480846 These proposed rules add a new Chapter 39 to Title 22-A DCMR to provide standards and certification requirements for Mental Health Clubhouse, and in Chapter 34 establish a requirement for certification before Clubhosue services can be billed ...

 

DEPARTMENT OF MENTAL HEALTH

 

SECOND 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, an amendment to  Chapter 34 , and to add a new Chapter 39 of Title 22A of the District of Columbia Municipal Regulations (“DCMR”), to allow Clubhouse services to be offered as a type of Community Support within the Mental Health Rehabilitation Services (“MHRS”).

 

The purpose of the amendment to Chapter 34 and the new Chapter 39 of Title 22A DCMR is to create certification standards for a community support Mental Health Rehabilitation Service (“MHRS”) 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 of the DCMR, as well as comply with the requirements of this new Chapter.      

 

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 (ICCD) 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 will 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.  

 

These emergency rules were first adopted and became effective on May 4, 2010, and were published in the D.C. Register on May 7, 2010 at 57 DCR 00410.  Comments were received that led to a cite correction in the Chapter 34 amendment, as well as a clarification that the Clubhouse services require an Axis I or Axis II Personality Disorder diagnosis.  This second emergency rulemaking was adopted and became effective on August 3, 2010.  The emergency rules will remain in effect for one hundred twenty (120) days or until December 1, 2010, unless superseded by publication of another rulemaking notice in the DC 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 from the date of publication of this notice in the DC Register.  

 

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

 

3418.13           Community Support services provided through a Mental Health Clubhouse established under Chapter 39 of this Title must meet all of the requirements of Chapter 39.

 

Chapter 39 of Title 22A is added as follows:

 

3900                MENTAL HEALTH CLUBHOUSE CERTIFICATION STANDARDS

 

3900.1             These rules establish the requirements and process for certification of a mental health services provider as a Mental Health Clubhouse (“Clubhouse”) in the District of Columbia. 

 

3900.2             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;

 

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

 

3900.3             Clubhouse program participants are referred to collectively as “members” and each individually as a “member.”  

 

3900.4             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.

 

3900.5             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 the individual members to achieve or regain the confidence and skills necessary to lead vocationally-productive and socially-satisfying lives.

 

3900.6             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. 

 

3900.7             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.

 

3900.8             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.

 

 

3900.9             A Clubhouse shall be:

 

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

 

(b)               currently certified by ICCD as a Clubhouse;

 

(c)                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)               certified by the Department as a Clubhouse in accordance with the requirements of this Chapter.

 

3901                CERTIFICATION APPLICATION

 

3901.1             No person shall operate a Clubhouse unless certified in accordance with this chapter. 

 

3901.2             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 evidence that may be required by the Department.

 

3901.3             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.

 

3901.4             Certification as a Clubhouse is effective for a maximum of two calendar years       from the date of issuance of certification by the Department, subject to the provider’s continuous compliance with these certification standards. Certification shall remain in effect until it expires, is renewed or revoked. Certification shall specify the effective date of the certification and be included on the MHRS certification.

3901.5             Certification is not transferable to any other organization.

 

3902                CERTIFICATION REQUIREMENTS

 

3902.1              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.

 

3903                CLUBHOUSE SERVICES Eligibility

 

3903.1             To be eligible for Clubhouse services, a consumer shall:

 

(a)                Be seriously and persistently mentally ill and have a primary diagnosis from the DSM-IV-TR on Axis 1, or a primary diagnosis on Axis II of a Personality Disorder; and

 

(b)               Be at least eighteen (18) years of age.           

 

3904                CLUBHOUSE SERVICES

 

3904.1             The Clubhouse service is primarily rehabilitative in nature. A Clubhouse uses a wellness model that offers a setting to restore independent living skills. 

 

3904.2             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.

 

3904.3             A Clubhouse provides members with coping and wellness strategies to support members’:

 

(a)        support and assistance in returning to school;

 

(b)        remedial education;

 

(c)        transitional employment;

 

(d)       community involvement;

 

(e)        assistance in developing or improving relationships with family and friends;

 

(f)        support and assistance with grooming and hygiene;

 

(g)         whole health and wellness activities; and

 

(h)        interpersonal and social activities.

 

3904.4             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.

 

 

3905                CLUBHOUSE STAFF

 

3905.1             A provider of Clubhouse services must have one or more staff persons certified by the U.S. Psychiatric Rehabilitation Association (“USPRA”) as a Certified Psychiatric Rehabilitation Practitioner (“CPRP”) to develop the rehabilitation plan and supervise credentialed staff who are not CPRP’s. 

 

3905.2             Staff members who have not been certified from the USPRA as a CPRP must be   credentialed 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 below.

 

3905.3             Staffing ratios must comply with ICCD standards.

 

3905.4             Clubhouse services may be provided by a team of staff that is responsible for an       assigned group of consumers, or by staff who are individually responsible for assigned consumers.

 

3905.5             Clubhouse staff who are credentialed must be supervised by a Qualified Practitioner (“QP”).

 

3906                REIMBURSEMENT LIMITATIONS

 

3906.1             Clubhouse services may be reimbursed for a maximum of 475 units quarterly, per member per fiscal year. 

 

3906.2             Clubhouse services may be authorized for a maximum of ninety (90) days at a time, in accordance with the requirements of the IRP and the annual rehabilitation plan.

 

3906.3             Clubhouse services may not be reimbursed for the same consumer on the same day as rehabilitation/day services, intensive day services or assertive community treatment.

 

3906.4             The following services that may not be reimbursed through Medicaid include, but are not limited to:

 

(a)        Transportation services;

 

(b)        Vocational services;

 

(c)        School and educational services;

 

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

 

(d)               Socialization services;

 

(f)        Screening and prevention services (other than those provided under Early and Periodic Screening, Diagnosis and Treatment requirements);

 

(g)        Services which are not medically necessary as recommended in an approved IRP/IPC;

 

(h)        Services which are not provided and documented in accordance with these certification standards;

 

(i)         Services which are not mental health services; and

 

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

 

3907                REHABILITATION RECORDS AND DOCUMENTATION REQUIREMENTS

3907.1             Each Clubhouse shall establish and adhere to policies and procedures for clinical and rehabilitative record documentation, security, and confidentiality of consumer and family information, clinical records retention, maintenance, purging and destruction, and for disclosure of consumer and family information, and informed consent that comply with applicable federal and District laws and regulations (“Rehabilitation Records Policy”). 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 which includes information deemed necessary to provide treatment, protect the Clubhouse, or comply with applicable federal and District laws and regulations; and 

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

 

3907.2             The following documents shall be included in the member’s clinical and rehabilitative record:

 

(a)        current psychiatric evaluation;

 

(b)        referral from a psychiatrist, psychologist, psychiatric APRN, LICSW, certified addictions professional or licensed practitioner of the healing arts recommending Clubhouse services;

 

(c)        current annual treatment plan prepared by a CSA in accordance with the MHRS certification standards (Title 22A Chapter 34 Sections 3407 - 3408) (“IRP”) which includes a recommendation for Clubhouse services;

 

(d)       a 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 consumer, including enrollment information;

 

(f)        identification of 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 consumers’ and families’ special needs, 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 below);

 

(l)         discharge planning information;

 

(m)       appropriate consents for service;

 

(n)        appropriate release of information forms; and

 

(o)        signed Consumer Rights Statement.

 

3907.3             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;

 

(b)        describe what supportive interventions 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;

 

(d)       be signed and dated by the staff member making the entry. 

 

3907.4             Clubhouse staff shall write a monthly progress note that meets the requirements of Title 22A chapter 34 Subsection 3410.7.  A staff member with a CPRP shall countersign monthly progress notes made be credentialed staff.  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. 

 

3907.5             The Clubhouse shall provide the member’s referring CSA with a copy of the     member’s rehabilitation plan and the monthly progress notes.  

 

3907.6             The Clubhouse shall ensure that that all clinical and rehabilitative records of members are completed promptly, filed, and retained in accordance with the MHRS provider’s Rehabilitation Records Policy. 

 

3907.8             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 performed to enhance and support the member’s rehabilitation in social, educational, pre-vocational and transitional employment and what supportive interventions were used to improve the member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements; and

 

(4)        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;

 

(5)        is forwarded to the Clubhouse within ten (10) days of completion. 

 

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

 

3908                CLUBHOUSE REFERRALS        

 

3908.1             Referrals to the Clubhouse may be made by a CSA, family member, advocates or other service provider. 

 

3908.2             Referrals from a CSA shall be made in writing and include the following information:

 

(a)      Current IRP;

 

(b)        Current psychiatric evaluation;          

 

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

 

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

 

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

 

3908.3             Self-referrals, referrals from a relative, other service provider or 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)        Current psychiatric evaluation (if available);

 

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

 

(d)       Crisis Plan (if available); and

 

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

 

3908.4             Persons referred to the Clubhouse from a non-CSA shall be referred by the Clubhouse to a CSA for eligibility determination, enrollment and development of a treatment plan. 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.

 

3908.5             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 (“Collaboration Policy”).  The Collaboration Policy shall: 

 

(a)        Be part of the Clubhouse’s Rehabilitation Plan Review Policy as described in subsection 3909.8 below;

(b)        Require the Clubhouse to incorporate CSA-developed Diagnostic/Assessment material into the rehab development process; and

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

3909                REHABILITATION PLANS

 

3909.1             A Clubhouse shall prepare an annual rehabilitation plan for each member, in accordance with ICCD standards and this chapter.

 

3909.2             The annual rehabilitation plan shall be developed by the Clubhouse in accordance with the member’s IRP.

 

3909.3             A member’s annual rehabilitation plan shall be completed within thirty (30) days after the member is referred to the Clubhouse for services.  A referral is deemed to be complete after the Clubhouse receives the information described in section 3908.2 above from the referring CSA or other referral source(s).

 

3909.4             The annual rehabilitation plan shall:

 

(a)        describe the Goals, Objectives and 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.

 

3909.5             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.

 

3909.6             A Clubhouse shall review each member’s annual rehabilitation plan on a quarterly basis or more frequently if necessary to address changes in circumstances, including changes in the IRP.

 

3909.7             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 does not sign shall be recorded in the member’s clinical record.

 

3909.8             A Clubhouse shall develop policies and procedures for the rehabilitation plan development and review (Rehabilitation Plan Review Policy). 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 occurs

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.

 

3910                CLUBHOUSE STAFF TRAINING REQUIREMENTS.

 

3910.1             Staff shall receive training in accordance with the ICCD standards.

 

3910.2             Staff shall also receive the following training required for MHRS provider staff in accordance with Title 22A Section 3410 during the first three (3) months of employment and on an ongoing basis thereafter:

 

(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, 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 bloodborne pathogens standard, communicable diseases and universal precautions.

 

3910.3             The Clubhouse shall maintain documentation that staff have completed required training.

 

3910.4             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 (Annual Training Plan):

 

(a)        The subjects identified in section 3910.2 above;

 

(b)        Safety and risk management; and

 

(c)        The Disaster Evacuation Plan.

 

3999                DEFINITIONS

 

                        Clubhouse Standards – The International Standards for Clubhouse Programs consensually agreed upon by the worldwide Clubhouse community.

 

                        Core Services Agency or “CSA” – 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 – adult, children, or youth who seek or receive mental health services or mental health supports funded or regulated by the Department.   

 

                        International Center for Clubhouse Development or “ICCD” – the international organization that establishes standards for the operation of certified mental health clubhouse programs.  ICCD is responsible for evaluating and certifying mental health clubhouse programs.

 

                        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 MAA (now DHCF)/ Department Interagency Agreement, and this chapter.

 

Qualified Practitioner - (i) a psychiatrist; (ii) a psychologist; (iii) an independent clinical social worker; (iv) an advance practice registered nurse; (v) a registered nurse; (vi) a licensed professional counselor; (vii) an independent social worker; and (viii) an addiction counselor.

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

 

                        Treatment plan or “IRP” – means the individualized service plan for a

person with mental illness who is receiving MHRS, as further described in 22A DCMR §3407 and §3408.

 

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.