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Behavioral Health Agency Rulemaking Workshop - Notes September 14, 2021 Agenda:

• Review draft language

• Review nesting certifications chart

• Discuss hot topics (mobile units!) Telephone support services: JT – Subsection (4) relating to forty hours of training requirements. DCRs do not require that amount of training so there was a recommendation to remove that requirement. If we remove do we need to replace with something else? Maybe some requirements? Ideas? Mike D. – Core competency? List of things an individual would need to be supervised. JT – where can I find a resource for that? Mike D. – ASAM assessment; group; ind serv; treatment planning. Stripped down version for licensure as a framework. JT – applicable to the work that the individual would be doing. Amy C. - Agree with core competencies based on education requirements (WAC) rather than hours. Becky O. - That feels like a lot for just phone services JT – we would need to tailor it but using that as a framework. Pattie M. - I think that including core competencies is excellent. And it might be great to have min/max hours so that it can’t be interpreted inappropriately. ? this is a question BH support services: JT – Case management. We talked about broadening to include general CM but maybe we need to pull out rehabilitative case management? WE don’t want to regulate things there are no benefits. We are required to have case management but we don’t’ have to have general case management. Keep as is and only keeping rehabilitative case management. Is it beneficial to include general case management or keep as rehabilitative Kelli M. - I agree - removing general case management and keep rehab cm only. Joan B. - YES- Only keep specific to rehab. Loose the other generalized case manager out Brooke E. - Agree. I don't think there is a need/benefit to including case management. Allie F. - I suggest we keep it to just rehabilitative CM. Laura M. - agreed rehabilitative case management JT – Subsection (3) – abbreviated assessment. Core certification requirements…..is an assessment required? By assessment, I mean a full biopsychosocial assessment. What is expected for only support services? I received feedback that the agency needs to have a way to conduct a screening or abbreviated assessment to determine that the support service is appropriate in meeting the needs and goals. Doesn’t need to be a full assessment. And for the ISP, it needs to be documentation showing how that support service will help the individual meet their goals. The assessment and ISP need to be completed by appropriate credentialed staff. Support service agencies may not have that level of staff to do that work. The carve out was so the agency could contract that out. The updated language is meant to clarify what level of assessment and plan is needed. Does this make sense? Laura M. - I would add document a support plan (B) JT – I did include “a copy” of a support plan. Joan B. - Screening or "needs assessment" instead of "assessment" would be more appropriate for support services only. Assessment pertains more to clinical intensive bio/psycho/social. That was the original intent of the "Brief" term that should have been written as "brief screening"

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Beth G. - For Peer run organizations, we do not do assessments. Becky O. - If we have adequately defined "behavioral health support service" then this might work Joan B. - Need to get away from "ISP" language as well and use something like "support plan", "action plan, etc. Becky O. - I like "needs assessment" Amy S. - For individuals coming for employment services at a Behavioral Health agency, do they need to have a full assessment? Or a screening only? Marc B. - Funding often is tied to medical necessity. How will this be determined? JT – they need to show how they meet the need but there is some flexibility to that. Marc B. - A diagnosis needs to be given and this comes from an assessment JT – the other thing we want to be mindful of is that agencies do provide clinical services so the individual will have a full assessment and ISP. If that is the case, we wouldn’t need to have “in addition” a screening and assessment. The existing could be used. Jen K. - In 3b. the duplicative use of the word "plans" is confusing. Perhaps "intends" instead of the 2nd "plans"? Joan B. - "Medical necessity" pertains to clinical services, not supportive services Pattie M. - For Foundational Community Supports, Housing & employment the "assessments", are the creation of a service plan. They are based on needs and are done by CPC's, which are one of the provider types able to do those specific supports. If med necessity is required, then documentation can be requested from other providers. There is also a notion for the individual to report, like homelessness, etc. It is not a clinical assessment for those services, just peer services. Becky O. - So the language should get clear around Julie's point...(3) says "must" Joan B. - Clients enrolling into support services would just need to meet admission criteria established by the agency serving the client Becky O. - Maybe "(3) An agency only providing..." Marc B. - any services funded by Medicaid for example needs to be tied to a diagnosis. Getting documentation from other agencies is often tough. JT – I can flag to discuss with HCA. We are doing two things: rules have been tied to Medicaid funding but there are some agencies that don’t bill Medicaid, so sometimes this is above and beyond. We need to find balance. Becky O. - We should continue to keep the billing and licensing unbuckled Joan B. - You could also use something similarly used for SUD field like SBIRT (screening, brief intervention and referral to treatment) but say instead ... and referral to "services" JT – Psychiatric med monitoring. If we change the support plan language, we include it here as well, so we don’t lose that carve out. Crisis support services: JT – also called outpatient crisis stabilization. In current WAC there is a carve out for any type of assessment/ISP. If there are no certification standards, does it fit under this category or would it fit better under information and assistance along with telephone crisis support? OR if we are modifying and only doing a screening, would it still work? Going back up to BH cert standards, would the crisis support services fit better under this category or should we leave under support services with carve outs? JT - We have two certifications – info/assist/referral (telephone and crisis support); not many certification standards apply but have a carve out to 0640. JT - Means that the requirements would apply to the crisis support service unless we did carve outs. If we made all of these carve outs, does nit really belong here? Pattie M. - that is a great question- either is a effective solution

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Becky O. – clarify, make sure there is a difference between the supports for call-ins and referrals. Level of intervention. it is more than info and referral...it is more like another support "intervention" JT – more appropriate place where it is now. Modify. Amy S. - Would there be requirements in WAC for Screening and Support Plans? David C. – Agree with previous caller. There are different services. Crisis work on the phone is one thing. Step up – diagnosis and treatment. Putting them under one – I’m not in support of that. Need three distinct steps. Pattie M. - I think that level of intervention is also a path to other services where a full assessment is required. however, requiring an assessment may be a barrier (is a barrier) for those in crisis. sometimes just getting them to meet is all you can do. Amy S. - Would a MHP need to conduct the screening? JT – no I don’t think so. would be good to clarify. Purpose of the abbreviated assessment wouldn’t require an MHP to do that. Sarah B. - I agree, requiring an assessment for crisis services would be a barrier for some individuals, but that various levels may be more appropriate. Mike D. - Making an it require an MHP would increase barriers to care, especially with blended teams. Stephanie T. - I agree; this is definitely a robust service. I would recommend leaving it under the support services category with the carve outs. Our staff complete a crisis assessment that is focused on the crisis at hand, and immediate needs. While we certainly have safety plans and progress notes, I want to steer clear of requiring an ISP for these short, focused interventions. JT – Thank you - this gives me the direction I needed. JT – subsection (3)(b) SUDP specific language. Include those who have a co-occurring enhancement. Added that where it was appropriate. JT – (4)(a) – what we come up with competencies will be inserted here. Outpatient crisis BH services: Crisis outreach or intervention/observation JT – most other states call it observation and have a lot of rules around this but we don’t want to go that far right now. We can think more about that. There were some requirements that were in the BH crisis outreach section that would also apply to the crisis intervention. For crisis outreach, they need to provide telephone screening – do we want that for crisis intervention also? Becky O. – yes, there will be some triage-ing need Joan B. - Can someone share examples of when they provided SUD specific crisis intervention and what is normally done other than refer to detox or treatment? Becky O. – DCR staff are providing integrated interventions – many examples. Brooke E. – There are a number of interventions that can happen. Remove the barrier of the SUDP being part of the crisis services. JT – Modified language to use appropriately credentialed staff to provide SUD treatment. “OR” if not, then you have to have training. If you are credentialed, you don’t need additional training, if not then you need it. Brooke E. - Great - that is helpful language - to understand that piece. Thanks for that clarification/additional info. Joan B. - SUD crisis intervention would not require SUDP in my opinion either but just need some basic training on recognition of substance abuse crisis, including lethal OD and things like that. I like "appropriately credentialed" JT – subsection (6) pulled from language that would apply to outreach and intervention. No changes just moved it up from under outreach services.

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JT – Crisis outreach services. Crossed out language was moved up to apply to outreach and intervention. No changes made. Sarah B. - Sorry for going back. For 1 b, is there more clarification for the behavioral health crisis intervention? Are we expecting 24hr follow-up? JT – If you have recommendations about what would be appropriate to include, please send via email or type in questions box. I’m still trying to figure out if and what standards to apply to the 23-hour model. Joan B. - 24 hour f/u seems VERY best practices and should be included for sure! JT – just for the 23-hour model and not to general crisis outreach or would it apply to both? Sarah B. - For our region, we have multiple crisis providers that work at various times. Will the same agency be expected to follow-up? Becky O. – Careful with follow up language. Individuals may not have a stable address or contact information. Clear to allow for the reality – it can be difficult. Stephanie T. – I would not be in favor of adding the 24-hour follow-up to Crisis Outreach. While it may be a best practice, I recommend we stick to true requirements in WAC. Joan B. - I think it would be important who would be responsible for the 24 hour f/u. Is it the referring agency, the crisis agency,??? Yes, it's hard to reach them sometimes, but we should still document the try. Becky O. - develop and document and appropriate after-care plan Beth G. - I feel 24 hour follow up should be included 'if possible' Christopher D. - 24-hour follow-up is part of the contract for crisis services. May be provided in person or by phone. Becky O. - 3b is about accountability and a carry over from RSN/BHO, 3c is a nod toward the level of dangerousness of these situations...I do think this is only for outreach. JT – subsection (3) Crisis outreach requirements. Documentation – would documentation of the nature of the crisis apply to both intervention and outreach? Or just outreach? JT – we talked about whether there were req specific to SUD residential that apply to youth – should it also apply to MH? Yes, training req and academic and schoolwork. Is this appropriate? Joan M. – We talked at the council meeting last week; layed out concept. There were some concern but I sent out the language to a few members. I’m waiting for more specific feedback. JT – thank you for doing that? Take a look and send feedback. It’s a big change and if I do this, I’ll need to mention in the SA. Joan B. - Whether more change or more work, we need to have consistency between SUD and MH. What applies SUD residential should apply MH residential OR look at revising or removing some of the SUD requirements. Joan B. - Negotiate? Remove some from SUD add some from MH? JT – standardization would be great if we can get there and if it makes sense. JT – methods of ind care? It’s another way of referencing trauma informed care. Added clarifying language. Becky O. – subsection (4) – some programs this is a huge burden that is not always able to met. JT – thank you for pointing this out. The RTF rules doesn’t say it needs to be conducted within 24-hours. I’ll look into this more. Joan B. - Agree w/Becky. Med eval a barrier and should say med screening Medically supported WDM JT – Adding level 3.5 model language. After additional conversation it sounds like there is a workaround for reimbursement so to avoid confusion for ASAM criteria, we decided to not include that at this time. JT – subsection (6) no changes - leave current WAC language.

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CERTIFICATION AND INDIVIDUAL SERVICE STANDARDS FOR BEHAVIORAL HEALTH INFORMATION, ASSISTANCE AND REFERRAL SERVICES

246-341-XXX1 Behavioral health information, assistance and referral—Certification Standards.

(1) Agencies certified for behavioral health information, assistance and referral services provide information, assistance and referral services that are considered nontreatment behavioral health services that support an individual who has a need for interventions related to behavioral health. Behavioral health information, assistance and referral services under this certification include services such as: (a) Crisis telephone support in accordance with the individual services standards in WAC 246-341-XXX2; and (b) Emergency service patrol in accordance with the individual service standards in WAC 246-341-XXX3.

(2) Agencies providing information, assistance and referral services are not required to meet the requirements under WAC 246-341-0640. (3) Agencies providing information and assistance services must maintain and provide a list of resources, including self-help groups, behavioral health services referral options, legal, employment, education, interpreter, and social and health services that can be used by staff members to refer an individual to appropriate services.

246-341-XXX2

Telephone support services- Individual service standards.

Crisis telephone support services are services provided as a means of first contact to an individual in crisis. These services may include de-escalation and referral.

(1) An agency providing telephone support services must: (a) Have services available 24 hours per day, seven days per week; (b) Assure communication and coordination with the individual's mental health

or substance use treatment provider, if indicated and appropriate; (c) Remain on the phone with the individual in crisis in order to provide

stabilization and support until the crisis is resolved or referral to another service is accomplished;

(d) As appropriate, refer individuals to voluntary or involuntary treatment facilities for admission on a seven-day-a-week, twenty-four-hour-a-day basis, including arrangements for contacting the designated crisis responder;

(2) Documentation of a telephone crisis service must include the following:

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(a) A brief summary of each crisis service encounter, including the date, time, and duration of the encounter; (b) The names of the participants; (c) A follow-up plan or disposition, including any referrals for services, including emergency medical services; (d) Whether the individual has a crisis plan and any request to obtain the crisis plan; and (e) The name and credential, if applicable, of the staff person providing the service.

(3) An agency providing telephone services for mental health is not required to

follow the consultation requirement in WAC 246-341-0515(3). (4) An agency providing telephone services for substance use disorder must: (a) Ensure each staff member completes forty hours of training that covers

substance use disorders before assigning the staff member unsupervised duties; and

(b) Ensure a substance use disorder professional or a substance use disorder professional trainee is available or on staff twenty-four hours a day, seven days a week.

CERTIFICATION AND INDIVIDUAL SERVICE STANDARDS FOR BEHAVIORAL HEALTH SUPPORT SERVICES 246-341-XXX4

Behavioral health support services—Certification standards (1) Agencies certified for behavioral health support provide services to promote

socialization, recovery, self-advocacy, development of natural supports, and maintenance of community living skills for individuals with a behavioral health diagnosis. Behavioral health support services under this certification include services such as:

(a) Supported employment in accordance with the individual service standards in WAC 246-341-XXX5; (b) Supportive housing in accordance with the individual service standards in WAC 246-341-XXX6; (c) Peer support; (d) Consumer-run clubhouse in accordance with the individual service standards in WAC 246-341-XXX7; (e) Case managementRehabilitative case management; (f) Psychiatric medication monitoring in accordance with the individual service standards in WAC 246-341-XXX8; (g) Day support; and (h) Crisis support in accordance with the individual service standards in WAC 246-31-XXX9.

Commented [TJ(1]: Need more?

Commented [TJ(2]: RCM is the only case management that is required to be “certified” in order to get reimbursed. If there is not a great benefit to including general case management to the WAC then it may be better just to remove it.

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(2) An agency certified to provide behavioral health support services is not required to meet the requirements in WAC 246-341-0640, but must instead meet the requirements in subsection (3).

(3) An agency providing any behavioral health support service must: (a) Conduct a screening process that determines the appropriateness of the

support service(s) based on the individuals needs and goals; (b) Develop a support plan that indicates the goal(s) the individual plans to

achieve through receiving the support service(s) and the progress made toward the goal(s);

(a)(c) mMaintain an individual's health record that contains documentation of the following:

(ia) The name of the agency or other sources through which the individual was referred, if applicable; (iib) Determination of the appropriateness of the support service(s); A copy of an assessment conducted by a licensed behavioral health agency or appropriately credentialed professional. If the agency conducts assessments on individuals the agency must become certified for assessment, treatment and intervention services in accordance with WAC 246-341-XX10. (iiic) A copy of the support plan and progress toward meeting the individual’s goal(s)an individual service plan conducted by a licensed behavioral health agency or appropriately credentialed professional indicating the appropriateness of the support services based on the individual’s needs and goals . (ivd) Any referral made to a more intensive level of care when appropriate; (ve) Consent to include the individual's family members, significant others, and other relevant treatment providers as necessary to provide support to the individual; (vif) A brief summary of each service encounter, including the date, time, and duration of the encounter; (viig) Names of participant(s), including the name of the individual who provided the service; and (viiih) Any information or copies of documents shared by or with a behavioral health agency or credentialed behavioral health professional. (ixi) Discharge information as follows:

(Ai) A discharge statement if the individual left without notice; or (Bii) Discharge information for an individual who did not leave without notice,

completed within seven working days of the individual's discharge, including the date of discharge and continuing care plan.:

(A) The date of discharge; and (B) Continuing care plan.

(4) An agency may use a full assessment and individual service plan if it is certified for intervention, assessment and treatment services or has operate through an agreement with another a licensed behavioral health agency that provides certified for intervention, assessment and treatment services in order to meet the requirements in (3)(a) and (b).

Commented [TJ(3]: Current WAC allows for “abbreviated” requirements for assessment and ISP. It has never been clear to me what that meant. I assume that abbreviated meant that the agency could contract with another agency for the full bio/psycho/social assessment and ISP, but that was still somewhat of a barrier to some agencies that only provide support services such as peer support or Clubhouse. I inquired internally some more, and it came down to confusion over the definition of “assessment”. In all other places in our WAC the assessment means the full bio/psycho/social assessment. The abbreviated assessment for support services was intended to be more like a screening assessment that the support service is appropriate and a higher level of care isn’t required and the ISP could just be a simple plan that attaches the support service to the individuals goals for recovery and support. See revised language.

Commented [TJ(4]: A full assessment and ISP can substitute for the screening and support plan so the work doesn’t have to be duplicated.

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The agreement must specify the responsibility for initial assessments, the determination of appropriate services, individual service planning, and the documentation of these requirements. (5) Agencies certified for support services may also choose to provide behavioral health information, assistance and referral services without additional certification in accordance with the applicable certification and individual service requirements.

246-341-XXX8

Psychiatric medication monitoring services- Individual service standards.

(1) Medication monitoring services occur face-to-face and: (a) Include one-on-one cueing, observing, and encouraging an individual to take

medication as prescribed; (b) Include reporting any pertinent information related to the individual's

adherence to the medication back to the agency that is providing psychiatric medication services; and

(c) May take place at any location and for as long as it is clinically necessary. (2) An agency providing medication monitoring services must: (a) Ensure that the staff positions responsible for providing either medication

monitoring, or delivery services, or both, are clearly identified in the agency's medication monitoring services policy;

(b) Have appropriate policies and procedures in place when the agency providing medication monitoring services maintains or delivers medication to the individual that address:

(i) The maintenance of a medication log documenting the type and dosage of medications, and the time and date;

(ii) Reasonable precautions that need to be taken when transporting medications to the intended individual and to assure staff safety during the transportation; and

(iii) The prevention of contamination of medication during delivery, if delivery is provided.

(c) Ensure that the individual's health record includes documentation of medication monitoring services.

(3) A support plan or Aan individual service plan is not required when providing psychiatric medication monitoring services.

WAC 246-341-XXX9

Crisis support services- Individual service standards.

Crisis support services include short-term (less than two weeks per episode)

face-to-face assistance with life skills training and understanding of medication effects

on an individual.

Commented [TJ(5]: Current WAC has a carve out from all of 0640 and would not apply the abbreviated support service requirements. If carved out from all certification requirements in the support services certification, should this move to information and assistance? Would the modified requirements be able to be applied?

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(1) An agency providing crisis support services must:

(a) Assure communication and coordination with the individual's mental health care or substance use treatment provider, if indicated and appropriate;

(b) If an individual is found to be experiencing an acute crisis, remain with the individual in order to provide stabilization and support until the crisis is resolved or referral to another service is accomplished;

(c) As appropriate, refer individuals to voluntary or involuntary treatment facilities for admission on a seven-day-a-week, twenty-four-hour-a-day basis, including arrangements for contacting the designated crisis responder; and

(d) Transport or arrange for transport of an individual in a safe and timely manner, when necessary

(2) Documentation of crisis support services must include the following: (a) A follow-up plan or disposition, including any referrals for services, including

emergency medical services; (b) Whether the individual has a crisis plan and any request to obtain the crisis

plan; and (c) The name and credential, if applicable, of the staff person providing the

service.

(3) An agency providing crisis support services for mental health is not required to follow the consultation requirement in WAC 246-341-0515(3).

(4) An agency providing crisis support services for substance use disorder must: (a) Ensure each staff member completes forty hours of training that covers

substance use disorders before assigning the staff member unsupervised duties; and

(b) Ensure a professional appropriately credentialed to provide substance use disorder treatment substance use disorder professional or a substance use disorder professional trainee is available or on staff twenty-four hours a day, seven days a week.

(5) When services are provided in a private home or nonpublic setting the agency must:

(a) Have a written plan for training, staff back-up, information sharing, and communication for staff members who respond to a crisis in an individual's personal residence or in a nonpublic setting; (c) Ensure that a staff member responding to a crisis is able to be accompanied

by a second trained individual when services are provided in the individual's personal residence or other nonpublic location;

(d) Ensure that any staff member who engages in home visits is provided access, by their employer, to a wireless telephone or comparable device for the purpose of emergency communication as described in RCW 71.05.710;

(e) Provide staff members who are sent to a private home or other private location to evaluate an individual in crisis prompt access to information about any

Commented [TJ(6]: Note for Kysenia- rejected track changes. Check in master draft.

Commented [TJ(7]: Covered in CS.

Commented [TJ(8]: Matches other language in the WAC. This would include professionals on this list: https://www.doh.wa.gov/Portals/1/Documents/Pubs/670158.pdf including those with a co-occuring enhancement.

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history of dangerousness or potential dangerousness on the individual they are being sent to evaluate that is documented in a crisis plan(s) or commitment record(s). This information must be made available without unduly delaying the crisis response.

CERTIFICATION AND INDIVIDUAL SERVICE STANDARDS FOR BEHAVIORAL HEALTH OUTPATIENT CRISIS SERVICES

246-341-XX17 Outpatient crisis behavioral health services—certification standards. (1) Agencies certified for outpatient crisis behavioral health provide services to stabilize an individual in crisis to prevent further deterioration, provide immediate treatment or intervention in a location best suited to meet the needs of the individual, and provide treatment services in the least restrictive environment available. Outpatient behavioral health crisis services under this certification include services such as: (a) Behavioral health crisis outreach in accordance with the individual service standards in WAC 246-341-XX18; and (b) Behavioral health crisis interventionobservation.

(2) An agency certified for outpatient crisis behavioral health services does not need to meet the requirements in WAC 246-341-0640.

(3) An agency providing any outpatient crisis behavioral health service must:

(a) Provide crisis telephone screening. (b) For mental health crisis, ensure face-to-face outreach services are provided

by a mental health professional or a department-credentialed staff person with documented training in crisis response.

(c) For an SUD crisis, ensure face-to-face outreach services are provided by a professional appropriately credentialed to provide substance use disorder treatment, or individual who has completed training that covers substance use disorders.

(d) Resolve the crisis in the least restrictive manner possible.

(a) Require that trained staff remain with the individual in crisis in order to provide stabilization and support until the crisis is resolved or referral to another service is accomplished; (b) Determine if an individual has a crisis plan and request a copy if available; (c) As appropriate, refer individuals to voluntary or involuntary treatment facilities for admission on a seven-day-a-week, twenty-four-hour-a-day basis, including arrangements for contacting the designated crisis responder; (d) Maintain a current list of local resources for legal, employment, education, interpreter, and social and health services.

Commented [TJ(9]: Other states call the 23-hour model “observation”

Commented [TJ(10]: Is this required for crisis intervention or only crisis outreach?

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(e) Transport or arrange for transport of an individual in a safe and timely manner, when necessary; (f) Be available twenty-four hours a day, seven days a week; and (g) Include family members, significant others, and other relevant treatment providers, as necessary, to provide support to the individual in crisis. (4) Documentation of a crisis service must include the following, as applicable to the crisis service provided: (a) A brief summary of each crisis service encounter, including the date, time, and duration of the encounter; (b) The names of the participants; (c) A follow-up plan or disposition, including any referrals for services, including emergency medical services; (d) Whether the individual has a crisis plan and any request to obtain the crisis plan; and (e) The name and credential, if applicable, of the staff person providing the service. (5) An agency providing SUD crisis services must: (a) Ensure each staff member completes forty hours of training that covers substance use disorders before assigning the staff member unsupervised duties; (b) Ensure a substance use disorder professional or a substance use disorder professional traineea professional appropriately credentialed to provide substance use disorder treatment is available or on staff twenty-four hours a day, seven days a week; and; (c) Maintain a current directory of all certified substance use disorder service providers in the state. (6) An agency utilizing certified peer counselors to provide crisis outreach services

must: (a) Ensure services are provided by a person recognized by the health care authority as a peer counselor, as defined in WAC 246-341-0200; (b) Ensure services provided by a peer counselor are within the scope of the peer counselor's training and credential; (e) Ensure peer counselors receive annual training that is relevant to their unique working environment.

(6)(7) Agencies certified for behavioral health crisis services may choose to provide

information, assistance and referral and behavioral health support services without additional certification in accordance with the certification and individual service standards.

246-341-XX18

Behavioral health crisis outreach services—individual service standards.

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Behavioral health crisis outreach services are face-to-face intervention services provided to assist individuals in a community setting. A community setting can be an individual's home, an emergency room, a nursing facility, or other private or public location.

(14) When services are provided in a private home or nonpublic setting the agency must: (a) Have a written plan for training, staff back-up, information sharing, and communication for staff members who respond to a crisis in an individual's personal residence or in a nonpublic setting; (b) Ensure that a staff member responding to a crisis is able to be accompanied by a second trained individual when services are provided in the individual's personal residence or other nonpublic location; (c) Ensure that any staff member who engages in home visits is provided access, by their employer, to a wireless telephone or comparable device for the purpose of emergency communication as described in RCW 71.05.710; (d) Provide staff members who are sent to a private home or other private location to evaluate an individual in crisis prompt access to information about any history of dangerousness or potential dangerousness on the individual they are being sent to evaluate that is documented in a crisis plan(s) or commitment record(s). This information must be made available without unduly delaying the crisis response. (1) An agency certified to provide crisis outreach services must: (a) Provide crisis telephone screening. (b) For mental health crisis, ensure face-to-face outreach services are provided by a mental health professional or a department-credentialed staff person with documented training in crisis response. (c) For an SUD crisis, ensure face-to-face outreach services are provided by an SUDP, SUDPT, or individual who has completed forty hours of training that covers substance use disorders. (d) Resolve the crisis in the least restrictive manner possible. (2) An agency utilizing certified peer counselors to provide crisis outreach services must: (a) Ensure services are provided by a person recognized by the health care authority as a peer counselor, as defined in WAC 246-341-0200; (b) Ensure services provided by a peer counselor are within the scope of the peer counselor's training and credential; (2c) If utilizing peer counselors for crisis outreach response: (a)Ensure that a peer counselor responding to an initial crisis visit is accompanied by a mental health or substance use disorder professional appropriately credentialed to provide substance use disorder treatments as appropriate to the crisis; (b)d) Develop and implement policies and procedures for determining when peer counselors may provide follow-up crisis outreach services without being accompanied by a mental health professional or substance use disorder professional.; and

(e) Ensure peer counselors receive annual training that is relevant to their unique working environment.

Commented [TJ(11]: Moved up from below.

Commented [TJ(12]: Moved under certification requirements

Commented [TJ(13]: Moved under certification requirements.

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(3) In addition to the documentation requirements in WAC 246-341-0900246-341-XX17, documentation must include:

(a) The nature of the crisis; (b) The time elapsed from the initial contact to the face-to-face response; (c) The outcome, including the basis for a decision not to respond in person.

(4) When services are provided in a private home or nonpublic setting the agency must: (a) Have a written plan for training, staff back-up, information sharing, and communication for staff members who respond to a crisis in an individual's personal residence or in a nonpublic setting; (b) Ensure that a staff member responding to a crisis is able to be accompanied by a second trained individual when services are provided in the individual's personal residence or other nonpublic location; (c) Ensure that any staff member who engages in home visits is provided access, by their employer, to a wireless telephone or comparable device for the purpose of emergency communication as described in RCW 71.05.710; (d) Provide staff members who are sent to a private home or other private location to evaluate an individual in crisis prompt access to information about any history of dangerousness or potential dangerousness on the individual they are being sent to evaluate that is documented in a crisis plan(s) or commitment record(s). This information must be made available without unduly delaying the crisis response.

246-341-XXXX

Behavioral health crisis intervention services—individual service standards.

CERTIFICATION AND INDIVIDUAL SERVICE STANDARDS FOR BEHAVIORAL HEALTH RESIDENTIAL AND INPATIENT SERVICES

246-341-XX19 Behavioral health residential and inpatient services—certification standards.

Commented [TJ(14]: Apply to crisis intervention/observation?

Commented [TJ(15]: Only apply to outreach?

Commented [TJ(16]: What else would we include for ISS requirements?

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(1) Agencies certified for behavioral health residential and inpatient services provide voluntary behavioral health intervention, assessment, and treatment services in a residential treatment facility or hospital. Residential and inpatient services under this certification include services such as: (a) Residential and inpatient mental health treatment in accordance with the individual service standards in WAC 246-341-XX21; and (b) Residential and inpatient substance use disorder treatment in accordance with the individual service standards in WAC 246-341-XX20. (2) Agencies certified for behavioral health residential and inpatient services must: (a) Be a facility licensed by the department as:

(i) A hospital licensed under chapter 70.41 RCW; (ii) A private psychiatric and alcoholism hospital licensed under

chapter 71.12 RCW; (iii) A private alcohol and substance use disorder hospital licensed under

chapter 71.12 RCW; or (iv) A residential treatment facility licensed under chapter 71.12 RCW; (b) Must ensure access to necessary medical treatment, including emergency

life-sustaining treatment and medication; (c) Must review the individual's crisis or recovery plan, if applicable and available; (d) Must determine the individual's risk of harm to self, others, or property; (e) Must coordinate with the individual's current treatment provider, if applicable,

to assure continuity of care during admission and upon discharge; (f) Must develop and provide to the individual a discharge summary that must

include: (i) A continuing care recommendation; and (ii) Scheduled follow-up appointments, including the time and date of the

appointment(s), when possible; (h) If providing services to adults and minors, an agency must: (i) Ensure that a minor who is at least age thirteen but not yet age eighteen is

served with adults only if the minor's clinical record contains: (A) Documentation that justifies such placement; and (B) A professional judgment that placement in an inpatient facility that serves

adults will not harm the minor; (ii) Ensure the following for individuals who share a room: (A) An individual fifteen years of age or younger must not room with an individual

eighteen years of age or older; (B) Anyone under thirteen years of age must be evaluated for clinical

appropriateness before being placed in a room with an individual thirteen to sixteen years of age; and

(C) An individual sixteen or seventeen years of age must be evaluated for clinical appropriateness before being placed in a room with an individual eighteen years of age or older.

(3) An agency providing residential or inpatient mental health or substance use disorder services to youth must follow these additional requirements:

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(a) Allow communication between the youth and the youth's parent or if applicable, a legal guardian, and facilitate the communication when clinically appropriate.

(b) Notify the parent or legal guardian within two hours of any significant decrease in the behavioral or physical health status of the youth and document all notification and attempts of notification in the clinical record.

(c) Discharge the youth to the care of the youth's parent or if applicable, legal guardian. For an unplanned discharge and when the parent or legal guardian is not available, the agency must contact the state child protective services.

(d) Ensure a staff member who demonstrates knowledge of adolescent development and substance use disorders is available at the agency or available by phone.

(e) Ensure staff members are trained in safe and therapeutic techniques for dealing with a youth's behavior and emotional crisis, including:

(i) Verbal deescalation; (ii) Crisis intervention; (iii) Anger management; (vi) Suicide assessment and intervention; (v) Conflict management and problem solving skills; (vii) Management of assaultive behavior; (viii) Proper use of therapeutic physical intervention techniques; and (ix) Emergency procedures. (f) Provide group meetings to promote personal growth. (g) Provide leisure, and other therapy or related activities. (h) Provide seven or more hours of structured recreation each week, that is led or

supervised by staff members. (i) Provide each youth one or more hours per day, five days each week, of

supervised academic tutoring or instruction by a certified teacher when the youth is unable to attend school for an estimated period of four weeks or more. The agency must:

(i) Document the individual's most recent academic placement and achievement level; and

(ii) Obtain school work from the individual's school, or when applicable, provide school work and assignments consistent with the individual's academic level and functioning.

(j) Conduct random and regular room checks when an individual is in their room, and more often when clinically indicated.

(k) Ensure each individual's clinical record: (l) Contains any consent or release forms signed by the youth and their parent or

legal guardian; (ii) Contains the parent's or other referring person's agreement to participate in

the treatment process, as appropriate and if possible; and (iii) Documents any problems identified in specific youth assessment, including

any referrals to school and community support services, on the individual service plan. (4) Agencies certified for behavioral health residential and inpatient services may

choose to provide information, assistance and referral, behavioral health support

Commented [TJ(17]: Double checking this makes sense for MH? Would it only be for longer term services like more than 2 weeks, or???

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services, intervention, assessment and treatment services, or outpatient behavioral health crisis services without additional certification in accordance with the applicable certification and individual service standards.

246-341-XX20

Residential and inpatient substance use disorder treatment services—Individual service standards.

Residential substance use disorder treatment services provide substance use disorder treatment for an individual in a facility with twenty-four hours a day supervision.

(1) An agency providing residential and inpatient substance use disorder treatment services must:

(a) Provide education to each individual admitted to the treatment facility on: (i) Substance use disorders; (ii) Relapse prevention; (iii) Bloodborne pathogens; (iv) Tuberculosis (TB); (v) Emotional, physical, and sexual abuse; and (vi) Nicotine use disorder. (b) Maintain a list or source of resources, including self-help groups, and referral

options that can be used by staff to refer an individual to appropriate services; and (c) Develop and implement written procedures for: (i) Urinalysis and drug testing, including laboratory testing; and (ii) How agency staff members respond to medical and psychiatric emergencies. (3) An agency that provides services to a pregnant woman must: (a) Develop and implement a written procedure to address specific issues

regarding the woman's pregnancy and prenatal care needs; (b) Provide referral information to applicable resources; and (c) Provide education on the impact of substance use during pregnancy, risks to

the developing fetus, and the importance of informing medical practitioners of chemical use during pregnancy.

(4) An agency that provides an assessment to an individual under RCW 46.61.5056 must also meet the requirements for driving under the influence (DUI) assessment providers in WAC 246-341-0820.

(5) An agency that provides substance use disorder residential services to youth must:

(a) Ensure staff members are trained in safe and therapeutic techniques for dealing with a youth's behavior and emotional crisis, including:

(i) Verbal deescalation; (ii) Crisis intervention; (iii) Anger management; (vi) Suicide assessment and intervention; (v) Conflict management and problem solving skills; (vii) Management of assaultive behavior; (viii) Proper use of therapeutic physical intervention techniques; and

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(ix) Emergency procedures. (b) Provide group meetings to promote personal growth. (c) Provide leisure, and other therapy or related activities. (d) Provide seven or more hours of structured recreation each week, that is led or

supervised by staff members. (e) Provide each youth one or more hours per day, five days each week, of

supervised academic tutoring or instruction by a certified teacher when the youth is unable to attend school for an estimated period of four weeks or more. The agency must:

(i) Document the individual's most recent academic placement and achievement level; and

(ii) Obtain school work from the individual's school, or when applicable, provide school work and assignments consistent with the individual's academic level and functioning.

(f) Conduct random and regular room checks when an individual is in their room, and more often when clinically indicated.

(g) Ensure each individual's clinical record: (i) Contains any consent or release forms signed by the youth and their parent or

legal guardian; (ii) Contains the parent's or other referring person's agreement to participate in

the treatment process, as appropriate and if possible; and (iii) Documents any problems identified in specific youth assessment, including

any referrals to school and community support services, on the individual service plan. (56) Inform individuals of their treatment options so they can make individualized

choices for their treatment. This includes, as applicable, the initiation, continuation, or discontinuation of medications for substance use disorders.

(67) For individuals choosing to initiate or continue medications for their substance use disorder, make available on-site or facilitate off-site access to continue or initiate Federal Drug Administration (FDA)-approved medication for any substance use disorder, when clinically appropriate as determined by a medical practitioner.

(78) Provide continuity of care that allows individuals to receive timely and appropriate follow-up services upon discharge and, if applicable, allows the individual to continue medications with no missed doses.

(89) Document in the clinical record: (a) The individual being informed of their treatment options including the use of

medications for substance use disorder; (b) The continuation or initiation of FDA-approved medication for substance use

disorder treatment that has been provided on-site or facilitated off-site, if applicable; (c) Referrals made to behavioral health providers including documentation that a

discharge summary was provided to the receiving behavioral health provider as allowed under 42 C.F.R. Part 2; and

(d) Contact or attempts to follow up with the individual post-discharge including the date of correspondence.

(910) An agency may not deny admission based solely on an individual taking FDA-approved medications, under the supervision of a medical provider, for their substance use disorder or require titration of dosages in order to be admitted or remain in the program.

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246-341-XX21

Residential and inpatient Mental health services—Individual service standards.

(1) An agency providing residential and inpatient mental health services must develop and implement an individualized annual training plan for agency staff members, to include at least:

(a) Least restrictive alternative options available in the community and how to access them;

(b) Methods of providing individualized treatmentindividual care; and (c) Deescalation training and management of assaultive and self-destructive

behaviors, including proper and safe use of seclusion and restraint procedures. (3) If contract staff are providing direct services, the facility must ensure

compliance with the training requirements outlined in subsection (12) of this section. (4) A behavioral health agency providing mental health inpatient services must: (a) Document that each individual has received evaluations to determine the

nature of the disorder and the treatment necessary, including: (i) A health assessment of the individual's physical condition to determine if the

individual needs to be transferred to an appropriate hospital for treatment; (ii) Examination and medical evaluation within twenty-four hours of admission by

a licensed physician, advanced registered nurse practitioner, or physician assistant; (iii) Consideration of less restrictive alternative treatment at the time of

admission; and (iv) The admission diagnosis and what information the determination was based

upon. (b) Ensure the rights of individuals to make mental health advance directives,

and facility protocols for responding to individual and agent requests consistent with RCW 71.32.150.

(c) Ensure examination and evaluation of a minor by a children's mental health specialist occurs within twenty-four hours of admission.

CERTIFICATION STANDARDS FOR CLINICAL WITHDRAWAL MANAGEMENT

246-341-XX22 Medically supported withdrawal management- certification standards.

Medically supported substance use disorder withdrawal management services are provided to assist in the process of withdrawal from psychoactive substances in a safe and effective manner that includes medical intervention.

(1) An agency certified for medically supported withdrawal management services must:

(a) Ensure the individual receives a substance use disorder screening before admission;

(b) Provide counseling to each individual that addresses the individual's: (i) Substance use disorder and motivation; and

Commented [TJ(18]: Another term for referencing trauma-informed care, per internal staff.

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(ii) Continuing care needs and need for referral to other services. (c) Have a medical provider or nursing staff on-site for a minimum of 8 hours per

day or more, and otherwise on-call 24/7, as appropriate to the level of care provided. (cd) Maintain a list of resources and referral options that can be used by staff

members to refer an individual to appropriate services; and (de) Post any rules and responsibilities for individuals receiving treatment,

including information on potential use of increased motivation interventions or sanctions, in a public place in the facility.

(2) Ensure that each staff member providing withdrawal management services to an individual, with the exception of substance use disorder professionals, substance use disorder professional trainees, physicians, physician assistants, advanced registered nurse practitioners, or person with a co-occurring disorder specialist enhancement, completes a minimum of forty hours of documented training before being assigned individual care duties. This personnel training must include the following topics:

(a) Substance use disorders; (b) Infectious diseases, to include hepatitis and tuberculosis (TB); and (c) Withdrawal screening, admission, and signs of trauma. (3) An agency certified for clinical withdrawal management services must meet

the certification standards for residential and inpatient behavioral health services in WAC 246-341-XX19 and the individual service requirements for inpatient and residential substance use disorder services in WAC 246-341-XX20.

(4) An agency certified for clinical withdrawal services may choose to provide information, assistance and referral, behavioral health support services, intervention, assessment and treatment services, outpatient behavioral health crisis services, or residential or inpatient behavioral health treatment services without additional certification in accordance with the applicable certification and individual service standards.

CERTIFICATION STANDARDS FOR CRISIS STABILIZATION UNIT AND TRIAGE SERVICES

246-341-XX23

Crisis stabilization unit and triage- certification standards.

An agency certified to provide crisis stabilization unit or triage services must meet all of the following criteria:

(1) A triage facility must be licensed as a residential treatment facility under chapter 71.12 RCW.

(2) If a crisis stabilization unit or triage facility is part of a jail, the unit must be located in an area of the building that is physically separate from the general population. "Physically separate" means:

(a) Out of sight and sound of the general population at all times; (b) Located in an area with no foot traffic between other areas of the building,

except in the case of emergency evacuation; and

Commented [TJ(19]: After consultation with other providers and internally it was determined not to add this language at this time.

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(c) Has a secured entrance and exit between the unit and the rest of the facility. (3) Ensure that a mental health professional is on-site at least eight hours per

day, seven days a week, and accessible twenty-four hours per day, seven days per week.

(4) Ensure a mental health professional assesses an individual within three hours of the individual's arrival at the facility.

(5) An agency certified to provide crisis stabilization unit or triage services must meet the individual service standards for residential and inpatient mental health services in WAC 246-341-XX21 and WAC 246-341-XX24 if providing involuntary crisis stabilization unit or triage services..

(6) For persons admitted to the crisis stabilization unit or triage facility on a voluntary basis, the clinical record must meet the clinical record requirements in WAC 246-341-0640.An agency providing crisis stabilization unit or triage services to involuntary individuals must meet the certification standards for involuntary behavioral health residential and inpatient services in WAC 246-341-XX24. (7)(8) An agency certified crisis stabilization unit or triage services may choose to

provide information, assistance and referral, behavioral health support services, intervention, assessment and treatment services, outpatient behavioral health crisis services, or residential or inpatient behavioral health treatment services without additional certification in accordance with the applicable certification and individual service standards.

Commented [TJ(20]: Copied existing language in WAC. Current language: (5) For persons admitted to the crisis

stabilization unit or triage facility on a voluntary basis, the clinical record must meet the clinical record requirements in WAC 246-341-0640.