PA Criteria for Behavioral Health Inpatient Admission

CRITERIA FOR ADMISSION TO A BEHAVIORAL HEALTH HOSPITAL OR BEHAVIORAL HEALTH INPATIENT FACILITY

A person must meet ALL criteria in Sections A, C, and D, and at least ONE of the criteria in Section B. for admission to a behavioral health hospital or behavioral health inpatient facility.

1. DIAGNOSIS

   A behavioral health diagnosis is required for admission to an inpatient setting; also, a behavioral health diagnosis is required to be documented at the time of discharge from inpatient services.

2. BEHAVIOR AND FUNCTIONING
   1. Imminent risk of danger to self or others as a result of a behavioral health condition as evidenced by:
   1. Current suicidal ideation, behavior or intent,
   2. Current homicidal or significant assaultive ideation, behavior or intent, or
   3. Immediate physiologic jeopardy.
   2. Disturbance of mood, thought or behavior which renders the person acutely incapable of developmentally appropriate self-care or self-regulation;
   3. Disturbance of mood, thought or behavior that requires an assessment or medication trial that cannot be safely or adequately implemented in a less restrictive setting; or
   4. Level of functioning that does not meet the above criteria, but the person cannot return to his or her residence due to risk of harm to self or others due to a treatable behavioral health disorder, or there is a likelihood of imminent behavioral decompensation.
3. INTENSITY OF SERVICE

   This type of service provides planned, comprehensive assessment or treatment involving close daily psychiatric supervision and 24 hour medical supervision.

   Treatment should be in the least restrictive type of service consistent with the person’s need and therefore should not be instituted unless there is documentation of a failure to respond to or professional judgment of an inability to be safely managed in a less restrictive type of service.

4. EXPECTED RESPONSE

   The client's behaviors and symptoms, which were identified as reasons for admission, can be effectively treated by medically indicated treatment available in this setting.

   The treatment can reasonably be expected to improve or stabilize the patient's condition so that this type of service will no longer be needed.

CONTINUED BEHAVIORAL HEALTH HOSPITAL FACILITY OR BEHAVIORAL HEALTH INPATIENT FACILITY AUTHORIZATION CRITERIA

A person must meet ALL criteria in Sections A and E, at least ONE of the criteria in each of Sections B, C and must meet Section D for continued stay in a behavioral health hospital facility or behavioral health inpatient facility.

1. DIAGNOSIS

   A specified behavioral health diagnosis is required to be documented at the time of discharge from inpatient services.

2. BEHAVIOR AND FUNCTIONING
   1. Emergence or continued evidence of symptoms which reflect imminent risk of danger to self or others as a result of a behavioral health condition, as evidenced by:
      1. Current suicidal ideation, behavior or intent, or
      2. Current homicidal or significant assaultive ideation, behavior or intent, or
      3. Ongoing physiologic jeopardy; or
   2. Continued disturbance of mood, thought or behavior which renders the person acutely incapable of developmentally appropriate self-care or self-regulation; or
   3. Significant regression of the person’s condition is anticipated without continuity of this type of service.
3. INTENSITY OF SERVICE

   There is documented evidence that the person requires at least one of the following:

   1. Continued planned, comprehensive assessment or treatment involving close daily psychiatric supervision and 24 hour medical supervision. This may be as a result of a change in diagnosis, treatment failure, or newly-discovered aspect of the person’s case necessitating a significant change in the treatment plan; or
   2. Close, continuous, 24 hour skilled medical/nursing supervision of the person’s behaviors, which are due to a behavioral health condition, in order to prevent injury to the person or others; or
   3. Pharmacotherapy which requires continuous, skilled medical/nursing supervision for safe, effective use; or
   4. Skilled nursing observation and care in the management of disturbances of mood, thought or behavior which cannot be provided by non-medical personnel; or
   5. Repeated need for the use of physical restraint to ensure the safety of the person or facility staff; or
   6. Behavioral Health Hospital Facility or Behavioral Health Inpatient Facility services may be continued if the person no longer requires the type of service provided in a behavioral health hospital facility or behavioral health inpatient facility but there is not an available lower intensity of services suitable to the behavioral health needs of the person or the person cannot return to the person’s residence because of a risk of harm to self or others.
4. EXPECTED RESPONSE

   There is documented evidence that:

   1. Active treatment is provided that is reducing the severity of disturbances of mood, thought or behavior which were identified as reasons for admission; or
   2. There has been a re-evaluation and subsequent change in the treatment plan.
      
      AND
      
      
   3. There is still an expectation that continued treatment in this type of service can reasonably be expected to improve or stabilize the patient’s condition so that this type of service will no longer be needed, or
   4. There is no less restrictive type of service available to safely meet the person’s behavioral health needs.
5. DISCHARGE PLAN

   There is a written plan for discharge with specific discharge criteria and recommendations for aftercare treatment that comply with current standards for medically necessary covered services, cost effectiveness, and least restrictive environment. Discharge planning should be initiated at time

BEHAVIORAL HEALTH INPATIENT FACILITY (FORMERLY LICENSED AS LEVEL I RESIDENT TREATMENT FACILITIES) ADMISSION AUTHORIZATION CRITERIA

1. PURPOSE

   Behavioral Health Inpatient Facility services provide treatment for children and adolescents who demonstrate severe and persistent psychiatric disorders, when outpatient services (ambulatory care) in the community do not meet their treatment needs and they require services at a psychiatric residential treatment facility under the direction of a psychiatrist. These services are designed for children and adolescents who have significant deficits in social, behavioral, psychiatric, and psychological functioning and who require active treatment in a controlled environment with a high degree of psychiatric oversight, 24 hour nursing presence, effective program and treatment availability, and continuous supervision provided by professional behavioral health staff.

   Admissions to a Behavioral Health Inpatient Facility are not emergent or urgent and are always prior authorized.

   Such admissions are only appropriate where outpatient care has failed or where the child’s/adolescent’s psychiatric treatment needs are so severe they can only be met by the degree of specialized professional treatment available in a Behavioral Health Inpatient Facility. Active treatment focuses on specific targeted goals identified by the Child and Family Team, and are designed to enable the child/adolescent to be discharged from the psychiatric residential treatment facility at the earliest possible time. A lack of available outpatient services is not in and of itself the sole criterion for admission to or discharge from a Behavioral Health Inpatient Facility.

   Determination of the need for services is based on regulations found in Title 42 of the Code of Federal Regulations:

   § 441.152 Certification of need for services
   1. A team specified in § 441.154 must certify that—
      Ambulatory care resources available in the community do not meet the treatment needs of the recipient;
      Proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician; and
      The services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed.
   2. The certification specified in this section and in §441.153 satisfies the utilization control requirement for physician certification in §§456.60, 456.160, and 456.360 of this subchapter.
   § 441.154 Active treatment

   Inpatient psychiatric services must involve ‘‘active treatment’’, which means implementation of a professionally developed and supervised individual plan of care, described in § 441.155 that is—

   1. Developed and implemented no later than 14 days after admission; and
   2. Designed to achieve the recipient’s discharge from inpatient status at the earliest possible time.
2. BEHAVIOR AND FUNCTIONING REQUIRED FOR ADMISSION
   1. Symptoms or functional impairments of the individual's psychiatric condition are of a severe and persistent nature.
   2. In addition, all of the following must be met to ensure appropriate, cost effective and least restrictive care in this setting:
      1. Ambulatory care resources (outpatient medically necessary behavioral health services) in the community do not meet the treatment needs of the child/adolescent;
      2. The child/adolescent does not require a level of medical or professional supervision that surpasses that which is available at a Behavioral Health Inpatient Facility. For example, children/adolescents actively showing signs of danger to self or danger to others may require inpatient psychiatric treatment at an acute psychiatric hospital;
      3. The admission is not used primarily, and in a clinically inappropriate manner, as:
         1. An alternative to incarceration, preventative detention, or as a means to ensure community safety in a child/adolescent exhibiting primarily delinquent/antisocial behavior,
         2. The equivalent of safe housing, permanency placement,
         3. An alternative to parents’/guardian’s or other agency’s capacity to provide for the child
         4. or adolescent, or
         5. An intervention when other less restrictive alternatives are available and not being utilized.
3. EXPECTED IMPROVEMENT DUE TO ACTIVE TREATMENT

   Active treatment with the services available at this level of care can reasonably be expected to improve the child/adolescent’s psychiatric condition in order to achieve discharge from the psychiatric residential treatment facility at the earliest possible time and facilitate his/her return to outpatient care and/or family living.

4. DISCHARGE PLAN

   There is a written plan for discharge with specific discharge criteria and recommendations for aftercare treatment that includes involvement of the Child and Family Team and complies with current standards for medically necessary covered behavioral health services, cost effectiveness, and least restrictive environment and is in conformance with all applicable regulations. Discharge planning should start at time of admission to ensure all needs have been addressed to prepare for a safe and supported transition to lower level services.

BEHAVIORAL HEALTH INPATIENT FACILITY (FORMERLY LICENSED AS LEVEL I RESIDENTIAL TREATMENT FACILITIES - RTC) CONTINUED STAY AUTHORIZATION CRITERIA

1. PURPOSE

   Behavioral Health Inpatient Facility services provide treatment for children and adolescents who demonstrate severe and persistent psychiatric disorders, when outpatient services (ambulatory care) in the community do not meet their treatment needs and they require services under the direction of a psychiatrist at a Behavioral Health Inpatient Facility. These services are designed for children and adolescents who have significant deficits in social, behavioral, psychiatric, and psychological functioning and who require active treatment in a controlled environment with a high degree of psychiatric oversight, 24 hour nursing presence, effective program and treatment availability and continuous supervision provided by professional behavioral health staff.

   Continued stays in a Behavioral Health Inpatient Facility are not emergent or urgent and are always prior authorized.

   Such admissions are only appropriate where outpatient care has failed or where the child’s/adolescent’s psychiatric treatment needs are so intense that they can only be met by the degree of specialized professional treatment available in a Behavioral Health Inpatient Facility. Active treatment focuses on specific targeted goals identified by the Child and Family Team, and are designed to enable the child/adolescent to be discharged from the Behavioral Health Inpatient Facility at the earliest possible time. A lack of available outpatient services is not in and of itself the sole criterion for continued stay at a Behavioral Health Inpatient Facility. If a child/adolescent receiving services no longer requires this level of care, but services suitable to meet his/her behavioral health needs are not available or he/she cannot return to his/her previous residence because of a risk of harm to self or others, services may continue to be authorized with an, active attempt to secure a suitable discharge placement or residence.

   Determination of the need for services on regulations found in Title 42 of the Code of Federal Regulations:

   § 441.152 Certification of need for services
   1. A team specified in § 441.154 must certify that—
      1. Ambulatory care resources available in the community do not meet the treatment needs of the recipient;
      2. Proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician; and
      3. The services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed.
   2. The certification specified in this section and in §441.153 satisfies the utilization control requirement for physician certification in §§456.60, 456.160, and 456.360 of this subchapter.
   § 441.154 Active treatment

   Inpatient psychiatric services must involve ‘‘active treatment’’, which means implementation of a professionally developed and supervised individual plan of care, described in § 441.155 that is—

   1. Developed and implemented no later than 14 days after admission; and
   2. Designed to achieve the recipient’s discharge from inpatient status at the earliest possible time.
2. BEHAVIOR AND FUNCTIONING REQUIRED FOR CONTINUED STAY
   1. The symptoms or functional impairments of the individual's psychiatric condition are of a severe and persistent nature
   2. In addition, all of the following must be met to ensure appropriate, cost effective and least restrictive care in this setting:
      1. Ambulatory care resources (outpatient medically necessary behavioral health services) in the community do not meet the treatment needs of the child/adolescent;
      2. The child/adolescent does not require a level of medical or professional behavioral health supervision that surpasses that which is available at a Behavioral Health Inpatient Facility. For example, children/adolescents actively showing signs of danger to self or danger to others may require behavioral health inpatient treatment at an acute psychiatric hospital;
      3. The continued stay is not used primarily and in a clinically inappropriate manner as:
         1. An alternative to incarceration, preventative detention, or as a means to ensure community safety in a child/adolescent exhibiting primarily delinquent/antisocial behavior,
         2. The equivalent of child protection, safe housing, permanency placement,
         3. An alternative to parents’/guardian’s or other agency’s capacity to provide for child or adolescent, or
         4. An intervention when other outpatient care is available and not being utilized.
3. EXPECTED IMPROVEMENT DUE TO ACTIVE TREATMENT

   The child/adolescent is receiving services which are improving his/her psychiatric condition in order to achieve discharge from inpatient status at the earliest possible time and facilitate his/her return to outpatient care and/or family living.

   The professionally developed and supervised individual service plan has been changed (revised) if necessary to respond to any identified lack of progress.

4. DISCHARGE PLAN

   There is a written plan for discharge with specific discharge criteria and recommendations for aftercare treatment that includes involvement of the Child and Family Team and complies with current standards for medically necessary covered behavioral health services, cost effectiveness, and least restrictive environment and is in conformance with 42 CFR. Discharge planning should start at time of admission to ensure all needs have been addressed to prepare for a safe and supported transition to lower level services.