PATERSON-PASSAIC COUNTY-BERGEN COUNTY
PATERSON-PASSAIC COUNTY-BERGEN COUNTY
HIV HEALTH SERVICES PLANNING COUNCIL
MENTAL HEALTH THERAPY/COUNSELING
MINIMUM STANDARDS OF CARE
April / May 2009
Adopted August 25, 2009
Purpose
In an effort to promote its vision for an effective, compassionate system of HIV/AIDS health care services for the diverse community of Paterson/Passaic Bergen County, the Planning Council has committed to the ongoing development of quality of care standards that is consistent with the ever changing challenges in the epidemic. These quality standards were developed in partnership with the Administrative Agent, the mental health service providers, the HIV/AIDS Program, which is responsible for the initiation and use of these standards and an ongoing monitoring of compliance at the individual provider level throughout the funding cycle. Through the use of these standards, the Planning Council will strengthen the development of a support system that supports client centered service delivery across all stages of the disease process.
Goal
The goal of the PPCBC HIV Health Services Planning Council is to ensure a system of quality mental health therapy/counseling that is client-centered, efficient, and effective. The goal of service delivery is to assist the client in stabilizing and increasing the mental health level of functioning and supporting engagement and adherence to medical care and treatment.
Mental Health Therapy / Counseling Definition
HRSA Definition of Service (See HRSA 2007 Data Report Instructions, pages 15-18): Psychological and psychiatric treatment and counseling services offered to individuals with a diagnosed mental illness, conducted in a group or individual setting and provided by a mental health professional licensed or authorized within the State to render such services. This typically includes psychiatrists, psychologists, and licensed clinical social workers.
Mental Health Treatment programs in PPBC Ryan White Part A TGA design and deliver comprehensive services for individual clients, family and significant others who are experiencing the effects of mental health disorders in conjunction with HIV/AIDS. Treatment plans include four basic modalities: Individual, Group, Family Therapy and Psychiatric/Psychological assessment and evaluation. Mental health services include psychiatric treatment and linkages to other services and providers as appropriate.
Standards of Care
Standard A: Licensure or Assurance
A.1. HRSA: The Agency shall comply with Health Resources Services Administration (HRSA) standards as well as all federal, state, and local requirements for certification and/or license.
A.2. Client Eligibility: The agency shall maintain detailed records in legible form, documenting the eligibility (including, but not limited to, proof of HIV status and financial qualifications) of each client and demographics for each client at least annually. Such records shall be maintained for a minimum of three years.
A.3. Licensure: All agency staff, contractors, and consultants, who provide direct care services and require licensure, shall be properly licensed by the State of New Jersey.
A.4. Competent Staff: Human Resources certify competent experienced staff in the provision of quality clinical care for Mental Health Services of PLWH/A. This standard is evidenced by meeting the requirements for New Jersey licensed Mental Health Professionals as outlined by the Department of Law & Public Safety, Division of Consumer Affairs.
A.5. American Disabilities Act (ADA) Compliance: All agencies must be in compliance with the ADA. Example of evidence: Agency demonstrates that the needs of disabled client’s are met.
Standard B: Staff Qualifications for Levels of Care
B.1. Levels of Care: Mental Health Therapy/Counseling services are defined further according to two levels of care and the professionals who may conduct each service.
Level I – Mental Health Therapy / Counseling
This level consists of licensed professional mental health services and includes intensive mental health therapy and counseling (individual, family and group) conducted by a Psychiatrist, Ph.D. level Psychologist, Licensed Clinical Social Worker, Licensed Social Worker under the supervision of a LCSW, or Clinical Nurse Specialist. Direct providers must possess postgraduate degrees in the appropriate counseling-related field, and be certified as a professional practitioner by their appropriate professional association. Interns in these related fields must be supervised by a New Jersey State licensed mental health professional.
Level II – Mental Health Counseling
This level consists of professional mental health services including general mental health counseling (individual, family and group) provided by trained mental health professionals, pastors, Certified Alcohol and Drug Counselors, Bachelor’s level Social Workers, peers and other paraprofessionals. Those direct providers who do not possess postgraduate degrees and/or who are not licensed must be supervised by a New Jersey State licensed mental health professional who has a postgraduate degree in the appropriate counseling-related field and is certified as a professional practitioner by their appropriate professional association.
B.2. HIV / AIDS: Staff and volunteers will have knowledge of the HIV/AIDS disease process, the effects of related illnesses and co-morbidities on clients, the psychosocial effects on clients, and current strategies for management of the disease.
B.3. Resources: Staff and volunteers will have knowledge of obtaining community resources.
B.4. Linkages: Staff and volunteers will have skills and experience necessary to work effectively with HIV/AIDS service providers in a variety of disciplines and at all levels, and with a variety of clients.
B.5. Cultural Sensitivity: Staff and volunteers will have cultural sensitivity in working with persons most affected by the HIV/AIDS epidemic, such as those who are medically underserved or part of a disproportionately-affected population.
Standard C: Client Rights, Responsibilities, and Confidentiality
C.1. Orientation to Services: The agency shall provide an orientation for clients, during which the clients are made aware of their rights, obligations, and services available to them, and also realistic expectations of the service. A Management Information System (MIS) consent form shall be signed by the client, witnessed, dated and included in the client’s file. This form shall be updated annually.
C.2. Instruments and Tools: The agency shall develop the following and utilize them as indicated:
C.2.1. Client Bill of Rights and Responsibilities: This shall take into account state and federal laws protecting the rights of the client. This form shall be signed by the client, witnessed, and dated. A signed copy shall be given to the client, and a copy shall be included in the client’s file. This form shall be updated annually. This form must include policy statements on:
• Privacy
• Confidentiality
• Self-determination
• Non-discrimination
• Compassionate non-judgmental care
• Dignity and self respect
• Change or discontinue service
• Grievance procedure written at a no higher than 8th grade reading level
• Verbal and written client appeal process.
C.2.2. Emergency and Evacuation Procedures: The agency shall have written emergency procedures, including evacuation procedures (post in agency).
C.2.3. Release of Information: The agency shall have a “release/exchange of information” form, to be signed by the client prior to the release/exchange of any information about the client.
C.2.4. Eligibility Process: The agency shall provide an intake and eligibility assessment process, including written criteria for acceptance/rejection, and ranking criteria for eligible applicants when waiting list exists.
C.2.5. Abuse / Neglect: The agency shall have a written policy and procedures to ensure that any incidents of abuse, neglect or exploitation of clients are reported to the proper authorities.
C.3. Grievances: The agency shall develop and follow a written procedure to monitor complaints, client surveys, and telephone responses, and shall follow up as indicated. This procedure shall be posted for all clients to read.
C.4. Confidentiality: The agency shall comply with all applicable federal, state, and local laws, rules, and regulations (“Laws”), including without limitations to the Health Insurance Portability and Accountability Act “HIPPA” (42 USC sections 1320d et. seq.).
C.5. File Storage: The agency shall maintain client files in a locked and secure area.
C.6. Access to Files: Client files will be available to the client upon written request, as allowed by law.
Standard D: Access, Care, and Outreach
D.1. Access: Provider must provide access to services in accordance with the following standards:
D.1.1. Site Access: Mental Health Therapy / Counseling sites may be located in medical provider settings, community-based agencies, drug treatment agencies, child health service settings, or other settings where the client can comfortably receive a service.
D.1.2. Access For Persons With Disabilities: All agencies must be in compliance with the American Disabilities Act (ADA).
D.1.3. Cultural / Language / Reading Level Access / Facilitating Sign Language: Agencies will ensure culturally and linguistically appropriate services for all clients.
Examples of evidence:
• The agency has a written policy on file detailing the process for language translation.
• The agency has documentation confirming that each staff member has received cultural diversity training within the first year of hire and every two years thereafter.
D.1.4. Office / Service Availability: The agency shall be available to clients via telephone, on a walk-in basis, if possible, or through written correspondence should they require additional information, referrals, or support.
D.2. Care: Care begins with the first contact the agency has with a client.
D.2.1. Screening, Intake, Orientation, and Evaluation: The agency shall conduct a timely screening, intake, orientation, and evaluation of each client. Following a referral or request for mental health therapy / counseling services, each client is screened within 5 business days to determine eligibility and need for services:
1. The client has a HIV positive diagnosis;
2. Client is affected or infected with HIV; service must have a direct benefit to PLWH/A
3. Whether a medical or other life-threatening crisis is being experienced and needs to be immediately addressed;
4. Identification of client needs and, given these needs, whether mental health therapy/counseling services are appropriate;
5. Financial eligibility in accordance with the HIV/AIDS Treatment Modernization Act of 2006.
D.3. Outreach and Community Collaboration: The Agency should have an outreach plan for all its Ryan White HIV/AIDS Treatment Modernization Act-supported programs and services.
D.3.1. Linkages: The agency shall develop and maintain linkages with primary health care, support, and other access service providers, and enter into Memoranda of Agreement or Understanding with agencies as appropriate to ensure that client services within the continuum of care are coordinated as needed.
D.3.2. Collaboration: The agency shall collaborate with other service providers as necessary to improve service provision, avoid duplication, and prevent client abuse of the care system.
Standard E: Service Delivery
Service Category Definition: Mental Health Therapy / Counseling services are defined according to two levels of care:
Level I – Mental Health Therapy / Counseling
This level consists of licensed professional mental health services and includes intensive mental health therapy and counseling (individual, family and group) conducted by a Psychiatrist, Ph.D. level Psychologist, Licensed Clinical Social Worker, Licensed Social Worker under the supervision of a LCSW, Clinical Nurse Specialist. Direct providers must possess postgraduate degrees in the appropriate counseling-related field, and be certified as a professional practitioner by their appropriate professional association. Interns in these related fields must be supervised by a licensed mental health professional.
Level II – Mental Health Counseling
This level consists of professional mental health services including general mental health counseling (individual, family and group) provided by trained mental health professionals, pastors and paraprofessionals. Those direct providers who do not possess postgraduate degrees and/or who are not licensed must be supervised by a New Jersey State licensed mental health professional who has a postgraduate degree in the appropriate counseling-related field and is certified as a professional practitioner by their appropriate professional association.
E.1. Overview of Services: Upon referral/request for mental health therapy/counseling, each client is given a verbal or written overview of mental health therapy / counseling services, eligibility criteria for services, and the roles and responsibilities of the mental health provider under the Ryan White Part A provisions.
Example of evidence:
• Client file contains documentation that the client has received an overview of services, roles and responsibilities of Part A mental health therapy / counseling.
E.2. Client Assessment: Each client who consents to receive mental health therapy / counseling services receives a biopsychosocial assessment within 30 days of the client’s initial screening to identify the client’s strengths, resources, needs and problems and includes the following areas:
6. Identification of source if referred to services
7. Basic demographic information
8. History: chief complaint, present illness, past psychiatric history, family history, social and personal history, substance use history, medical history, current and recent medications, premorbid personality
9. Complete mental status evaluation: appearance and behavior, talk, mood, self attitude, suicidal risk, homicidal risk, abnormal beliefs, (delusions, overvalued ideas), perceptual disturbances (hallucinations. illusions), obsessions/compulsions, phobia, panic attacks, judgment and insight.
10. Cognitive assessment: level of consciousness, orientation, memory, and language.
11. Laboratory assessment, as clinically indicated.
12. Multi-axis; differential diagnosis leading to final diagnostic formulation.
13. Support Systems
14. Assessment for abuse, neglect, and violence
15. Vocational Assessment
E.3. Individualized Treatment Plan: At the completion of the biopsychosocial assessment, each client and respective mental health provider shall develop an initial, Individualized Treatment Plan (ITP) which:
16. Includes realistic, measurable, and mutually acceptable goals, identifies problem areas, treatment goals and actions(s) and modality needed to achieve each goal, including target date for accomplishment, and includes the actual or potential provider. Both the client and mental health provider sign and date the Treatment Plan. This treatment plan needs to be signed and dated in the client file.
E.3.1. Updated ITP: The mental health provider will update the Individualized Treatment Plan with the client every 90 days:
17. Assessment of progress toward goal achievement.
18. Effectiveness of the treatment
19. Revised Individualized Treatment Plan needs to be in client file.
E.4. Written Documentation: Written/supportive documentation is kept for each client in their client file which includes:
20. The client’s name and/or unique identifier number.
21. The mental health provider’s name.
22. The date and a summary of the contact signed by the mental health provider.
23. Collateral contacts including family contact will be documented and signed by the mental health provider.
24. Indication of changes in the client’s biopsychosocial situation.
25. Information relating to the services provided which further reflects progress toward reaching goals identified in the ITP.
Standard F: Education, Supervision and Training Programs
F.1. Mental Health Provider Education: All mental health providers meet minimum qualification requirements according to those outlined in Section B.1.
The agency shall provide initial in-service orientation and training for new staff and volunteers-to include Universal Precautions, and periodic staff development training and case conferences for all staff and volunteers required to ensure continued delivery of high quality services.
F.2. Supervision: The agency shall provide regular, ongoing, qualified supervision. `
F.2.1. Appropriate supervisor qualification: Each agency providing mental health services establishes qualifications for supervisors of mental health providers.
F.2.2. Frequency of Supervision: A process exists by which each mental health provider is assigned to, and receives supervision from a qualified supervisor, at a minimum on a monthly basis.
Examples of evidence:
26. Agency files indicated that qualified supervisors exist (in-agency supervisors or those who travel from other agencies to provide supervisory tasks).
27. Personnel files indicated that qualified supervisors provide guidance and conduct performance review of mental health therapy/counseling staff.
28. Documentation of dates of supervision meetings.
F.3. Training: The agency shall provide or send staff to appropriate trainings and updates.
F.3.1. HIV Trainings: All staff will be required to attend trainings to have at least a minimal level of understanding of HIV and the issues faced by the clients served:
29. HIV training received prior to hiring date or within the employee’s probationary period (3 months) in personnel record.
30. Attendance at a minimum of two HIV-related training programs a year.
F.3.2. Continuing Education: The agency shall provide the opportunity for licensed / credentialed staff to take relevant outside courses to both improve their skills and earn CEUs sufficient to maintain licensure. A personnel file for each mental health provider indicates that all qualifications are met including the following documentation:
31. Resume indicates credentials or degrees as appropriate and required by the individual agency.
32. Documentation of HIV training received prior to hiring date or within the employee’s probationary period (3 months) in personnel record.
33. Other diplomas and certification are noted in personnel record.
34. Documentation of attendance at a minimum of two HIV-related training programs a year.
35. Documented attendance at CEU courses in accordance with appropriate level of licensure.
Standard G: Continuous Quality Improvement
G.1. Contractual Requirements: Each agency will ensure that all mental health providers have knowledge of the contractual requirements for the provision of mental health services. Documentation that mental health providers have participated in the TGA’s evaluation of mental health services will be in providers personnel file.
G.2. Evaluation & Outcomes: The agency shall develop and utilize a mechanism of annual evaluation to identify program areas that are in need of improvement, updating, etc. This mechanism should include, at a minimum, consideration of the changing needs of the client, level of achievement of desirable client outcomes, and client satisfaction/dissatisfaction with services as discerned through staff observation, interaction, and or a client satisfaction survey. Provider will participate in this evaluation and outcome measures as required by the Ryan White Part A program.
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