§ 5221.53. Recipient right of appeal.
(a) Department actions for misutilization or abuse against a staff or consumer receiving intensive case management are subject to the right of appeal in accordance with Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings).
(b) Adults and children who have been terminated from intensive case management services over their objections, or the objection of a parent if the child is 13 years of age or younger, shall have the right to appeal the decision in accordance with procedures as outlined in Mental Retardation Bulletin Number 99-86-01 (a joint Mental Health/Mental Retardation Bulletin: Procedures for Review of Service Eligibility and Termination Decisions) effective January 17, 1986 and subsequent revisions of policy. Copies of the bulletin may be obtained from the county administrator.
APPENDIX A
INTENSIVE CASE MANAGEMENT GUIDELINES
Case management is a service which will assist eligible individuals with mental illness, including children with a serious mental illness or emotional disorder, in gaining access to needed medical, social, educational and other services. Activities undertaken by staff providing case management services shall include:
Linking with services—Assisting the consumer in locating and obtaining services specified in the treatment or services plan, or both, including arranging for the consumer to be established with the appropriate service provider.
Monitoring of service delivery—There shall be an ongoing review and written record of the person’s receipt of, and participation in, services. Contact with the consumer shall be made on a regular basis to determine his opinion on progress, satisfaction with the service or provider, and needed revisions to the treatment plan. Contact with the consumer’s therapist shall be made on a regular basis to determine if the person is progressing on issues identified in the treatment plan and if specific services continue to be needed and appropriate. A process shall be developed for resolution between staff members with levels of appeal to be pursued when there is clinical disagreement on the nature and extent of progress a particular consumer is making. Regular contacts shall be made with other public agencies serving the consumer and with parents, if the consumer is a child.
Gaining access to services—Aggressive and creative attempts are required to help the person gain resources and services identified in the treatment or service plan, or both. This may include home and community visits and other efforts as needed. It does not preclude the consumer’s therapist from accompanying the case manager on these visits. Home and community shall be defined broadly to include field contacts which may take place on the street, at the person’s residence or place of work, psychiatric treatment facilities, rehabilitation programs and other agencies where support or entitlements are available to the recipient. (Medicaid may not be billed for case management services provided to eligible persons in hospitals, SNF, ICF and ICF/MR facilities for which Medicaid is being billed for treatment nor for persons in jail.)
Assessment and service planning—A review of clinical assessment information and a general discussion with the consumer is required regarding unmet needs and plans for the future.
Problem resolution—Active efforts to assist the person in gaining access to needed services and entitlements. Staff shall have easy access to communicate with the county administrator for the purpose of obtaining assistance in resolving issues which prevent a person from receiving needed treatment, rehabilitation and support services. On a systems level, this may include providing information to help plan modifications to existing services or implement new services to meet identified needs and providing information to help plan modifications for accessing resources.
Informal support network building—Contact with the person’s family, not family counseling or therapy, and friends, with the permission and cooperation of the adult person, to enhance the person’s informal support network.
Use of community resources—Assistance to persons in identifying, accessing and learning to use community resources appropriately to meet his daily living needs shall be provided as needed. This may include the use of public transportation, the library, stores and the like. This will be done by making a referral to an appropriate service provider, creating such a resource if it does not already exist, in providing assistance directly to the consumer if no other resources are available to provide instruction.
PENNSYLVANIA CASE MANAGEMENT SERVICES FOR
CHILDREN AND ADOLESCENTS WITH SEVERE
EMOTIONAL DISTURBANCE AND THEIR FAMILIESA. Core Values for the System of Care.
1. The system of care should be child-centered, with the needs of the child and family dictating the types and mix of services provided.
2. The system of care should be community-based, with the focus of services as well as management and decision-making responsibility resting at the community level.
B. Principles of Services for Children & Adolescents in Pennsylvania.
1. Children and adolescents deserve to live and grow in nurturing families.
2. Children and adolescents’ needs for security and permanancy in family relationships should pervade all planning.
3. The family setting should be the first focus for treatment for the child or adolescent. Out-of-home placement should be the last alternative. Young children should not need to be in a State hospital to receive appropriate mental health treatment.
4. Communities should develop a rich array of services for children and their families so that alternatives to out-of-home placement are available, such as home-based services, parent support groups, day treatment facilities, crisis centers and respite care.
5. Parents and the child should participate fully in service planning decisions.
6. The uniqueness and dignity of the child or adolescent and his family should govern service decisions. Individualized service plans should reflect the child or adolescent’s developmental needs which include family, emotional, intellectual, physical and social factors. The older adolescent’s right to risk should be considered. Children and adolescents should not need to be labeled in order to receive necessary services.
7. The community service systems which are involved with the child and family should participate and share placement, program, funding and discharge responsibilities.
8. The primary responsibility for the child or adolescent should remain with the family and community. Pre-placement planning should include a discharge plan.
9. Case management should be provided to each child and family to ensure that multiple services are delivered in a coordinated, time-limited and therapeutic manner which meet the needs of child and family.
10. Each child should have an advocate.
The Pennsylvania Child and Adolescent Service System Program (CASSP) guidelines which follow form the foundation for intensive case management services for children and their families:
1. The major thrust of the case management service shall be the commitment to permanancy planning for each child and adolescent with severe emotional problems.
2. The relationship of the case manager with the family shall be one of a partnership, embodying the concept of ‘‘parents and professionals as partners.’’
3. The process of providing case management services to children and adolescents and their families shall be based on the developmental needs and phases of the children and adolescents as they progress to adulthood.
4. The case manager will first utilize the normalizing community services as resources in serving the child and family rather than ‘‘specialty services.’’
5. The case management services shall be delivered in the context of a systems approach, recognizing that case management services shall be integrated with the other child-serving agencies and systems serving the child.
6. The case manager needs to view the family as the primary care giver and recognize the family as the primary resource in the care and treatment of their children.
7. The role of the case manager most often will be that of teacher and consultant to the family.
Cross References This appendix cited in 55 Pa. Code § 5221.31 (relating to responsibilities of providers).
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