PART I - Department of Behavioral Health and Developmental ...

ServiceDefinitionAdmissionCriteriaContinuingStay CriteriaDischargeCriteriaServiceExclusionsClinicalExclusionsRequiredComponentsStaffingRequirementsA short-term stay in a licensed and accredited community-based hospital for the treatment or habilitation of a psychiatric and/or substance related disorder. Services areof short duration and provide treatment for an acute psychiatric or behavioral episode. This service may also include Medically Managed Inpatient Detoxification at ASAMLevel IV-D.1. Individual with serious mental illness/SED that is experiencing serious impairment; persistent, recurrent, severe, or major symptoms (such as psychoses); or who isexperiencing major suicidal, homicidal or high risk tendencies as a result of the mental illness; or2. Individual’s need is assessed for 24/7 supports which must be one-on-one and may not be met by any service array which is available in the community; or3. Individual is assessed as meeting diagnostic criteria for a Substance Related Disorder according to the latest version of the DSM; and one or more of the following:A. Individual is experiencing signs of severe withdrawal, or there is evidence (based on history of substance intake, age, gender, previous withdrawal history, presentsymptoms, physical condition, and/or emotional/behavioral condition) that severe withdrawal syndrome is imminent; orB. Level IV-D is the only available level of service that can provide the medical support and comfort needed by the individual, as evidenced by:i. A detoxification regimen or individual’s response to that regimen that requires monitoring or intervention more frequently than hourly, orii. The individual’s need for detoxification or stabilization while pregnant, until she can be safely treated in a less intensive service.1. Individual continues to meet admission criteria; and2. Individual’s withdrawal signs and symptoms are not sufficiently resolved to the extent that they can be safely managed in less intensive services;1. An adequate continuing care plan has been established; and one or more of the following:2. Individual no longer meets admission and continued stay criteria; or3. Individual requests discharge and individual is not imminently dangerous to self or others; or4. Transfer to another service/level of care is warranted by change in the individual’s condition; or5. Individual requires services not available in this level of care.This service may not be provided simultaneously to any other service in the service array excepting short-term access to services that provide continuity of care orsupport planning for discharge from this service.Individuals with any of the following unless there is clearly documented evidence of an acute psychiatric/addiction episode overlaying the primary diagnosis: Autism,Developmental Disabilities, Organic Mental Disorder; or Traumatic Brain Injury1. This service must be licensed by DCH/HFR under the Rules and Regulations for Drug Abuse Treatment Programs, 290-4-22. A physician’s order in the individual’s record is required to initiate detoxification services. Verbal orders or those initiated by a Physician’s Assistant or Clinical NurseSpecialist are acceptable provided the physician signs them within 24 hours or the next working day.Detoxification services must be provided only by nursing or other licensed medical staff under supervision of a physician.FY2013 Provider Manual for Community Behavioral Health Providers Page 104