255709 These emergency and proposed rules add a new Chapter 39 to Title 22, Subtitle A to establish certification standards for a Mental Health Clubhouse; and amend Chapter 34 of Title 22, Subtitle A to require certification as a Clubhouse before ...

 

DEPARTMENT OF MENTAL HEALTH

_____________________________________

NOTICE OF EMERGENCY AND PROPOSED RULEMAKING

 

The Director of the Department of Mental Health (“Department”), pursuant to the authority set forth in sections 104 and 105 of the Department of Mental Health Establishment Amendment Act of 2001, effective December 18, 2001 (D.C. Law 14-56; D.C. Official Code §§ 7-1131.04 and 7-1131.05), hereby gives notice of his intent to adopt on an emergency basis amendments to  Chapter 34  of Title 22A of the District of Columbia Municipal Regulations (“DCMR”), and a new Chapter 39 of Title 22A DCMR.

 

The purpose of the amendments is to create certification standards for a community support Mental Health Rehabilitation Service entitled “Mental Health Clubhouse” (“Clubhouse”).   A Clubhouse must be operated by an agency that is certified as a core services agency pursuant to Chapter 34 of Title 22A DCMR, as well as comply with the requirements of the new Chapter 39.      

 

A Clubhouse is a place where people with serious mental illness, known as “members,” participate in their own recovery process by working and socializing together in a safe and welcoming environment.  A Clubhouse offers a community-based approach to recovery that complements available psychiatric treatment.  A Clubhouse operates in accordance with established standards coordinated by the International Center for Clubhouse Development that have proved to be effective throughout the world. 

 

Issuance of these rules on an emergency basis is necessary to expand the availability of community-based recovery-oriented programs for mental health consumers in the District of Columbia.  Promulgation of the rules is expected to allow Medicaid funding to assist in the provision of these services, without which fewer people could benefit.  Emergency action is necessary for the immediate preservation of the health, welfare, and safety of children, youth, and adults with mental illness in need of mental health services.

 

The emergency rulemaking was adopted and became effective on May 4, 2010.  The emergency rules will remain in effect for one hundred twenty (120) days unless superseded by publication of another rulemaking notice in the D.C. Register, whichever comes first.

 

The Director also gives notice of intent to take final rulemaking action to adopt the proposed rules in not less than thirty (30) days after the date of publication of this notice in the D.C. Register.  

 

Section 3418.13 of Chapter 34 of Title 22A DCMR is amended to read as follows:

 

3418.13           Community support services provided through a Mental Health Clubhouse established under Chapter 39 must meet the requirements of section 3426.

 

Title 22A DCMR is amended by adding a new chapter 39 to read as follows:

 

CHAPTER 39  MENTAL HEALTH CLUBHOUSES

 

3900                PURPOSE

 

3900.1             This chapter establishes the process for certification of a mental health services provider as a Mental Health Clubhouse (“Clubhouse”) and the standards and procedures under which a Clubhouse must operate. 

 

3901                OVERVIEW OF CLUBHOUSES

 

3901.1             A Clubhouse is a place where people with serious mental illness participate in their own recovery process by working and socializing together in a safe and welcoming environment.

 

3901.2             Clubhouse services:

 

(a)        Are structured, community-support services provided primarily in a group rehabilitative setting;

 

(b)        Utilize behavioral, cognitive, or supportive interventions to improve a member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements; and

 

(c)        Are provided in a collaborative environment where Clubhouse staff and members work side by side.

 

3901.3             Clubhouse program participants are referred to collectively as “members” and each individually as a “member.” 

 

3901.4             Clubhouse members, with staff assistance:

 

(a)                Operate all aspects of the Clubhouse, including food service, clerical, reception, janitorial, and other member supports and services such as employment, housing, and education;

 

(b)               Participate in the day-to-day decision-making and governance of the Clubhouse; and

 

(c)                Plan community projects and social activities to engage members in the community.

 

3901.5             A Clubhouse is organized through a work-ordered day, in accordance with International Center for Clubhouse Development (“ICCD”) standards.  The goal  of the work-ordered day, Clubhouse decision-making opportunities and social activities, is for members to achieve or regain the confidence and skills necessary to lead vocationally productive and socially satisfying lives.

 

3901.6             Clubhouse activities focus on alleviating a member’s psychiatric symptoms, including, but not limited to confusion, anxiety, disorientation, distraction, preoccupation, isolation, withdrawal, and feelings of low self-worth, in order to  improve a member’s reality orientation, social adaptation, and other daily living skills. 

 

3901.7             Clubhouse services are strength-based and focus on:

 

(a)                Promoting the member’s recovery;

 

(b)               The member’s self-concept;  and

 

(c)                Meaningful life activities which include higher education and work, meaningful relationships, symptom stability, increased coping skills, and achievement of the highest level of functioning in the community for the member.

 

3901.8             The focus of interventions in the Clubhouse is the individualized goals related to:

 

(a)                Addressing the member’s daily living and personal development;

 

(b)               Developing strategies and supportive interventions that will maintain stability for the member;

 

(c)                Assisting the member to increase social support skills that ameliorate life stresses resulting from mental illness;  

 

(d)               Helping the member to develop the skills needed to go back to school and work; and

 

(e)                Improving family functioning.

 

3902                GENERAL CERTIFICATION STANDARDS

 

3902.1             No person shall operate a Clubhouse unless certified in accordance with this chapter. 

 

3902.2             In order to be certified by the District, a Clubhouse shall:

 

(a)                Be organized and operated in accordance with the International Standards for Clubhouse Programs established by the ICCD as amended from time to time;

 

(b)               Be currently certified by ICCD as a Clubhouse;

 

(c)                Be operated by an agency certified by the Department as a core services agency in accordance with the certification standards for mental health rehabilitation services (“MHRS”) providers set forth in 22A DCMR Chapter 34; and

 

(d)               Meet the standards and requirements of this chapter.

 

3903                CERTIFICATION APPLICATION

 

3903.1             An organization seeking certification from the Department as a Clubhouse shall submit an application to the Department in the format established by the Department.  The completed application shall include:

 

(a)                Evidence of current certification as a Clubhouse by ICCD;

 

(b)               Evidence that the Clubhouse is operated by an agency with current certification as a core services agency by the Department; and

 

(c)                Other information or evidence that may be required by the Department.

 

3903.2             Applications for certification as a Clubhouse shall be processed by the Department in  accordance with the rules established for MHRS certification set forth in 22A DCMR §3401.

 

3903.3             Certification as a Clubhouse shall be effective for a maximum of two (2) years from the date the certification is issued by the Department and shall be subject to the provider’s continuous compliance with the requirements and standards set forth in this chapter and Chapter 34. Each certification shall specify the effective date and end date of the certification and be included on the MHRS certification.

3903.4             Certification is not transferable to any other organization.

 

3904                CERTIFICATION REQUIREMENTS

 

3904.1             A Clubhouse shall comply with all of the certification requirements set forth in chapter 34 of Title 22A except for the following sections: 3405.6, 3405.7, 3406, 3407, 3410.2, 3410.7, 3410.9, 3410.12-3410.15, 3410.16, 3410.18, 3410.20, 3410.20, 3410.24, 3410.27(b)-(d), 3410.28(a)-(g), (k), and (l), 3410.31(c)-(e), 3410.36, 3412.2-3412.5, 3412.6(b)-(e), 3412.7-3412.10, 3412.13-3412.14, 3412.16-3412.17.

 

3905                CLUBHOUSE SERVICES Eligibility

 

3905.1             To be eligible for Clubhouse services, a consumer shall:

 

(a)                Be seriously and persistently mentally ill and have a primary diagnosis on either Axis 1 or 2 of the DSM-IV-TR; and

 

(b)               Be at least eighteen (18) years of age; and

 

(c)                Have a recommendation for Clubhouse services in his or her annual treatment plan.           

 

3906                CLUBHOUSE SERVICES

 

3906.1             Clubhouse services shall be primarily rehabilitative in nature.

 

3906.2             A Clubhouse shall use a wellness model that offers a setting to restore independent living skills. 

 

3906.3             Clubhouse services may also be used to facilitate cognitive and socialization skills necessary for functioning in a work environment focusing on maximum recovery and independence.

 

3906.4             A Clubhouse shall provide members with coping and wellness strategies to support members:

 

(a)        Returning to school;

 

(b)        Remedial education;

 

(c)        Transitional employment;

 

(d)       Community involvement;

 

(e)        Developing and improving relationships with family and friends;

 

(f)        Grooming and hygiene;

 

(g)        Whole health and wellness activities; and

 

(h)        Interpersonal and social activities.

 

3906.5             A Clubhouse shall have policies and procedures that address the provision of Clubhouse services including descriptions of:

 

(a)        The particular rehabilitation and recovery models utilized; and

 

(b)        Types of intervention practiced.

 

3907                CLUBHOUSE STAFF

 

3907.1             A provider of Clubhouse services shall have at least one (1) staff person certified by the U.S. Psychiatric Rehabilitation Association (“USPRA”) as a Certified Psychiatric Rehabilitation Practitioner (“CPRP”).

 

3907.2             A CPRP or CPRPs shall develop the rehabilitation plan. 

 

3907.3             A CPRP who is not a qualified practitioner must be supervised by a qualified practitioner (“QP”).

 

3907.4             Staff members who have not been certified by the USPRA as a CPRP must be credentialed by the Clubhouse and have, at a minimum, a bachelor’s level degree or the equivalent experience, and have received the training required by the ICCD standards and section 3909.

 

3907.5             Clubhouse staff who are credentialed must be supervised by a CPRP and by a qualified practitioner, if the CPRP is not a qualified practitioner.

 

3907.6             Staffing ratios of the Clubhouse shall comply with ICCD standards.

 

3907.7             Clubhouse services may be provided by a team of staff that is responsible for an       assigned group of members or by staff who are individually responsible for assigned members.

 

3908                REIMBURSEMENT LIMITATIONS

 

3908.1             Clubhouse services may be reimbursed for a maximum of four hundred and seventy-five (475) units per ninety (90) days per member.

 

3908.2             Clubhouse services for an individual member may be authorized for a maximum of ninety (90) days at a time, in accordance with the requirements of the member’s treatment plan and the member’s annual rehabilitation plan.

 

3908.3             Clubhouse services shall not be reimbursed for a member if the Clubhouse services are provided to the member on the same day that rehabilitation/day services, intensive day services, or assertive community treatment is provided to the member.

 

3908.4             The following services are not eligible for reimbursement as Clubhouse services:

 

(a)        Transportation services;

 

(b)        Vocational services;

 

(c)        School and educational services;

 

(d)       Services rendered by parents or other family members;

 

(e)        Socialization services;

 

(f)        Services which are not medically necessary as recommended in an approved individual treatment plan or Individual Recovery Plan (“IRP”);

 

(g)        Services which are not provided and documented in accordance with the certification standards of this chapter;

 

(h)        Services which are not mental health services;

 

(i)         Services furnished to persons other than the consumer when those services are not directed primarily to the well-being and benefit of the consumer; or

 

(j)         Such other services that are determined to be ineligible for Medicaid reimbursement.

 

3909                REHABILITATION RECORDS AND DOCUMENTATION REQUIREMENTS

3909.1             Each Clubhouse shall establish and adhere to policies and procedures to ensure the proper documentation, security, and confidentiality of member and family information, and member clinical and rehabilitative records, including policies and procedures related to records retention, records maintenance, purging and destruction of records, disclosure of consumer and family information, and informed consent  (“Rehabilitation Records Policy”).  The policies and procedures shall comply with applicable federal and District laws and regulations.

3909.2             The Rehabilitation Records Policy shall:

 

(a)        Require the Clubhouse to maintain all clinical and rehabilitative records in a secured and locked storage area; 

 

(b)        Require the Clubhouse to maintain and secure a current, clear, organized, and comprehensive clinical and rehabilitative record for every individual assessed, treated, or served;

 

(c)        Require that the clinical and rehabilitative records include information deemed necessary to provide treatment, protect the Clubhouse, and comply with applicable federal and District laws and regulations; and 

(c)        Set forth requirements for documentation maintained in the clinical and rehabilitative record.

 

3909.3             The following documents shall be included in a member’s clinical and rehabilitative record:

 

(a)        Current psychiatric evaluation;

 

(b)        Referral from a psychiatrist, psychologist, psychiatric Advanced Practice Psychiatric Nurse (“APRN”), Licensed Independent Clinical Social Worker (“LICSW”), certified addictions professional, or licensed practitioner of the healing arts recommending Clubhouse services;

 

(c)        Current annual treatment plan (“IRP”) prepared by a CSA in accordance with the MHRS certification standards (§§ 3407 and 3408 of this title).  The IRP must include a recommendation for Clubhouse services;

 

(d)       Current annual rehabilitation plan completed by the Clubhouse, signed by the Clubhouse director or other qualified practitioner, and reviewed quarterly;

 

(e)        Identifying information about the member, including enrollment information;

 

(f)        Identification of, and contact information for, a person to be contacted in the event of emergency;

 

(g)        Basic screening and intake information;

 

(h)        Advance instructions and advance directives; 

 

(i)         Methods for addressing special needs of the member and the member’s family, especially those which relate to communication, cultural, and social factors;

 

(j)         Detailed description of services provided;

 

(k)        Progress notes (as further described in subsections 3907.3 and 3907.4);

 

(l)         Discharge planning information;

 

(m)       Appropriate consents for service;

 

(n)        Appropriate release of information forms; and

 

(o)        Signed Consumer Rights Statement.

 

3909.4             The Clubhouse staff shall write a daily progress note.  The daily progress note shall:

 

(a)        Describe the activities performed to enhance and/or support the member’s rehabilitation in social, educational, pre-vocational, and transitional employment settings;

 

(b)        Describe the supportive interventions that were used to improve a member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements;

 

(c)        Document the member’s response to the activities and interventions described in the progress note, including the choices and perceptions of the consumer regarding the service(s) provided; and

 

(d)       Be signed and dated by the staff member making the note. 

 

3909.5             Clubhouse staff shall write a monthly progress note that meets the requirements of §3410.7 of this title.  If the monthly note is written by a credentialed staff person, it shall be countersigned by a CPRP. If the monthly note is written by credentialed staff and the CPRP is not a qualified practitioner, the note must also be countersigned by a Qualified Practitioner. 

 

3909.6             The Clubhouse shall provide the member’s referring CSA with a copy of the member’s rehabilitation plan and the monthly progress notes.  

 

3909.7             The Clubhouse shall ensure that that all clinical and rehabilitative records of members are completed promptly and filed and retained in accordance with the Clubhouse’s Rehabilitation Records Policy. 

 

3909.8             The member’s referring CSA shall:

 

(a)        Prepare a monthly progress note at the end of each month that:

 

(1)        Reflects how the services provided by the Clubhouse are linked to the goals and objectives of the member’s IRP and rehabilitation plan;

 

(2)        Describes the member’s progress relative to the IRP and the rehabilitation plan;

 

(3)        Describes the activities that were performed to enhance and support the member’s rehabilitation in social, educational , pre-vocational, and transitional employment settings;

 

(4)        Describes the supportive interventions that were used to improve the member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements;

 

(5)        Is signed by a qualified practitioner employed by the CSA, who is responsible for coordinating services for the member and ensuring that all MHRS services, including Clubhouse services, are delivered in accordance with the IRP; and

 

(6)        Is forwarded to the Clubhouse within ten (10) days after it is completed. 

 

(b)        Provide to the Clubhouse the member’s current IRP and any updates to the IRP.

 

3910                CLUBHOUSE REFERRALS        

 

3910.1             A referral to the Clubhouse may be made by a CSA, a family member, an advocate, or another service provider. 

 

3910.2             A referral from a CSA shall be made in writing and include the following information:

 

(a)        The consumer’s current IRP;

 

(b)        The consumer’s current psychiatric evaluation;         

 

(c)        Contact information for the consumer, including emergency contact information (relative, friend, or guardian as applicable);

 

(d)       Crisis plan for the consumer (if available); and

 

(e)        Advance directives or instructions (if available).  

 

3910.3             A person enrolled with a CSA must have a psychiatric assessment and an IRP that requires Clubhouse services in order to participate in the Clubhouse.

 

3910.4             A self-referral or a referral from a relative, another service provider, or an advocate shall be made in writing and include the following information: 

 

(a)        Name of the person’s CSA or current mental health service provider (if applicable);

 

(b)        The person’s current psychiatric evaluation (if available);

 

(c)        Contact information for the person, including emergency contact information (relative, friend, or guardian as applicable);

 

(d)       Crisis plan for the person (if available); and

 

(e)        Advance directives or instructions (if available). 

 

3910.5             A person referred to a Clubhouse from a non-CSA shall be referred by the Clubhouse to a CSA for eligibility determination, enrollment, and development of a treatment plan.

 

3910.6             A Clubhouse shall establish and adhere to policies and procedures governing its collaboration with a referring CSA in the development, implementation, evaluation, and revision of each member’s IRP and annual rehabilitation plan, as appropriate, that comply with the Department rules (the “Collaboration Policy”).

 

3910.7             The Collaboration Policy shall: 

 

(a)        Be part of the Clubhouse’s Rehabilitation Plan Review Policy as described in subsection 3911.9;

(b)        Require the Clubhouse to incorporate CSA-developed diagnostic/assessment material into the rehabilitation development process; and

(c)        Require the Clubhouse to coordinate the member’s program with the member’s clinical manager.

3911                REHABILITATION PLANS

 

3911.1             A Clubhouse shall prepare an annual rehabilitation plan for each member, in accordance with ICCD standards and this chapter.

 

3911.2             The annual rehabilitation plan shall be developed by the Clubhouse in accordance with the member’s IRP.

 

3911.3             A member’s annual rehabilitation plan shall be completed within thirty (30) days after the member’s referral to the Clubhouse for services is complete.  A referral is deemed to be complete after the Clubhouse receives the information described in section 3910.2 above from the referring CSA or other referral sources.

 

3911.4             The annual rehabilitation plan shall:

 

(a)        Describe the goals and objectives planned for the member;

 

(b)        Describe the interventions to be used to achieve the goals and objectives;

 

(b)        Describe the methods for determining the effectiveness of the annual rehabilitation plan; and

 

(c)        Include a brief discussion about the member’s participation in and agreement to the goals, objectives, and interventions described in the annual rehabilitation plan.

 

3911.5             A Clubhouse shall provide a copy of the annual rehabilitation plan for each member to:

                       

(a)        The member;

 

(b)        The referring agency, if applicable (CSA or other mental health provider agency); and

 

(c)        Anyone designated by the member.

 

3911.6             A Clubhouse shall review each member’s annual rehabilitation plan at least on a quarterly basis and more frequently if necessary to address changes in circumstances, including changes in the IRP.

 

3911.7             A Clubhouse shall obtain the member’s signature on the annual rehabilitation plan.  If the member does not demonstrate the capacity to sign or does not sign the annual rehabilitation plan, the reasons that the member did not sign shall be recorded in the member’s clinical record.

 

3911.8             A Clubhouse shall develop policies and procedures for the rehabilitation plan development and review (the “Rehabilitation Plan Review Policy”).

 

3911.9             The Rehabilitation Plan Review Policy shall:

 

(a)        Include procedures for reviewing each member’s IRP and ensuring that the annual rehabilitation plan contains goals, objectives, and interventions designed to meet the treatment goals set forth in the IRP with respect to the provision of Clubhouse services to the member;

 

(b)               Require that review of each annual rehabilitation plan for a member occur after receipt of the current IRP from the member’s CSA;

 

(c)                Require reviews of the annual rehabilitation plan every ninety (90) days;  and

 

(d)               Require that the rehabilitation plan review demonstrate how the rehabilitation plan is used to modify or change goals, objectives, and interventions, consistent with the IRP.

 

3912                CLUBHOUSE STAFF TRAINING REQUIREMENTS

 

3912.1             Clubhouse staff shall receive training in accordance with ICCD standards.

 

3912.2             Clubhouse staff shall also receive training required for MHRS provider staff in accordance with section 3410 of this title.  Such training shall be provided during the first three (3) months of employment and on an ongoing basis thereafter and shall include the following subjects:

 

(a)        Mental illnesses and evidence-based clinical interventions;

 

(b)        Consumer rights;

 

(c)        Definitions and types of abuse and neglect and the Clubhouse policies regarding investigation of allegations of abuse and neglect;

 

(d)       Knowledge of medication and its benefits and side effects;

 

(e)        Integrated treatment for co-occurring psychiatric and addictive disorders;

 

(f)        Behavior management;

 

(g)        Handling emergency situations;

 

(h)        Recordkeeping and clinical documentation;

 

(i)         Confidentiality;

 

(j)         Cultural competence and its relationship to treatment outcomes; and

 

(k)        Infection control guidelines including compliance with the blood borne pathogens standard, communicable diseases, and universal precautions.

 

3912.3             The Clubhouse shall maintain documentation that staff have completed required training.

 

3912.4             Each Clubhouse shall establish and adhere to an annual training plan for staff to ensure that all staff receives at a minimum, annual training on the following topics:

 

(a)        The subjects identified in section 3912.2 above;

 

(b)        Safety and risk management; and

 

(c)        The disaster evacuation plan for the Clubhouse.

 

3999                DEFINITIONS

 

                        Clubhouse Standards – the International Standards for Clubhouse Programs.

 

                        Core services agency – a Department-certified community-based MHRS provider that has entered into a Human Care Agreement with the Department to provide specified MHRS in accordance with the requirements of 22A DCMR Chapter 34.

 

                        Consumer – an adult, child, or youth who seeks or receives mental health services or mental health supports funded or regulated by the Department.   

 

                        Member – a consumer who has joined a mental health Clubhouse.

 

Mental Health Rehabilitation Services or “MHRS” –  mental health rehabilitative or palliative services provided by a Department-certified community mental health provider to consumers in accordance with the District of Columbia State Medicaid Plan, the Medical Assistance Administration (now Department of Health Care Finance) Department Interagency Agreement, and this chapter.

 

Qualified practitioner – a psychiatrist, psychologist, independent clinical social worker, advanced practice registered nurse, registered nurse, licensed professional counselor, independent social worker, or addiction counselor.

                        Rehabilitation plan – the plan developed to provide services to Clubhouse members in accordance with ICCD standards. 

 

                        Individualized Recovery Plan or “IRP” – the individualized service plan for a

person with mental illness who is receiving MHRS, as further described and defined in §§3407, 3408, and 3499 of this title.

 

All persons desiring to comment on the subject matter of this emergency and proposed rulemaking should file comments in writing not later than thirty (30) days after the date of publication of this notice in the D.C. Register.  Comments should be filed with the Office of General Counsel for the Department of Mental Health at 64 New York Avenue, N.E., 4^th Floor, Washington, D.C. 20002, or e-mailed to Suzanne Fenzel, Assistant Attorney General, at [e-mail].  Copies of the proposed rules may be obtained from www.dmh.dc.gov or from the Department of Mental Health at the address above.