Administrative
What are the current releases of information needed at admission?
Bonus: Explain why for each
1) Self - request own records after discharge
2) PCP - BSAS coordination of care
3) Emergency Contact - BSAS Licensing Requirement
4) Preferred Pharmacy - Required to ask all patients upon admission and discharge if they want Narcan, if yes we send request to their pharmacy to bill insurance (new BSAS Regulation)
How often does a CANS Assessment need to be completed on the VG?
Admission then every 6 months.
What are the 2 first steps in scheduling the patient for annual evaluation?
Send new forms packet to portal
Send any measures needed
What are the 3 main types of discharges?
Successful
Voluntarily
Involuntary
In addition to the intake forms what should clients complete before an intake/annual?
Clinical History Form (new clients) & TB Risk (New & Annual).
What is a TPO? and when do I need to get one signed?
42 CFR Part 2 single release form for treatment, payment, and healthcare operations (TPO). Clients with identified SUD diagnosis receiving services.
What is the purpose of the "intake" with a provider versus the administrative intake? - Date of Assessment is admission to program
Explain therapeutic process/relationship
Collect background information to complete assessment (biopsychosocial)
After completing a new intake (assessment) what 2 things need to be updated from that assessment?
Treatment Plan
Diagnosis
What is the policy for cancellation/no-shows
2 cancelled in 30-day period removed from provider's schedule and put on a call list.
No Show: each should have a documented call log/note attempting to contact the client. After 2 no-shows they are removed from provider's schedule and put on call list.
After 30-days of no contact a patient can be discharged from program.
I complete a treatment plan outside of the session with the client - what should I do next?
Before a patient is seen by a provider what needs to be completed?
Bonus: What is the newest consent forms this year?
Intake forms - no consent to treatment means no treatment should be provided
Bonus: AI Consent
What items require selecting the supervisor for signature?
Assessment
Treatment Plan
Discharge Plan
Patients who report a SI history or current SI/SIB what should be completed?
CSSRS & anyone scoring as moderate to high risk - a safety plan
What are the steps to completing a discharge?
1) Complete discharge/transition mobile note in patient chart (with/without patient)
2) Send appropriate PT Letter for those that did not participate in discharge planning (no-contact 30+ days, multiple no-shows/cancellations)
3) Close the Treatment Plan and sign in patient signature "discharged"
4) Notify front office - they will make inactive once balance/insurance claims are checked.
SELECT SUPERVISOR
How do you distinguish between what goes in the clinical record and what goes into the patient profile?
Profile - "about the person"
Chart - "about the care"
How soon after an assessment is completed should the treatment plan be signed by the patient and clinician
within 30 days of intake admission
For new patients in therapy how often should you schedule them for sessions (considered relationship building)
What is the appeal process for involuntary terminations?
Written statement with patient contact information to the ED for follow up.
What is the difference between a treatment plan UPDATE and a treatment plan REVIEW.
Update: any changes need to made (change to dates, review cycle, goals, objectives)
Review: Annually to align with the new assessment information.
How often should records be updated and reviewed?
Every time something occurs/daily. Keep records as "fresh" as possible for compliance, audits, and good patient care coordination.
Look out for and respond to appointment notes/alerts to help everyone out!
How often are you supposed to update an assessment & treatment plan
Every year - or if clinically indicated/Warranted.
DOUBLE POINTS: give an example of clinically indicated
What are the 3 tiers of documentation
Golden standard - at time of visit with patient
Silver - 24-48 hours after visit
Bronze - by end of week from the visit
How often should active clients be reviewed for appropriate discharge coordination?
Often - it is the responsibility of provider staff to keep on top of patient's treatment course and determine who needs outreach vs discharge.
When should I update someone's diagnosis?
Annually review diagnosis to see if still matching presenting problem. Diagnoses are updated when new clinical information emerges, such as a shift in presenting problems or the achievement of "remission".