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

4. ORDER/RECOMMENDATION FOR COURSE OF TREATMENT 5A. All services must be recommended (“ordered”) by a physician or other appropriately licensed practitioner. Thepractitioner(s) authorized to recommend/order specific services may be found within Part I, Section IV of this ProviderManualB. All recommendations/orders expire at the time of the expiration of the current authorization.C. The recommendation/order for a course of treatment must specify each service (by official Group Name) to beprovided and shall be reviewed and signed by the appropriately licensed practitioner(s) on or before the initial date ofservice AND on or before the effective date of each reauthorization of service(s). If the provider utilizes servicepackages (i.e. Intensive Outpatient) to order services, each service included in the service package must beindividually named (by official Group Name) in the recommendation/order.D. There are two formats that may be used for writing a recommendation/order:i. An individualized recovery/resiliency plan (IRP) which fulfills the required components listed below, can beused as a recommendation/order for the applicable authorization period for services indicated within the plan.ii. A stand-alone recommendation/order in the client record which fulfills the required components listed below.E. Required Components of the recommendation/order include:i. Consumer name,ii. All services recommended as a course of treatment/ordered as indicated by Group Name as listed in thecurrent DBHDD Provider Manual,iii. Signature and credentials 6 of appropriately licensed practitioner(s),iv. Printed or stamped name and credentials of appropriately licensed practitioner(s), andv. Date of signature(s).F. When more than one physician is involved in an individual’s treatment, there is evidence that a RN or MD has reviewedall in-field information to assure there are no contradictions or inadvertent contraindications within the services andtreatment orders or plan.G. Should the recommendation for course of treatment (order) cross multiple pages in a paper record, the provider isresponsible for ensuring that it is clear that the additional pages are a continuation of the order. For example, in a 2page order, page 2 must contain the name of the consumer, a page number, and indication that the signature of thepractitioner indicates authorization for services as noted on page 1.H. Recommendation for course of treatment (“orders”) may be made verbally. This required components of the verbalrecommendation/order include:i. The provider must have policies and procedures which govern procedures for verbal orders;ii. Recommendations/Orders must be documented in the medical record and include:1. Consumer name,2. All services recommended as a course of treatment/ordered as indicated by official Group Nameas listed in the current DBHDD Provider Manual,3. Printed or stamped name and credentials of appropriately licensed practitioner(s) recommendingservice, and4. Date of verbal order(s); and5. Printed or stamped name, credentials, original signature, and date signed by the staff memberreceiving the verbal order. Provider’s policy must specify which staff can accept verbal orders forservices.iii. Verbal orders must be authenticated by the ordering practitioner’s signature within seven (7) calendar daysof the issuance of orders. This may be an original signature or faxed signed order.iv. Faxed orders signed by the ordering practitioner are acceptable and a preferred alternative to verbal orders.The fax must be dated upon receipt and contain Required Components 1-5 above.5. TREATMENT PLANNINGTreatment planning documentation is included in the consumer’s Individualized Recovery/Resiliency Plan (IRP). The IRPplanning is intended to develop a plan which focuses on the individual’s hopes, dreams and vision of a life well-lived. Everyrecord must contain an IRP in accordance with content set forth in this Manual. The IRP should be reviewed frequently andevolve to best meet the individual’s needs. This plan sets forth the course of services by integrating the information gatheredfrom the current assessment, status, functioning, and past treatment history into a clinically sound plan.A. An individualized resiliency/recovery plan is developed with the guidance of an in-field professional. The individualsdirect decisions that impact their lives. Others assisting in the development of the IRP are persons who are:5Note that the following requirements apply only to recommendation/orders for services as defined in Part I of this Provider Manual.Standards regarding orders for medication and procedures can be found in Section I of these Community Service Standards for All Providers.6See Section II of the Community Service Standards for All Providers for additional information regarding credentials.FY2013 Provider Manual for Community Behavioral Health Providers Page 171