APPENDIX B: Comprehensive Clinical Assessment & PCP Guidelines
Protocol For Conducting
A Comprehensive Clinical Assessment
Definition: The Comprehensive Clinical Assessment is an intensive clinical and functional face-to-face evaluation of an individual’s presenting MH/DD/SAS condition(s). The assessment provides a written determination of needed supports/services and the basis on which the person-centered plan is developed.
Purpose: The purpose of the assessment is to provide a means for gathering the clinical and diagnostic information necessary to develop a treatment plan and gives the individual completing the person centered plan the necessary assessment information.
Required elements:
▪ Chronological general health and behavioral health history;
▪ biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weaknesses in each area;
▪ description of the presenting problems, precipitating events, symptoms, and current medications;
▪ strengths / problem summary;
▪ evidence of recipient or family participation;
▪ analysis and interpretation of the assessment information with an appropriate case formulation;
▪ diagnoses on all five (5) axes of DSM-IV; and
▪ recommendations for additional assessments, services, support, or treatment based
Who completes the Comprehensive Clinical Assessment?
▪ A licensed professional, (e.g. MD, NP, PA, LCSW, LPC, licensed psychologist).
The Comprehensive Clinical Assessment may be billed using the following codes:
▪ Diagnostic Assessment: T1023
▪ Evaluation/Intake: 90801, 90802
▪ Assessment: H0001, H0031
▪ Evaluation and Management Codes E/M
Effectiveness of the Assessment:
An effective assessment process results in a person centered plan that:
▪ identifies the strengths and preferences of the individual,
▪ identifies obstacles to the person achieving identified goals and proposes ways to address these
obstacles,
▪ clearly articulates specific support needs,
▪ reflects planning to address risks and potential crisis, and
▪ results in outcomes that ensure health and safety, are reflective of individual preferences, promote greater
independence, and promote greater community inclusion.
Referral/Consultation: If psychiatric issues are noted referral for a psychiatric evaluation is appropriate.
Guidelines:
▪ When possible, a preliminary admission screening is conducted by the Qualified Professional within 24 –
48 hours of receiving the referral. The purpose of the preliminary screening is to assess the background
of the case, appropriateness for services using the service definition admission criteria, and willingness
of the consumer to participate/readiness for change.
▪ The comprehensive clinical assessment must be conducted within 2-3 days after assessing
appropriateness for service based on the specified admission criteria, unless otherwise specified as
sooner according to the Triage Severity Determination. The Program Director takes the clinical
recommendations of the Licensed Professional into consideration in determining whether or not a new
case is accepted.
UPDATED PCP GUIDELINES
The Introductory Person-Centered Plan
The Introductory PCP is a plan for an individual who is new to the MH/DD/SA service system, or who has been completely discharged with
no services for 60 days. The provision of an Introductory PCP allows The Ship Group Community Services to quickly gather the information
needed to request authorization from Value Options or the LME [for individuals not covered by Medicaid].
For a new consumer entering the service system through STR, the Introductory PCP must be completed by a Qualified Professional [or
licensed professional] from the chosen provider agency for any of the services listed below which perform the function of a clinical home
provider:
▪ Targeted Case Management
▪ Assertive Community Treatment Team
▪ Community Support Team
▪ Intensive In-Home Services
▪ Multisystemic Therapy
▪ Substance Abuse Comprehensive Outpatient Treatment
▪ Substance Abuse Intensive Outpatient Program
The Introductory PCP comprises the following elements:
▪ Action Plan
▪ Crisis Prevention/Crisis Response/Diagnostic Information (Continuation) - the second page of the Crisis Plan reflecting contact
and other information
▪ Signature Page from the PCP, including:
a. Confirmation of Medical Necessity/Service Order - dated signature
b. Person Receiving Services - dated signature [required when the person is his/her own legally responsible person]
c. Legally Responsible Person - dated signature [required when the person receiving services is not his/her own legally responsible person]
d. Person Responsible for the Plan - dated signature
The following documents are required to process an initial authorization:
▪ The Introductory PCP
▪ TAR/ORF-2/CTCM form [for Value Options ], or form used by LME for prior approval/authorization
▪ Person-Centered Plan [PCP] Consumer Admission Form [for submission to the LME]
Development of the Intro-PCP takes place during the initial treatment team meeting, which may be the same day as the Comprehensive Clinical Assessment. Evidence of the treatment team meeting, including participation of the person-receiving services will be supported through documentation in the consumer file. The QP/LP is responsible for development of the PCP and coordinating service needs. Additionally, for clinical services that involve provision of services utilizing a team approach, the team lead is the person responsible for the plan as indicated by team lead signature in the appropriate areas of the PCP.
The Complete Person-Centered Plan
Services that were authorized from the Introductory PCP are in effect for the duration indicated by the authorizing agency. From this point forward, no additional authorizations will be granted based on the Introductory PCP. A comprehensive clinical assessment [CCA] must have been completed prior to the development of the treatment plan. The results and recommendations outlined in the comprehensive clinical assessment must be addressed and incorporated into the Complete PCP.
Completion of the following pages of the PCP will meet the requirements for a Complete PCP:
▪ Participants Involved in Complete Plan Development
▪ Personal Dialogue/Interview
▪ Family, Legally Responsible Person, Informal Supports Dialogue/Interview
▪ Summary of Assessment and Observations
▪ Action Plan and Action Plan/Continuation
▪ Crisis Plan
▪ Comments and Signatures
The following must be completed and submitted to Value Options [LME for state-funded services] for further authorization to occur.
▪ A new TAR/ORF-2/CTCM form,
▪ The Complete PCP [for the first authorization after the submission of the Introductory PCP]
The PCP is sent to the LME for administrative review and authorization of state-funded services. For Medicaid services, a copy of the PCP is sent to Value Options with the request for authorization of Medicaid services, as well as to the LME to include in the individual’s administrative record for purposes which include, but are not limited to:
▪ Care coordination;
▪ Quality management;
▪ Review of a sample of PCPs for consumers in the LME’s catchment area who receive
Medicaid-funded services; and
▪ Monitoring the effectiveness of the PCPs.
The Person-Centered Plan Format
DMH/DD/SAS and the Division of Medical Assistance [DMA] have developed and approved standardized templates for the PCP. Providers of individuals who are not funded by the CAP-MR/DD waiver and for whom a Person-Centered Plan is required shall use the standard Person-Centered Plan templates. Clinical home providers must also complete the PCP Consumer Admission Form for submission to the LME.
In addition to the PCP, the submission of an accompanying PCP Consumer Admission Form to the LME is required. To access this form,
complete with instructions, please see the links below:
PCP Consumer Admission Form and Instructions –Word format:
PCP Consumer Admission Form and Instructions – Print only version:
The Crisis Plan as a Required Component of the Person-Centered Plan
The PCP contains a section for a Crisis Plan, which is a required component of all PCPs. A PCP is not considered complete without a Crisis Plan, except as outlined above within the context of an Introductory PCP and the Complete PCP. At a minimum, the Crisis Plan shall address the following when the PCP has been competed:
▪ Supports/interventions aimed at preventing a crisis [proactive]
▪ Supports/interventions to employ if there is a crisis [reactive]
▪ Symptoms or behaviors that may trigger the onset of a crisis
▪ Crisis prevention and early intervention strategies
▪ Strategies for crisis response and stabilization
▪ Specific recommendations if person arrives at the Crisis and Assessment Service
▪ All current medications
▪ Strategies for determining, after the crisis, what worked and what did not, and for making
changes in the plan
▪ Contact list, including First Responder information
▪ Advance directives
▪ Crisis Plan distribution list
Signing the Person-Centered Plan
The Person-Centered Plan Instructions specify who should sign the PCP. Guidance regarding signature requirements on the PCP is as follows:
▪ All signatures must contain the appropriate credentials/degree/licensure or title when signatures are entered on the signature pages of the PCP. Dated signatures are also required for most signatories of the PCP. The signature is authenticated when the person responsible for the plan [LP for Intensive In-Home or QP], the individual and/or legally responsible person, and the licensed professional [constituting the service order], each enter the date next to their signature. In addition, it is recommended that all signatures are legible and contain at least the first and last name of the person signing.
▪ For medical necessity of Medicaid-covered services, a licensed physician [MD or DO], licensed psychologist, licensed physician assistant, or a licensed family nurse practitioner must sign and date the PCP, indicating that the requested services are medically necessary and constituting the service order. Sometimes a verbal order may be utilized to allow a service to be initiated.
▪ For medical necessity of state-funded services, it is recommended that one of the same four practitioners noted above sign the PCP; however, if a licensed professional listed above does not sign the PCP, then it is required that the person responsible for the plan/clinical home [Qualified Professional] sign the PCP indicating that the requested services are medically necessary and constituting the service order. One of these signatures and the date of signature are required.
▪ The Qualified (Licensed) Professional who is responsible for the individual’s clinical home and responsible for developing the PCP must sign the PCP.
▪ The person receiving the services is required to sign and date the PCP, indicating confirmation and agreement with the services/supports outlined in the PCP, as well as confirming choice of service providers if the person is his/her own legally responsible party.
▪ The legally responsible person, if not the person receiving the services, signs and dates the PCP confirming involvement and agreement. If the provider who developed the PCP is unable to obtain the signature of the legally responsible person, there shall be documentation on the signature page or in a service note, reflecting due diligence in the efforts to obtain the signature and documentation stating why the signature could not be obtained. When this occurs, there shall be ongoing attempts to obtain the signature as soon as possible.
▪ When the CEO of an LME or the director of a local department of social services is the legal representative/legally responsible person for an individual, and the director delegates authority to another staff person to act on his behalf in participating in PCP and other planning meetings, that staff person may sign the PCP, subsequent revisions, and/or other such documents as the legally responsible person. Such delegation must be in writing [delegation letter] and signed by the agency director. A copy of this letter should be presented at the meeting and then filed in the service record. The designee would sign the PCP, stating that he/she is signing for the actual guardian, i.e., Suzie Smith [agency director] by John S. Doe [designated person].
▪ Other team members involved in the development of the PCP may also sign the PCP to confirm participation and agreement with the services/supports listed, but these signatures are not required.
There are special conditions upon which the signature of a minor is required. The following section outlines these conditions.
Signatures of Minors
One of the signatures referenced is the signature of a minor. Two laws serve as the policy documents for the issue of the signature of a minor:
▪ G.S. § 90-21.5, found here:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_90/GS_90-21.5.html
and
▪ G.S. § 122C-223, found here:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_122C/GS_122C-223.html
From these documents, the following policy conclusions have been derived concerning the signature of a minor:
1. There are some situations where a minor’s consent for treatment is sufficient. According to G.S. § 90-21.5,
“(a) Any minor may give effective consent to a physician licensed to practice medicine in North Carolina for medical health services for the prevention, diagnosis, and treatment of:
(i) venereal disease and other diseases reportable under G.S. 130A-135,
(ii) pregnancy,
(iii) abuse of controlled substances or alcohol, and
(iv) emotional disturbance.
This section does not authorize the…admission to a 24-hour facility licensed under Article 2 of Chapter 122C of the General Statutes except as provided in G.S. 122C-222 [Admission to State Facilities]. This section does not prohibit the admission of a minor to a treatment
facility upon his own written application in an emergency situation as authorized by G.S. 122C-222.
(b) Any minor who is emancipated may consent to any medical treatment, dental, and health services for himself or for his child.”
Under the above circumstances, the minor’s signature on the plan is sufficient. However, once the legally responsible person becomes
involved, the legally responsible person shall also sign the plan.
2. For minors receiving outpatient substance abuse services, the plan shall include both the staff and the child or adolescent’s signatures demonstrating the involvement of all parties in the development of the plan and the child or adolescent’s consent/agreement to the plan. Consistent with North Carolina law [G.S. § 90-21.5], the plan may be implemented without parental consent when services are provided under the direction and supervision of a physician. When services are not provided under the direction and supervision of a physician, the plan shall also require the signature of the parent or guardian of the child or adolescent demonstrating the involvement of the parent or guardian in the development of the plan and the parent’s or guardian’s consent/agreement to the plan.
3. For an emergency admission to a twenty-four-hour facility, per G.S. § 122C-223(a), “in an emergency situation when the legally responsible person does not appear with the minor to apply for admission, a minor who is mentally ill or a substance abuser and in need of treatment may be admitted to a twenty-four-hour facility upon his own application.” In this case, the minor’s signature on the plan would be sufficient.
4. For an emergency admission to a twenty-four-hour facility, per G.S. § 122C-223(b), “within 24 hours of admission, the facility shall notify the legally responsible person of the admission unless notification is impossible due to an inability to identify, to locate, or to contact him after all reasonable means to establish contact have been attempted.” Once contacted, the legally responsible person is required to sign the plan.
5. For an emergency admission to a twenty-four-hour facility, per G.S. § 122C-223(c), “If the legally responsible person cannot be located within 72 hours of admission, the responsible professional shall initiate proceedings for juvenile protective services.” In this case, the individual designated from juvenile protective services shall sign the plan.
Note: For minors receiving substance services in a non-emergency admission to a twenty-four-hour facility, both the legally responsible person and the minor are required to sign the plan.
Note: Within Substance Abuse Non-Medical Community Residential Treatment [SANMCRT], Residential Recovery Programs for Individuals with Substance Abuse Disorders and Their Children, the PCP shall also include goals for the parent-child interaction.
Review and Revision of the Person-Centered Plan
At a minimum, the PCP shall be rewritten annually, based on the date the PCP was valid for billing. [See below for more information regarding validity of the PCP]. However, the expectation is that the PCP will be reviewed and updated more frequently, due to the changing needs of the individual served. The PCP must be reviewed and revised whenever the following situations occur:
▪ The target date assigned to each goal is due to expire and is in need of review;
▪ The individual’s needs change and a new service is being requested;
▪ The individual’s needs change and an existing service is being reduced or terminated;
▪ The individual’s needs change and goals needs to be revised, added, or terminated;
▪ The designated service provider changes; or
▪ It is time for the annual rewrite of the PCP, based on the date the PCP was valid for billing.
Note: For Medicaid-funded services, all concurrent requests for authorization require an updated or revised PCP to be submitted to Value Options, or the request will be returned.
Note: A PCP is valid for billing when the last of the three required signatures is in place:
1. Dated signature of the person ordering the service[s];
2. Dated signature of the person to whom the PCP belongs [or legally responsible person]; and
3. Dated signature of the Qualified Professional who wrote the PCP [clinical home provider].
Note: Target dates may not exceed twelve (12) months. The required signatures as outlined above must be obtained for all PCP reviews on the Plan Update/Revision Signature page, whether or not the review resulted in a change to the plan.
Reminder: A licensed professional - a licensed physician [MD or DO], licensed psychologist, licensed physician assistant, or a licensed family nurse practitioner [for Medicaid], or a licensed professional or Qualified Professional [for state-funded individuals when service orders are required] must sign and date the review and revision of the PCP whenever the following occur:
▪ A new service is requested; or
▪ It is time for the annual review to re-establish medical necessity for the services identified on the PCP and execute a new service order.
Detailed instructions for reviewing and revising PCPs are contained in the Person-Centered Planning Instruction Manual.
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