I
ICT SERVICES
ICT Staffing Plan
DBHDS- Office of Licensing
| |Intensive Community Treatment Team | |H | | | | |
|I | | |O |Education |License / Certificate |QMHP |# |
|C |Census = ______ (≤ 80) | |U |Degree | |(Q) |Yrs Exp in|
|T | | |R | |(e.g., MD, LCSW, LPC, | |MH |
| |Staff Position: | |S |(e.g., MD, MSW, MS, |CSAC, CRC, CPRP, RN, |QPPMH | |
| | |Name: |Per Wk |MA, BS, BA, AA, HS) |LPN) |(P) | |
|1. |Team Leader | | | | | | |
|2. |Nurse | | | | | | |
|3. |Substance Abuse Specialist | | | | | | |
|4. |Vocational Specialist | | | | | | |
|5. |Peer Specialist | | | | | | |
|6. | | | | | | | |
|7. | | | | | | | |
|8. | | | | | | | |
|9. | | | | | | | |
|10. | | | | | | | |
|11. |Program Assistant | | | | | | |
|12. |Psychiatrist | | | | | | |
Standards Check:
____Sum Hours Per Wk #1-#10 ≥ 200 ____80% of #1 - #10 = QMHP ____#1 = QMHP, Yrs Exp ≥ 3 ____ #5 = QMHP or QPPMH
____ #5 = MH/SMI Service Recipient ____#2 = RN, Yrs Exp ≥ 1 or ____ ≥ ½ of #3 - #4 = Master’s
LPN, Yrs Exp ≥ 3
____Hours Per Wk #11 ≥ 40 ____#12 = Board Cert. or Elig. ____Hours Per Wk #12 ( census ≥ .32 ____Census ( FTEs (excluding
#11, #12) ≤ 10
Notes: ___________________________________________________________________________________________________________________________
ICT Licensing Standards Checklist
____Team holds daily meetings Monday through Friday (at least four times per week) to plan and review services. (attach schedule)
____Team operates at least eight hours each weekday and provides services as needed in the evenings and on weekends. (attach schedule)
____Team makes crisis services available 24 hours per day or ____Team coordinates with crisis services daily. (attach schedule/agreement)
____Team provides multiple consumer contacts weekly. Total weekly contacts divided by total census is ≥ 3.
____Team provides face-to-face contact to all consumers. Exceptions are explained in individual consumer records.
____Daily Team meetings are held at regular times to: ____Review status and ____note last contact with ALL consumers
____Assign daily tasks ____Assign weekly tasks ___Revise ISPs
____Plan for crisis services ____Add/revise planned contacts
____Team maintains daily log that includes: ____Consumer roster ____Brief individual service contact notes
____Team maintains individual weekly notes for each consumer noting progress in achievement of ISP goals and objectives.
____Team maintains individual assessments including all of the following domains:
___1. Psychiatric history, mental status and diagnosis, including the content of an advance directive;
___2. Medical, dental and other health needs;
___3. Extent and effect of drug or alcohol use;
___4. Education and employment including current daily structures use of time, school or work status, interests and preferences and the effect of psychiatric
symptomatology on educational and employment performance;
___5. Social development and functioning including childhood and family history, culture and religious beliefs leisure interests and social skills;
___6. Housing and daily living skills, including the support needed to obtain and maintain decent, affordable housing integrated into the broader community; the current ability to meet basic needs such as personal hygiene, food preparation, housekeeping, shopping, money management and the use of public transportation and other community based resources;
___7. Family and social network including the current scope and strength of a individual’s network of family, peers, friends, and co-workers and their understanding and expectations of the team’s services;
___8. Finances and benefits including the management of income, the need for and eligibility for benefits and the limitations and restrictions of those benefits; and
___9. Legal and criminal justice involvement including the guardianship, commitment, representative payee status and the experience as either victim or accused person.
PACT SERVICES
PACT Staffing Plan
DBHDS- Office of Licensing
| |Program of Assertive Community Treatment | |H | | | | |
|P | | |O |Education |License / Certificate |QMHP |# |
|A |Census = ______ (≤ 120) | |U |Degree | |(Q) |Yrs Exp in|
|C | | |R | |(e.g., MD, LCSW, LPC, | |MH |
|T |Staff Position: | |S |(e.g., MD, MSW, MS, |CSAC, CRC, CPRP, RN, |QPPMH | |
| | |Name: |Per Wk |MA, BS, BA, AA, HS) |LPN) |(P) | |
|1. |Team Leader | | | | | | |
|2. |Nurse | | | | | | |
|3. |Nurse | | | | | | |
|4. |Nurse | | | | | | |
|5. |Substance Abuse Specialist | | | | | | |
|6. |Vocational Specialist | | | | | | |
|7. |Other MH Professional | | | | | | |
|8. |Other MH Professional | | | | | | |
|9. |Other MH Professional | | | | | | |
|10. |Peer Specialist | | | | | | |
|11. | | | | | | | |
|12. | | | | | | | |
|13. | | | | | | | |
|14. |Program Assistant | | | | | | |
|15. |Psychiatrist | | | | | | |
Standards Check:
____Sum Hours Per Wk #1 - #13 ≥ 400 ____80% of #1 - #13 = QMHP ____#1 = QMHP, Yrs Exp ≥ 3 ____ #10 = QMHP or QPPMH
____ #10 = MH/SMI Service Recipient ____#2 = RN, Yrs Exp ≥ 1 ____#3 - #4 = RN, Yrs Exp ≥ 1 or ____#3-#4 = LPN, Yrs Exp ≥ 3
____ ≥ ½ of #5 - #9 = Master’s ____Hours Per Wk #14 ≥ 40 ____#15 = Board Cert. or Elig. ____Hours Per Wk #15 ( census ≥ .32
____Census ( FTEs (excluding #14, #15) ≤ 10
Notes: ___________________________________________________________________________________________________________________________
PACT Licensing Standards Checklist
____Team holds daily meetings Monday through Friday (at least four times per week) to plan and review services. (attach schedule)
____Team operates at least 12 hours each weekday and 8 hours each weekend day and holiday. (attach schedule)
____Team is available 24 hours daily and provides after-hours on-call services by telephone and/or in person. (attach schedule)
____Team makes crisis services available 24 hours per day or ____Team coordinates with crisis services daily. (attach schedule/agreement)
____Team provides multiple consumer contacts weekly. Total weekly contacts divided by total census is ≥ 3.
____Team provides face-to-face contact to all consumers. Exceptions are explained in individual consumer records.
____Daily Team meetings are held at regular times to: ____Review status and ____note last contact with ALL consumers
____Assign daily tasks ____Assign weekly tasks ___Revise ISPs
____Plan for crisis services ____Add/revise planned contacts
____Team maintains daily log that includes: ____Consumer roster ____Brief individual service contact notes
____Team maintains individual weekly notes for each consumer noting progress in achievement of ISP goals and objectives.
____Team maintains individual assessments including all of the following domains:
___1. Psychiatric history, mental status and diagnosis, including the content of an advance directive;
___2. Medical, dental and other health needs;
___3. Extent and effect of drug or alcohol use;
___4. Education and employment including current daily structures use of time, school or work status, interests and preferences and the effect of psychiatric symptomatology on educational and employment performance;
___5. Social development and functioning including childhood and family history, culture and religious beliefs leisure interests and social skills;
___6. Housing and daily living skills, including the support needed to obtain and maintain decent, affordable housing integrated into the broader community; the current ability to meet basic needs such as personal hygiene, food preparation, housekeeping, shopping, money management and the use of public transportation and other community based resources;
___7. Family and social network including the current scope and strength of a individual’s network of family, peers, friends, and co-workers and their understanding and expectations of the team’s services;
___8. Finances and benefits including the management of income, the need for and eligibility for benefits and the limitations and restrictions of those benefits; and
___9. Legal and criminal justice involvement including the guardianship, commitment, representative payee status and the experience as either victim or accused person.
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