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Where am I now in relation to this outcome? CHARACTERISTICS/OBSERVATION (List characteristics/observations based on preliminary knowledge): Short Range Goal Support/Intervention to Reach Goal Who will Provide Support/Intervention/ Service? Support/Service & frequency Target Date (Not to exceed 12 months.)Reviewed DateStatus CodeJustification for Continuation/Discontinuation of Goal/ // // // // // /Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued CHARACTERISTICS/OBSERVATION (List characteristics/observations based on preliminary knowledge): Short Range Goal Support/Intervention to Reach Goal Who will Provide Support/Intervention/ Service? Support/Service & frequencyTarget Date (Not to exceed 12 months.)Reviewed DateStatus CodeJustification for Continuation/Discontinuation of Goal/ // // // // // /Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued CRISIS PREVENTION/CRISIS RESPONSE (CONTINUATION) Contact List (Include names as applicable, relationship and direct phone numbers or extension.) First Responder: Telephone #: ( ) - Legally Responsible Person: (NOTE: Complete if NOT the individual) Telephone #: If applicable- Attach a copy of any applicable supporting legal documents, such as Court-Ordered Guardianship, Power of Attorney, etc. Date of Legal Document: / / Natural/Community Supports: Name: Telephone #: ( ) - Name: Telephone #: ( ) - Professional Supports: Name: Telephone #: ( ) - Medical Home: Telephone #: ( ) - Preferred Psychiatric Inpatient /Respite Provider: Telephone #: ( ) - Other Professional Supports: Name: Telephone #: ( ) - Name: Telephone #: ( ) - Advanced Directives: (Advance Directives allow you to plan ahead for care in the event that there are times that you are unable to speak for yourself). I have a Living Will. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX I have a Health Care Power of Attorney. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX I have an Advanced Instruction for Mental Health Treatment. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX Emergency Contact or Next of Kin: Relationship to Person: (Address): (Street/mailing address) (City/State/Zip) Home Phone: ( ) - Work or Cell Phone: ( ) - Crisis Plan Distribution List: 1. 2. 3. 4. SUMMARY OF ASSESSMENTS/OBSERVATIONS (DSM* Code) (Diagnosis) (Diagnosis Date) Axis I/ /Axis II/ /Axis III/ /Axis IV/ /Axis V/ / (*The Diagnostic & Statistical Manual of Mental Health Disorders IV-TR, 2000 organizes psychiatric diagnosis on 5 axes. They are listed below): Axis I: Major Mental Disorders: Developmental Disorders and Learning Disabilities Axis II: Personality Conditions and Mental Retardation Axis III: Any Non-Psychiatric Medical Condition Axis IV: Social Functioning and how symptoms affect the person Axis V: Global Assessment of Functioning (GAF) based on a scale of 100-0 for adults and/or the Children’s Global Assessment Scale, also a 100-point scale All Current Medications (* Update and revise list of medications anytime there is a change.) Dose: .Frequency: Reason for Change: Date Pharmacy: List all Known Allergies: (*Update and revise list of allergies anytime there is a change).1. 3. 2. 4. SIGNATURES SERVICE ORDERS: REQUIRED for all Medicaid funded services; RECOMMENDED for State funded services. (SECTION A): For services ordered by one of the Medicaid approved licensed signatories (see Instruction Manual). My signature below confirms the following: (Check all appropriate boxes.) Medical necessity for services requested is present, and constitutes the Service Order(s). The licensed professional who signs this service order has had direct contact with the individual - FORMCHECKBOX Yes FORMCHECKBOX No The licensed professional who signs this service order has reviewed the individual’s assessment - FORMCHECKBOX Yes FORMCHECKBOX No Signature: License #: Date: ___/___/___ (Name/Title Required) (SECTION B): For Qualified Professionals (QP) / Licensed Professionals (LP) ordering: CAP-MR/DD or Medicaid Targeted Case Management (TCM) services (if not ordered in Section A) OR recommended for any state-funded services not ordered in Section A. My signature below confirms the following: (Check all appropriate boxes.) FORMCHECKBOX Medical necessity for the CAP-MR/DD services requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the Medicaid TCM service requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the State-funded service(s) requested is present, and constitutes the Service Order Signature: License #: Date: ___/___/___ (Name/Title Required. Signatory in this section must be a Qualified or Licensed Professional.) (If Applicable) Annual review of medical necessity and re-ordering of services is due upon the annual rewrite of the Person Centered Plan (PCP) PERSON RECEIVING SERVICES I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan. Signature: Date: ___/___/___ (Required when person is his/her own legally responsible person) LEGALLY RESPONSIBLE PERSON: Required if other than the person to whom the PCP belongs. FORMCHECKBOX I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. FORMCHECKBOX I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this PCP. FORMCHECKBOX For CAP-MR/DD services only, I confirm and understand that I have the choice of seeking care in an intermediate care facility for individuals with mental retardation instead of participating in the Community Alternatives Program for individuals with mental retardation/developmental disabilities (CAP-MR/DD). Signature: Date: ___/___/___ (Required, if other than the individual) SIGNATURES – Continued: PERSON RESPONSIBLE FOR THE PCP: The following signature confirms the responsibility of the QP/LP for the development of this PCP. The signature indicates agreement with the services/supports to be provided. *For Adults (21 years of age for Medicaid, 18 years of age for State funded services). Signature: Date: ___/___/___ (Person responsible for the PCP) For individuals who are less than 21 years of age (less than 18 for State funded services) and who are receiving or in need of enhanced services and who are actively involved with the Department of Juvenile Justice and Delinquency Prevention or the adult criminal court system, the person responsible for the PCP must attest that he or she has completed the following requirements as specified below: FORMCHECKBOX Met with the Child and Family Team - Date: ___/___/___ FORMCHECKBOX OR Child and Family Team meeting scheduled for - Date: ___/___/___ FORMCHECKBOX OR Assigned a TASC Care Manager - Date: ___/___/___ FORMCHECKBOX AND conferred with the clinical staff of the applicable LME to conduct care coordination. If the statements above do not apply, please check the box below and then sign as the Person Responsible for the PCP: FORMCHECKBOX This child is not actively involved with the Department of Juvenile Justice and Prevention or the adult criminal court system. Signature: Date: ___/___/___ (Person responsible for the PCP) OTHER TEAM MEMBERS Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ ‘S PERSON-CENTERED DESCRIPTION/PLAN Name: (Preferred Name): DOB: ___/___/___Medicaid ID: Record #: Person’s Address: (Street/mailing address) (City/State/Zip) Telephone #: (Home) ( ) - (Work) ( ) -Date of Plan: ___/___/___ Date of 1st Complete PCP if prior plan was an Introductory PCP: ___/___/___CAP Only: (Check the box that applies) FORMCHECKBOX Supports Waiver FORMCHECKBOX Supports Waiver – Self Direction FORMCHECKBOX Comprehensive Waiver Participants Involved in Plan Development Name (person to whom this plan belongs): Role: FORMCHECKBOX Facilitated the PCP/CFT meeting FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Name: Relation/Agency: How long have you known each other? Role: FORMCHECKBOX Facilitator of PCP/CFT meetings FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Name: Relation/Agency: How long have you known each other? Role: FORMCHECKBOX Facilitator of PCP/CFT meetings FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Name: Relation/Agency: How long have you known each other? Role: FORMCHECKBOX Facilitator of PCP/CFT meetings FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Name: Relation/Agency: How long have you known each other? Role: FORMCHECKBOX Facilitator of PCP/CFT meetings FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Name: Relation/Agency: How long have you known each other? Role: FORMCHECKBOX Facilitator of PCP/CFT meetings FORMCHECKBOX Participated in @ least 1 planning meeting FORMCHECKBOX Provided written input FORMCHECKBOX Telephone participation FORMCHECKBOX Invited, but no participation FORMCHECKBOX Other: Other individuals that I or my family would like to be part of this planning process now or in the future. Personal Dialogue/Interview Date(s) of Interview(s): ___/___/___ (This section must include what is important TO the person to whom this plan belongs. Also include issues related to the person’s environment, culture, ethnicity and race as appropriate.) ADD/REVISE INFORMATION WHENEVER NEW THINGS ARE LEARNED ABOUT THIS PERSON. SIGN NAME (NO INITIALS) AND DATE (NEXT TO THE CHANGE), EACH TIME THIS SECTION IS ADDED TO OR REVISED. What is working best in my life right now? (What makes the most sense for me right now?) What is not working in my life right now? (What does not make sense for me right now?) Strengths: (Examples – What are my special talents/traits? What do I like and admire about myself?) What is important TO me: (Examples - What are the people/activities/things/places that matter to me in everyday life? What don’t I want in my life?) Supports: (Examples - What do others need to know or do to support me best in relationships, in things I like to do, in work or school and ways to stay healthy and safe, taking into account what is important TO me?) Long Term Outcomes: (Examples - What are the things I want to accomplish in the next year? What are my hopes/dreams for the future?) Family/Legally Responsible Person/Informal Supports Dialogue/Interview Date(s) of Interview(s): ___/___/___ (This section must include what is important TO the person and what is important FOR the person from the interviewee’s perspective. Also include issues related to the person’s environment, culture, ethnicity and race as appropriate.) ADD/REVISE INFORMATION WHENEVER NEW THINGS ARE LEARNED ABOUT THIS PERSON. SIGN NAME (NO INITIALS) AND DATE (NEXT TO THE CHANGE), EACH TIME THIS SECTION IS ADDED TO OR REVISED. What is working best in his/her life right now? (What makes the most sense for him/her right now?) What is not working in his/her life right now? (What does not make sense for him/her right now?) Strengths: (Examples - What are the person’s special talents/traits? What do people like and admire about this person?) What is Important FOR this person: (Examples - What are the people/activities/things/places that matter to this person in everyday life? What does the person not want in his/her life?) Supports: What is important FOR this person? (Examples - What do others need to know or do to support this person best in relationships, in things he/she likes to do, in work or school and ways to stay healthy and safe?) Long Term Outcomes: (Examples - What are the things the person wants to accomplish in the next year? What are this person’s hopes/dreams for the future?) Service/Support Providers Dialogue/Interview Date(s) of Interview(s): ___/___/___ (This section must include what is important TO the person and what is important FOR the person from the interviewee’s perspective. Also include issues related to the person’s environment, culture, ethnicity and race as appropriate.) ADD/REVISE INFORMATION WHENEVER NEW THINGS ARE LEARNED ABOUT THIS PERSON. SIGN NAME (NO INITIALS) AND DATE (NEXT TO THE CHANGE), EACH TIME THIS SECTION IS ADDED TO OR REVISED. What is working best in his/her life right now? (What makes the most sense for him/her right now?) What is not working in his/her life right now? (What does not make sense for him/her right now?) Strengths: (Examples - What are the person’s special talents/traits? What do people like and admire about this person?) What is Important FOR this person: (Examples - What are the people/activities/things/places that matter to this person in everyday life? What does the person not want in this person’s life?) Supports: What is important FOR this person? (Examples - What do others need to know or do to support this person best in relationships, in things he/she likes to do, in work or school and ways to stay healthy and safe?) Long Term Outcomes: (Examples - What are the things the person wants to accomplish in the next year? What are this person’s hopes/dreams for the future?) SUMMARY OF ASSESSMENTS/OBSERVATIONS COMPREHENSIVE CLINICAL ASSESSMENT(s) – CCA: List evaluations completed RECOMMENDATIONS FROM ALL ASSESSMENTS LAST DATE COMPLETED APPROXIMATE DUE DATE / // / / // /NC TOPPS (MH/SA only) *(Not a comprehensive clinical assessment) / // /NC-SNAP (DD only) *(Not a comprehensive clinical assessment) / // /Risk Assessment Tool (CAP-MR/DD Only) *(Not a Comprehensive Clinical Assessment)/ // / ADDITIONAL ASSESSMENTS RECOMMENDED REASON FOR RECOMMENDATION APPROXIMATE DUE DATE DATE COMPLETED / // / / // / CHARACTERISTICS/OBSERVATIONS OF THIS PERSON: (Based on the interviews, dialogues, and assessments. Enter characteristics and observations that will result in Action Plans.)1. 2. 3. 4. 5. 6. (DSM* Code) (Diagnosis) (Diagnosis Date) Axis I/ /Axis II/ /Axis III/ /Axis IV/ /Axis V/ / All Current Medications (* Update and revise list of medications anytime there is a change.) Dose: .Frequency: Reason for Change: Date Pharmacy: List all Known Allergies: (*Update and revise list of allergies anytime there is a change).1. 3. 2. 4. ACTION PLAN Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others.) Where am I now in the process of achieving this outcome? CHARACTERISTICS/OBSERVATION #: Short Range Goal (Taken from - “What’s Important TO & FOR me” sections) Support/Intervention to Reach Goal (Taken from Supports Sections) Who will Provide Support/Intervention/ Service? Support/Service & frequency Target Date (Not to exceed 12 months.)Reviewed DateStatus CodeJustification for Continuation/Discontinuation of Goal/ // // // // // /Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued CHARACTERISTICS/OBSERVATION #: Short Range Goal (Taken from - “What’s Important TO & FOR me”) Support/Intervention to Reach Goal (Taken from Supports Sections) Who will Provide Support/Intervention/ Service? Support/Service & frequency Target Date (Not to exceed 12 months.)Reviewed DateStatus CodeJustification for Continuation/Discontinuation of Goal/ // // // // // /Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued ** Copy and use as many Action Plan pages as needed. CRISIS PREVENTION/CRISIS RESPONSE (Use this form or attach your crisis plan.) Health and behavioral concerns that may trigger the onset of a crisis (Include lessons learned from previous crisis events): Crisis prevention and early intervention strategies (List everything that can be done to help this person avoid a crisis): Strategies for crisis response and stabilization (Focus first on natural and community supports. Begin with least restrictive steps. Include process for obtaining back-up in case of emergency and planning for use of respite, if an option. List everything you know that has worked to help this person to become stable): Specific recommendations for interacting with the person receiving a Crisis Service: After the crisis, identify strategies for determining what worked and what did not work: Strategies identified to be followed after a crisis to determine what worked and what did not work, and make changes to the PCP including this Crisis Plan. CONSENT/RELEASES OF INFORMATION (For individuals or agencies included on the Contact List below). The Individual or Legally Responsible Person has given legal, written consent for the following: FORMCHECKBOX The First Responder agency to release information to a Crisis Service provider. FORMCHECKBOX The Natural/Community Supports listed to be contacted during a crisis. FORMCHECKBOX The Professional Supports/treating Psychiatrist or Other Professional Supports listed to be contacted during a crisis. FORMCHECKBOX The Medical Home listed to be contacted during a crisis. FORMCHECKBOX The preferred Psychiatric Inpatient provider or Respite provider to be contacted during a crisis. FORMCHECKBOX The Crisis Plan to be distributed to those on the Crisis Plan Distribution List. FORMCHECKBOX Other: _________________________________________________ CRISIS PREVENTION/CRISIS RESPONSE (CONTINUATION) Contact List (Include names as applicable, relationship and direct phone numbers or extension.) First Responder: Telephone #: ( ) - Legally Responsible Person: (NOTE: Complete if NOT the individual) Telephone #: ( ) - If applicable- Attach a copy of any applicable supporting legal documents, such as Court-Ordered Guardianship, Power of Attorney, etc. Date of Legal Document: ___/___/___ Natural/Community Supports: Name: Telephone #: ( ) - Name: Telephone #: ( ) - Professional Supports: Name: Telephone #: ( ) - Medical Home: Telephone #: ( ) - Preferred Psychiatric Inpatient /Respite Provider: Telephone #: ( ) - Other Professional Supports: Name: Telephone #: ( ) - Name: Telephone #: ( ) - Advanced Directives: (Advance Directives allow you to plan ahead for care in the event that there are times that you are unable to speak for yourself). I have a Living Will. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX I have a Health Care Power of Attorney. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX I have an Advanced Instruction for Mental Health Treatment. FORMCHECKBOX Yes FORMCHECKBOX No If no, I would like one. FORMCHECKBOX Emergency Contact or Next of Kin: Relationship to Person: (Address): (Street/mailing address) (City/State/Zip) Home Phone: ( ) - Work or Cell Phone: ( ) - Crisis Plan Distribution List: 1. 2. 3. 4. SIGNATURES SERVICE ORDERS: REQUIRED for all Medicaid funded services; RECOMMENDED for State funded services. (SECTION A): For services ordered by one of the Medicaid approved licensed signatories (see Instruction Manual). My signature below confirms the following: (Check all appropriate boxes.) Medical necessity for services requested is present, and constitutes the Service Order(s). The licensed professional who signs this service order has had direct contact with the individual - FORMCHECKBOX Yes FORMCHECKBOX No The licensed professional who signs this service order has reviewed the individual’s assessment - FORMCHECKBOX Yes FORMCHECKBOX No Signature: License #: Date: ___/___/___ (Name/Title Required) (SECTION B): For Qualified Professionals (QP) / Licensed Professionals (LP) ordering: CAP-MR/DD or Medicaid Targeted Case Management (TCM) services (if not ordered in Section A) OR recommended for any state-funded services not ordered in Section A. My signature below confirms the following: (Check all appropriate boxes.) FORMCHECKBOX Medical necessity for the CAP-MR/DD services requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the Medicaid TCM service requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the State-funded service(s) requested is present, and constitutes the Service Order Signature: License #: Date: ___/___/___ (Name/Title Required. Signatory in this section must be a Qualified or Licensed Professional.) (If Applicable) Annual review of medical necessity and re-ordering of services is due upon the annual rewrite of the Person Centered Plan (PCP) PERSON RECEIVING SERVICES I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan. Signature: Date: ___/___/___ (Required when person is his/her own legally responsible person) LEGALLY RESPONSIBLE PERSON: Required if other than the person to whom the PCP belongs. FORMCHECKBOX I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. FORMCHECKBOX I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this PCP. FORMCHECKBOX For CAP-MR/DD services only, I confirm and understand that I have the choice of seeking care in an intermediate care facility for individuals with mental retardation instead of participating in the Community Alternatives Program for individuals with mental retardation/developmental disabilities (CAP-MR/DD). Signature: Date: ___/___/___ (Required, if other than the individual) SIGNATURES – Continued: PERSON RESPONSIBLE FOR THE PCP: The following signature confirms the responsibility of the QP/LP for the development of this PCP. The signature indicates agreement with the services/supports to be provided. *For Adults (21 years of age for Medicaid, 18 years of age for State funded services). Signature: Date: ___/___/___ (Person responsible for the PCP) For individuals who are less than 21 years of age (less than 18 for State funded services) and who are receiving or in need of enhanced services and who are actively involved with the Department of Juvenile Justice and Delinquency Prevention or the adult criminal court system, the person responsible for the PCP must attest that he or she has completed the following requirements as specified below: FORMCHECKBOX Met with the Child and Family Team - Date: ___/___/___ FORMCHECKBOX OR Child and Family Team meeting scheduled for - Date: ___/___/___ FORMCHECKBOX OR Assigned a TASC Care Manager - Date: ___/___/___ FORMCHECKBOX AND conferred with the clinical staff of the applicable LME to conduct care coordination. If the statements above do not apply, please check the box below and then sign as the Person Responsible for the PCP: FORMCHECKBOX This child is not actively involved with the Department of Juvenile Justice and Prevention or the adult criminal court system. Signature: Date: ___/___/___ (Person responsible for the PCP) OTHER TEAM MEMBERS Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ PERSON-CENTERED DESCRIPTION/PLAN (UPDATE/REVISION) (For use ONLY if a new service or a new goal is added to the PCP during the plan year.) Name: (Preferred Name): DOB: / /Medicaid ID: Record #: Person’s Address: (Street/mailing address) (City/State/Zip) Telephone #: (Home) ( ) - (Work) ( ) -Update/Revision Date: / / Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others.) Where am I now in the process of achieving this outcome? CHARACTERISTICS/OBSERVATION #: Short Range Goal (Taken from - “What’s Important TO & FOR me” sections) Support/Intervention to Reach Goal (Taken from Supports Sections) Who will Provide Support/Intervention/ Service? Support/Service & frequency Target Date (Not to exceed 12 months.)Reviewed DateStatus CodeJustification for Continuation/Discontinuation of Goal / / / / / / / / / / / / Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued ** Copy and use as many Action Plan pages as needed. (Provide signatures on the Supplemental Update/Revision PCP Signature Document) UPDATE/REVISION SIGNATURES (For use with ALL updates/revisions) SERVICE ORDERS: REQUIRED for all Medicaid funded services; RECOMMENDED for State funded services. (SECTION A): For services ordered by one of the Medicaid approved licensed signatories (see Instruction Manual). My signature below confirms the following: (Check all appropriate boxes.) Medical necessity for services requested is present, and constitutes the Service Order(s). The licensed professional who signs this service order has had direct contact with the individual - FORMCHECKBOX Yes FORMCHECKBOX No The licensed professional who signs this service order has reviewed the individual’s assessment - FORMCHECKBOX Yes FORMCHECKBOX No Signature: License #: Date: ___/___/___ (Name/Title Required) (SECTION B): For Qualified Professionals (QP) / Licensed Professionals (LP) ordering: CAP-MR/DD or Medicaid Targeted Case Management (TCM) services (if not ordered in Section A) OR recommended for any state-funded services not ordered in Section A. My signature below confirms the following: (Check all appropriate boxes.) FORMCHECKBOX Medical necessity for the CAP-MR/DD services requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the Medicaid TCM service requested is present, and constitutes the Service Order. FORMCHECKBOX Medical necessity for the State-funded service(s) requested is present, and constitutes the Service Order Signature: License #: Date: ___/___/___ (Name/Title Required. Signatory in this section must be a Qualified or Licensed Professional.) (If Applicable) Annual review of medical necessity and re-ordering of services is due upon the annual rewrite of the Person Centered Plan (PCP) PERSON RECEIVING SERVICES I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan. Signature: Date: ___/___/___ (Required when person is his/her own legally responsible person) LEGALLY RESPONSIBLE PERSON: Required if other than the person to whom the PCP belongs. FORMCHECKBOX I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. FORMCHECKBOX I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this PCP. FORMCHECKBOX For CAP-MR/DD services only, I confirm and understand that I have the choice of seeking care in an intermediate care facility for individuals with mental retardation instead of participating in the Community Alternatives Program for individuals with mental retardation/developmental disabilities (CAP-MR/DD). Signature: Date: ___/___/___ (Required, if other than the individual) UPDATE/REVISION SIGNATURES, Continued: (For use with ALL updates/revisions) PERSON RESPONSIBLE FOR THE PCP: The following signature confirms the responsibility of the QP/LP for the development of this Update/Revision to the PCP. The signature indicates agreement with the services/supports to be provided. *For Adults (21 years of age for Medicaid, 18 years of age for State funded services). Signature: Date: ___/___/___ (Person responsible for the PCP)\ For individuals who are less than 21 years of age (less than 18 for State funded services) and who are receiving or in need of enhanced services and who are actively involved with the Department of Juvenile Justice and Delinquency Prevention or the adult criminal court system, the person responsible for the PCP must attest that he or she has completed the following requirements as specified below: FORMCHECKBOX Met with the Child and Family Team - Date: ___/___/___ FORMCHECKBOX OR Child and Family Team meeting scheduled for - Date: ___/___/___ FORMCHECKBOX OR Assigned a TASC Care Manager - Date: ___/___/___ FORMCHECKBOX AND conferred with the clinical staff of the applicable LME to conduct care coordination. If the statements above do not apply, please check the box below and then sign as the Person Responsible for the PCP: FORMCHECKBOX This child is not actively involved with the Department of Juvenile Justice and Prevention or the adult criminal court system. Signature: Date: ___/___/___ (Person responsible for the PCP) OTHER TEAM MEMBERS Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ Other Team Member Signature: Date: ___/___/___ (( LME Consumer Admission and Discharge Form (( (Revision of the former Person-Centered Plan (PCP) Consumer Admission Form) Consumer First Name, M.I., and Last Name Consumer Maiden Name MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt. _________________ ___ _______________________ __________________________ __ __/__ __/__ __ __ __ _________________ ___ ___ ___ ___ ___ __ __ __ __ __ __ __ __ A. First Name ® B. MI ® C. Last Name ® D. Maiden Name ® E. Consumer DOB ® F. LME Name ® G. LME Facility Code ® H. LME Consumer Record No. ® Instructions: The LME Consumer Admission and Discharge Form is required to be completed by providers within 30 calendar days of any service initiation or service provision for any publicly funded DMH/DD/SAS consumer, and at completion of an episode of care (discharge). This includes all consumers supported through funding from, but not limited to, IPRS, Single Stream Funding, waiver program, and non-UCR advances and cost reimbursement, for any service which includes, but is not limited to, outreach, drop-in, assessment, evaluation, intake, crisis, support, and approved regular and alternative services, and 2) all consumers receiving any Medicaid Enhanced Benefits Service. The form is required to be submitted to the LME for each new consumer, or with outreach, transitional or inactive consumers for whom a service is being provided or a new LME episode of care is being initiated. (An inactive consumer is defined generally as one with a minimum of no reimbursable or reportable services or service-related activity within prior 60 days). Consumer admission information is required to be completed on all consumers served, regardless of residency status, and updated periodically when new consumer data is collected or when existing data is modified. Discharge data is required to be completed at the conclusion of an LME episode of care. This form is required to be submitted to the LME and to Value Options (or the designated services authorization entity) in accordance with Division Announcements, Communication Bulletins, Implementation Updates, and the current version of the CDW Reporting Requirements and Definitions as referenced on the Division web page and HIPAA, 42 CFR, Part 2, and GS 122C regulations. Any electronic transmittal is required to conform to HIPAA standards for electronic health care transactions, and conform to a uniform format specified by the Division, including required encryption for secure transmission of data. See current DMH/DD/SAS CDW Reporting Requirements and CDW Data Dictionary. FOR CONSUMER ADMISSION COMPLETE ITEMS 1 THROUGH 33. 1. ___________________________________________________________ Name of LME responsible for receiving this Consumer Admission and Discharge Form 2. Consumer Current CDW Admission Date: __ __/__ __/__ __ __ __ MM DD YYYY 3. Consumer Co. of Residence: ______________________ or __ __ __ (Enter county name or county code from CDW Data Dictionary.) Co. Code 4. Consumer’s (Physical) Residence Zip Code: __ __ __ __ __-__ __ __ __ 5. Ethnicity: (( One) FORMCHECKBOX Hispanic, Mexican American FORMCHECKBOX Hispanic, Puerto Rican FORMCHECKBOX Hispanic, Cuban FORMCHECKBOX Hispanic, Other FORMCHECKBOX Not Hispanic Origin 6. Marital Status at time of Admission: (( One) FORMCHECKBOX Annulled FORMCHECKBOX Single (Never Married) FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Domestic Partners 7. Race: (( One) FORMCHECKBOX Black/Afric. Amer. FORMCHECKBOX White/Anglo/Cauc. FORMCHECKBOX Amer. Ind./Native American FORMCHECKBOX Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Pacific Islander FORMCHECKBOX Multiracial FORMCHECKBOX Other (Describe): ____________________ 8. Gender: (( One) FORMCHECKBOX Male FORMCHECKBOX Female 9. Veteran Status: (( One) FORMCHECKBOX Yes FORMCHECKBOX No 10. Education Level at time of Admission (highest grade/degree completed): __ __ (Enter code from attached instructions.) 11. Employment Status at time of Admission: __ __ (Enter code from attached instructions.) 12. Annual Family Income of Non-Medicaid Consumers Only: (Enter the value of annual family income at time of admission, measured in whole dollars, as determined by the LME for the purpose of fee determination) $__ __, __ __ __, __ __ __.00 13. Family Size of Non-Medicaid Consumers Only: (Enter the no. of persons living in the family at time of admission, including consumer, as determined by the LME for the purpose of fee determination) # = __ __14. Number of Consumer Arrests in the 30 Days Prior to Admission # = __ __ 15. Living Arrangement (residential) at time of admission: ___ ___ (Enter code from attached instructions.) 16. Admission Referral Source of consumer to facility: ___ ___ (Enter code from attached instructions.) 17. Is consumer proficient in English?(( One) FORMCHECKBOX Yes FORMCHECKBOX No 18. Primary Language: (( One) FORMCHECKBOX English FORMCHECKBOX Sign Language FORMCHECKBOX French FORMCHECKBOX Spanish FORMCHECKBOX Other FORMCHECKBOX None 19. If female, is consumer pregnant at the time of admission? FORMCHECKBOX Yes FORMCHECKBOX No 20. Diagnosis(es) Effective Date: __ __/__ __/__ __ __ __ (for current episode) MM DD YYYY 21. Diagnosis Code(s) (ICD-9): (List up to three ICD-9 diagnoses in order of importance) 21a) __ __ __.__ __ 21b) __ __ __.__ __ 121c) __ __ __.__ __ 22. Date Started Substance Abuse Treatment: __ __/__ __/__ __ __ __ FORMCHECKBOX Not a Sub. Abuse Consumer (current episode) MM DD YYYY 23. Provide information on Admission Substance Abuse (Drug of Choice) Details: FORMCHECKBOX Not a Substance Abuse Consumer (Enter codes from attached instructions) 23a) SA Drug Code 23b) Age of First Use 23c) Use Frequency 23d) Route of Admin. 1) Primary Substance __ __ __ __ __ __ 2) Secondary Substance __ __ __ __ __ __ 3) Additional Substance __ __ __ __ __ __ 24. Opioid Replacement Therapy: Identify whether the use of methadone or buprenorphine is part of the consumer’s treatment plan or PCP. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not a Substance Abuse Consumer 25. Consumer Unique Identifier: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___-___ 26. Consumer Social Security Number: ___ ___ ___-___ ___-___ ___ ___ ___ (Needed for cross referencing with CNDS) (( LME Consumer Admission and Discharge Form (( (Revision of the former Person-Centered Plan (PCP) Consumer Admission Form) Consumer First Name, M.I., and Last Name Consumer Maiden Name MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt. _________________ ___ _______________________ __________________________ __ __/__ __/__ __ __ __ _________________ ___ ___ ___ ___ ___ __ __ __ __ __ __ __ __ A. First Name ® B. MI ® C. Last Name ® D. Maiden Name ® E. Consumer DOB ® F. LME Name ® G. LME Facility Code ® H. LME Consumer Record No. ® 26a. Consumer’s IPRS Target Population Eligibility (check one box and complete eligibility begin and end dates on one primary population that applies):* IPRS Target PopulationEligibility Begin DateEligibility End Date IPRS Target PopulationEligibility Begin DateEligibility End Date A) FORMCHECKBOX AMI – Adult with Mental Illness (P) FORMCHECKBOX ASCDR – ASA Injecting Drug User/Communicable Disease (B) FORMCHECKBOX AMSRE – AMH Stable Recovery Population (Q) FORMCHECKBOX ASWOM – ASA Women (C) FORMCHECKBOX AMAO – AMH Assessment Only (R) FORMCHECKBOX ASDSS – ASA DSS Involved (D) FORMCHECKBOX AMCS – AMH Crisis Services (S) FORMCHECKBOX ASCJO – ASA Criminal Justice Offender (E) FORMCHECKBOX AMCEP – AMH Community Enhancement Program (T) FORMCHECKBOX ASTER – ASA Treatment Engagement and Recovery (F) FORMCHECKBOX CMSED – CMH Seriously Emotionally Disturbed Child (U) FORMCHECKBOX ASAO – ASA Assessment Only (G) FORMCHECKBOX CMECD – CMH Early Childhood Disorder (V) FORMCHECKBOX ASCS – ASA Crisis Services (H) FORMCHECKBOX CMAO – CMH Assessment Only (W) FORMCHECKBOX CSSAD – CSA Child with Substance Abuse Disorder (I) FORMCHECKBOX CMCS – CMH Crisis Services (X) FORMCHECKBOX CSMAJ – CSA Child in the MAJORS SA/JJ Program (J) FORMCHECKBOX ADSN – Adult with Developmental Disability (Y) FORMCHECKBOX CSAO – CSA Assessment Only (K) FORMCHECKBOX ADAO – ADD Assessment Only (Z) FORMCHECKBOX CSCS – CSA Crisis Services (L) FORMCHECKBOX ADCS – ADD Crisis Services (AA) FORMCHECKBOX AMVET – Veteran and Family (age 18 and over) (Scheduled for January, 2009 implementation) (M) FORMCHECKBOX CDSN – CDD Developmental Disability (BB) FORMCHECKBOX CMVET – Veteran and Family (under age 18) (Scheduled for January, 2009 implementation) (N) FORMCHECKBOX CDAO – CDD Assessment Only (XX) FORMCHECKBOX No IPRS Target Population (Not eligible for IPRS funding) (O) FORMCHECKBOX CDCS – CDD Crisis Services *Note: IPRS Target Population indicated represents the consumer’s principal or primary diagnosis and the main focus of attention or treatment, and that is chiefly responsible for the need for services received for the current episode of care. IPRS Target Population Details are posted on the DMHDDSAS web site at HYPERLINK "http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm" http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm (( LME Consumer Admission and Discharge Form (( (Revision of the former Person-Centered Plan (PCP) Consumer Admission Form) Consumer First Name, M.I., and Last Name Consumer Maiden Name MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt. _________________ ___ _______________________ __________________________ __ __/__ __/__ __ __ __ _________________ ___ ___ ___ ___ ___ __ __ __ __ __ __ __ __ __ __ A. First Name ® B. MI ® C. Last Name ® D. Maiden Name ® E. Consumer DOB ® F. LME Name ® G. LME Facility Code ® H. LME Consumer Record No. ® 27. Consumer Medicaid Number: (Required of All Medicaid Consumers) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Health/Medical Insurance: (( One for Primary Insurance) FORMCHECKBOX Private Insurance/health plan FORMCHECKBOX Medicaid FORMCHECKBOX Medicare FORMCHECKBOX Health Choice FORMCHECKBOX TRICARE FORMCHECKBOX CHAMPVA FORMCHECKBOX Other insurance FORMCHECKBOX None FORMCHECKBOX Unknown Complete provider identifying information below (as applicable): 29. ___________________________________________________ Name of Provider Agency Completing this Admission Form 30. ___________________________________________________ First and Last Name of Provider Staff Submitting this Admission Form to LME 31. ___________________________________________________ E-Mail Address of Provider Staff Submitting this Admission Form to LME 32. __ __ __-__ __ __- __ __ __ __ -__ __ __ __ ADM Provider Staff Area Code, Phone No., & Ext. MM DD YYYY 33. ___ ___ /___ ___ /___ ___ ___ ___ Date ADM Form Submitted to LME 38. Number of Consumer Arrests in the 30 Days Prior to Discharge: # = __ __ 39. Living Arrangement (residential) at Time of Discharge: __ __ (Enter code from attached instructions.) 40. Date Consumer Was Last Seen for a Service: __ __/__ __/__ __ __ __ MM DD YYYY Enter the day when the consumer was last seen for a service. The day may be the same date as the date of discharge. In the event of a change of service or provider within an episode of treatment, it is the date the consumer transferred to another service or provider. 41. Provide information on Discharge Substance Abuse (Drug of Choice) Details: FORMCHECKBOX Not a Substance Abuse Consumer (Enter codes from attached instructions) 41a) SA Drug Code 41b) Use Frequency 41c) Route of Admin. 1) Primary Substance __ __ __ __ __ 2) Secondary Substance __ __ __ __ __ 3) Additional Substance __ __ __ __ __ 42. ___________________________________________________ Name of Provider Agency Completing this Discharge Form (FOR CONSUMER DISCHARGE COMPLETE ITEMS 34 THROUGH 46.( 34. Consumer Current CDW Discharge Date: __ __/__ __/__ __ __ __ MM DD YYYY 35. Reason for Discharge, Transfer, or Discontinuance of Treatment: (( One) FORMCHECKBOX 1=death FORMCHECKBOX 2=evaluation completed FORMCHECKBOX 3=treatment completed FORMCHECKBOX 4=consumer not available FORMCHECKBOX 5=consumer refused treatment FORMCHECKBOX 6=consumer no show FORMCHECKBOX 7=service not available FORMCHECKBOX 8=other 36. Discharge Referral to: Person or agency that client was referred to at Discharge. (Enter code from attached instructions.) __ __ 37. Employment Status at Time of Discharge: __ __ (Enter code from attached instructions.) 43. ___________________________________________________ First and Last Name of Provider Staff Submitting this Discharge Form to LME 44. ___________________________________________________ E-Mail Address of Provider Staff Submitting this Discharge Form to LME 45. __ __ __-__ __ __- __ __ __ __ -__ __ __ __ DSG Provider Area Code, Phone No., & Ext. MM DD YYYY 46. ___ ___/___ ___/___ ___ ___ ___ Date DSG Form Submitted to LMENC Division of Mental Health, Developmental Disabilities and Substance Abuse Services INSTRUCTIONS FOR LME CONSUMER ADMISSION AND DISCHARGE FORM A. Consumer First Name: Enter consumer’s First Name. B. Consumer Middle Initial: Enter consumer’s Middle Initial. C. Consumer Last Name: Enter consumer’s Last Name. D. Maiden Name: Enter female consumer’s Maiden Name. (required for females) Use maiden name when constructing unique ID for females in Question #25. E. Consumer DOB: Enter consumer’s date of birth, by month, day, and year: 8 characters. F. LME Name: Enter LME name. G. LME Facility Code: LME Facility Code may be completed as indicated by LME, or may be assigned by LME upon receipt of Form: 5 characters. H. LME Consumer Record No: LME Consumer Record Number may be completed as indicated by LME, or may be assigned by the LME upon receipt of Form: 10 characters. FOR CONSUMER ADMISSION COMPLETE ITEMS 1 THROUGH 33. 1. Name of LME responsible for receiving this Consumer’s Admission and Discharge Form: Enter the name of the LME responsible for receiving this consumer’s Admission and Discharge Form. 2. Consumer Current CDW Admission Date: Enter month, day, and year which represents the date that this consumer was admitted to a facility for the current episode of care: 8 characters. 3. Consumer Co. of Residence: Enter a county name or valid county code (3 characters) for the state of North Carolina as listed in the CDW Data Dictionary. 4. Consumer’s (Physical) Residence Zip Code: Indicate the consumer’s residential zip code: 9 characters. 5. Ethnicity: Indicate the consumer’s Hispanic origin: (( One). 6. Marital Status at the time of admission: Indicate the consumer’s marital status at time of the current admission: (( One). 7. Race: Indicate the consumer’s primary racial affiliation: (( One). 8. Gender: Indicate the consumer’s sex: (( One). 9. Veteran Status: Indicate whether the individual has served on active duty in the armed forces of the U.S., including the Coast Guard: (( One). 10. Education Level at Time of Admission: Enter the appropriate Education Level code from CDW list below for highest grade/degree completed by the consumer at time of the current admission: 2 characters. 00= None, never attended school 01= First grade 02= Second grade 03= Third grade 04= Fourth grade 05= Fifth grade 06= Sixth grade 07= Seventh grade 08= Eighth grade 09= Ninth grade 10= Tenth grade 11= Eleventh grade 12= Twelfth grade/high school graduate 14= Some college 16= Baccalaureate degree 17= Post graduate school (after MA/MS) 18= Post bachelor’s degree 20= GED 30= Kindergarten 35= Associate degree 50= School for special skills 80= Technical trade school 81= Ungraded 82= Special education 11. Employment Status at Time of Admission: Enter the appropriate Employment Status code from CDW list below for consumer’s temporary or permanent employment status at time of the current admission: 2 characters. 00= Unemployed 01= Employed full time 02= Employed part time 03= Not in work force, student 04= Not in work force, retired 05= Not in work force, homemaker 06= Not in work force, not available for work 07= Armed Forces/National Guard 08= Seasonal/Migrant worker 12. Family Income of Non-Medicaid Consumers: Enter the value of annual family income at time of admission (measured in whole dollars) as determined by the LME for the purpose of fee determination. If the LME collects weekly income multiply by 52 or if the LME collects monthly income multiply by 12. It should be noted that at least 90% of non-Medicaid consumer demographic records must contain a value other than unknown and will be monitored through the Performance Contract: 8 characters. (Required of Non-Medicaid Consumers only) 13. Family Size of Non-Medicaid Consumers: Enter the no. of persons living in the family at time of admission (including consumer) as determined by the LME for the purpose of fee determination. It should be noted that at least 90% of non-Medicaid demographic records must contain a value other than unknown and will be monitored through the Performance Contract: 2 characters. (Required of Non-Medicaid Consumers only) 14. Number of Consumer Arrests in the 30 Days Prior to Admission: Enter the number of consumer arrests in the 30 days prior to admission. The number of arrests in the 30 days preceding the date of admission to treatment. This item is intended to capture the number of times the client was arrested for any cause during the 30 days preceding the date of admission to treatment. Any formal arrest is to be counted regardless of whether incarceration or conviction resulted and regardless of the status of the arrest proceedings at the time of admission. It should be noted that this data field is primarily collected for Substance Abuse and Mental Health clients. Developmental Disability clients should be coded as a 98. Additionally, a threshold level of at least 90% of something other than unknown (97) will be monitored through the Performance Contract: 2 characters. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services INSTRUCTIONS FOR LME CONSUMER ADMISSION AND DISCHARGE FORM 15. Living Arrangement at time of Admission: Enter the appropriate Living Arrangement code from CDW list below for consumer’s residential status at time of the current admission: 2 characters. 01= Private residence (house, apartment, mobile home, child living with family) 02= Other independent (rooming house, dormitory, barracks, fraternity house, work bunk house, or ship) 03= Homeless (street, vehicle, shelter for homeless) 04= Correctional facility (prison, jail, training school, detention center) 05= Institution (psychiatric hospital, developmental disability center, Wright, ADATC) 06= Residential facility excluding nursing homes (halfway house, group home, child care institution, DDA group home) 07= Foster family, alternative family living 08= Nursing home (ICF, SNF) 09= Adult care home – 7 or more beds (rest home) 10= Adult care home – 6 or fewer beds (family care home) 11= Community ICF-MR 12= Community ICF-MR, 70 or more beds 00= Other 16. Admission Referral Source: Enter the appropriate Admission Referral Source code from the CDW list below for principal source that referred the consumer to the facility for the current admission: 2 characters. 01= Self or no referral 10= Family or friends 21= Other outpatient and residential non-state facility 22= State facility 23= Psychiatric service, General hospital 32= Non-residential treatment/habilitation program 41= Private physician 44= Nursing home board and care 46= Veteran’s Administration 48= Other health care 60= Community agency 71= Court, corrections, prisons 80= Schools 99= Other 17. English Proficiency: Indicate whether English is spoken and understood by the consumer at a relatively high level of proficiency, e.g. no interpreter is required: (( One). Primary Language: Indicate the language spoken and/or understood by the consumer: (( One). 19. Pregnancy Status: Indicate whether the consumer is pregnant at the time of the current admission: (( One.) 20. Diagnosis(es) Effective Date: Enter the date by month, day, and year that the consumer is formally admitted to a program for treatment of the specified ICD- 9 diagnosis code(s) described in this form or is assessed with this diagnosis: 8 characters. 21. Diagnosis Code(s) (ICD-9): Enter up to three ICD-9 codes describing, in order of importance, the condition(s) established after screening and assessment, to be chiefly responsible for occasioning this admission of a consumer: 5 characters. 22. Date Started Substance Abuse Treatment: Enter date by month, day, and year for first substance abuse treatment in the current admission: 8 characters. 23a. Substance(s) Abused: Enter the appropriate Substance Abuse code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current admission: 2 characters. 00= None (e.g. client in remission) 01= Alcohol 02= Cocaine/Crack 03= Marijuana/Hashish (Cannibus) 04= Heroin 05= Non-Prescription Methadone 06= Other Opiates and Synthetics (Morphine, codeine, Dilaudid, Percodan) 07= PCP (Phencyclidine) 08= Other Hallucinogens (LSD, MDA, Psilocybin, Mescaline) 09= Methamphetamine (Ice) 10= Other Amphetamines (Dextroamphetamine, Dexedrine, Amphetamine, Crank, Speed) 11= Other Stimulants (e.g. caffeine) 12= Benzodiazepine (Valium, Librium, Tranxene) 13= Other Tranquilizers (Thorazine, Haldol) 14= Barbiturates (Phenobarbital, Secobarbital, Pentobarbital) 15= Other Sedatives and Hypnotics (Doriden, Quaalude) 16= Inhalants (Nitrites, Freon, glue, turpentine, paint thinner, rubbing alcohol) 17= Over the counter drugs (e.g. diet tablets, cough syrup) 18= Other 19= Tobacco 23b.Age of First Use: 2 characters. 23c. Frequency of Use: Enter the appropriate code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current admission episode: 1 character. 0= Not used in past month 1= Used one to three times in past month 2= Used one to two times in past week 3= Used three to six times in past week 4= Used daily in past week 23d.Usual Route of Administration: Enter the appropriate Usual Route of Administration code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current admission: 1 character. 1= Oral 2= Smoking 3= Inhalation 4= Injection 5= Other NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services INSTRUCTIONS FOR LME CONSUMER ADMISSION AND DISCHARGE FORM 24. Opioid Replacement Therapy: Identify whether the use of methadone or buprenorphine is part of the consumer’s treatment plan or PCP. Complete consumer identifying numbers below (as applicable and available): 25. Consumer Unique Identifier: Enter consumer number: 10 or 11 characters. The unique identifier consists of the first three characters of last name, 1st character of first name, 6 character birth date, and an identifier if more than one LME consumer has the same unique identifier number. Use Maiden Name when constructing Unique Identifier for females. 26. Consumer Social Security Number: Enter consumer number: 9 characters. This number is needed for cross-referencing with the Department’s Common Name Database Services (CNDS). A consumer SSN will not always be available to a provider when completing this Form. 26a. IPRS Target Population: Check one box that apply to consumer’s IPRS Target Population Eligibility and complete eligibility begin and end dates on one primary population that applies. 27. Consumer Medicaid Number: Enter consumer number: 10 characters. 28. Health/Medical Insurance: Check one box for primary health or medical insurance. 29. Name of Provider Agency: Enter name of provider agency completing admission. 30. First and Last Name of Provider Staff submitting this Form to LME: Enter first and last name of staff submitting this admission form to LME. 31. E-Mail of Provider Staff submitting this Form to LME: Enter e-mail address of provider staff submitting this admission form to LME. 32. Area Code and Phone No. of Provider: Enter area code and phone number of provider staff submitting this admission form to the LME: 10 characters. 33. Date ADM Form Submitted to LME: Enter date by month, day, and year that this admission form was submitted to the LME by the provider: 8 characters. (FOR CONSUMER DISCHARGE COMPLETE ITEMS 34 THROUGH 46.( 34. Consumer Current CDW Discharge Date: Enter month, day, and year which represents the date that this consumer was discharged from a facility for the current episode of care: 8 characters. 35. Reason for Discharge, Transfer, or Discontinuance of Treatment: Check (() the box that best describes the reason for discharge. 36. Discharge Referral Source to: Person or agency that client was referred to at Discharge. Enter the appropriate Discharge Referral Source code from the CDW list below for principal source that the facility referred the consumer to for the current discharge: 2 characters. 01= Self or no referral 10= Family or friends 21= Other outpatient and residential non-state facility 22= State facility 23= Psychiatric service, General hospital 32= Non-residential treatment/habilitation program 41= Private physician 44= Nursing home board and care 46= Veteran’s Administration 48= Other health care 60= Community agency 71= Court, corrections, prisons 80= Schools 99= Other 37. Employment Status at time of Discharge: Enter the appropriate Employment Status code from CDW list below for consumer’s temporary or permanent employment status at time of the current discharge: 2 characters. 00= Unemployed 01= Employed full time 02= Employed part time 03= Not in work force, student 04= Not in work force, retired 05= Not in work force, homemaker 06= Not in work force, not available for work 07= Armed Forces/National Guard 08= Seasonal/Migrant worker 38. Number of Consumer Arrests in the 30 Days Prior to Discharge: The number of arrests in the 30 days preceding the date of discharge from treatment. This item is intended to capture the number of times the client was arrested for any cause during the 30 days preceding the date of discharge from treatment. Any formal arrest is to be counted regardless of whether incarceration or conviction resulted and regardless of the status of the arrest proceedings at the time of discharge. It should be noted that this data field is primarily collected for Substance Abuse and Mental Health clients. Developmental Disability clients should be coded as a 98. Additionally, a threshold level of at least 90% of something other than unknown (97) will be monitored through the Performance Contract. 39. Living Arrangement (residential) at time of Discharge: Enter the appropriate Living Arrangement code from CDW list below for consumer’s residential status at time of the current admission: 2 characters. 01= Private residence (house, apartment, mobile home, child living with family) 02= Other independent (rooming house, dormitory, barracks, fraternity house, work bunk house, or ship) 03= Homeless (street, vehicle, shelter for homeless) 04= Correctional facility (prison, jail, training school, detention center) 05= Institution (psychiatric hospital, developmental disability center, Wright, ADATC) 06= Residential facility excluding nursing homes (halfway house, group home, child care institution, DDA group home) 07= Foster family, alternative family living 08= Nursing home (ICF, SNF) 09= Adult care home – 7 or more beds (rest home) 10= Adult care home – 6 or fewer beds (family care home) 11= Community ICF-MR 12= Community ICF-MR, 70 or more beds 00= OtherNC Division of Mental Health, Developmental Disabilities and Substance Abuse Services INSTRUCTIONS FOR LME CONSUMER ADMISSION AND DISCHARGE FORM 40. Date Consumer Was Last Seen for a Service: Enter the day when the consumer was last seen for a service. The day may be the same date as the date of discharge. In the event of a change of service or provider within an episode of treatment, it is the date the consumer transferred to another service or provided. 41a. Information on Discharge Substance Abuse (Drug of Choice) Details: Enter the appropriate Substance Abuse code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current discharge: 2 characters. 00= None (e.g. client in remission) 01= Alcohol 02= Cocaine/Crack 03= Marijuana/Hashish (Cannibus) 04= Heroin 05= Non-Prescription Methadone 06= Other Opiates & Synthetics (Morphine, codeine, Dilaudid, Percodan) 07= PCP (Phencyclidine) 08= Other Hallucinogens (LSD, MDA, Psilocybin, Mescaline) 09= Methamphetamine (Ice) 10= Other Amphetamines (Dextroamphetamine, Dexedrine, Amphetamine, Crank, Speed) 11= Other Stimulants (e.g. caffeine) 12= Benzodiazepine (Valium, Librium, Tranxene) 13= Other Tranquilizers (Thorazine, Haldol) 14= Barbiturates (Phenobarbital, Secobarbital, Pentobarbital) 15= Other Sedatives and Hypnotics (Doriden, Quaalude) 16= Inhalants (Nitrites, Freon, glue, turpentine, paint thinner, rubbing alcohol) 17= Over the counter drugs (e.g. diet tablets, cough syrup) 18= Other 19= Tobacco 41b. Frequency of Use: Enter the appropriate code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current admission episode: 1 character. 0 = Not used in past month 1= Used one to three times in past month 2 =Used one to two times in past week 3= Used three to six times in past week 4= Used daily in past week 41c. Usual Route of Administration: Enter the appropriate Usual Route of Administration code from the CDW list below for Primary, Secondary, and Additional Substance Abused by the consumer in the 30 days prior to the current admission: 1 character. 1= Oral 2= Smoking 3= Inhalation 4= Injection 5= Other 42. Name of Discharge Provider Agency: Enter name of provider agency completing. 43. First and Last Name of Provider Staff Submitting this Discharge Form to LME. E-Mail Address of Provider Staff Submitting this Discharge Form to LME. Provider Area Code, Phone No., & Ext. Enter the area code, phone number, and extension of the provider staff who competed the LME Consumer Discharge Form. Date Discharge Form Submitted to LME. (1) Consumer Name:(2) Medicaid ID:(3) Consumer Record Number: (4) Effective Date:(5) Revision Effective Date:(6) LME Name: (7) SNAP Index Score: (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)Service/EquipmentService CodeProvider AgencyUnits a MonthUnit IntervalFROM DateTO DateEstablished RateMax. Monthly AuthorizationAnnual CAP-MR Author. (18) TOTAL MONTHLY AND ANNUAL AUTHORIZED CAP-MRDD WAIVER LIMITS Annual Authorization Limits Within LME Approved Authority (19) Comments: CAP-MR/DD Cost Summary 10/1/2007 APPENDIX B Core Rules Self Study – Client Records Checklist Name of Agency: Date of Self Study Completed: Date of on-site review if applicable: CLIENT RECORDS CHECKLIST The following information is required in client records. Records may be reviewed on-site.Service:LME USE ONLYClient :_______________MetNot MetNACheck if on-site review is neededComments1.Client Face Sheet [27G.0206(a)(1)] 2.Emergency Information [27G.0206(a)(5)] 3.Consent for Treatment [27D.0303(d)] 4.Consent for planned use of a restrictive intervention (not to exceed 6 mo)[27D.0303(b)] 5.Consent to seek emergency care from hospital or physician [27G.0206(a)(6)]. 6.Consent to Release Information, if applic. (26B .0202 & .0203) 7.Disclosure of Confidential Info Form A64(26B .0301) 8.State required forms are utilized, to include CAP-MR/DD Plan of Care and cost summary, DHHS Restrictive Intervention Details Report & DHHS Incident & Death Report. 9.Explanation of Client Rights (27D.0201) 10.If applicable, physical disorders dx. ICD-9-CM 11.Screening [27G.0201(a)(6)] 12.Assessed presenting problem/need [27G.0201(a)(6)(A)] 13.Assessed agency ability to meet needs [27G.0201(a)(6)(B)] 14.Disposition (referrals & recommendations) [27G.0201(a)(6)(C)] 15.Service Order 16.Present for type services 17.Pre-dates services 18.Signed by authorized person 19.Assessment: [27G.0205(a)] 20.Completed according to policy, prior to delivery of services [27G.0205(a)] 21.Reason for admission: presenting problem [27G.0205(a)(1)] 22.Strengths described [27G.0205(a)(2)] 23.Preferences 24.Diagnosis according to DSM-IV-TR [27G.0206(a)(2) 25.Social/family/medical history [27G.0205(a)(4)] 26.Evaluations present [27G.0205(a)(5)] 27.Mental status, as appropriate 28.Other eval. or doc. used to meet elements are referenced and doc. to note review and that info is current & accurate. 29.Assessment is reviewed & updated as appropriate 30.Service Plan: [27G .0205(c )] 31.Began at admission (Must be prior to delivery of services) 32.Updated/revised to reflect needs or changes 33.Based on assessment of needs/problems with capabilities, interests, preferences, aspirations, & tx. & personal supports. [27G .0205(c )] 34.Developed with client/responsible person within 30 days if expected to receive services beyond 30 days. [27G .0205(c )] 35.Includes: [27G .0205(d)] 36. - service goals/outcomes & projected date of achievement [27G .0205(d)(1)] 37. - specific modalities/interventions/strategies with frequency & duration [27G .0205(d)(2)] 38. - responsibilities of team members [27G .0205(d)(3)] 39. - target date for review of goals, modalities, frequency, etc., with client or responsible person that does not exceed 12 months [27G .0205(d)(4)] 40. - basis for evaluation or assessment of outcome achievement [27G .0205(d)(5)] 41. - signature of staff & consumer/legally responsible person (or statement of why not) (Minor receiving mh or sa services have exceptions) [27G .0205(d)(6)] 42.CAP-MR/DD has plan of care and cost summary from CAP manual. 43.If services delivered prior to establishment of plan, documentation of strategies used. [27G .0205(b)] 44.Include planned restrictive intervention & approvals [27E.0104(f)] 45.Restriction of Rights documented 46.Review/Revision of Service Plan 47.Doc. of review by resp. prof. by target dates, when needs change, or service provider changes. 48.Review of goals, modalities/intervention, frequency & duration 49.Staff's dated signature & consumer/legally responsible person's dated signature for consent/agreement to plan or why not obtained. (even if no changes) 50.CAP has a new plan annually during the consumers' birthday month. 51. Psychosocial Plan review every six months 52.Progress Notes 53.Full date service provided (mo/day/yr) 54.Duration of service for periodic & day/night 55.Purpose of contact as it relates to goal 56.description of intervention/activity 57.Assessment of progress towards goals/outcomes 58.Professionals signature & credentials, degree, or license who provided service 59.Paraprofessionals signature & position who provided service. 60.Periodic service note at least daily per service 61.CAP services this applies to are: Crisis Stabilization, Family Training & Therapeutic Case Consultation. 62.Date of service, duration of service, task performed, signature documented daily to reflect service provided for Personal Assistance, MR Personal Care, In-Home Aide, Interpreter, CAP respite. Non-CAP respite has hourly-per date of service Y community per 63.Documentation of service is within 24 working hours 64.Incidents 65.Record the description of event, action taken on behalf of client and client's conditions following the event.(27G .0603) 66.Use of planned interventions [27E.0104(g)] 67.Use of protective devices documented [27E.0105(a)] 68.Incident report filed separately from record 69.Medication: (27G.0209) 70.Written order for prescription and non prescription drugs by person authorized by law to prescribe drugs. [27G.0209(a)(1)] 71.Written order for self administration [27G.0209(c)(2)] 72.Refusal of medication documented [27G.0209(h)] 73.Psychotropic drugs reviewed by physician or pharmacist every six months & recorded. [27G.0209(f)(1)] 74.Medication Administration Record (MAR) [27G.0209(c)(4)] 75.Consumer's name [27G.0209(c)(4)(A)] 76.Name, strength, quantity of drug [27G.0209(c)(4)(B)] 77.Instructions for administration [27G.0209(c)(4)(C)] 78.Date and time drug administered [27G.0209(c)(4)(D)] 79.Name or initials of person administering meds. [27G.0209(c)(4)(E)] 80.Medications Errors [27G.0209(h)] 81.Drug administration error and significant adverse reactions reported immediately to physician or pharmacist. Drug administration and drug reaction shall be properly recorded in drug record. [27G.0209(h)] 82.Orders & copies of lab tests 83.Case Management Service Notes 84.Date of service 85.Type of activity 86.Location where service provided 87.Brief description of activity & outcome 88.Total time (duration) 89.Signature & credentials, degree or licensure of case manager 90.Service Authorization/Utilization Reviews APPENDIX C MH/DD/SA Service Delivery Table MH/DD/SA Service Delivery TableEntries in italics indicate basic services. Procedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?YP620Adult Developmental Vocational Program [ADVP] Each 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteNNYP830Alcohol and/or Drug Assessment – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventNNH0005Alcohol and/or Drug Services; Group Counseling by ClinicianEach 15 MinutesPeriodicPer EventYAfter 8/26 visitsYYP835Alcohol and/or Drug Services; Group Counseling by Non-Licensed ProviderEach 15 MinutesPeriodicPer EventYNH0014Ambulatory Detoxification Each 15 Minutes24-HourPer Date of ServiceYYH0040Assertive Community Treatment Team [ACTT]Per Event - Must meet 4-Contact ThresholdPeriodicPer Date of ServiceYYYP230Assertive Outreach Each 15 MinutesPeriodicPer Contact/Date of ServiceNNH0001Behavioral Health AssessmentEach 15 MinutesPeriodicPer EventNYH0004Behavioral Health Counseling and TherapyEach 15 MinutesPeriodicPer EventYAfter 8/26 visitsYYP831Behavioral Health Counseling – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventYNYP832Behavioral Health Counseling – Group Therapy – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventYNYP833Behavioral Health Counseling – Family Therapy with Client – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventYNYP834Behavioral Health Counseling – Family Therapy without Client – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventYNH0004HQBehavioral Health Counseling Outpatient Treatment – GroupEach 15 MinutesPeriodicPer EventYAfter 8/26 visitsYH0004HRBehavioral Health Counseling Outpatient Treatment - Family Therapy With ClientEach 15 MinutesPeriodicPer EventYAfter 8/26 visitsYH0004HSBehavioral Health Counseling Outpatient Treatment - Family Therapy Without ClientEach 15 MinutesPeriodicPer EventYAfter 8/26 visitsYH2012HAChild and Adolescent Day Treatment Per HourDay/NightPer Date of ServiceYYS5145Child and Adolescent Residential Treatment - Level II - Family Type Per Day24-HourPer Date of ServiceYYProcedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?H2020Child & Adolescent Residential Treatment - Level II – Program Type Per Day24-HourPer ShiftYYH0019Child and Adolescent Residential Treatment - Levels III - IV [Behavioral Health – Long Term Residential]Per Day24-HourPer ShiftYYYP650Community Rehabilitation Program [Sheltered Workshop] Each 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteN QP/AP must certify eligibilityNYA213Community Respite [CMSED] Per Day24-HourPer Date of ServiceNNYP730Community RespitePer Day24-HourPer Date of ServiceNNH0036 HB, with primary modifierCommunity Support: Adults Each 15 MinutesPeriodicPer Contact/Date of Service YYH0036 HA,, with primary modifierCommunity Support: Children/Adolescents Each 15 MinutesPeriodicPer Contact/Date of Service YYH0036 HQ, with primary modifierCommunity Support: GroupEach 15 MinutesPeriodicPer Contact/Date of Service YYH2015HTCommunity Support Team [CST] Each 15 MinutesPeriodicPer Contact/Date of ServiceYYYM580Day Supports Per DayPeriodicPer Date of ServiceNNYP660Day/Evening ActivityEach 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteNNYP610Developmental DayEach 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteNNH2014Developmental Therapy - Professional – IndividualEach 15 MinutesPeriodicPer Date of Service YNH2014HQDevelopmental Therapy -Professional – GroupEach 15 MinutesPeriodicPer Date of Service YNH2014HMDevelopmental Therapy - Paraprofessional - IndividualEach 15 MinutesPeriodicPer Date of Service YNH2014U1Developmental Therapy - Paraprofessional – GroupEach 15 MinutesPeriodicPer Date of Service YNT1023Diagnostic AssessmentPer EventPeriodicPer EventNYYP690Drop-In Center – AttendanceEach 15 MinutesDay/NightPer Date of Service [recommended]NNYP692Drop-In Center – Coverage HoursEach 15 MinutesDay/NightPer Date of Service [recommended]NNYP485Facility Based Crisis Program - Non-MedicaidPer Hour24-HourPer ShiftYNYM755Family Living – HighPer Day24-HourMonthlyNNProcedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?YP740Family Living – LowPer Day24-HourMonthlyNNYP750Family Living – ModeratePer Day24-HourMonthlyNNYM600Financial Support ServicesEach 15 MinutesPeriodicPer Date of ServiceNNYP780Group Living – HighPer Day24-HourMonthlyNNYP760Group Living – LowPer Day24-HourMonthlyNNYP770Group Living – ModeratePer Day24-HourMonthlyNNYM686GuardianshipPer MonthMonthlyMonthlyNNYA125Hourly Respite [CMSED]Each 15 MinutesPeriodicPer Date of ServiceNNYP011Hourly Respite – GroupEach 15 MinutesPeriodicPer Date of ServiceNNYP010Hourly Respite – IndividualEach 15 MinutesPeriodicPer Date of ServiceNNYM700Independent Living – MR/MIPer DayNANANNYM716Individual SupportsPer MonthMonthlyMonthlyNNYP820Inpatient HospitalizationPer Day24-HourPer ShiftYNH2022Intensive In-Home ServicesPer DayPeriodicPer Date of ServiceYYYM645Long-Term Vocational Support Each 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteNNH2036Medically Supervised or ADATC Detoxification/Crisis StabilizationPer Day24-HourPer Date of ServiceYYH0031Mental Health Assessment Each 15 MinutesPeriodicPer EventNYYP836Mental Health Assessment – Non-Licensed ProviderEach 15 MinutesPeriodicPer EventNNH2011Mobile Crisis Management Each 15 MinutesPeriodicPer Date of ServiceYYH2033Multisystemic TherapyEach 15 MinutesPeriodicPer Date of ServiceYYH0010Non-Hospital Medical DetoxificationPer Day24-HourPer Date of ServiceYYH0020Opioid TreatmentPer EventPeriodicPer EventYYH0035Partial Hospitalization – Children and AdultsEach 15 MinutesDay/NightPer Contact/Date of Service, or meet Medicare requirements if billing MedicareYYProcedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?YP020Personal Assistance – IndividualEach 15 MinutesPeriodicPer Date of ServiceNNYM050Personal Care ServicesEach 15 MinutesPeriodicPer Date of ServiceNNS9484Professional Treatment Services In Facility-Based Crisis Program Per Hour24-HourPer ShiftYYYA230Psychiatric Residential Treatment Facility [PRTF]Per Day24-HourPer ShiftYYH2017Psychosocial Rehabilitation [PSR] Each 15 MinutesDay/NightPer Date of ServiceYYYM850Residential SupportsPer DayPeriodicPer Date of ServiceNNYA234Room and Board – Level II [Age 5 or Less] Per DayNANANNYA235Room and Board – Level II [Age 6-12] Per DayNANANNYA236Room and Board – Level II [Age 13+] Per DayNANANNYA232Room and Board – Level III [1-4 Beds]Per DayNANANNYA233Room and Board – Level III [5+ Beds]Per DayNANANNYA237Room and Board – Level IV [1-4 Beds]Per DayNANANNYA238Room and Board – Level IV [5+ Beds]Per DayNANANNYP790Social Setting DetoxificationPer Day24-HourPer ShiftYNH2035Substance Abuse Comprehensive Outpatient Treatment [SACOT]Per HourPeriodicPer Date of ServiceYYH2034Substance Abuse Halfway HousePer Day24-HourPer Date of ServiceYNH0015Substance Abuse Intensive Outpatient Program [SAIOP]Per Event Per Day, [with a 3-hour minimum]Day/NightPer Date of ServiceYYH0013Substance Abuse Medically Monitored Community Residential TreatmentPer Day24-HourPer ShiftYYH0012HBSubstance Abuse Non-Medical Community Residential Treatment – AdultPer Day24-HourPer ShiftYYYM725Supervised Living – HighPer Day24-HourMonthlyNNYP710Supervised Living – LowPer DayClient Bed DayMonthlyNNProcedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?YP720Supervised Living – ModeratePer Day24-HourMonthly Y - Only if live-in employed NYM811Supervised Living – MR/MI - 1 ResidentPer DayDailyMonthlyNNYM812Supervised Living – MR/MI - 2 ResidentsPer DayDailyMonthlyNNYM813Supervised Living – MR/MI - 3 ResidentsPer DayDailyMonthlyNNYM814Supervised Living – MR/MI - 4 ResidentsPer DayDailyMonthlyNNYM815Supervised Living – MR/MI - 5 ResidentsPer DayDailyMonthlyNNYM816Supervised Living – MR/MI - 6 ResidentsPer DayDailyMonthlyNNYP640Supported Employment – GroupPer DayDay/NightQuarterlyNNYP630Supported Employment – IndividualPer DayDay/NightQuarterlyNNT1017HITargeted Case Management [TCM]Each 15 MinutesPeriodicPer Contact/Date of ServiceYYYA255Therapeutic Leave - Residential Level II - Therapeutic Foster CarePer Day24-HourPer EventNNYA254Therapeutic Leave - Residential Level II - Program TypePer Day24-HourPer EventNNYA256Therapeutic Leave - Residential Level III - [1-4 Beds]Per Day24-HourPer EventNNYA257Therapeutic Leave - Residential Level III - [5+ Beds]Per Day24-HourPer EventNNYA258Therapeutic Leave - Residential Level IV - [1-4 Beds]Per Day24-HourPer EventNNYA259Therapeutic Leave - Residential Level IV - [5+ Beds]Per Day24-HourPer EventNNYA265Therapeutic Leave Room and Board - Level II - [Age 5 or less]Per DayNANANNYA266Therapeutic Leave Room and Board - Level II - [Age 6-12]Per DayNANANNYA267Therapeutic Leave Room and Board - Level II - [Age 13+]Per DayNANANNYA263Therapeutic Leave Room and Board - Level III - [1-4 Beds]Per DayNANANNProcedure Code:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?YA264Therapeutic Leave Room and Board - Level III - [5+ Beds]Per DayNANANNYA268Therapeutic Leave Room and Board - Level IV - [1-4 Beds]Per DayNANA NNYA269Therapeutic Leave Room and Board - Level IV - [5+ Beds]Per DayNANANNYA241Wilderness CampPer Day24-HourPer Date of ServiceNNCAP-MR/DD Procedure Codes:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid? S5102 Adult Day Health Care Services Per Day Day/Night Per Date of Service Y Y T2028Augmentative Communication – PurchasesNANAPer EventYYV5336Augmentative Communication – RepairsNANAPer EventYYH0045HICrisis RespitePer Day24-HourPer Date of ServiceYYH2011Crisis ServicesEach 15 MinutesPeriodicPer Date of ServiceYYT2021HQDay Support – Group – 2 or More Clients, Each 15 MinutesPeriodicPer Date of ServiceYYT2021Day Support – IndividualEach 15 MinutesPeriodicPer Date of ServiceYYT1019Enhanced Personal CareEach 15 MinutesPeriodicPer Date of ServiceYYT1005Enhanced Respite CareEach 15 MinutesPeriodicPer Date of ServiceYYH2015HQHome and Community Support – Group of 2 or More ClientsEach 15 MinutesPeriodicPer Date of ServiceYYH2015Home and Community Support – IndividualEach 15 MinutesPeriodicPer Date of ServiceYYS5165Home ModificationsNANAPer EventYYT2033Home Support – Level 1Per Day24-HourPer Date of ServiceYYCAP-MR/DD Procedure Codes:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?T2014HIHome Support – Level 2Per Day24-HourPer Date of ServiceYY T2020HI Home Support – Level 3Per Day24-HourPer Date of ServiceYYT2033HI Home Support – Level 4Per Day24-HourPer Date of ServiceYYT2016 Home Support – Level 5Per Day24-HourPer Date of ServiceYYS5110Individual Caregiver Training and EducationEach 15 MinutesPeriodicPer Date of ServiceYYH2023HQLong Term Vocational Supports – Group [2-3 clients]Each 15 MinutesDay/NightPer Date of ServiceYYH2023Long Term Vocational Supports – IndividualEach 15 MinutesDay/NightPer Date of ServiceYYS5161Personal Emergency Response SystemPer MonthNAPer EventYYS5125Personal Care ServicesEach 15 MinutesPeriodicPer Date of ServiceYYH2016Residential Support – Level 1Per DayDay/NightPer Date of ServiceYYT2014Residential Support – Level 2Per DayDay/NightPer Date of ServiceYYT2020Residential Support – Level 3Per DayDay/NightPer Date of ServiceYYH2016HIResidential Support – Level 4Per DayDay/NightPer Date of ServiceYYH0045Respite Care – Institutional Per Day24-HourState Developmental Center documentation requirementsYYT1005TERespite Care – Nursing – LPNEach 15 MinutesPeriodicPer Date of ServiceYYT1005TDRespite Care – Nursing – RNEach 15 MinutesPeriodicPer Date of ServiceYYS5150HQRespite – Non Institutional Nursing – Group [2-3 Clients]Each 15 MinutesPeriodicPer Date of ServiceYYS5150Respite – Non Institutional – IndividualEach 15 MinutesPeriodicPer Date of ServiceYYT2025Specialized Consultative Services Each 15 MinutesPeriodicPer Date of ServiceYYT1999Specialized Equipment and SuppliesNANAPer EventYYCAP-MR/DD Procedure Codes:Service Description:Billing Unit:Type of Service:Minimum Frequency of Service Documentation:Service Order?Covered by Medicaid?H2025HQSupported Employment – GroupEach 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteYYH2025Supported Employment – IndividualEach 15 MinutesDay/NightDuration per DOS; w/ Quarterly NoteYYT2001TransportationNANAPer EventYYT2039Vehicle AdaptationsNANAPer EventYY For more information about service codes and target populations, see IPRS Service Array: HYPERLINK "http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm" http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm APPENDIX D Sample Forms and the CAP-MR/DD Residential Support and Home Support Grid Instructions for Using the Sample Grid Sample Grid Form Sample Service Note A Sample Service Note B Sample Service Note C Sample Service Note D Sample Form for PSR Daily Note CAP-MR/DD Residential Support and Home Support Grid APPENDIX D INSTRUCTIONS FOR USING THE SAMPLE GRID The use of a service grid is limited to the following services: Behavioral Health Prevention Education Services in Selective and Indicated Populations; Child and Adolescent Residential Treatment – Level II – Family Type Day Supports [CAP-MR/DD]; Home and Community Supports [CAP-MR/DD]; Home Supports CAP-MR/DD]; Long Term Vocational Supports [CAP-MR/DD]; Personal Care [CAP-MR/DD], unless provided by a home care agency that is following home care licensure rules. Note: When Personal Care [CAP-MR/DD] is provided within the context of Residential Supports, it may be documented using the CAP-MR/DD Residential Support Grid found at the end of this Appendix; Personal Care Services [DD], unless provided by a home care agency that is following home care licensure rules; Residential Supports [CAP-MR/DD], must address Habilitation, Personal Care, and Support [See CAP-MR/DD Residential Support and Home Support Grid at the end of this Appendix.]; Residential Treatment – Family Type - Level II; Respite – all categories, except for Institutional Respite, which shall follow the State Developmental Centers’ documentation requirements; and Supported Employment Services [CAP-MR/DD] Purpose: The purpose of the grid is to provide a means to quickly capture the goal(s) addressed, the staff’s intervention/activity and the assessment of the individual’s progress toward the goals established. Page __ of __: The number of sheets that will be needed per 15-day cycle will depend on how many goals the individual has in the service plan. Consumer’s Name: Enter the individual’s name as recorded in his or her service record. Medicaid ID Number: Enter the Medicaid ID number for all Medicaid-eligible individuals. Record Number: Enter the individual’s medical record number. Month/Year: Enter the month and year service was received by the individual. Shift: When appropriate, enter the shift for which the entries represent. Specify Service: Enter the specific service for which the form is being used, i.e., Residential Treatment - Level II, Supported Employment [CAP-MR/DD], etc. Area Program/LME: Enter the name of the area program/LME. Service Provider/Agency: If the service is provided by an agency other than the area program/LME, enter the name of the provider/agency. Goal(s): Enter the goal as stated in the individual’s service plan. The goal should be written as documented in the service plan. Key: A key(s) utilizing letters shall be developed to reflect interventions/activities. A key(s) utilizing numbers shall be developed to reflect the assessment of the individual’s progress toward the goals. All keys developed shall be identified in a Key Menu. On the grid in the Key box, identify in the top part of the box labeled, “I”, the key to be used to reflect the interventions/activities. On the bottom part labeled, “A”, the key is used to reflect the assessment of the individual’s progress toward the goals. Numbered Boxes 1-15/16-31: Each numbered box represents a day of the month. The number of boxes used will depend on how many days are in that particular month. Each box is divided into an upper half and a lower half. The top half of the box represents the intervention/activity provided - [noted as an I in top half of the key section], and the lower half [noted as an A] represents the assessment of the individual’s progress toward the goals. Based upon the key identified in the Key box, assign a letter which represents the intervention/activity provided and a number which represents the assessment of the individual’s progress toward goals. A number can be placed in front of the key used to signify how many interventions/activities the staff provided. Duration: Enter the total amount of time spent performing the intervention(s) when required. Date: Enter the date the documentation is initialed for services provided to the individual. Initials: The provider shall enter his or her initials for each day he or she provides a service to the individual. The initials shall correspond to the section on the back of the form called, “All Staff Persons Working with This Individual Must Fill Out the Information Below.” Comments: Each entry shall be dated. This section is for entering additional or clarifying information, e.g., to further explain the interventions/activities provided or to further describe the individual’s response to the interventions provided and progress toward goals. All Staff Persons Working With This Individual Must Fill Out The Information Below: A staff person working with the individual shall complete this section which includes the staff person’s printed name, full signature, and initials. Goals Key 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16(I)(A)(I)(A)(I)(A) Duration [when required]: Date: Initials: Date:Comments: All Staff Persons Working with This Individual must fill out the information belowStaff Name (Please Print):Staff Signature [full signature required]:Initials: Goals Key 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (I)(A)(I)(A)(I)(A) Duration [when required]: Date: Initials: Date:Comments: All Staff Persons Working with This Individual must fill out the information belowStaff Name (Please Print):Staff Signature [full signature required]:Initials:Name: 1. Date of Service 2. Identification of Recipient – if different from the client 3. Purpose of ContactMedicaid ID Number: 4. Description of Intervention(s) 5. Effectiveness of the Intervention(s)Record Number: 6. Duration of the Service - All periodic, as required by the specific service, or as otherwise required 7. Professional Signature - Degree, credentials, or licensure Paraprofessional Signature – PositionName : 1. Date of Service 2. Identification of Recipient – if different from the client 3. Purpose of ContactMedicaid ID Number: 4. Description of Intervention(s) 5. Effectiveness of the Intervention(s)Record Number: 6. Duration of the Service - All periodic, as required by the specific service, or as otherwise required 7. Professional Signature - Degree, credentials, or licensure Paraprofessional Signature – Position NAME: Medicaid ID #:Record Number: Date Duration Instructions: Briefly state purpose of contact, describe the intervention(s), and the effectiveness of the intervention(s). *Full Signature Required Purpose of Contact: DESCRIPTION OF THE INTERVENTION(S): EFFECTIVENESS OF THE INTERVENTION(S): PURPOSE OF CONTACT: DESCRIPTION OF THE INTERVENTION(S): EFFECTIVENESS OF THE INTERVENTION(S): PURPOSE OF CONTACT: DESCRIPTION OF THE INTERVENTION(S): EFFECTIVENESS OF THE INTERVENTION(S): PURPOSE OF CONTACT: DESCRIPTION OF THE INTERVENTION(S): EFFECTIVENESS OF THE INTERVENTION(S): * For professionals - signature, credentials, degree or licensure; for paraprofessionals - signature and position Individual: Medicaid ID#: Record Number: Date:*Shift/Duration of Service: Purpose of Contact: Intervention(s) [what you did]: Effectiveness of the Intervention(s):*Full Signature RequiredDate:*Shift/Duration of Service: Purpose of Contact: Intervention(s) [what you did]: Effectiveness of the Intervention(s):*Full Signature RequiredDate:*Shift/Duration of Service: Purpose of Contact: Intervention(s) [what you did]: Effectiveness of the Intervention(s):*Full Signature Required * For professionals – signature, credentials, degree or licensure; for paraprofessional - signature & position Psychosocial Rehabilitation [PSR] Daily Notes Name of Individual: _________________________________________________ Medicaid ID Number: __________________________ Record Number: _____________________________ Date: Duration - Time spent performing the interventions: Instructions: Briefly state purpose of contact, description of intervention/activity, and the effectiveness of the intervention/activity. Staff Signature/Position [full signature required] Purpose of Contact: [Individual’s goals may be pre-printed here.] The following Interventions/Activities were provided to the member and participation was encouraged, monitored and/or modeled by staff: ___Pre-vocational ___Recreation/Leisure ___Community Living ___Social Relationships ___Educational ___Personal Care/Daily Living ___Other ______________________________ Effectiveness of the Interventions: Purpose of Contact: [Individual’s goals may be pre-printed here.] The following Interventions/Activities were provided to the member and participation was encouraged, monitored and/or modeled by staff: ___Pre-vocational ___Recreation/Leisure ___Community Living ___Social Relationships ___Educational ___Personal Care/Daily Living ___Other ______________________________ Effectiveness of the Interventions: Goals:Key123456789101112131415(I) (A)Int.(I) (A)Int.(I) (A)Int.(I) (A)Int.(I) (A)Int.Duration [when required]:Date:Initials: Page 1 DATEINTS Comments on Habilitative and Personal Care Services All Staff Persons Working with This Individual must fill out the information below Staff Name (Please Print): Staff Signature [full signature required]: Initials: Page 2 GoalsKey16171819202122232425262728293031(I) (A)Int.(I) (A)Int.(I) (A)Int.(I) (A)Int.(I) (A)Int.Duration [when required]: Date:Initials: Page 3 DA T EI N T S Comments on Habilitative and Personal Care Services All Staff Persons Working with This Individual must fill out the information below Staff Name (Please Print): Staff Signature [full signature required]: Initials: Page 4 APPENDIX E Accessing Care: A Flow Chart for New Medicaid and New State Funded Consumers APPENDIX F General Statute for Minor Consent Appendix F General Statute for Minor Consent G.S. § 90-21.5 - Minor’s Consent Sufficient for Certain Medical Health Services Any minor may give effective consent to a physician licensed to practice medicine in North Carolina for medical health services for the prevention, diagnosis and treatment of (i) venereal disease and other diseases reportable under G.S. § 130-135, (ii) pregnancy, (iii) abuse of controlled substances or alcohol, and (iv) emotional disturbance. This section does not authorize the inducing of an abortion, performance of a sterilization operation, or admission to a 24-hour facility licensed under Article 2 of Chapter 122C of the General Statutes except as provided in G.S. § 122C-222. This section does not prohibit the admission of a minor to a treatment facility upon his own written application in an emergency situation as authorized by G.S. § 122C-222. Any minor who is emancipated may consent to any medical treatment, dental and health services for himself or for his child. APPENDIX G Behavioral Health Prevention Education Services for Children and Adolescents in Selective and Indicated Populations Appendix G Behavioral Health Prevention Education Services for Children and Adolescents in Selective and Indicated Populations Behavioral Health Prevention Education Services for children and adolescents who meet eligibility for selective and indicated population criteria are designed to prevent or delay the first use of substances, or to reduce or eliminate the use of substances. This service is provided in a group modality and is intended to meet the substance abuse prevention and/or early intervention needs of participants with identified risk factors for substance abuse problems [Selective] and/or with identified early problems related to substance use [Indicated]. Participants in Behavioral Health Prevention Education Services have identified risk factors or show emerging signs of use and the potential for substance abuse. The most typical program has a provider working directly with participants or parents [in a group setting] in a wide variety of settings including naturally occurring settings [school or community, etc.] on reducing known risk factors and/or enhancing protective factors that occur in that setting. Services are designed to explore and address the individual's behaviors or risk factors that appear to be related to substance use and to assist the individual in recognizing the harmful consequences of substance use. This service includes education and training of caregivers and others who have a legitimate role in addressing the risk factors identified in the service plan. This service includes, but is not limited to, children of substance abuser groups, education services for youth, parenting/family management services, peer leader/helper programs, and small group sessions. This service is preventive in nature and is not intended for individuals who have been determined to have a diagnosable substance abuse or mental health disorder which requires treatment. This service is time-limited, based on the duration of the curriculum-based program used. A provider is required to utilize an evidenced-based program in one of three nationally-approved categories: Promising Programs, Effective Programs, and Model Programs. The Behavioral Health Prevention Education Services documentation shall be required for all children and adolescents receiving substance abuse selective and indicated prevention services and shall meet the following minimum requirements: Documentation of Child and Adolescent Risk Profile: Documentation of the findings of a child or adolescent risk profile that identifies one or more risk factors for substance abuse. Assessment and Plan: The Assessment of the participant shall include: a. Documentation of the findings on a child or adolescent risk profile that identifies one or more designated risk factors for substance abuse; b. Documentation of individual risk factor(s), history of substance use, if any, a description of the child’s or adolescent’s current substance use patterns, if any, and attitudes toward use; and c. Other relevant histories and mental status that are sufficient to rule out other conditions suggesting the need for further assessment and/or treatment for a substance abuse or dependence diagnosis and/or a co-occurring psychiatric diagnosis. 2. The Plan shall: a. Be based on an identification of the child’s, adolescent’s, and/or family’s problems, needs, and risk factors, with recognition of the strengths, supports, and protective factors; b. Match the child or adolescent risk profile with appropriate evidence- based Selective or Indicated Substance Abuse Prevention goals that address the child’s or adolescent’s and/or family’s knowledge, skills, attitudes, intentions, and/or behaviors; and c. Be signed by the participant and the parent/guardian, as appropriate, prior to the delivery of services. 3. Following the delivery of each service, the minimum standard for documentation in the service record shall be a Service Grid which includes: a. Identification of the evidence-based program being implemented; b. Full date and duration of the service that was provided; c. Listing of the individual child or adolescent and/or his or her family members that were in attendance; d. Identification of the curriculum module delivered; e. Identification of the module goal; f. Identification of the activity description of the module delivered; g. Initials of the staff member providing the service which shall correspond to a signature with credentials identified on the signature log section of the Service Grid; and h) In addition to the above, notation of significant findings or changes in the status of the child or adolescent that pertain to the appropriateness of provision of services at the current level of care and/or the need for referral for other services shall be documented. Consent for Participation: In all circumstances, the child or adolescent shall sign consent for participation in behavioral health prevention education services. Service Grid: A service grid shall include a notation following the delivery of each service and shall include the date and duration of the service that was provided, a listing of the individual child or adolescent and/or his or her family members that were in attendance, an identification of the evidence-based program module and service type, session goal, standard activity description, and initials of the staff member providing the service. The initials shall correspond to a signature with credentials identified on the signature log section of the service grid. Also to be documented, as appropriate, shall be a special notation of any child or adolescent significant findings or changes in status that pertain to the provision of services at the current level of care or the need for referral for other services. Individual and Family Outcomes: Documentation shall include the findings of the standardized pre-tests and post-tests associated with the evidence-based program being implemented, and the individual and/or family outcomes resulting from the program intervention. APPENDIX H Glossary Glossary ACCESS - An array of treatments, services and supports is available; individuals know how and where to obtain them; and there are no system barriers or obstacles to getting what they need, when they are needed. ACCREDITATION - Certification by an external entity that an organization has met a set of standards. ALCOHOL AND DRUG EDUCATION TRAFFIC SCHOOL [ADETS] - An approved curriculum which shall: 1. Include 10 to 13 contact hours in a classroom setting; 2. Be provided by area programs or their designated agencies with certified ADETS instructors; and 3. Be designed for persons: a. who have only one DWI conviction [lifetime]; b. whose assessment did not identify a "Substance Abuse Handicap;" and c. whose alcohol concentration was .14 or less. AMERICAN SOCIETY OF ADDICTION MEDICINE [ASAM] PLACEMENT CRITERIA - The Patient Placement Criteria for the Treatment of Substance-Related Disorders produced by the American Society of Addiction Medicine. These criteria are used as guides for the provision of substance abuse treatment that is appropriate for the individual. AREA AUTHORITY/COUNTY PROGRAM - A program that is certified by the DHHS Secretary to manage, oversee and sometimes directly provide mental health, developmental disabilities, and substance abuse services in a specified geographic area. Most Area Programs have already changed or will soon be changing to Local Management Entities [LME]. ARRAY OF SERVICES - Group of services available. ASSESSMENT - A comprehensive examination and evaluation of a person’s needs for psychiatric, developmental disability, or substance abuse treatment services and/or supports according to applicable requirements. BASIC BENEFITS - Traditional behavioral health services under the Medicaid State Plan, including physician services, often referred to as outpatient treatment or medication management services, which include those services covered in Medicaid’s Clinical Coverage Policy 8C – Outpatient Behavioral Health Services Provided by Direct Enrolled Providers. These services may also be provided to individuals who meet medical necessity criteria for MH/DD/SA Community Intervention Services, but for whom services are limited to outpatient and/or medication management services only. BEST PRACTICE(S) - Interventions, treatments, services, or actions that have been shown to generate the best outcomes or results. The terms, “evidence-based” or “research-based” may also be used. BLOCK GRANT - Funds received from the federal government [or others], in a lump sum, for services specified in an application plan that meet the intent of the block grant purpose. The Division of MH/DD/SAS receives three block grants: the Mental Health Block Grant, the Substance Abuse Prevention and Treatment Block Grant, and the Social Services Block Grant. CAP-MR/DD - The acronym for the Community Alternatives Program for Persons with Mental Retardation/Developmental Disabilities. CAP-MR/DD provides home and community-based care as an alternative to care in an Intermediate Care Facility for persons with Mental Retardation/Developmental Disabilities [ICF-MR]. CAP-MR/DD WAIVER - A Medicaid community care funding source for persons with MR/DD who require an ICF/MR level of care that offers specific services in the community. CARE COORDINATION - Activities conducted by a provider agency for the purposes of managing a specific individual’s care to ensure that he or she receives the most appropriate services and supports. Care coordination includes the sharing of pertinent clinical information in order to cooperate in serving the same individual, or in order to transfer care for an individual between providers. It includes participation in person-centered planning, convening Child and Family Teams [for children and youth], and discharge planning for individuals in state facilities and other inpatient services. Care coordination also includes facilitating appropriate connections to clinical home providers, if none has been identified, and to other MH/DD/SA service providers and primary health care services, when warranted. For LMEs, the care coordination function is defined within the organizational structure of the LME cost model. CATCHMENT AREA - The geographic area of the state served by a specific county/area program or LME. CENTERS FOR MEDICARE AND MEDICAID SERVICES [CMS] - The US federal agency that administers Medicare, Medicaid, and the State Children’s Health Insurance Program. This agency approves the North Carolina Medicaid Plan. CLAIM - An itemized statement of services, performed by a provider network member or facility, which is submitted for payment. CLINICAL HOME - Lead service provider agency that has the designated responsibility for the coordination of a person’s services. Qualified Professionals carry out the clinical home functions which include the responsibility for assuring the completion of a comprehensive clinical assessment, the development of the PCP, and ensuring that the appropriate behavioral health services and supports are in place when individuals need them. Clinical home provider agencies are specifically responsible for the following functions: Carried out by a Qualified Professional [QP]; Assurance that a comprehensive clinical assessment is completed upon service entry [individuals who are new to the MH/DD/SA service system]; Development of the PCP & Crisis Plan; Submission of the LME Consumer Admission and Discharge Form, NC-TOPPS & NC-SNAP; Submission of the ITR/OFR-2/CTCM Form; and Assurance of first response to emergencies or crises. Typically, the clinical home provider is the provider agency that has the most experience with and knowledge of the individual’s needs, preferences, and progress. All clinical home providers of Medicaid-funded services are endorsed by the LME for enrollment with DMA. COMMUNITY INTERVENTION SERVICE [CIS] AGENCY - Term used as a provider agency classification to confirm that the agency has met the eligibility criteria for entering into a participation agreement with the Division of Medical Assistance to provide certain specific services that have been endorsed or approved by the entity [the LME for MH/DD/SAS] responsible for determining such eligibility. Once approval or endorsement has been awarded, the service provider agency may then achieve approved status as a Medicaid Provider of Community Intervention Services and enter into a participation agreement to provide the services. COMMUNITY INTERVENTION SERVICES - Specific MH/DD/SA services that are delineated in Clinical Coverage Policy 8A and subject to provider endorsement by the LME and direct enrollment with DMA for Medicaid-covered services. COMPREHENSIVE CLINICAL ASSESSMENT - An intensive clinical and functional face-to-face evaluation of an individual’s presenting mental health, developmental disability, and/or substance abuse condition that results in the issuance of a written report, providing the clinical basis for the development of a Person-Centered Plan [PCP] and recommendations for services/supports/treatment. CONFIDENTIAL INFORMATION - Any information, whether recorded or not, relating to an individual served by a facility that was received in connection with the performance of any function of the facility. Confidential information does not include statistical information from reports and records or information regarding treatment or services shared for training, treatment, habilitation, or monitoring purposes that does not identify individuals either directly or by reference to publicly known or available information. CONFIDENTIALITY - Keeping information private. Allowing records or information to be seen or used only by those with legal rights or permission. CONSENT - Giving approval or agreeing to something. For example, in education, a parent must give consent before a child can be evaluated or placed in a special program. Consent is usually documented in writing and may be given for regular treatment, emergency medical care, and participation as a subject in a research project. The individual giving consent in a particular situation must have the legal authority to do so. CONSENT FOR PARTICIPATION - A signed agreement to take part in treatment required for children and adolescents receiving substance abuse treatment. CONSULTATION - Information shared between or among peers or professionals to increase the ability to manage challenging circumstances. CONSUMER DATA WAREHOUSE [CDW] - A database containing data regarding demographic, clinical outcomes, and satisfaction data regarding individuals served by MH/DD/SA service providers. The data stored in the CDW is the main source of information regarding block grant programs and to fulfill legislative requests. The information is also used for planning and evaluation of services. CORE SERVICES - Services that are necessary for the basic foundation of any service delivery system. Core services under the Division of MH/DD/SAS are of two types: frontend service capacity, such as screening, assessment, triage, emergency services, service coordination, and referral; and indirect services, such as prevention, education, and consultation at a community level. Membership in a target population is not required to access a core service. COST SUMMARY - A document summarizing the costs of CAP-MR/DD services for a CAP-MR/DD Program participant. The cost summary must match all waiver services that are reflected in the Plan of Care and cover a twelve-month period. COUNTERSIGNATURE - Additional signatures, other than the signature of the individual who actually provided the service. Countersignatures are sometimes used to indicate the review and approval of documentation within the context of clinical supervision. Countersignatures are not required by the State, but countersignature entries in the service records may be required based upon the provider agency’s policy when such a policy exists. CRISIS PLAN - A crisis plan is developed as part of the individual’s Person-Centered Plan and is designed to facilitate stabilization in response to stressful life events that may seriously interfere with a person's ability to cope or manage his or her life. The event may be emotional, physical, or situational in nature. The event is the perception of and response to the situation, not the situation itself. Essential elements include: 1. A proactive component that identifies early known warning signals and triggers of an impending crisis. 2. An intervention component for steps when the individual is experiencing emotional, physical, or situational difficulties that interfere with his/her ability to manage immediate needs without assistance. Information about the process or procedure which will be followed when a crisis event or emergency situation occurs, such as who to call as First Responder, what actions to take with the individual in crisis, and what crisis services or hospitals should be used. DAY/NIGHT SERVICES - Services provided on a regular basis, in a structured environment that is offered to the same individual for a period of three or more hours within a 24hour period. This term generally refers to services that are a part of daily or regular group programming, but are not 24-hour residential services. Some examples of Day/Night Services are: Substance Abuse Intensive Outpatient Program, Day Treatment Programs and Partial Hospitalization, Developmental Day, Psychosocial Rehabilitation, ADVP, Supported Employment, Community Rehabilitation Program [Sheltered Workshop], and Day/Evening Activity. DEPARTMENT OF HEALTH AND HUMAN SERVICES [DHHS] - The North Carolina agency that oversees state government human services programs and activities. DEVELOPMENTAL DISABILITY - A severe, chronic disability of a person which: 1. is attributable to a mental or physical impairment or combination of mental and physical impairments; 2. is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22; 3. is likely to continue indefinitely; 4. results in substantial functional limitations in three of more of the following areas of major life activity; self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction and economic self-sufficiency; and 5. reflects the person’s need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated; or 6. when applied to children from birth through four years of age, may be evidenced as a developmental delay. DIAGNOSTIC AND STATISTICAL MANUAL [DSM-IV-TR] - A reference book, published by the American Psychiatric Association, of special codes that identify and describe MH/DD/SA disorders and their symptoms. DIAGNOSTIC ASSESSMENT - An intensive clinical and functional face to face evaluation of an individual’s mental health or substance abuse condition that results in the issuance of a Diagnostic Assessment report with a recommendation regarding whether the individual meets target population criteria, and provides the basis for the development of an initial Person-Centered Plan. DISCHARGE PLAN - A document generated at the time service is terminated that contains recommendations for further services designed to enable the person to live as normally as possible. DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES [DMH/DD/SAS] - A division of the State of North Carolina, Department of Health and Human Services, responsible for administering and overseeing public mental health, developmental disabilities and substance abuse programs and services. DMA - The acronym for the North Carolina Division of Medical Assistance located in the Department of Health and Human Services. This is the agency that operates the Medicaid Program for North Carolina. DRUG EDUCATION SCHOOL [DES] - A prevention and intervention service which provides an educational program for drug offenders as provided in the North Carolina Controlled Substances Act and Regulations. DURATION - The total amount of time spent performing intervention(s). When applicable, this amount of time is documented in service notes and is billed within payor reimbursement guidelines for the service. Duration is required to be recorded: for all periodic services, unless the periodic service is billed on a per event basis; for all services as required by the Medicaid State Plan; for all services as required by Medicaid Clinical Coverage Policies; or whenever duration is required by the service definition. EARLY PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICES [EPSDT] - Services provided under Medicaid to children under age 21 to determine the need for mental health, developmental disabilities or substance abuse services. Providers are required to provide needed service identified through screening. ELECTRONIC RECORD - A computer-based service record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical support systems, links to medical knowledge, and other aids. A record is not considered computer-based if it is only stored electronically in a computer as a word-processing file and not as a part of an electronic database. ELECTRONIC SIGNATURE - A computer process whereby service documentation authorship and/or approval can be documented by a specific individual. Guidelines for electronic signature must be followed to ensure proper review of documentation, secure passwords, and individual documented agreement with the electronic signature guidelines. EMPLOYEE ASSISTANCE PROGRAM [EAP] - A worksite-based program designed to assist: [1] work organizations in addressing productivity issues, and [2] employees in identifying and resolving personal concerns, including, but not limited to, health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance. EVALUATION - More in-depth than an assessment, examination of specific needs or problems by professionals using specific evaluation tools. EVIDENCE-BASED PRACTICE - Evidence Based Practice [EBP] refers to a research-based treatment approach or protocol that has been found to have clinical efficacy and effectiveness for individuals with certain emotional or behavioral challenges. FIRST RESPONDER - The provider designated in the PCP to provide crisis response on a 24/7/365 basis. Typically, the first responder is the provider who has the most sustained contact and familiarity with the clinical dynamics of the individual being served. FOLLOW-UP - A process of checking on the progress of a person who has completed treatment or other services, has been discharged, or has been referred to other services and supports. GUARDIAN - An individual who has been given the legal responsibility to care for a child or adult who is incapable of taking care of themselves due to age or lack of capacity. The appointed individual is often responsible for both taking care of the child or incapable adult and their affairs. A legal guardian may provide permission for an individual to receive treatment. Also, a person appointed as a guardian of the person or general guardian by the court under Chapters 7A or 35A or former Chapters 33 or 35 of the General Statutes. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT [HIPAA] - A federal Act that protects people who change jobs, are self-employed, or who have pre-existing conditions. The Act aims to make sure that prospective or current recipient of services are not discriminated against based on health status. HIPAA also protects the privacy and security of an individual’s protected health information. HOME CARE AGENCY - An agency that is licensed by the Division of Facility Services [DFS] to provide home care services and directly-related medical supplies and appliances to an individual at his home. Home care services include nursing care; physical, occupational, or speech therapy; medical social services; "hands-on" in-home aide services; infusion nursing services; and assistance with pulmonary care, pulmonary rehabilitation, or ventilation. INCIDENT AND DEATH REPORT - A report of any incident, unusual occurrence, medication error, or death of a person that occurs while an individual is under the care of a service provider. In order to maintain authorization to provide publicly-funded MH/DD/SA services and good licensure status, a provider must follow the requirements for incident response and reporting as set forth in 10A NCAC 27G .0600, in accordance with Section 4.5 of NC Session Law 2002-164 [Senate Bill 163]. For full details on these requirements, consult the Administrative Code and the DHHS Incident and Death Reporting Form QM02 and Manual, which can be found under “Forms” at: HYPERLINK "http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/index.htm" http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/index.htm INDEPENDENT PRACTITIONER - A licensed practitioner who does not need to be endorsed by an LME and who may be directly enrolled with Medicaid to provide basic benefit services. INDIVIDUALIZED EDUCATION PROGRAM [IEP] - A written plan for a child with special education needs. The plan is based on results from an evaluation and is developed by a team that includes the child’s parents, teachers, other school representatives, specialists, and the child when appropriate. INPATIENT - A person who is hospitalized. An inpatient facility may be hospital or non-hospital based, such as PRTF. INTEGRATED PAYMENT AND REPORTING SYSTEM [IPRS] - An electronic, web-based system used to track, pay and report on all claims submitted by providers for services rendered. INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION OR DEVELOPMENTAL DISABILITIES [ICF MR/DD] - A facility that provides ICF level of care to eligible persons who have mental retardation or developmental disabilities. INTERNATIONAL CLASSIFICATION OF DISEASES [ICD-9-CM] - The International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2, US Department of Health and Human Services, US Government Printing Office, Washington, DC. This document provides diagnostic categorization and coding of illnesses. LEGALLY RESPONSIBLE PERSON - When applied to an adult, who has been adjudicated incompetent, a guardian; when applied to a minor, a parent, guardian, a person standing in loco parentis, or a legal custodian other than a parent who has been granted specific authority by law or in a custody order to consent for medical care, including psychiatric treatment; or when applied to an adult who is incapable as defined in G.S. 122C72(c) and who has not been adjudicated incompetent, a health care agent named pursuant to a valid health care power of attorney as prescribed in Article 3 of Chapter 32 of the General Statutes. LATE ENTRY – An entry in a service record that describes an event or episode of treatment that exceeds the allowable time frames for that documentation to be considered current. Please see Chapter 9 for specific guidance regarding allowable time frames per service type. LICENSURE - A state or federal regulatory system for service providers to protect the public health and welfare. Examples of licensure include licensure of individuals by professional boards, such as the NC Psychology Board, or the NC Substance Abuse Professional Certification Board. Examples of licensure also include licensure of facilities used to provide MH/DD/SA services by the NC Division of Facility Services. LOCAL MANAGEMENT ENTITY [LME] - The local agency that plans, develops, implements, and monitors services within a specified geographic area, according to requirements of the Division of MH/DD/SAS. Includes developing a full range of services that provides inpatient and outpatient treatment, services, and/or supports for both insured and uninsured individuals. See also AREA AUTHORITY/COUNTY PROGRAM. MASTER INDEX - This index is a file of persons served. This list shall be permanently maintained manually or electronically by all service provider agencies. MEDICAID - A jointly-funded federal and state program that provides hospital and medical expense coverage to low-income individuals, certain elderly people, and people with disabilities. MEDICAL NECESSITY - Criteria established to ensure that treatment is necessary and appropriate for the condition or disorder for which the treatment is provided in order to meet the specific preventive, diagnostic, therapeutic, and rehabilitative needs of the individual. In order for a service to be eligible for reimbursement by Medicaid or the State, the individual must have an established diagnosis reflecting the medical necessity criteria inherent in the service. MEDICARE - A federal government hospital and medical expense insurance plan primarily for elderly people and people with disabilities. MINOR [OR UNEMANCIPATED MINOR] - Any person under the age of 18 who has not been married or has not been emancipated pursuant to Article 35 of Chapter 7B of the General Statutes. MODIFIED RECORD - A clinical service record which has requirements that are either different from those that are usually associated with a full clinical service record, or which contains only certain components of a full service record. The use of modified records is limited to those approved by DMH/DD/SAS, and used only if there are no other services being provided. When an individual receives additional services, then a full service record shall be merged into the full service record. Modified records may only be used for: Respite [if respite is the only service being provided]; Behavioral Health Prevention Education Services for Children & Adolescents in Selective and Indicated Prevention Services, Universal Prevention Services, and other services, if approved by the Division. MR-2 [OR MR2] - A form used in the CAP/MR-DD program. The ICF-MR Level of Care determination is assessed and documented on the MR2 form by a physician or clinical psychologist licensed by the State of North Carolina. The physician/licensed psychologist providing the assessment will complete the MR2 for individuals that, based on the assessment results, appear to meet the ICF-MR level of care. NORTH CAROLINA ADMINISTRATIVE CODE [NCAC] - State rules and regulations. The rules governing MH/DD/SA service can be found in 10A NCAC, Chapters 26-31, linked here: HYPERLINK "http://reports.oah.state.nc.us/ncac.asp?folderName=\\Title%2010A%20-%20Health%20and%20Human%20Services" http://reports.oah.state.nc.us/ncac.asp?folderName=\Title%2010A%20-%20Health%20and%20Human%20Services . NORTH CAROLINA TREATMENT OUTCOMES AND PROGRAM PERFORMANCE SYSTEM [NC-TOPPS] - Refers to the program by which the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services [DMH/DD/SAS] measures outcomes and performance for Substance Abuse and Mental Health service recipients. NC-TOPPS captures key information on a person's current episode of treatment, aids in evaluation of active treatment services, and provides data for meeting federal performance and outcome measurement requirements. OUTCOMES - At the individual level, events used to determine the extent to which service recipients improve their levels of functioning, improve their quality of life, or attain personal life goals as a result of treatments, services and/or supports provided by the public and/or private systems. At the system level, outcomes are events used to determine if the system is functioning properly. OVERSIGHT - Activities conducted by a government regulatory or funding agency [or other responsible agency] for the purpose of determining how a provider agency is functioning financially or programmatically. This includes LME activities related to provider endorsement and ongoing monitoring, service authorization, claims payment, and pre- and post-payment reviews. Oversight also includes audits, investigations, and other regulatory activities conducted by DMH/DD/SAS, DHSR, DMA, DSS, of other state agencies with responsibility for ensuring compliance with state and federal law, the quality of services, and/or the safety of consumers. PENDING RECORD - A record that has the potential to become a full service record, once it is determined that the individual meets the requirements that call for the establishment of a full service record, and usually created when an individual presents for screening for possible services, or when there is insufficient, partial, or incomplete information available and a full service record cannot be established. A pending record may be used when there may have been some intervention, such as an initial screening, but the individual is not subsequently enrolled in active treatment. Services that are typically documented in a pending record include: Screening, Triage, and Referral; Court ordered consultation and/or evaluations that do not result in a subsequent MH/DD/SA service; AssCOurt-CouCooooertive Outreach; and Drop-In Center Services. PERIODIC SERVICES - A service provided on an episodic basis, either regularly or intermittently, through short, recurring visits for persons with mental illness, developmental disabilities, or who are substance abusers. PERSON-CENTERED PLANNING - An approach in which the individual directs his/her own planning process with the focus being on the expressed preferences, needs, and plans for his/her future. This process involves learning about the individual's whole life, not just the issues related to the person's disability. The process involves assembling a group of supporters, on an as-needed basis, who are selected by the individual with the disability and who have the closest personal relationship with them and are committed to supporting the person in pursuit of real life dreams. Those involved with the planning process are interested in learning who the person is as an individual and what he/she desires in life. The process is interested in identifying and gaining access to supports from a variety of community resources, one of which is the community MH/DD/SA service system that will assist the person in pursuit of the life he/she wants. Person-centered planning results in a written individual support plan. PERSON-CENTERED-PLAN - An individualized and comprehensive plan that specifies all services and supports to be delivered to the individual eligible for mental health and/or developmental disability and/or substance abuse services according to NC Mental Health Reform requirements. A person-centered plan generates action or positive steps that the person can take towards realizing a better and more complete life. Plans also are designed to ensure that supports are delivered in a consistent, respectful manner and offer valuable insight into how to assess the quality of services being provided. PLAN OF CARE - For the CAP-MR/DD Waiver, the person-centered plan is called the Plan of Care. It is a means for people with disabilities or long-term care needs to exercise choice and responsibility in the development and implementation of their care plan. The individual directs the planning process that identifies strengths, capacities, desires and support needs. PREVENTION - Activities aimed at teaching and empowering individuals and systems to meet the challenges of life events and transitions by creating and reinforcing healthy behaviors and lifestyles and by reducing risks contributing to mental illness, developmental disabilities and substance abuse. Universal prevention programs reach the general population; selective prevention programs target groups at risk for mental illness, developmental disabilities and substance abuse; indicated prevention programs are designed for people who are already experiencing mental illness or addiction disorders. PRIOR AUTHORIZATION - A managed care process that approves the provision of services before they are delivered. ValueOptions performs prior authorization for Medicaid funded services. State funded services that require prior authorization receive this from the LMEs. PROTECTED HEALTH INFORMATION [PHI] - PHI is individually identifiable health information that is transmitted by, or maintained in, electronic media or any other form or medium. This information must relate to 1) the past, present, or future physical or mental health, or condition of an individual; 2) provision of health care to an individual; or 3) payment for the provision of health care to an individual. If the information identifies or provides a reasonable basis to believe it can be used to identify an individual, it is considered individually identifiable health information. See Part II, 45 CFR 164.501. PROVIDER - A person or an agency that provides MH/DD/SA services, treatment, supports. PUBLIC MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES SYSTEM - The network of managing entities, service providers, government agencies, institutions, advocacy organizations, commissions and boards responsible for the provision of publicly-funded services to individuals. QUALIFIED PROFESSIONAL - Any individual with appropriate training or experience in the fields of mental health, developmental disabilities, or substance abuse treatment as specified by the General Statutes or by rule. QUALIFIED PROVIDER - A provider who meets the provider qualifications as defined by rules adopted by the Secretary of Health and Human Services. QUALITY ASSURANCE [QA] - A process to assure that services are minimally adequate, individual rights are protected, and organizations are fiscally sound. QA involves periodic monitoring of compliance with standards. Examples include: establishment of minimum requirements for documentation, service provision, licensure and certification of individuals, facilities, and programs; and investigation of allegations of fraud and abuse. See also, QUALITY MANAGEMENT. QUALITY IMPROVEMENT [QI] - A process to assure that services, administrative processes, and staff are constantly improving and learning new and better ways to provide services and conduct business. QUALITY MANAGEMENT [QM] - A framework for assessing and improving services and supports, operations, and financial performance. Processes include: quality assurance, such as external review of appropriateness of documentation, monitoring, and quality improvement, such as design and implementation of actions to address access. See also QUALITY ASSURANCE AND QUALITY IMPROVEMENT. RECIPIENT - A person authorized for Medicaid or other program or insurance coverage. Also, an individual receiving a given service. RECORD RETENTION AND DISPOSITION SCHEDULE FOR STATE AND AREA FACILITIES - This schedule determines the procedures for the management, retention, and destruction of records by the Division of MH/DD/SAS facilities, and the LMEs and their contractors. Please find link here: HYPERLINK "http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm10-3retentionupdated5-05.pdf" http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm10-3retentionupdated5-05.pdf REFERRAL - The process of establishing a link between a person and another service or support by providing authorized documentation of the person's needs and recommendations for treatment, services, and supports. It includes follow–up in a timely manner consistent with best practice guidelines. SCREENING - An abbreviated assessment or series of questions intended to determine whether the person needs referral to a provider for additional services. A screening may be done face-to-face or by telephone, by a clinician or paraprofessional who has been specially trained to conduct screenings. Screening is a core or basic service available to anyone who needs it, whether or not they meet criteria for target or priority populations. SCREENING, TRIAGE AND REFERRAL - This process involves a brief interview designed to first determine if there is a MH/DD/SA service need, the likely area[s] of need, as well as the immediacy of need [emergent, urgent, or routine]. The individual is then connected to an appropriate provider for services based upon the area and level of need indicated. SERVICE GRID - A method of documentation of service provision that is approved for use for specific services. SERVICE ORDER - Written authorization by the appropriate professional as evidence of the medical necessity of a given service. SERVICE PROVIDER - Any person or agency giving some type of service to children or their families. A service provider, or service provider agency, is part of the provider community under Mental Health Reform. SERVICE RECORD - A document that is required to demonstrate evidence of a documented account of all service provision to a person, including pertinent facts, findings, and observations about a person’s course of treatment/habilitation and the person’s treatment/habilitation history. The individual’s service record provides a chronological record of the care and services which the individual has received and is an essential element in contributing to a high standard of care. SERVICE RECORD NUMBER CONTROL REGISTER - This register controls the assignment of service record numbers. Any person admitted shall retain the same service record number on subsequent admission. This shall be permanently maintained manually or electronically by all service provider agencies. STANDARDS - Activities generally accepted to be the best method of practice. Also, the requirements of licensing, certifying, accrediting, or funding groups. STATE PLAN [DMH/DD/SAS] - The annually updated statewide plan that forms the basis and framework for MH/DD/SA services provided across the state. STATE PLAN [NORTH CAROLINA MEDICAID] - All of the formal policies, processes, and procedures approved by the US federal agency Centers for Medicare & Medicaid [CMS] regarding the Medicaid Program in North Carolina. This includes approval of Medicaid services and service definitions. TANGIBLE SUPPORTS - Concrete resources that are available as a part of the CAP-MR/DD Program to assist in improving an individual’s level of functioning, for example, “Home Modifications.” TARGETED CASE MANAGEMENT - A service approved only for individuals with a developmental disability that involves locating, obtaining, coordinating, and monitoring social, habilitative, and medical services, as well as other services and supports related to maintaining an individual’s health, safety and well-being in the community. TARGET POPULATIONS - A categorization in IPRS that applies to the classification of individuals who meet eligibility requirements in order to receive benefits for mental health, developmental disabilities, or substance abuse conditions, according to the North Carolina State Plan for Mental Health Reform. In general, individuals who meet Target Population eligibility are those with the most serious or severe unmet challenges and needs. TREATMENT ACCOUNTABILITY FOR SAFER COMMUNITIES [TASC] - A service designed to offer a supervised communitybased alternative to incarceration or potential incarceration, primarily to individuals who are alcohol or other drug abusers, but also to individuals who are mentally ill or developmentally disabled and who are involved in crimes of a nonviolent nature. This service provides a liaison between the criminal justice system and alcohol and other drug treatment and educational services. It provides screening, identification, evaluation, referral, and monitoring of alcohol or other drug abusers for the criminal justice system. TWENTY-FOUR -HOUR FACILITY - A facility wherein a service is provided to the same individual on a 24hour continuous basis, and includes residential and hospital facilities. UTILIZATION MANAGEMENT [UM] - A process to regulate the provision of services in relation to the capacity of the system and the needs of individuals. This process should guard against under-utilization as well as over-utilization of services to assure that the frequency and type of services fit the needs of individuals. UM is typically an externally-imposed process, based on clinically defined criteria. UTILIZATION REVIEW [UR] - An analysis of services, through systematic case review, with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided. UR is typically an internally- imposed process that employs clinically established criteria. Appendix A REFER TO PCP MANUAL FOR ADDITIONAL INSTRUCTION Appendix A REFER TO PCP MANUAL FOR ADDITIONAL INSTRUCTION Appendix A Appendix A Appendix A PAGE Appendix B B- PAGE 4 Appendix B Appendix C PAGE 8 Appendix C: January 1, 2008 / April 1, 2009 C - Appendix D January 1, 2008 / April 1, 2009 D- PAGE 2 North Carolina Division of Mental Health/ Developmental Disabilities/ Substance Abuse Services Note: This sample grid may only be used for Behavioral Health Prevention Education Services in Selective and Indicated Populations, Day Supports [CAP-MR/DD], Home and Community Supports [CAP-MR/DD], Personal Care [DD], Personal Care [CAP-MR/DD], Residential Treatment – Family Type [Level II], Respite [except for Institutional Respite], and Supported Employment Services [CAP-MR/DD]. Name of Individual: Medicaid ID#:Record #:Month/Year:Specify Service:Area Program/LME: Service Provider/ Agency: January 1, 2008 / April 1, 2009 Page 1 of ___ Sample Grid Form North Carolina Division of Mental Health/ Developmental Disabilities/ Substance Abuse Services Note: This sample grid may only be used for Behavioral Health Prevention Education Services in Selective and Indicated Populations, Day Supports [CAP-MR/DD], Home and Community Supports [CAP-MR/DD], Personal Care [DD], Personal Care [CAP-MR/DD], Residential Treatment – Family Type [Level II], Respite [except for Institutional Respite], and Supported Employment Services [CAP-MR/DD]. Name of Individual: Medicaid ID#:Record #:Month/Year:Specify Service:Area Program/LME: Service Provider/ Agency: January 1, 2008 / April 1, 2009 Page PAGE 4 of ___ Sample Grid Form Service Notes NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services January 1, 2008 Sample Service Note A January 1, 2008 Sample Service Note B Service Notes NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services January 1, 2008 / April 1, 2009 Sample Service Note C NC Division of Mental Health, Developmental Service Notes Disabilities, and Substance Abuse Services November, 2007 Sample Service Note C NC Division of Mental Health, Developmental Service Notes Disabilities, and Substance Abuse Services January 1, 2008 / April 1, 2009 Sample Service Note D North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services November, 2007/Rev. 2/09 Page 1 of _____ Psychosocial Rehabilitation [PSR] Daily Notes North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services January 1, 2008 / April 1, 2009 Page 1 of _____ Psychosocial Rehabilitation [PSR] Daily Notes North Carolina Division of Mental Health/ Developmental Disabilities/ Substance Abuse Services Consumer NameRecord NumberMonth/YearShiftSpecify ServiceArea Program/LMEService Provider/ Agency January 1, 2008 / April 1, 2009 CAP-MR/DD Residential Support and Home Support Grid Appendix E Page 1 of 2: Requirements for Service Provision Approved DMHDDSAS/DMA: Effective 06/30/06 Appendix E Appendix F Appendix F F-1 PAGE G- PAGE 2 Appendix G Appendix G Appendix H H - PAGE 9 Appendix H ADM-DSG 1 ADM-DSG 2 ADM-DSG 3 ADM-DSG A ADM-DSG B ADM-DSG C ADM-DSG D Insert PC Tasks, Check When Completed. 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