Indiana Health Coverage Programs



|Indiana Health Coverage Programs |

|[pic] |Psychiatric residential treatment Facility addendum |

| |ATTESTATION LETTER MUST BE COMPLETED BY ALL PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES AND SUBMITTED WITH PROVIDER ENROLLMENT |

| |APPLICATION |

|PROVIDERS ENROLLING AS PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES MUST READ THIS IMPORTANT NOTICE AND SUBMIT AN ATTESTATION LETTER (see attached example) |

|WITH THE SIGNED MEDICAID PROVIDER AGREEMENT |

|Indiana Medicaid rules at 405 IAC 5-20-3.1 stipulate the following requirements for Psychiatric Residential Treatment Facility (PRTF) providers: |

|(1) The facility must be licensed as a private secure care institution under 470 IAC 3-13. |

|(2) The facility must be accredited by the Joint Commission on Accreditation of Healthcare Organizations, the American Osteopathic Association, or the |

|Council on Accreditation of Services for Families and Children. |

|(3) The facility must comply with all requirements in 42 CFR 483, Subpart G governing the use of restraint and seclusion. |

|Pursuant to 405 IAC 5-20-3.1(3), Medicaid-participating PRTFs must comply with federal requirements in 42 CFR Part 483, Subpart G governing the use of |

|restraint and seclusion, and, where they differ from Indiana residential licensing rules at 470 IAC 3-13, the federal requirements take precedence over |

|Indiana licensing rule requirements governing the use of restraint and seclusion. |

|Background |

|On January 22, 2001, the federal Centers for Medicare and Medicaid Services (CMS) published an interim final rule establishing standards for the use of |

|restraint and seclusion in Psychiatric Residential Treatment Facilities (PRTFs) providing Medicaid-covered inpatient psychiatric services to individuals |

|under age 21. An amendment and clarification to the Psych Under 21 rule was published on May 22, 2001, with an immediate effective date. The rule establishes|

|a Condition of Participation (“CoP”) for the use of restraint and seclusion that PRTFs must meet in order to provide or continue to provide services under |

|the Medicaid Inpatient Psych Under 21 benefit. The CoP specifies requirements designed to protect residents against the improper use of restraint and |

|seclusion, including but not limited to: parental/guardian notification when restraint or seclusion is used; reporting of serious occurrences involving a |

|resident; age appropriate time limits for use of restraint or seclusion; staff education and training requirements; requirements for monitoring residents in |

|and immediately after restraint or seclusion, etc. The following Web site displays the amendment to the interim final rule published May 22, 2001: |

| |

|Reporting |

|Under the Psych Under 21 rule, each PRTF is required to report a resident’s death, a resident’s serious injury, and a resident’s suicide attempt to the state|

|Medicaid agency and the state-designated Protection and Advocacy system. Section 42 CFR 483.374(c) requires: “In addition to the reporting requirements |

|contained in paragraph (b) of this section, facilities must report the death of any resident to the Centers for Medicare and Medicaid Services (CMS) regional|

|office. Staff must report the death of any resident to the CMS regional office by no later than close of business the next business day after the resident’s |

|death. Staff must document in the resident’s record that the death was reported to the CMS regional office.” |

|Required Attestation |

|Section 483.374(a) of the rule requires a facility enrolling as a Medicaid provider of PRTF services to meet the requirements of the Psych Under 21 rule at |

|the time it executes a provider agreement with the Medicaid agency and submit an attestation of compliance at that time. Thereafter, annual attestations are |

|required by July 21st, or by the next business day if July 21st falls on a weekend or holiday. The attestation must be signed by an individual who has the |

|legal authority to obligate the facility (facility director). A new attestation must be submitted whenever a new person takes over the position of facility |

|director. |

|On the following page a model attestation letter is provided for your use in preparing and submitting the required attestation with your signed Indiana |

|Medicaid provider agreement. This attestation must include the following required information(marked with an*) and be signed by an individual (facility |

|director) who has the legal authority to obligate the facility. |

|*Name of the Psychiatric Residential Treatment Facility (PRTF) |

|*PRTF Address, City, State, ZIP Code |

|*PRTF Telephone Number |

|*PRTF Fax Number (if applicable) |

|*PRTF Indiana Medicaid Provider ID Number |

|*PRTF ID Number for State Survey Agency Tracking purposes: 15L _ _ _ (this number is assigned upon completion of the PRTF’s Indiana Medicaid provider |

|enrollment) |

|*Number of beds in the facility |

|*Number of individuals currently served in the PRTF who are receiving Indiana Medicaid-covered Psych |

|Under 21 (PRTF) benefits |

|*Number of individuals, if any, whose PRTF services are being paid for by a state Medicaid agency other |

|than Indiana Medicaid |

Provider Attestation Letter

Facility Name: ______________________________________________________________________

Address: ___________________________________________________________________________

City, State, ZIP: _____________________________________________________________________

Telephone Number: _____________________ Fax: ___________________ E-mail: _______________

|Medicaid Provider Number | |

|State Survey Number (internal use) | |

|Number of Beds in Facility | |

|Number of individuals currently served in the PRTF who are receiving Indiana Medicaid covered Psych Under | |

|21 (PRTF) benefits | |

|Number of individuals, if any, whose PRTF services are being paid for by a state Medicaid agency other | |

|than Indiana Medicaid | |

Dear Indiana Medicaid Program:

A reasonable investigation subject to my control having been conducted in the subject facility, I make the following certification. Based upon my personal knowledge and belief, I attest that the

(Name of Facility) ____________________________________________________________ hereby complies with all of the requirements set forth in the interim final rule governing the use of restraint and seclusion in psychiatric residential treatment facilities providing inpatient psychiatric services to individuals under age 21 published on January 22, 2001, and amended with the publication of May 22, 2001 (Psych Under 21 rule).

I understand that the Centers for Medicare and Medicaid Services (CMS, formerly HCFA), the State Medicaid Agency or their representatives may rely on this attestation in determining whether the facility is entitled to payment for its services and, pursuant to Medicaid regulations at 431.610, have the right to validate that

(Name of Facility) ____________________________________________________________

is in compliance with the requirements set forth in the Psych Under 21 rule and to investigate serious occurrences as defined under this rule.

(Name of Facility)____________________________________________________________ will submit a new attestation of compliance by July 21st of each year (or by the next business day if July 21st falls on a weekend or holiday).

In addition, I will notify the Indiana Office of Medicaid Policy and Planning immediately if I vacate this position so that an attestation can be submitted by my successor. I will also notify the State Medicaid Agency if it is my belief that

(Name of Facility)_____________________________________________________________

is out of compliance with the requirements set forth in the Psych Under 21 rule.

Signature _____________________________________Title __________________________

This attestation must be signed by an individual who has legal authority to obligate the facility.

Printed Name__________________________________ Date___________________________

EDS-Provider Enrollment

PO Box 7263

Indianapolis, IN 46207-7263 Revision Date June 2005

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