have done here to note that these are things that we believe providers are probably already doing because these are things that a provider would need to do to assure that they continue to be compliant with Rule 132. And since it is the provider's responsibility to assure that they are compliant with 132, if they're doing their job well, and we believe since most of our findings are demonstrating high levels of compliance that they are doing their job well, that these are the things that they would be doing.

 So, we want to see that there is an active system for determining compliance with all the client record requirements in this rule. So, there should be some way that the provider has for just in some intervals reviewing what they're doing and assuring that their notes are okay, that their treatment plans are okay, that their mental health assessments are okay, that they've got things in place, they're getting the reviews done in six months or a year. So, just those sorts of things that it's a self-monitoring process.

 Page ten: Personnel requirements. We have tried to clarify here what the requirements are according to state law and that providers need to perform a background check on direct care people in compliance with the Healthcare Worker Background Check Act. One of the things that is not in rule, but that we recognize and accept is that DCFS providers already have to do background checks through a LEEDS process and that will be acceptable and we will not require another background check based on the Healthcare Worker Background Check Act.

 So, we only want to see one background check done. We do not need to see multiple ones done. And then, we give you information about where the background check information is and where the actual act is.

 In addition to that, all providers will have to verify on the Healthcare Worker Registry that none of their staff have ever been found to have abused or neglected someone because the law there says that if they have abused or egregiously neglected someone, they cannot work in any capacity in one of our provider agencies. So, it's not even a secretarial position or a janitor position. If someone has been found to have abused or egregiously neglected someone, they cannot work around people with disabilities.

 Slide 11: Recordkeeping. We really reviewed this carefully and we could find no reason for some of the requirements we had. We discussed them and we looked at where other parts of the state or other parts of our departments were already requiring some of the documentation, some of the reviews, some of the audits that we had listed in this section, so we removed them. We do not want to be redundant. I know you all believe that sometimes we still are, but we really are trying not to be. And so, we removed many of the recordkeeping requirements that had been in this section because we found that we did not need to review them.

 On slide 12: Client Rights. We added here that clients must have their rights explained to them annually. Considering the population that we serve that's covered by this rule, it is well worth it. I mean it's very important because people tend to forget what their rights are. They tend to perhaps think that they have a right that they don't have, but it's important that they always understand what their rights are. And since we have said that that must be done annually, anybody that's in your program that's been there longer than a year and therefore you have not explained those rights annually, you will have 60 days from the date that the rule amendments are adopted to explain the rights to all of those people.

 And then also in this section, we added language to clarify restriction of right requirements. So, if someone has their rights restricted, there are some very specific things that you must do when you restrict those rights. You have to have a plan and it has to have objectives for how the client gets their rights back. The plan must be signed by the client or the client's parent or guardian, the Q and the L. And it always is important that the client that is affected by these restrictions be notified and given a copy of the plan to remove the restriction.

 Move on to slide 13: Service Documentation. The first point there is that no documentation requirements were added. So, we really don't think we did a whole lot of adding of onerous responsibilities in these amendments. We did a lot of trying to clarify and simplify. So, we did not add documentation requirements for services. We will, however, no longer accept any sort of summary note - daily, weekly, monthly. There will be no allowance for summary notes.

 I didn't introduce at the beginning my co-speakers here, but Kristy Herman from DCFS is here with me and she will talk more detail about some of the documentation requirements under each service. But, we really tried to make the documentation requirement fit the services. So, rather than having the general requirement for documentation and then try to make them fit to each service, we have specified for each service what the documentation requirements are.

 Now, that doesn't eliminate the need to have a note, have a description of what went on in the note, have the date on the note, have the beginning time and duration or ending time, and have it signed and dated by the person that delivered the service. All of that is still in place. So, Kristy will explain more about that under each service. And here are the definitions, and I said earlier that we had defined activity versus intervention. So, here is the definition on this slide of those two pieces and the differences between them.

 On slide 14, we have some examples of how we have applied the differing requirements for documentation. For instance, for mental health assessment and ITP development review and modification, the documentation now must include a description of the time spent and what was done with developing, reviewing or modifying the ITP. Under Psychotropic Medication Administration, documentation must describe the activity. So, the activity is, obviously, administering medication. It probably would be best to say what medication, but this is what you did. There is no expectation that there's a response or a progress towards goals. Therapy/counseling on the other hand continues to say, "Must include a description of the intervention, the client or family/guardian's response to the intervention and progress towards goals and objectives in the ITP. So, you can see the difference there in what the documentation requirements will be.

 On slide 15 under Mode of Service Delivery, we expanded the allowance for the use of videoconferencing. We will allow, for instance, videoconferencing to be use with psychotropic medication monitoring and training. We want to keep emphasizing to you that none of this happens until the amendments are adopted and so, don't think you have to necessarily do anything yet or don't reduce what you're doing yet based on what these amendments are expected to be. We will expand our allowance for videoconferencing in recognition of the wider use of telemedicine.

 Okay, now my co-speaker, and before I turn this over to Kristy too, somebody else that I did not introduce is Lee Ann Reinert. Lee Ann is on the call with us today to respond to anything clinical that might come up that we need her for. Kristy Herman from DCFS was formerly from IPI is going to go through with you all of the services and things that are different about the services.  

K. Herman  Thank you, Cathy, very much. I want to spend some time upfront talking about the major changes that we made to the mental health assessment and to the treatment plan, and then we will get into some of the specific changes that were made in the services.

 So, we're going to start on slide 16, speaking about the mental health assessment. The vast majority of the changes that are going to be implemented are made to consolidate or to remove required components of the MHA. We went through and determined that there were many components and many items in the MHA that we really could either do without or we could consolidate. I want to go through a couple of those that are on slide 16.

 "Extent, nature and severity of presenting problems" has now been consolidated to "reasons for seeking treatment, including symptoms." So, we will be looking for what symptoms are bringing the client to treatment, but again, hitting the extent, nature and severity of those will not be required. In addition, we've eliminated all of the specific items that were attached to the Mental Status Evaluation and we are really going to rely on the Q and L to identify what items are most salient to the client's mental status and to include those in the mental health assessment.

 In addition, we are not going to require a list of psychotropic meds that the client has taken or is currently taking. We just want to know if in fact the client has or is taking medication. So, let's move on to slide 17.

 Again, one of the examples of where we took some stand-alone MHA items and consolidated them is under "Strengths and resources." That will be a new section required. There are several items that are listed in "Strengths and resources" as examples of items that can be addressed to flesh out the strengths and resources that the client has, but you are not required to hit each individual one that's listed. Any time you see an e.g. in the rule, it means that those are examples of what can be addressed. We will also accept a client report on their general health. You don't have to have the specific findings for their last physical exam.

 The last bullet is an important note that I want to cover quickly. In the revisions to the rule, we have said that you do not have to include the specific part 132 services that are going to be provided on the MHA report. So, that is not required per se. However, an important note: If there is going to be any kind of gap in time between the completion of the MHA and the completion of the ITP, you still will need to have on the MHA report those specific part 132 services that you are going to provide in order for those to be determined to be medically necessary and properly authorized.

 So, if the MHA and ITP are done on the same day then you do not have to have the part 132 services on the MHA. If there is any kind of time gap between the MHA and the ITP, you will need to have the part 132 services included.

 I also want to just mention quickly about medical necessity since I mentioned that. In the current rule, there is some additional information about what we're looking for for medical necessity. That is in the current rule that was previously adopted. That information will need to be included in the MHA. So, make sure that you have reviewed the current rule for the requirements on medical necessity and that once the revisions are adopted that you begin documenting that in your mental health assessment.

 Okay, let's move on to slide 18, just a few points about the treatment plan. Not much was revised in the treatment plan section. One thing that we did do was to make it consistent with the Confidentiality Act, which states that a copy of the signed ITP must be given to the client. There is no room for contraindications of giving the client a copy of their ITP. So, while that is currently the case, it will not be once the rule amendments take effect.

 If you currently have a client where you did document that there was a contraindication for them being given a copy of their ITP, you will have 60 days after the amendments are adopted to document that you did give them a copy of their ITP. Okay, I'm going to move now into the specific services that we're going to talk about and we're going to start that on slide 19.

 One of the big revisions that we made was to community support. However, we did not substantially change the definition. The definition remains the same. We made a few wording changes that, again, were not substantive, but what we did was consolidate it from "community support individual" and "community support group" into one service. So, that service definition is now under "Community Support." "Individual" and "group" are the modalities that you can use to provide that service. They have the same service definition.

 This makes it consistent with other services like therapy/counseling that has different modalities, but again, the same service definition. So, the requirements remain the same about how you document your groups, how you document your community support individual interventions, and also for DHS/DMH providers, the utilization management requirements for community support group will also still apply. So therefore, you need to make sure that on your treatment plan, you are still indicating "community support individual" and "community support group" and indicating the amount, frequency and duration for each of those services.

 In slide 20, we are going to talk about case management - client-centered consultation. We did make a fairly substantive change to the service definition. And what we did was clarify what constitutes professional communication and who can be involved in that professional communication. So, the people who can be involved are provider staff of the agency or between provider staff and staff of other agencies who are involved in service provision to the client.

 Professional communication includes offering or obtaining a professional opinion regarding the client's current functioning level, improving the client's functioning level, discussing the client's progress and treatment, adjusting the client's current treatment, or addressing the client's need for additional or alternative mental health services. So, when you are engaging in a consultation with another professional staff, these types of services must be provided in order for it to qualify as client-centered consultation. Family members have been removed from the definition.

 So, if you were consulting with a family member about the client, it will not be client-centered consultation. However, you still have the availability of community support services and family therapy/counseling services in order to engage the family and bill for those services. So again, family members can be included in community support and also can be included in therapy/counseling, but will no longer be allowed for client-centered consultation. I want to note one exception to that and that is for professional foster parents when they are being consulted in their role as a staff person involved in the client's treatment.

 So, let's move on to slide 21; very quickly about assertive community treatment and community support team. For assertive community treatment or ACT, you must have a certified recovery support specialist on the team and for community support team, you may have either a certified recovery support specialist or a certified family partnership professional. And agencies will have 12 months after the rule amendments are adopted to make sure that these certified people are on the team.

 On slide 22, we just have one very quick note about psychosocial rehabilitation. We removed the minimum amount of time of 25 hours a week that the service must be made available.

 So, I am going to now turn this back over to Cathy who's to go through a couple of more slides before we open it up to questions and answers.

C. Cumpston Thank you, Kristy. I just wanted to remind you, all, again, as I had pointed out at the very beginning that when these amendments are adopted, we will let you all know. The rule as adopted will be posted. The survey tool, which is the guidelines, instructions, and checklist, will be posted. We will do an updated service definition and reimbursement guide, which will be posted, and we will also update our 132 Q&As, which are posted, to make sure that we no longer have any Q&A in there that is not relevant to the current rule requirements.

 The next couple of slides are resources for you. We have the DHS Bureau of Accreditation Licensure and Certification. They have a Chicago, Springfield, and Marion office, and those are the phone numbers for those. We also list the Infant Parent Institute phone number in Champaign and the Illinois Mental Health Collaborative for Access and Choice and their phone number. And then, we also have a slide with some of our e-mails and phone numbers where you can reach us if you need to, and also to remind you that any time you have a Rule 132 question, there is an e-mail address that you can send that to. We meet on a weekly basis, a group of us from DCFS, IPI, the collaborative, DMH, and BALC, to jointly review those questions and respond to them and we then always send the response back to the person that asked it and then on a quarterly basis, make sure those get added to the Q&As on the Web page. And then, again, to remind you of where those Q&A responses are.

 So, I would now, Dave, ask for you to open this to questions. However, I do want to ask that everyone focus their questions on the amendment to the rule and to talk about what was presented today rather than asking about other interpretations of rule. Again, if you have those, we would be glad to address them, but we would prefer that those get sent to the DHS MH e-mail address so that we can, together as a group, respond to those to continue to assure as best we can that there is consistency. So, we would now open it to questions.

Moderator First, we'll hear from the line of Sheila Ferguson and Ms. Ferguson, if you could announce who you're with I'd appreciate it.

S. Ferguson Hello, Sheila Ferguson. I'm a CEO here at Community Elements in Champaign. I wondered if you could take a couple of minutes to explain the rationale for the change in definition of MHP and RSA for that matter.

C. Cumpston From what perspective, Sheila - from just why we want a GED or why we have added this CFPP to the MHP?

S. Ferguson Both.

C. Cumpston Okay. All right, well, we recognize for certification purposes that the people that have gone through this certification have gone through a lot of training and they have learned a lot about the delivery of mental health services. The MHP already included the CRSS and we felt that it was important from a child and adolescent perspective to also include the CFPP.

 As far as having a GED or high school diploma, we just felt that that was an important basic starting point from which to move on into mental health services. Again, we did provide for a grandfather clause so that those people who are currently working for you and qualifying under those two titles will be able to continue to do so.

Moderator Thank you, Ms. Ferguson. Any further questions?

S. Ferguson Just a quick question. Is there a reason for limiting the disciplines that they come from in terms of the professions, their degrees?

C. Cumpston Oh, I'm sorry. I forgot about that part. We had been asked many times over the years to give examples. We frequently would get calls or e-mails saying, "Well would this qualify" or "Would that qualify?" And so, we had conversation about that and decided that we really did need to be more specific about what we felt were reasonable disciplines to be included.

S. Ferguson So, just another clarification. There isn't any CMS requirement about which disciplines should be included?

C. Cumpston Federal CMS?

S. Ferguson Yes.

C. Cumpston There are very few federal CMS requirements about anything in relationship to Medicaid. They expect that the Medicaid state agency, which in Illinois, of course, is HFS, will develop the requirements and of course, HFS is always integral in our working on amendments to this rule, we'll develop the requirements for the state. So no, there are no CMS requirements for most any of this.

S. Ferguson I guess our concern is just the limits on the disciplines, but I think as probably most people are waiting to see what JCAR rules and kind of moving on from there. Thanks.

C. Cumpston You're welcome.

Moderator Thank you very much. Next, we'll hear from the line of Rick German with Alexian Brothers. Go ahead, please.

R. German Hello, folks. How are you doing?

C. Cumpston We're doing great. How are you today?

R. German Very good, thank you. I'll be very brief. A couple of quick questions; you mentioned on page eight about extrapolation and extrapolation is not required, but allowed. Has the decision been made as to how that decision would be made whether or not to extrapolate?

C. Cumpston It has not. I think first of all, we would have to be more comfortable that the economy had improved, that extrapolating and taking money from providers wouldn't put them out of business. That is a big concern of ours right now. We're doing everything we can just to keep everybody afloat and to keep money flowing as best we can. So, that would be a very first consideration that we would make.

 Additionally, I think another consideration would be that we would perhaps get pressure from the feds. When the feds do an audit, they do extrapolate, but we haven't gotten any such pressure. So, we're just there in case that should happen.

 But, we don't have any immediate plans to do so. Additionally, as I mentioned earlier, we would have to be very sure that we had a very sound process to assure a truly random sample of records to be reviewed that would stand up in court, and we don't currently have that. So, there are a lot of considerations that would have to be made before we would ever move to extrapolate anything and right now, we are not even considering doing so.

R. German Understandable and I think the fear some may have has to do with equitable extrapolation. If agency X is extrapolated and agency Y is not, how that decision might be made and it sounds like what you're saying is if there was federal pressure, it would probably be in an across the board process. Is that correct?

C. Cumpston Yes, it would.

R. German Thank you. The next question I have is in regards to redundant recordkeeping requirements. I love the idea behind that. Will there be a list of specific examples of redundancies that we can look for so we can change our process?

C. Cumpston When the rule amendments are adopted you would be able to see what had been removed and then you could change what you do based on that. Are you really wanting to know who is now requiring what we will no longer include in the rule?

R. German That's it.

C. Cumpston Yes. If you have contract language. So, you've got the community services agreement with DHS and you've got attachment B and you've got other perhaps attachments depending on where your funding comes from. There are requirements there. Make sure you are compliant with those requirements.  If you are contracted with other departments, make sure you're compliant with them.

 I mean we did not do a review of this where we know that those things we removed are actually required in any specific place by someone else. We determined that the requirements removed are more contract sorts of language or fiscal sorts of language and not really pertinent to the provision of mental health service. So, that's also why we removed them.

R. German Okay. I won't take up too much more time; two more quick ones. Under the "Restriction of client rights," we have, and it's a very small percentage; maybe I think we may have four clients out of the 4,000 we treat that we have administratively closed for behavioral reasons. Unfortunately, we did have a client attack a psychiatrist and that individual was closed.

 I am to understand that we have to have a written plan signed by the client and the parent or guardian Q and the L regarding the process for reinstating the right for treatment here. Is that correct in those cases?

C. Cumpston No. When somebody is terminated from services that is not a restriction of their rights. A restriction of right would be, and perhaps Kristy or Lee Ann might be able to help me with what actually restriction of rights might be.

 But if, for instance, somebody has the right to provide input or they have the right to have their treatment plan, or they have the right to refuse medication or they have-you'd have to go back and look at the mental health code and look at what people's rights are, and if you say that, "No, we're not going to let you do this while you are in treatment with us because of some reason," then you are restricting a right, but it is while they are in treatment. It is not their right to receive treatment from you.

 So, if they have done somebody that has caused you to terminate treatment for them, then that is not a restriction of rights and you do not have to do this.

R. German Got it. Last question; just so I'm clear, on the MHAs, we no longer are required to include the name and contact information for the client's primary care physician. Is that correct?

K. Herman No, that's not exactly correct. The primary care physician has been moved into a different section. So, it's still going to be required, but we moved it into identifying information.

C. Cumpston Yes. Instead of where it was, it is now-it's listed with identifying information - name, gender, date of birth, primary language and method of communication, name and contact information of client's primary care physician and guardian.

R. German Got it. That's all I have, folks. Thanks a lot.

C. Cumpston Okay.

Moderator Thank you. Next, we'll hear from the line of Linda Denson with the Chicago Department of Health. Go ahead, ma'am.

L. Denson Good afternoon.

C. Cumpston Good afternoon.

L. Denson I listened to your presentation. The only question that occurred to me was when on slide 18 where you talk about the signed ITP and you did say if there was a gap in time between the MHA and the ITP, but you didn't indicate how much time was within that gap.

C. Cumpston It would be any amount of time.

L. Denson It could be any amount of time. Then who makes the decision if you've exceeded that time? Is that something we can do as an organization?

C. Cumpston Well, first of all, the rule used to require that the 132 services to be provided had to be included on the mental health assessment.

L. Denson Correct.

C. Cumpston That was the requirement and then they also had to be included on the ITP.

L. Denson Correct.

C. Cumpston Well, we heard from a lot of providers that that was a redundant requirement because quite often, they would do the mental health assessment and the ITP all together. And so, we said, "All right, if you're doing them all together, you don't need to list the services in both places. However, if you're not doing them all together and you intend to provide any service after the completion of the mental health assessment and prior to the completion of the treatment plan, you have to have the services listed."

L. Denson But, you don't say how much time is given to do that.

C. Cumpston How many days do you have to complete - 45 days to complete the treatment plan?

K. Herman It depends if you did an admission note, or if you started with the MHA. The gap in time is-any gap in between the MHA and the ITP, if the services are not on the MHA, those services are not authorized. So, if you have even a day in between the MHA and the ITP and you do not put the services on the MHA and you do provide services on that day that you do not have in the ITP in place...

L. Denson Which most providers do.

K. Herman Exactly, those services are not going to be authorized.

L. Denson Okay.

C. Cumpston Therefore, you cannot bill for them.

L. Denson Okay. That's what I wanted to hear you say.

K. Herman in time between the MHA and the ITP where you may be billing for a service, you want to make sure that those services are on the MHA.

L. Denson Okay, thank you.

C. Cumpston Does that help?

L. Denson Yes, it helps a lot. That's what I needed you to say, that those services would be unbillable if they weren't on there.

C. Cumpston Yes, that's a good way to say it.

L. Denson Thank you.

Moderator Thank you very much. Next, we'll hear from the line of Roxie Oliver with Mental Health Centers. Go ahead please.

R. Oliver Hello.

C. Cumpston Hello, Roxie.

R. Oliver Hello. How are you all?

C. Cumpston Good. How are you doing?

R. Oliver Good. I have three questions. Going back to the primary care physician question, I understand that it's been combined into a different location. Does that mean that if we keep it in the location that we have it at on our application under the medical history, would that be okay, or do we have to put it under a certain section, the section that you have it in?

C. Cumpston No, that's fine. If it's on there now, that's fine.

R. Oliver Okay. So, it just needs to be on there.

C. Cumpston Exactly. You don't need to reorganize it. We reorganized it in the rules to kind of make more sense, but it's part of identifying information. So, you don't have to redo your form.

R. Oliver Okay, thank you.

C. Cumpston Sure.

R. Oliver The second question is just a clarification on the case management, client-centered consultation. It's pretty clear on the slide presentation that client-centered consultation cannot be done with family members. The draft rule that I have, which is in January, on page 20122 continues to list family members. So, there's a little incongruency there.

C. Cumpston Oh, you're absolutely right, Roxie and that was pointed out to us in the comments and that's one of the proposed changes to rule that we have included.

R. Oliver Okay. So, they cannot be included under client-centered consultation and the rule will be changed to reflect that.

C. Cumpston Yes, unfortunately, was a typo in the rule that was published.

R. Oliver Okay and then the last question I have is kind of, I guess, a technical question, but it's talking about the post-payment review process. When the collaborative ... usually they start doing their post-payment reviews usually in the fall. And so, since this rule hopefully will be adopted in 60 days, when the collaborative comes in the fall and they'll be looking at FY12 claims, which rule will they be using to check for compliance issues?

C. Cumpston The newly adopted one.

R. Oliver The newly adopted.

C. Cumpston I'm sorry, Roxie. Let me back up. When they're looking at any of the claims for services prior to the adoption of these amendments, they will be looking at the mental health assessments and the treatment plan and the documentation requirements of the rule prior to the changes. If they've got claims made after the rule amendments are adopted, given the 30 day/12 month grace periods, they will be looking with the new requirements. But, the actual post-payment review process will change to be as it is in the amendment.

R. Oliver Okay. So, I want to make sure I get this straight. So, when they come and they're looking at any file that was in FY12, like January, say a service in January or February of this year or even June of this year, they will use the former rule. But if they come in October and the amended rule is in September they would be using the new rule.

C. Cumpston Yes and the same thing will apply to certification reviews.

R. Oliver Okay, thank you.

C. Cumpston You're welcome.

Moderator Thank you very much. And next, we will go to the line of Becky Carroll in Christian County. Go ahead please.

B. Carroll Hello. I just had a couple of questions. First of all are on the 60 days changes once the adoption is taken care of. On the ITP, you had said something about if it was contraindicated. Can you define that first?

K. Herman In the past, if there was any kind of clinical contraindication that a client shouldn't be given a copy of their treatment plan, that was allowed. For instance, a therapist was concerned that the client would take the plan and mail it to somebody or post it on their wall or wouldn't protect it the way it is supposed to be. They could have said it was contraindicated to give this client a copy of their treatment plan. That is no longer allowed.

B. Carroll Okay, so anybody that declines, they don't want it, they don't need it is not a problem still.

K. Herman No. All you have to document as a provider is that you gave it to them.

C. Cumpston Yes, you gave it to them.

C. Cumpston Right. What they do with it after the fact if they don't want to keep a copy of it or they throw it in the trash that's what they do with it.

B. Carroll So, they can no longer say, "I don't want a copy." We still have to copy it and give it to them.

C. Cumpston Yes, go ahead and give it to them and they can then throw it in the trash as soon as you give it to them.

B. Carroll So, my question then is within 60 days-let's say this is adopted July 1st. Within 60 days, I have to make sure that I see every client that we have in our business and give them a copy and you want a new page saying that they received a copy.

K. Herman Not necessarily. No. This only applies if you have a client where you've documented a contraindication for them receiving or being given a copy of their treatment plan.

C. Cumpston Yes, this only applies to anybody who you have not documented that you've given one.

B. Carroll But, that's two different things. Contraindicated does not mean they didn't want it.

C. Cumpston Right. Well, if you have not documented that you gave them a copy of their treatment plan then you have 60 days to give them a copy of their treatment plan. I mean it doesn't say that you have to do that face-to-face. I suppose you could mail it to them.

B. Carroll Okay, but I need something in the file that you would look at then because I have a whole bunch that they don't want them. So, we mark on there that they did not want it and they put the reason for declining - they didn't need it, they already have it, they don't want it.

C. Cumpston If you have already documented that you had attempted to give them a copy and they said, "I do not want it," that's fine.

B. Carroll Okay.

K. Herman This change really is focused on the ones where there was some contraindication indicated by the therapist saying I'm not going to give to them because of this reason.

B. Carroll Okay. The other 60 day that you have is on a new copy of the client rights.

C. Cumpston Not a new copy of the client rights; a telling them of their rights.

B. Carroll Right. You said it needs to be in everybody's file within 60 days of the time that this comes into effect. So, if I have done that every year, once a year, on all my clients, are those still valid or do I need to redo it to show everybody within 60 day frame?

C. Cumpston No. If you've been doing it every year, you're good to go.

B. Carroll Okay. My last question then is on the summary notes. You said a summary note is no longer accepted.

C. Cumpston Right.

B. Carroll Okay. So, how will that impact or how would I do a PSR for the day? They have five classes in a day and they may attend one; they may attend five. So, if they attend five classes, I need five notes?

C. Cumpston Yes. You would be documenting what you delivered to them for PSR.

B. Carroll And, that can't be one note.

C. Cumpston Already we have been asking that you document what goes on in each event. So, it has not been acceptable for some time for you to just say, for instance, participated in PSR today.

B. Carroll No. We document each individual class and the title of the class and the instructor of the class, what the class was, the group activity, but then we do a summary of that client's attendance for those classes. So, there's one summary for all the classes that day and when I bill, it bundles it together anyway into one claim. So, I'm not sure why I should have to do five separate notes for five classes when the bill is going to come in as one class anyway, or one group.

C. Cumpston I think I'm not quite understanding.

B. Carroll Okay. If I have someone that attends five different classes throughout the day today, the PSR, five different groups, maybe even five different titles, everything is different to it. When those classes are done, you're saying I can't do a summary note. So, I need five separate notes.

C. Cumpston Tell me more about what you're now documenting. You have five classes and you have a person and they're all groups and you have a person that participates in all five of those.

B. Carroll Correct.

C. Cumpston All right. How do you document for that person's record what they have done for the day?

B. Carroll We have two things. We have a master roster where they have initialed their name and signed in and we were told initials were fine.

C. Cumpston Yes, so that you know who was...

B. Carroll ...who attended. We have that on file for any time it needs to be looked at and then we have a note which is the summary of that client. You know, "The client participated in five classes today. They did really well in this class or responded well in this class or responded well in this class. They struggled with maybe the, I don't know, budgeting class" and they do a summary of that class or those classes on one note.

C. Cumpston All right.

B. Carroll When I bill it, I will bill five specific classes, but it's all the same activity codes, same date, same time, same staff. So, this is bundled together as one event when it comes to you.

C. Cumpston I think from what you're describing that sounds okay.

B. Carroll But earlier you said no daily, weekly or monthly summaries.

C. Cumpston But, you're really describing, you're really documenting each class and you're really documenting what that particular client did in a particular class and how they responded that day to that class.

B. Carroll Correct, but it's on one note.

C. Cumpston Okay. What if that client one day decides-so, if they decided not to do two of the classes that day then your note would describe-

B. Carroll ...the other three that they attended.

C. Cumpston ...the three and it would also then describe their response to that intervention, which was PSR and how it related to their objective.

B. Carroll Correct.

C. Cumpston Okay. If it would be helpful to you, if you would like to send us more detail about how you're doing this just to be sure, we'd be glad to look at it for you, but it doesn't sound like what I think of as a summary note.

B. Carroll Okay. I just know that I'm billing five classes and we have one note.

C. Cumpston Yes, okay. Send it to us and let us look at it in more detail.

B. Carroll Okay, what Web address?

C. Cumpston

B. Carroll Okay, perfect.

C. Cumpston We'd be glad to look at that for you.

B. Carroll All right, thank you.

Moderator Thank you. Next, we will hear from the line of Sherry Peyton with the Egyptian Health Department. Go ahead please.

W. Scates This is Wanda Scates with Egyptian and I have a question on client rights. It's my understanding that we need two things. We need to amend all of our statement of rights to indicate how we will document a plan of restricting the client rights. Then, we also need to develop a plan that the client, the LPHA and the Q signs. Is that correct?

C. Cumpston Well, maybe. I think that what you need to do is amend your policy saying that if there is a restriction of rights, just like you said, the following things will happen and then, if you have anyone whose rights you are restricting then you should go back and develop a plan specific to them.

W. Scates Okay and we can do that. So, that really means then that every statement of rights will have to be-we will have to do a new one within 60 days because the old statement of rights will not contain this plan.

C. Cumpston Thank you. We hadn't thought about that. We had said that you had-no, we had thought about that. Well, we didn't think about it from a perspective of giving it to people.

W. Scates Well, I'm talking about that we have to amend the statement of rights ... given to people.

C. Cumpston Yes, I understand exactly what you're talking about because we have said that policy changes-we wanted you to actually redo your policy in 30 days. We then did not say in explaining to the clients that we wanted you to then re-explain the rights to everyone. I think that we still may not expect that of you.

W. Scates Okay. So, if we amend the policy then...

C. Cumpston Yes, if you amend the policy in 30 days and then those people that need to have their rights re-explained to them, if you have anyone that you haven't told their rights to in the last year then you could tell them with the new rights policy and anyone else, you would have on record that you had explained their rights to them within the last year. And then, when it comes up again, then you would add the new section for the new rights statement.

 However, if you do have anyone whose rights are being restricted then you do have to get this plan in place. But no, we will not require or expect that when you have changed this policy that you then have to go back and include that in an explanation to everyone until it is time to tell them of their rights again.

W. Scates Okay. So, it'll go in the policy, not in the statement of rights.

C. Cumpston Yes. Well, I mean you could put it in the statement of rights, but we wouldn't...

W. Scates Well, that's different for everybody.

C. Cumpston Okay.

Moderator Thank you very much. Next, we'll go to the line of Allen Hall with Met Fam Services. Go ahead please.

A. Hall Good afternoon, everyone. I had a question on the mental health assessment page and I was curious about the thinking and the language where you said "Change the extent, nature and severity of presenting problems to reasons for seeking treatment including symptoms." We've been working very hard since this is so linked to medical necessity to actually include how severe the presenting problems are in this first section, first page because it certainly speaks to the functioning decreases of people and we would include that functional language. I'm wondering is it that you just don't expect it in the presenting problem and it can occur later, or is this a different way of thinking that I don't understand?

K. Herman Well, one of the issues that we have had is that providers getting the extent, nature and severity of the presenting problems documented in the mental health assessment has been an ongoing struggle. They may get the nature, but not the extent or they may get the severity, but miss the nature and the extent. And so, in broadening it, we really wanted providers to focus on why does this client need treatment now?

 Now, I personally believe that putting the extent, nature, and severity offers a much better picture. But again, holding people to each of those three discrete items was problematic. So, if we can focus on what are the reasons that this client is seeking treatment, what symptoms are they experiencing, that is also going to help underlying medical necessity for treatment. Does that help?

A. Hall It does. It seems to be still for me somewhat loosening of the expectation, which I would be concerned in this era of medical necessity because we try to work with our staff to actually include people with long-standing problems, when was the most recent exacerbation, was there a precipitating event, what got the attention for someone coming into services of family or other reference because a change in symptoms. So, we really try to give, again, the most comprehensive reason so to speak for coming into services now.

K. Herman I would encourage you to continue with that practice because you are correct. I mean here, the language has changed to "Reasons for seeking treatment, including symptoms." But when you look at what the documentation requirements are for the medical necessity, it really does ask for much more specific information.

 So, I think that you are correct. It's just we had lots of problems with people being able to hit the extent, nature and severity. So, we broadened the language a bit to, again, focus on why is this client seeking treatment. I think all of the information that you referenced is also extremely useful.

A. Hall Thank you.

C. Cumpston You could continue to do exactly what you're doing.

A. Hall Thanks.

Moderator Thank you very much. Next, we will go to the line of Susan Hudson with Grundy County Health. Go ahead.

S. Hudson I have just a question of clarification on slide number 17 regarding the mental health assessment. As I understand, once the mental health assessment was completed, no services were to be offered until the ITP was developed and in place other than crisis intervention with the development of the ITP and possibly case management. But, it looks like it definitely was not to include therapy as I was given to understand.

 It now appears that when this is adopted, we would be able to provide therapy, for instance, or case management as long as it's identified in the MHA as interim service. Is that correct?

K. Herman Yes, I just want to offer a clarification on your first point. The services that you mentioned can be provided before the MHA is completed. So, that has been in rule and any service provided after the MHA is signed and dated had to be on the mental health assessment in order for it to be provided. So, I think there was a little bit of confusion between what could be provided before the MHA was completed and what could be provided before the ITP was completed. So, the change here does not impact those particular services that can be provided before the MHA is completed.

S. Hudson So, are you saying that actually therapy can be provided before the MHA?

K. Herman No. No, no, no. I'm sorry. Don't misunderstand. I want to be very, very clear. When you're doing the mental health assessment, you can do case management for the 30 days prior. You can do mental health assessment. You can do crisis intervention before the mental health assessment is completed. Once the mental health assessment is completed, any service that you have indicated on the MHA report can be provided after the MHA is completed.

S. Hudson All right and that would include therapy then.

K. Herman As long as it's on that MHA.

S. Hudson All right. That was the clarification I needed. Thank you.

K. Herman Okay.

Moderator Thank you very much. Next, we will go to the line of Theresa Good.... Go ahead please.

T. Good  Hello. We have a question on client rights and I was wondering if since we have 60 days of the effective date, what if our clients don't come in within those 60 days? Like we have three month med check clients. So, we could miss a few.

C. Cumpston Are your med check clients receiving 132 services?

T. Good  They could, yes.

C. Cumpston They could or they are?

T. Good  They are. We have both.

C. Cumpston Okay, because, again, remember, this rule only applies to 132 services.

T. Good  Correct. So, yes, it's a 132 service, every 90 days. So, if we have to re-explain the client rights annually what trouble are we seeing if we don't do it within 60 days?

C. Cumpston Big trouble.

T. Good  All right.

C. Cumpston Do what you can do to get the rights explained.

T. Good  Can we mail something?

C. Cumpston You could mail them a rights statement. That would be fine. There's nothing that says you couldn't do it that way, or you could also take your chances on what records will be pulled during a certification review.

K. Herman The other thing that you could do, I'll toss this out, is document the reason you weren't able to do it within the 60 days and just make sure that in the record, you're clearly stating you haven't seen the client within these 60 days. That would be another way to cover yourself.

T. Good  That helps.

C. Cumpston And then make sure that when they are in next that they get their rights explained to them.

T. Good  Yes, okay.

K. Herman Now, if we see in the record, "Well, we haven't seen the client in these 60 days" and then we see two appointments go by and you still haven't explained it to them that will be a problem.

T. Good  Then we will be in trouble.

K. Herman Then you will be in big trouble.

T. Good  Okay, thank you.

Moderator Thank you very much. Next, we will go to the line of Jessica ... with the Baby Fold.... Go ahead please.

Jessica I want to talk about slide 20, the case management client-centered consultation. I just have kind of a specific question. In a ... or like a child and family team meeting, we were billing client-centered consultations even if the child or the family were in there because there was a bunch of other professionals in there. Will we not be allowed to do that anymore?

K. Herman That will still be acceptable. I mean if the family is present in a professional meeting, you're still billing for that professional meeting. So, if the family is present that does not automatically mean that you cannot bill that.

Jessica Okay, great. Thank you.

Moderator Thank you. All right and next, we'll hear from the line of Pam White with The Human Service Center. Go ahead, please.

P. White Hello. I have several questions. The first one is on slide 12 regarding client rights and I just want to make sure that I heard this correctly. If we were to mail our clients an updated copy of their rights, did I hear it said that that would constitute explaining their rights?

C. Cumpston Well, that would be fine if there are people that you need to re-explain rights to within the 60 days and they're not going to be in and you cannot explain the rights to them. But, to just routinely mail copies of rights out and have that be acceptable as an explanation of rights is not allowable. But, if you have a lot of people that you're not going to see, that aren't going to be coming in, that you have not been explained the rights to them on an annual basis or they have been in service longer than 12 months and you need to get their rights explained to them then mailing out when they've not been there or when they're not going to be there would be acceptable. But, if they're coming in for regular treatment then we would expect that you would be explaining rights to them.

P. White Okay. Is that clarification included in the rule language?

C. Cumpston The rule just says that people will have their rights explained to them annually.

P. White Will it be in the interpretive guideline?

C. Cumpston The interpretive guidelines will offer that you have 60 days to do that.

P. White Okay. Another question I have is on slide 17 regarding the mental health assessment, the first bullet. Could you give us some examples of what you'd accept as employment history? The reason I'm asking is because our organization has been cited for this in previous post-payment reviews.

C. Cumpston Now, remember, that is an example of a strength and resource. That is only an example. What we want you to do with these amendments is talk about the client's strength and resources, and one of those might be employment history.

K. Herman So again, that was one of the items that we removed as a standalone item and consolidated under strengths and resources. So, if that client doesn't have an employment history or the employment history really doesn't apply as a strength or resource then you do not have to address it.

P. White Okay. Thank you. The next question, on slide 18 regarding the copy of the treatment plan. I wanted to clarify it. So, our organization has offered clients copies of their treatment plan, but if a client declines, we just documented that by their signature. Will that practice still be acceptable?

K. Herman Yes, that is fine. Again, this is not about a client declining to accept a copy that's been given to them. This particular item is about a therapist who says, "No, it is clinically contraindicated. I do not believe it's in the clinical best interest of this client to give them a copy." That is no longer allowed. If the client refuses, they refuse.

P. White Very good.

K. Herman Yes, you just have to document that you offered, that you gave them a copy.

P. White Or that they declined receipt of the copy that we offered?

K. Herman You gave it to them and they refused to take it, yes.

P. White Okay and last question is on slide 20. During the presentation-this is about case management client-centered consultation. During the presentation, the speaker gave some examples under that first bullet. Could those be repeated please?

K. Herman You know what? That is really just the definition. I'm happy to repeat it, but it is published in the rule. My point is you don't have to write it down.

P. White Could you just repeat those please?

K. Herman Sure, sure. Absolutely. This is about the professional communication and it includes offering or obtaining a professional opinion regarding the client's current functioning level or improving the client's functioning level, discussing the client's progress in treatment, adjusting the client's current treatment or addressing the client's need for additional or alternative mental health services. Again, that will be published in rule. That is a part of the new definition of client-centered consultation.

P. White Okay. Thank you very much.

K. Herman Okay, no problem.

Moderator Thank you. Next, we'll hear from the line of Laurie Holdener with the Chestnut Health.

L. Holdener Hello. I have a couple of questions. The first one is on slide ten regarding the Healthcare Registry. I just want to kind of double-check the intent of that. So, if the rule is adopted, we check the registry for every existing employee and then as new employees come on, we check the registry for them. That meets the intent of that requirement?

C. Cumpston Yes.

L. Holdener Okay. So, there is nothing saying that you have to recheck it at some point in the future to see if anybody's gotten anything, maybe if they worked at another organization at any other point in time.

C. Cumpston I don't know. Well, if they're working for you and working for somebody else?

L. Holdener Yes. I don't know that we've ever had it come up, but we have discussed it. We check the Healthcare Registry on everyone at the time of employment. So, that part's not a problem for us. I just was wondering if there was an expectation that you would have other ongoing checks to see if maybe somebody did get put on the registry maybe from being employed at another organization.

C. Cumpston I don't believe that there is such a requirement. Our rule does not require it.

L. Holdener Okay. That sounds fine. On page 14 regarding the mental health documentation, it says that it now must include a description of the time-okay, must include a description of the time spent with a client or collateral gathering information. What we were doing was basically on the mental health document itself, the assessment document, we would just have a place that had all of the required information around dates, start times, duration, staff signatures and credentials. The impression I get from that is that you're looking for like a progress note that also supports the document and that the document as a standalone would not be acceptable.

C. Cumpston So, what you had done to bill the service of mental health assessment was just around particular pieces of your mental health assessment. You had indicated the date, the time, the duration, signed and dated by whoever did that piece.

L. Holdener Right. Yes, normally, it always got done in one session, but there were occasions where it might be extended beyond. But yes, it broke out in terms of if it was extended.

C. Cumpston It was always done by one person in one setting.

L. Holdener Right and basically what we did was right above where their signature was, it had the billing code and all the required information, but the document itself, the assessment stood as the documentation of the assessment. But, it sounds like that won't work, that you're going to want the progress notes in addition to the document.

C. Cumpston I don't know that we need to change what you're doing because what the documentation requirement is for doing MHA or ITP development is to talk about basically the pieces that you have done. So, if Kristy, for instance, does parts one through four of the mental health assessment this afternoon then her note would say, "Today from this time to this time I completed blah, blah, blah, blah of the mental health assessment," signed and dated.

 But if Kristy spent today, this afternoon, a given period of time doing the entire mental health assessment and at the bottom of the mental health assessment it said, "Today from such-and-such to such-and-such I began and completed all components of the mental health assessment," signed and dated I think that would really be saying the same thing.

L. Holdener Okay. That sounds good. That's exactly what we do. If it doesn't get done in one setting, we do do a progress note that tells the part that we did complete. Okay.

C. Cumpston Excuse me just a minute. If anybody is-if you're doing pieces of it at any one time there better be a progress note describing what was done.

K. Herman I'll just jump in here quickly; sorry. The thing that we need to distinguish is that you are billing for the time spent with the client.

L. Holdener Oh, absolutely.

K. Herman Again, I'm not looking at this. I'm just hearing your description and the problem that I have just listening is that I'm not sure what part of it is billed for being with the client and what part of it is billed for just sitting down and completing the assessment.

L. Holdener Yes, no. Duration is only the time you're with the client.

K. HermanIs that very clearly indicated on there?

L. Holdener It says start time and duration and that's the way it's defined is the time you're with the client. I mean we never bill for paperwork.

But how do we know that looking at your notes?

K. Herman I guess that's my question. How would that be distinguished?

L. Holdener How is it distinguished in a progress note? I mean I don't understand.

W You said you didn't have a progress note.

L. Holdener No. I'm just saying how would that be different?

K. Herman  In the progress note what you would be documenting is the information that you gathered from the client and the discussion that you had with them or with the collateral. That is clearly what you would be billing for and documenting in the progress note. Does that make sense?

L. Holdener I'm not sure that it does. I mean I think I can kind of understand what you're saying. Yes. I mean that's a known and that's a given.

This is not a known or a given. You may know it and it may be a given to you but that is not necessarily common. For a reviewer it would not be assumed so I think that what you're doing is probably acceptable with some tweaking. I think that if somebody works with the client, completes the mental health assessment in one sitting, and has everything done and documents that on the mental health assessment such as, "Worked with client to complete all components of the mental health assessment from such and such a time to such and such a time," signs and dates it, that's almost like having a progress note on the mental health assessment.

L. Holdener Right, which was I think what we thought we were doing.

W Since, as Kristy said, we're not seeing what you have written, it may be just fine as long as it's clear that what you are billing for there is that the whole thing was done with the client in one sitting and you are billing for the time that the person worked with the client to complete the mental health assessment.

L. Holdener Okay. Alright. Then the last question I have, I think I understand about giving the copy of the ITP because we were doing much like the other agencies where we were saying we have a place where we offered it to them and they'd check whether they accept it or decline it. I think what I'm hearing you guys say is that it needs to say we gave that to them and they accepted it or declined it.

K. Herman Yes. It really needs to say gave not offered.

L. Holdener Right.

K. Herman You know a long time ago a couple of rules back it did say, "Offered." That language has been changed to, "Given," and that again is in keeping with the Confidentiality Act.

L. Holdener Okay. Then just one other quick question just on the client-centered consultation and not being able to do it with family members any more, I think that just feels surprising. I think in the environment that we're in with recovery and using a person's resources and strengths, which often time is their family member, it doesn't feel right that we can't bill for the times that we're trying to build those relationships and use the information that they have to help treat the person.

K. Herman I'm really glad that you brought that up because those types of interactions with the family do fit very well under community support in developing the natural supports for the client. They would not really fit very well under client-centered consultation but, again, they fit beautifully under community support and that is still an allowed and encouraged service for family members.

L. Holdener Okay.

K. Herman Does that help?

L. Holdener Yes. That does help.

K. Herman Okay. Good.

L. Holdener Alright. That's it. Thank you guys.

W Dave, before we take another question, I understand that some people didn't have a copy of the PowerPoint. It was sent out with the announcement of this training, so whoever received the announcement of the training would have then received the PowerPoint. I apologize if somebody didn't get that passed on to them and had to go through all of this without being able to look at the PowerPoint. Whoever in your agency received the notice of the training along with that notice came the PowerPoint. Thank you.

Moderator Alright. Thank you. Next, we'll hear from the line of Donna Marascas with North Point Resources. Go ahead please. Okay.

 Alright. Then we'll hear from the line of Amy Gilbert with Crosspoint Human Services. Go ahead please.

Yes. Can you hear me?

W Yes. We can.

D. Bowman Hello. Dave Bowman actually has the question from Crosspoint. I remember hearing you mention that the medical necessity will be included in the mental health assessment. I guess my question is maybe two things, one is it really hasn't technically been part of the mental health assessment and secondly, do you want it to be a freestanding section or can it be included in different parts throughout the mental health assessment? What do you think would be the best way to handle that?

K. Herman It doesn't necessarily have to be a specific section as long as you have hit all the requirements for medical necessity throughout the assessment. My recommendation would be that you have all of the items that are required under medical necessity highlighted on the assessment. That really is just to make sure that staff are aware of all of the items that need to be included and that they're clearly documenting them. I wouldn't just rely on your mental health assessment document to cover everything that's needed. Does that help?

D. Bowman That helps quite a bit. Thank you very much.

W And then it could especially be part of the summary because it's really the 'L' that is making the determination about medical necessity.

D. Bowman Well, in past I took the medical necessity component when it was first introduced and develop questions from those that fit all the circumstances for adults, for example, and children. Those were answered by the clinician specifically.

W Excellent.

D. Bowman Does that sound like maybe a good way to approach medical necessity?

W I think that sounds very good.

K. Herman Yes. Again, I would just encourage you to go back to the rule and make sure that all of your questions address the items that are specifically asked for under medical necessity.

D. Bowman Okay.

K. Herman If you already did that, great.

D. Bowman Okay. Alright. Thank you.

Moderator Thank you. Next we will go to the line of Mary Hough with Resurrection Behavioral Health. Go ahead please.

M. Hough Hello.

W Hello.

M. Hough Okay. Just making sure you can hear me. We just had a question regarding the mental status under the mental health assessment. It states that you've removed all the specific requirements of the mental status evaluation. Are you stating then that we don't have to do this in conjunction with the mental health assessment?

K. Herman No. There does have to be a part of the mental health assessment that's called the mental status evaluation.

M. Hough Okay.

K. Herman What we want to do is leave the option for the 'Q' and the 'L' to address the items that they really feel are relevant to the mental status of the client and not be boxed in by all of the checklist of things that we're required before.

M. Hough We have ours as a standalone document so I'm not exactly sure what requirement you're removing.

K. Herman Well that should have been a part of the mental health assessment.

M. Hough We do it with that but it's a freestanding document because other programs don't use that and we're all electronic.

C. Cumpston When the reviewers come in and they want to see a mental health assessment they're going to want to see all components of the mental health assessment. Whatever format you have them in you'll have to be able to show them that you have a completed mental health assessment with all components, including a mental status evaluation signed and dated by a 'Q' and an 'L'.

M. Hough Okay.

L. Reinert This is Lee Ann, Cathy, if I could add to that just a little bit. If you have one that you're already using there's nothing about the rule change that's going to make you stop doing what you're doing, as Cathy said, as long as you can show that it's a part of your mental health assessment report. The reason that we made the change was the rule as it stood before specified some various pieces of mental status evaluations or mental status exams, but it wasn't all the pieces of any one standardized mental status exam. It was kind of pick and choose, I guess, so rather than have certain pieces of different mental status exams somehow seem to be more important than others, what we want you to do is do a mental status exam but we're not telling you you have to do a specific one.

M. Hough Okay.

L. Reinert Make sense?

M. Hough Yes. It does.

L. Reinert Okay.

M. Hough Okay. Thank you.

C. Cumpston Thanks, Lee Ann.

L. Reinert Sure.

Moderator Thank you. Next we will hear from the line of Sue Ellen Dicker with the Center for Children's Services. Go ahead please.

A. Weedman Hello. This is Amy Weedman and my question is in regard to community support being consolidated. Does this mean that community support individual will also be subject to utilization management?

C. Cumpston No. It does not.

A. Weedman Thank you.

Moderator We'll hear next from Gary Weinstein with Transition Mental Health. Go ahead please.

N. Ricklinger Hello. This is Norma Ricklinger listening with Gary. I would like to know if I'm interpreting the part on service documentation Page 13 correctly. If I want to document an activity, for example, client-centered consultation, that's an action I would take on behalf of the client, is it correct to think that the documentation does not need the response or the progress for the goals?

C. Cumpston Very specifically in the rule documentation requirements for client-centered consultation says, "Specific documentation of the delivery of mental health client-centered consultation service must include a description of the consultation that occurred, the professional consulted, and the resulting recommendation."

N. Ricklinger Thank you very much.

C. Cumpston You're welcome.

Moderator Thank you. Next we will go to the line of Armando Pasado with the Department of Health. Go ahead please. Hello. Mr. Pasado, your line is open.

 We'll next to the line of Lynette Ashmore with Life Links Mental Health. Go ahead please.

L. Ashmore Hello. One of mine was answered on the community support but I did have another one. In our PSR program, five groups in one day, five notes. The other agency that talked about their one note summarizing the day's activities if you review that and find that to be acceptable, is that something you would share with the rest of us? If that's acceptable then we would consider changing to that system.

C. Cumpston We will review it when submitted and we will post on the Q&As.

L. Ashmore Okay. Thank you very much.

C. Cumpston You're welcome.

Moderator Thank you. Next we will go to the line of Linda Bruggeman with Newman Family Services. Your line is open.

L. Bruggeman Thank you. One of the questions was already answered but I want to follow up on a question that was asked earlier about billing for services that are listed on the mental health assessment but prior to when the treatment plan has been developed. The response that was given the woman was specifically asking about therapy. She was told that yes you could bill for therapy as long as you list it in the mental health assessment as a needed service. You could be billing for therapy prior to the development of the ITP. I'm wondering that's a huge change from what's currently in the service definition and reimbursement guide where ITP is a service requirement in order to bill for therapy, in order to bill for almost every other service except for crisis intervention and case management-

W Okay. I think you've brought up a really good point. You say that in the service definition and reimbursement guide it is checked that the MHA and the ITP must be completed.

L. Bruggeman Yes. It is.

W Okay. Thank you for that. We need to take a look at that.

L. Bruggeman Okay.

There's nothing in rule that has ever required that so I think we need to look at the service definition and reimbursement guide.

W The rule has always allowed that prior, as Kristy said, to the completion of the mental health assessment that 30 days of case management and crisis intervention services and of course mental health assessment could be done. Then, prior to the completion of the treatment plan, any service included on the mental health assessment within the 45 days allowed for completion of the treatment plan for those services then to be provided.  Now, if you didn't get the treatment plan done in the required amount of time then that was a problem.

L. Bruggeman Right, of course. That's a big difference in what we've previously based it on.

C. CumpstonWell, thank you for bringing it up. We really appreciate it.

We need to pay better attention to that. I think the service definition and reimbursement guide was really thinking of it from a perspective of, "Yes, this service does require a mental health assessment and does require a treatment plan." Anytime you have checkboxes for anything, sometimes they really don't address the specifics.

L. Bruggeman Right. Okay.

L. Bruggeman We will be able to bill based on the rule.

You can now.

L. Bruggeman That's great. Thank you.

W You're welcome.

Moderator Thank you. Next we'll go to the line of Steven Kiesle with Streamwood Health Care. Go ahead please.

S. Kiesle Hello.


W Hello.

S. Kiesle A couple of quick questions. Going back to Slide 12 explaining the rights to the clients, is it also then required that we go through that process with the guardians of those clients when we're working with children and adolescence?

W No.

C. Cumpston If you have somebody that has a guardian and you have in the past when services were initiated explained rights to the guardian instead of to the child then yes, the guardian would need to have the rights explained again

Yes, but your staff explanation now is to the client. Correct?

S. Kiesle We actually explain the rights and get a signature of that explanation from the client, as long as they're over the age of 12, and the guardian, which for most of our kids would DCFS.

C. Cumpston Right. If you are doing that practice you can continue with that practice.

S. Kiesle I guess my question is, are we required to because for annual notification we would need to be sending a form for signature to the DCFS worker for a signature and getting it back.

C. Cumpston Sorry. I'm going back to check myself here just to make sure that I'm correct and it says, "Staff shall inform the client prior to evaluation services of the following." If you are documenting your explanation to the client that is what is required by rule.

S. Kiesle Okay.

C. Cumpston To the client on the annual basis.

S. Kiesle Okay. We wouldn't necessarily have to notify the guardian on an annual basis.

C. Cumpston Not necessarily according to rule. I mean, again, if that is your practice and you want to continue that practice, I think it's a good practice. I wouldn't discourage it, but to be compliant with Part 132 it does specify that the staff shall inform the client prior to evaluation services.

S. Kiesle Alright. In regard to the redefinition of the MHP, will the revised rule define what related fields are acceptable for a Bachelor's degree?

W I believe it does - "And who possesses a Bachelor's degree" - and it says in the rule, "In counseling in guidance, rehabilitation counseling, social work, education, vocational counseling, psychology, pastoral counseling, family therapy, or related human service field. A Bachelor's degree in any other field with two years of supervised clinical experience in a mental health setting."

S. Kiesle I guess it's the related field that has usually brought up questions.

It still does say that. The rule as it was published back in December is available online so if you have questions about it you can always go back and look at that with the caveat that there have been changes made or suggested to it, we hope made to it, in response to comments we received, but that was not changed.

S. Kiesle Alright. Thank you.

Moderator Thank you. Next we will hear from the line of Vickie Headaway with Children's Place. Go ahead please.

V. Headaway Yes. Thank you so much. Good afternoon, everyone. We have two questions from two different people. The first question is regarding client rights. What age of client do we need to inform?

C. Cumpston There aren't any age restrictions on client rights.

V. Headaway If we have a four month old we need to inform them of their rights.

W According to rule, yes, you do. That probably wouldn't be very productive though, would it?

V. Headaway It wouldn't be.

W Let me see what the language in the rule actually says. Let's see. There's nothing about the age of the client. Okay. "Provider shall ensure that client's rights shall be protected. The right of client confidentiality shall be governed. Justification for restrictions shall be done. Staff shall inform the client prior to evaluation services and annually of the following things. The information shall be explained using language or a method of communication that the client understands. Documentation of such explanation shall be placed in the clinical record."

 I'm not quite sure what 132 services you're providing to a four month old that they'll be benefiting from, but I would assume that in such a case that a method that would be understood would be explanation to a parent or guardian.

V. Headaway Okay.

V. Headaway Then there is a second question.

W The second question same with age with giving the ITP, do we leave the ITP on the dresser of the four month or two month old or two year old child?

Again, parent/guardian.

V. Headaway Alright. Thank you.


C. Cumpston Just out of curiosity, are these mostly family services that you're offering or services directly to the very young children?

W These are wards of the department; actually some of them very, very clear mental health symptoms.

W How are you providing services? Describe a little to us about what you're doing with a four month old.

W Well, depending upon obviously what they come in with, our clinical director is a specialist in infant and child mental health. She is helping us figure out, again, based on the individual child, what might be done to alleviate the symptoms that are observed.

C. Cumpston Okay. Thank you. I really was just asking out of curiosity.

Yes. It's not easy.

Moderator Thank you very much. Next we will hear from the line of Mark Smits. Mr. Smits, I'm sorry, which organization are you with?

M. Smits Transitions of Western Illinois. My question has to do with documentation of the update of the client rights. Several people have mentioned getting client signature but the rule really isn't requiring that, is it? It's really requiring the staff documenting that they explained the rights again to the client. Is that correct?

C. Cumpston Yes. That is absolutely correct. I'm glad that you made that clarification because per rule what is being looked for is a dated statement from the staff saying, "I explained the rights to the client and I believe that the client understood them." A client signature actually does not suffice. It has to be that signed statement from the staff saying, "I explained it. I believe they understood it."

M. Smits Okay. I wanted to make sure that the same standard applied from the very beginning for the annual renewal of that. Okay. Then my second question is connected with that. Was the reason in your thinking that you didn't combine the annual update, or maybe it's allowable, we have two things that are due annually now - a mental health assessment update and refreshing the client about their rights. Could those be done at the same time? If you're calculating the client rights annual from the date of case opening that might always make you 30 days out of compliance on the initial one so that's why I'm asking.

K. Herman Yes. If you are going to link those two things, I would be sure that both of them fall within the 12-month time period, which means you may end up doing your mental health assessment a month early. If you explained rights when they came in and you didn't do your mental health assessment for 30 days later then you'd want to do your mental health assessment in eleven months instead of 12, if you want to link those two.

M. Smits Okay. Got it. Following up on that since we end up tracking things electronically, I'm sure a lot of other people do too, are you always going to be calculating from the date of case opening when that's required? Sometimes the client comes in and they're in crisis. You're not able to explain their rights to them because they're decompensated to the point they wouldn't understand them at that point while they're in crisis.

C. Cumpston Yes, I believe it specified you can do crisis before consent. I don't know that we specified that for client rights though.

M. Smits Does the annual calculate off of the date of case opening then

The annual would calculate from the statement that staff had signed and dated that they explain rights the previous year.

M. Smits Okay. Thank you.

Excuse me. I'm sorry. This was to go until 4:00 I believe, wasn't it?

Moderator That was the time reserved. It's entirely up to you though as how long you would like to go.

W How many more questions in queue?

Moderator Sure. Five, currently.

W Okay. Well then let's take those five and then anyone else that might have a question that they think of as those five are being addressed please send them into the e-mail address and we will then address them.

Moderator Good. We will open the line next of Sharon Lagi Phelps with Family Core. Go ahead please.

S. Phelps We're here.

Okay. Got your question?

S. Phelps How are you doing?

W Okay.

S. Phelps … explained about minors and explaining the client rights, but do we still need for minors to send the ITP and the client rights to the guardian at DCFS?

C. Cumpston The ITP, absolutely yes.

S. Phelps The client rights?

C. Cumpston The clients rights, again, it specifies in the rule that you are to explain that to the client prior to the initiation of services. If your practice is to send that to the guardian, as well, that's fine. I would encourage that but, again, rule specifies client.

W I would just like to add that this is not a change. It has not changed language at all in the rule for explanation of client rights. Whatever you have been doing, if it has been acceptable in survey or in survey findings, you're doing fine.

S. Phelps Thank you.

Moderator Thank you. Next we'll hear from the line of Jonah McReynolds with United Methodist. Go ahead please.

J. McReynolds Yes, sir. I have a question about the grandfathering in MHP. Say, for instance, an employee is working at an agency and they are grandfathered in at that agency. After the new rules are in place, they get a job at another agency. Are they still grandfathered in or do they have to now meet the new rule requirements?

They will have to meet the new rule requirements.

J. McReynolds Okay.

J. McReynolds The second question is concerning doing services written on the MHA, we are under the understanding that in order to do therapy services you have to have a mental health goal. Correct?

All services must be tied to a goal or objective. We don't do services with no reason.

J. McReynolds Okay. Well, isn't the whole purpose of doing an ITP to develop those goals? If you don't have a goal how can you do any kind of therapy services? You are saying that as long as a service is written on the MHA that you should be able to do those services but you cannot do therapy services without a mental health goal. Correct?

C. Cumpston I hear what you're saying, Jonah. If you're going to provide a therapy service after the MHA is completed but before the ITP is completed, you do need to reference back to the MHA.

J. McReynolds Okay. Well, the way we have it we don't have goals on our MHA. We put our goals on our ITPs. We just have their diagnosis.

C. Cumpston In your service documentation, do you have an area that says, "Goal worked on?"

J. McReynolds We have something called SAD, see admission note.

C. Cumpston You could see the admission note and if you were doing the MHA and the ITP was not yet completed but you were going to do therapy, you could say, "See the MHA."

J. McReynolds Okay.

C. Cumpston You guys are doing the admission note so your MHA and ITP, correct me if I'm wrong, should be done pretty much on the same day. Right?

J. McReynolds Yes. We do that.

C. Cumpston You're not going to have an issue there because you do the admission note. Does that make sense?

J. McReynolds Yes. Okay. Thank you.

C. Cumpston You're welcome.

Moderator Thank you. We will go next to the line of Linda Killeran with SIRSS. Go ahead please.

L. Killeran Greetings. Thank you. My understanding of that similar conversation was that we could provide those services in those 45 days but by the end of those 45 days there should be an ITP produced that would kind of backwardly cover those services that we had provided so that's not true. Is that what you're saying?

C. Cumpston Okay. We've gotten into our two different timelines now.

L. Killeran Otherwise, you could do your mental health assessment that says individual therapy, provide individual therapy for 43 days, and discharge the person and never have an ITP.

C. Cumpston No. You can't do that.

L. Killeran Okay.

C. Cumpston There are a couple of issues on the table. Let me take them one at a time. One, there are two different timelines in the rule and it depends on if you use an admission note or if you don't. If you use an admission note, you've got 30 days to complete the MHA and the ITP. That's one set of timelines. If you do not do an admission note, you have 30 days from the first face-to-face to complete the MHA and then you've got 45 days to do the ITP.

 In the time between the MHA and the ITP, if services are on that MHA, you can provide them, but that ITP has to be done in 45 days. If the client leaves in that intervening time at 43 days, you still have to complete an ITP that says, "The client was here. We did these services. They terminated services and here are the services that were provided." You have to close that loop between the MHA and the ITP when you do services in between the two.

L. Killeran That was my understanding. I just wanted to clarify. Thank you very much.

C. Cumpston Are we good?

L. Killeran Yes, ma'am. The second question had to do with the healthy kids mental health status screen. Once the doctor signs that and sends it in, does it say on there what services should be provided during those 30 days?

W It will probably not recommend specific 132 services. It will probably recommend that a child have a mental health assessment, may need mental health treatment. It is not linked to Rule 132 so it's rather vague. Don't expect it.

Usually I would think that it would actually come with the child and probably a parent rather than being mailed. It could be done a number of ways but it's only good for 60 days after the day of signature so if the client doesn't show up with it then just because you have it doesn't mean you can then begin treatment if nobody is showing up to get treatment. It's not going to come in saying they need therapy counseling, they need community support. They need anything that's specific to 132. It's just going to probably say mental health treatment.

L. Killeran If they needed therapy right away for some reason we could do it during those 30 days.

W Yes. You could.

L. Killeran Is there a similar requirement then that results in the mental health assessment and/or treatment plan to backwardly cover those?

W Absolutely. You treat it like an admission note without the specifics, which I'm sorry that it's going to be so vague. I really don't know how many of these you will end up ever seeing, but you still then do have the requirement that you do a mental health assessment and that you do a treatment plan and then the services have to have been assessed to be medically necessary to continue.

L. Killeran Okay. It's sort of like being in that 45 days but without anything on the mental health assessment to guide you.

W Yes. It is.

L. Killeran Alright. I think I understand. Thank you. That's it.

Moderator Thank you very much. The final question today comes Jean Marsarond with the Independent Center. Go ahead please.

L. Johnson Hello. This is Lisa Johnson. I had two questions. The first question is if a client doesn't show up within that year appointment to renew their rights statement and their other information that they need to sign then is it acceptable just to put a progress note stating that that they weren't there?

After an entire year?

L. Johnson No. Until they come to the next appointment. They missed the appointment and then the next appointment puts them outside of the year.

W Oh, okay. I thought you had people that you didn't even see at all. You would just document that.

L. Johnson Okay. Then my second question, and maybe you won't be able to answer it today, for doing the PSR notes, because we are talking about when you're doing interventions we are talking about response to intervention and then also how it relates to the person's goals, but when people have these activities throughout the day or the interventions through the day, it's often hard to speak to response to goal in one day like four times in a day. Do you see what I'm saying?

Just when we have bigger goals such as finding housing or developing coping skills that they need to continue to stay in the community. I'm looking for some help on how to avoid redundancy in notes because the PSR when we do it per event becomes rather cumbersome.

W I'm going to tackle this and perhaps let Kristy and Lee Ann jump in, but I think that one of the important parts of the delivery of any 132 service is that it is intended that the services is meeting some specific need of the client. If there are services that are being provided one after another after another and you cannot really distinguish either why they're being provided or that they are actually accomplishing something is perhaps not different every time but that there is response as a result of the service and there is progress being made then perhaps you need to rethink the service being offered.

 Every intervention, and you'd need to go back, of course, to the rule and look at the specific documentation that's now being required, you're going to have say something about what happened. What was the response? What was being done that was to accomplish a specific goal? That's just an expected documentation.

L. Johnson Right. I'm just looking at how to progress slip like five times in a day. If you could maybe in the future have some kind of training on just this particular part because I think when we do per but notes in a given day it becomes harder to really separate the progress as it relates to progress. Progress is very incremental but when you get so micro with it it's harder to demonstrate and it's harder to train other people how to do it.

C. Cumpston You're talking about a specific progress statement per service intervention.

L. Johnson Yes. We used to do the weekly note and now what we do is we talk about all the groups a person attended and how they relate to what their specific goals and objectives are. Then we talk about what their progress is as it relates to their treatment plans. Where we're talking each time about what their response at 9:00 versus what it was at 3:00 p.m. in terms of their progress on their treatment plan is a little harder to separate. Does that make sense to you?

C. Cumpston It does make sense and as the rule stands now and as the revision will stand, specific services that require that progress statement it is required per service. That is the requirement.

L. Johnson Right. I was just think it would be nice if the state could help us get a better grip on that.

C. Cumpston Sure.

L. Johnson That's all. Thank you.

Moderator No further questions in queue.

W Okay. Thank you all very much for participating with us today. Your questions have been very helpful to us, as well. On several situations it gave us an opportunity to rethink and to really get things nailed down a little bit better. That always happens when you amend a rule.

 Again, thank you all very much and we will keep you posted. When the rule amendments are adopted we will make sure that you know it.

Moderator Alright. Thank you very much. Ladies and gentlemen, that concludes your conference today. We appreciate your participation and your using AT&T Executive Teleconference. You may now disconnect.