Frequently Asked Questions (FAQs) for IRTS Variance Effective July 1, 2010

Question regarding R36V.04, Subdivision 3:

If the functional assessment, LOCUS assessment, or treatment plan is completed by the required timelines (10 day, 30 day etc) can the documentation be signed later?

DHS Response:

The signatures represent participation in the assessments and treatment plan development. The signatures are part of the requirement and are included in the timelines.

Question regarding R36V.04, Subdivision 3, (f):

Does the LOCUS replace all of the other IRTS eligibility criteria?

DHS Response:
No, the LOCUS is an assessment tool which is used with clinical judgment to determine an individual’s level of care needs.

Until October 1, 2010, the severity rating scale connected to the FA needs to continue to be completed as it relates to eligibility requirements. Starting October 1, 2010 the LOCUS will take the place of the severity rating scale. Additionally, IRTS eligibility is defined in MN statutes section 256b.0622, subd 3. An eligible recipient is an individual who: is age 18 or older; is diagnosed with a mental illness; because of a mental illness, has substantial disability and functional impairment in three or more of the areas listed in section 245.462, subdivision 11a, so that self-sufficiency is markedly reduced; has one or more of the following: a history of two or more inpatient hospitalizations in the past year, significant independent living instability, homelessness, or very frequent use of mental health and related services yielding poor outcomes; and in the written opinion of a licensed mental health professional, has the need for mental health services that cannot be met with other available community-based services, or is likely to experience a mental health crisis or require a more restrictive setting if intensive rehabilitative mental health services are not provided.

We encourage you to use the LOCUS once you have had the training. As long as the severity rating scale is completed there is no harm in also completing a LOCUS on recipients.

Questions regarding R36V.04, Subdivision 4:

Does the RN have to complete the Health Screening?

DHS Response:

The Health screening must be designed by the RN. The RN may train other staff persons to complete the screening. The staff should know what to do in response to the screening outcomes.

Our program requires a physical exam 30 days prior to or within 3 days of admission to the program. Can the physical count as the screening?

DHS Response:

Although a physical exam is likely to be more comprehensive than the required screening, the nursing policy and procedures must identify how and when the physical exam results will be used, how possible changes will be identified, and how follow up needs will be addressed.

Do staff have to administer meds or can they monitor and supervise individuals taking their meds?

DHS Response:

The RN determines whether staff administer medication or if the staff monitor and supervise medication administration by the recipient, based on individual needs.

Questions regarding R36V.04, Subdivision 3, (g):

a. How should we screen for the possibility of a co-occurring substance use disorder?

a. DHS Response:

Within ten days of admission, all recipients must be screened for the possibility of a co-occurring substance use disorder, unless they have a current substance use diagnosis. Screening tools and information is available at: www.dhs.state.mn.us/IDDT

b. What assessment tools are required for IDDT?

b. DHS Response:

For recipients who have current diagnosis of a substance use disorder or their screening indicates the possibility a substance use disorder, the license holder must conduct assessment of the recipient’s chemical use. The assessment must evaluate the recipient’s history of chemical use, relapse and re-hospitalization, and must assess the effects of the recipient’s chemical use related to: family and interpersonal conflict; financial concerns or problems; health concerns or problems; housing instability or homelessness; problems attaining and maintaining employment; legal problems, past and pending incarceration, violence, victimization; suicide attempts; and, non-compliance with medication and psychosocial treatment.

Specific tools are not identified in this Variance. The manual Integrated Treatment For Dual Disorder- A Guide to Effective Practice by Kim Mueser contains a functional assessment interview. Additional useful assessment tools in the manual include the Time –Line Follow-Back Calendar, Payoff Matrix, Functional Analysis Summary, and the Substance Abuse Treatment Scale

c. If an individual has a Rule 25 assessment, does it cover these assessment requirements?

c. DHS Response:

The assessment must evaluate the recipient’s history of chemical use relapse and re-hospitalization, and must assess the effects of the recipient’s chemical use related to: family and interpersonal conflict; financial concerns or problems; health concerns or problems; housing instability or homelessness; problems attaining and maintaining employment; legal problems, or past or pending incarceration, violence, victimization; suicide attempts; and, non-compliance with medication and psychosocial treatment.

A rule 25 assessment is considered current for 45 days or until the individual initiates treatment. If the Rule 25 assessment contains all of the above information and is current, the LH could use the R25 assessment to meet this requirement.

Question regarding R36V.04, Subdivision 5:

Why does the Variance require use of the IMR handouts and group manual developed by the department? Programs should be free to use educational handouts appropriate to the consumer. Some of the handouts are lengthy and not a good fit for some consumers.

DHS Response:

The use of individual and group interventions is based on the recipients’ individual treatment needs.

IMR ensures that treatment is always focused on the individual’s recovery.

The IMR material provides a foundation to ensure that an individual’s recovery goals are identified and that treatment planning is prioritized around recovery of what is important to the individual.

IMR provides a comprehensive approach about many treatment options available to individuals. IMR provides individuals education about and an array of choices about what they will learn to use to manage their illness.

The IMR handouts and group manual provided by the commissioner is consistent with the evidence based practice toolkit provided by SAMHSA.

Materials have been translated for Spanish, Hmong, Laotian, and Somali languages. Modules and handouts may be broken into several sections to meet individual needs.

Question regarding R36V.04, subd. 6(a) and (b):

What specific staff training and staffing levels are required for IDDT?

DHS Response:

Staffing levels are referred to in the IDDT service component because it is an important consideration when serving individuals with co-occurring disorders. The LH is expected to address this as a part of development of this service component. The program description, staff training plan and team meeting minutes are each areas that the LH could address the staffing levels specific to this service component.

Question regarding R36V.08:

Our staff orientation plan includes on the job training where the new staff shadows an experienced staff person for the first 10 days. Is this considered direct contact services?

DHS Response: Yes, on the job training is considered direct contact service because it includes providing face-to-face care, training, supervision, counseling, consultation, or medication assistance to persons served by the program.

Because on the job training is considered to be direct contact the license holder must have submitted a background study for the new staff person and the new staff must receive continuous direct supervision, until the back ground study notice allowing direct contact service has been received by the license holder from DHS.

Furthermore, R 36V.08, subd 2, (a), (1-4) requires orientation to these topics prior to direct contact service:

(1) Recipient rights; (2) Emergency procedures appropriate to the position, including but not limited to fires, inclement weather, missing persons, and recipients’ behavioral and medical emergencies; (3) Recovery concepts and principles; and, (4) Training related to the specific activities and job functions that the staff person will be responsible to carry out, including documentation of the delivery of services.

Although this section is not intended to limit your program’s ability to effectively provide on the job training, you must address these topics prior to job shadowing or on the job training. Ongoing job shadowing experiences and on the job training should be provided because staff development requires education, modeling, practice and demonstration of competence.

For training related to the specific activities and job functions that the staff person will be responsible to carry out, including documentation of the delivery of services job shadowing is especially important. Therefore, the use of a checklist for orientation and training may be used. This can clearly identify when the staff person has the freedom to act independently in each of their assigned job duties.

Questions regarding R36V.08:

a. Is there a time requirement as to how long staff orientation training has to be?

a. DHS Response:

This section does not require a minimum number of hours for orientation but rather identifies topics that must be addressed. Additional requirements include that staff are trained to carry out their job duties. The general orientation requirements identify topics that must be addressed; the amount of training the staff person needs depends on their job duties.

b. What is meant by trauma informed care?

b. DHS Response:

Trauma informed care means that program staff is informed that most recipients will have previous histories of violence and trauma. Trauma-informed care is based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatizing recipients.

Trauma Informed Care information is provided by SAMHSA at: www.mentalhealth.samhsa.gov/nctic

The Adult MH Division will provide Core Training on this topic on 12/13/10

c. If the calendar year requirements are changing mid year, how do you expect programs to manage the two standards this year? Please make sure that new standards in effect in July don’t affect annual training standards that programs are already underway in meeting.

c. DHS Response:
Training requirements for orientation will begin July 1 for staff who are hired on or after July 1.

d. Our staff need more training to provide medication administration> Can we send them to training and will this cost be covered in our rate?

d. DHS Response:

Staff training costs are typically an allowable expense. Programs that encounter unique training costs that have not been anticipated, are encouraged to contact the Adult MH Division.

Question regarding R36V.11, Subdivision 1: Admission and discharge criteria:

When the program has no openings are we required to meet the timelines identified in R36V.11, regarding making a determination within 72 hours?

DHS Response:

When a request is made for IRTS admission, the referent must be notified about bed availability and when the next opening is anticipated to occur. If there is bed availability, or an opening is anticipated within 72 hours, the timelines apply. If there are no openings anticipated for more than 72 hours, the LH must identify for the applicant or referent the information that is needed by the program to make an admission decision and the applicant or referent can be notified when an opening will occur.

IRTS providers are also expected to maintain current bed availability information at the Minnesota Health Access website.

Question regarding R36V.14, Subd. 6:

Our program offers an extended care program within our IRTS facility. Do you have a format/document that lists the essential questions or information that you are seeking in order to be in compliance with the ‘inform and submit plan” re: B36V.14 Physical Plant Subd.6 –the physical separation of services?

DHS Response:

The following information must be submitted to the licensing division:

Describe the nature of the service;

Describe how the service is physically separated from the IRT services;

Describe how staff time is accounted for if staff from the IRTS also staffs the other service.

Describe how client records are managed following discharge from the IRTS;

Describe how individuals who are discharged from the IRTS are informed about the service change.

Question

The new variance requires more time from the clinical supervisor. What about weekends, holidays and vacations?

DHS Response:

This service requires significant clinical supervision. Some programs have other mental health professionals on staff who assume of the responsibility for clinical supervision. Although this is not a change in policy, the new variance clearly identifies the significance of clinical supervision. With this information, some programs may need to hire additional MH professionals to work on call and part time in order to assure that program services are delivered with clinical supervision.

Question

Do staff have to participate in treatment team meetings in person or can they join by phone?

DHS Response:

The clinical supervisor must be physically present. There may be ways for others to participate by phone if the clinical supervisor identifies this option in the clinical supervision plan.

Question

Do we need to call individuals who are receiving the service recipient?

DHS Response:

No, programs should use the person’s name in all individual documentation. Programs determine the most appropriate person first language for their program descriptions, policies and procedures.

Question

Does the work being done by DHS around “Proposed Permanent Rules relating to Outpatient Mental Health Services” – i.e., clinical supervision, clinical supervisor, Diagnostic Assessment, etc… have any bearing on requirements that IRTS programs will be affected by?

DHS Response:

We anticipate that revisions to Rule 47 will be available in a timeframe that is consistent with when this variance will be codified. This will allow us to proposed statutory language consistent with the revised rule 47 language.

Question

If we follow this variance will we be in compliance with MN health care rules?

DHS Response:

These requirements support and do not conflict with MHCP but please follow chapter 16 regarding reimbursement requirements.

Question

The definition of seclusion could be construed to prevent facilities from using Wanderguard technology to prevent a client from leaving the building without an alarm going off to notify staff. This technology is most typically used for consumers who are vulnerable and disoriented and often may not be able to use good judgment about leaving in extremely cold weather. It is NOT coupled with any kind of physical restraint to return the client to the building. It also may be used with clients who feel concern about suicidal thoughts or urges to use chemicals, with their permission. It may also be used to allow someone under court supervision to come to a less restrictive setting like and IRTS, for a period of time while they adjust to the community or to allow symptoms to stabilize.

DHS Response: When Wanderguard technology is used as described here and is addressed in the recipient’s treatment plan, then it does not meet the definition of seclusion or restraint.

Question

If we have a referral for someone who needs a PCA can our rate be adjusted?

DHS Response:

The rate adjustment would require pre authorization with the host county and with DHS Adult Mental Health Division. This preauthorization is intended to ensure that all applicable billing resources are considered.

Question

If we have a referral for someone who needs an interpreter or translator, can our rate be adjusted?

DHS Response:

Question

We have training for staff for emergency situations that addresses safety. It includes some hands on restricting of recipients. We think it is important for staff to be able to use these techniques.

DHS Response: License holders may request a variance in order to continue using restraint as a safety measure. DHS will review your policy and procedures

DHS may establish a work group of service recipients, programs and advocates to address this issue. DHS will consider establishing a certification for programs which use restrictive procedures.

Question regarding R36V.05, Subd. 8:

The Critical Incident Reporting form requests that we fax it with the licensor’s name on the cover page. We do not know the name of our licensor. And have not always had the same person do our licensing reviews. Could you tell us who our licensor is?

DHS Response: Please feel free to omit the name of the licensor on the form unless the program has had recent contact with a licensor.

Question What kind of work experience can be used to qualify as a Mental Health practitioner? Is work experience as a PCA, in Adult Foster Care, CD treatment or school setting acceptable toward the minimum hours of supervised experience in the delivery of services to persons with mental illness?

DHS Response: The staff file must include verification of the staff person’s qualifications including verification of the work experience in the delivery of services to persons with mental illness. Work experience delivering services which are only offered to persons with mental illness such as ARMHS, ACT, CTSS or targeted case management must be verified with the staff person’s supervisor or employer in that work site.

Other work experience in the delivery of services to persons with mental illness must be more carefully vetted to ensure that the job duties for the qualified work experience were primarily focused on the delivery of services to persons with mental illness. Both the applicant/staff person and the person who provided the work supervision must identify the job duties performed and verify that these duties were the primary focus of the work experience.

Job duties for qualified work experience must be primarily one or more of the following activities:

completing functional assessments,
treatment/service planning and/or implementation,
services delivered used strategies and techniques identified in illness management and recovery practice; or
integrated dual disorder treatment; or
assisting individuals experiencing mental illness with activities of daily living.

Therefore, work experience in CD treatment must be verified to ensure that qualifying hours were in the delivery of integrated dual disorder treatment services for persons with co-occurring MI/CD.

Nursing work experience must be verified to ensure that the person’s primary duties were delivering services to persons with mental illness.

PCA work experience must be verified to ensure that the person’s primary duties were delivering services to a person with mental illness.

AFC work experience must be verified to ensure that the person’s primary duties were delivering services to persons with mental illness or co-occurring mental illness.

School experience must be verified to ensure that the person’s primary duties were delivering services to students who have been identified with a mental health condition.

Work duties which include services to persons who may or may not be identified as having a mental illness cannot be used for qualification purposes or duties which include incidentally serving individuals with mental illness do not qualify as supervised work experience in the delivery of services to persons with mental illness.

Question This question relates to the qualifications of a Mental Health Practitioner. Specifically what degrees are accepted as behavioral sciences or a related field as defined in MS, section 245.462, subdivision 17?

DHS Response: Please note that the definition of a mental health practitioner references the Adult Mental Health Act , MS, section 245.462, subdivision 17. This FAQ only refers to how behavioral sciences and related fields are being interpreted for Adult mental health Services.

For Adult Mental health Services behavioral science includes social work and psychology.

Related fields include nursing, occupational therapy, rehabilitation and vocational rehabilitation.

Other acceptable related fields must include 30 semester college credits in the following core class areas: human services, psychology, social work and rehabilitation. A valid transcript is required to demonstrate that the practitioner has the required qualifications.

Question What credentials are required in order for a mental health professional to be qualified to assure clinical supervision requirements?

DHS Response (10/2013):

A mental health professional assuring clinical supervision requirements must be a qualified provider in accordance with Minnesota Rules, part 9505.0371, subpart 5, item A as follows:

(1) in clinical social work, a person must be licensed as an independent clinical social worker by the Minnesota Board of Social Work under Minnesota Statutes, chapter 148D until August 1, 2011, and thereafter under Minnesota Statutes, chapter 148E;

(2) in psychology, a person licensed by the Minnesota Board of Psychology under Minnesota Statutes, sections 148.88 to 148.98, who has stated to the board competencies in the diagnosis and treatment of mental illness;

(3) in psychiatry, a physician licensed under Minnesota Statutes, chapter 147, who is certified by the American Board of Psychiatry and Neurology or is eligible for board certification;

(4) in marriage and family therapy, a person licensed as a marriage and family therapist by the Minnesota Board of Marriage and Family Therapy under Minnesota Statutes, sections 148B.29 to 148B.39, and defined in parts 5300.0100 to 5300.0350;

(5) in professional counseling, a person licensed as a professional clinical counselor by the Minnesota Board of Behavioral Health and Therapy under Minnesota Statutes, section 148B.5301;

(6) a tribally approved mental health care professional, who meets the standards in Minnesota Statutes, section 256B.02, subdivision 7, paragraphs (b) and (c), and who is serving a federally recognized Indian tribe; or

(7) in psychiatric nursing, a registered nurse who is licensed under Minnesota Statutes, sections 148.171 to 148.285, and meets one of the following criteria:

(a) is certified as a clinical nurse specialist;

(b) for children, is certified as a nurse practitioner in child or adolescent or family psychiatric and mental health nursing by a national nurse certification organization; or

(c) for adults, is certified as a nurse practitioner in adult or family psychiatric and mental health nursing by a national nurse certification organization.

Question regarding R36V.06, subdivision 1:

What quality assurance and improvement data or information must be reviewed each quarter?

DHS Response (10/2013):

The license holder must determine and document in the written quality assurance plan how the data or information related to paragraphs (a) through (c) will be reviewed. The data or information related to (a) through (c) is not required to be reviewed in its entirety each quarter. For example, it is appropriate for the license holder to focus on specific areas from each paragraph, (a) through (c), every quarter.

Question regarding R36V.04, subdivision 3, paragraph (c):

When must the individual abuse prevention plan be completed and in what format should it be contained in the recipient file?

DHS Response (10/2013):

The individual abuse prevention plan must be completed at the time the initial treatment plan is completed, and may be contained within the treatment plan if a program so chooses, provided all applicable requirements are met.

Question regarding R36V.04, subdivision 3, paragraph (h):

What is the acceptable format for an interpretive summary?

DHS Response (10/2013):

The interpretive summary does not need to be titled “interpretive summary.”

Regardless of what the license holder calls the summary, it must contain all applicable requirements. The summary does not need to be a stand-alone document and can be embedded in other assessments such as the diagnostic assessment.

Question regarding R36V.05, subdivision 7:

When must a discharge summary be completed for a planned discharge?

DHS Response (10/2013):

For planned discharges the discharge summary must be completed within five calendar days prior to, or on the day of discharge. For example, a program can complete a discharge summary one, two, three, or four days prior to a planned discharge.