APPENDIX G:

APPENDIX G:

THE SHIP GROUP COMMUNITY SERVICE LLC.

Policies & Procedures Manual

CLINICAL PRACTICE & GUIDANCE PROTOCOLS

Consumer Admissions, Re-evaluations, Transfers, Discharges &

Delivery of Quality Medically Necessary Services

POLICY In accordance with Critical Access Behavioral Health Agency guidelines, The Ship Group 

Community Services has developed Policies and Procedures for consumer admission, re-evaluation, 

transfer, and discharge. Clinicians will make every effort to follow procedures and timelines as outlined 

to ensure that processes from referral to service delivery are expedited responsibility and in accordance 

with clinical scopes of practice relative to consumer therapeutic needs. In accordance with our agency’s 

mission statement, education, safety, compassion, and self-determination are always considered in our 

promotion of behavioral health from the first point of contact to the last. 

OBJECTIVE: To outline the process for admissions, re-evaluations, transfers and discharges, 

including timelines, to provide clarity for staff and consumers relative to the delivery of quality, medically 

necessary services.

PROCEDURES

Admissions

STEP 1 - Once a referral is received from the consumer’s Primary Care Physician, the LME, etc., a PreAdmission Screening is completed based on triage severity criteria (within 1 hr if emergent, within 48 

hours if urgent or within 10 days if routine). It is during this screening that preliminary appropriateness for 

services is determined based on service definition criteria. 

STEP 2 –

(A) Consumers who are found to be inappropriate for agency services are then referred to other 

community agencies/resources after a thorough Case Review. Documentation of this meeting 

having occurred will be maintain in either a Case Communication Note or a Progress Note.

(B) Consumers considered to be appropriate for services complete an Intake Packet (Part 1)

within 24 hours of the Pre-Admission Screening, followed by a Comprehensive Clinical 

Assessment (CCA) within 48 hours.

STEP 3 – Once the CCA is complete, an appointment will be made for a psychiatric evaluation, if 

indicated, as well as appropriate appointments and referrals for additional treatment recommendations as 

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Policies & Procedures Manual

outlined by the clinical team in the Treatment Recommendations and/or Interdisciplinary Team Note 

sections of the CCA.

STEP 4 – In the event that the clinical presentation aligns with program admission criteria and the 

consumer is prepared to engage in treatment (appropriate for service) the consumer’s case is then 

discussed in a Treatment Team Meeting / Case Review, where a treatment plan including an Initial

Person Centered Plan (PCP) and Crisis Plan are developed and appropriate case assignments made.

STEP 5 – If services require prior authorization the CCA and PCP are then sent to the MD/NP/PA for 

review / signature and later submitted within 7 – 10 days for authorization. 

STEP 6 – Once authorized, the consumer would complete Intake Packet (Part 2) / the Welcome Packet 

and immediately begin services. 

Enhanced Services

Refer to policies and procedures for providing enhanced services, specifically Service Definition/Program Descriptions.

Targeted Case Management

Refer to policies and procedures for admissions as above.

Outpatient Therapy

Refer to policies and procedures for providing Outpatient Therapy.

Medication Management

Refer to policies and procedures for providing Medication Management Services.

(Also see Phases of Service Delivery Protocol)

Re-evaluations

All consumers will be evaluated annually to assess for any significant change in psychological, social or 

medical functioning. Additionally, re-evaluations will be completed when a significant change in clinical 

functioning and/or service needs is identified. These re-evaluations will be documented in the form of a 

new CCA or an addendum to an existing CCA. See Protocol for Re-evaluations

Transfers

Consumers will be transferred to another service/level of care when they no longer meet criteria for the 

current service. Refer to specific Program Descriptions and Level of Care Graduation of Intensities protocol 

/ pyramids. In such cases, the clinical justification for this change will be documented in an updated PCP 

and possibly in an addendum to an existing CCA following review by the clinical treatment team.

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Policies & Procedures Manual

Discharges

Consumers will be discharged from treatment for a number of reasons including improvement (no longer 

meet treatment criteria), lack of interest or motivation, noncompliance, and/or upon request. In such 

cases, the clinical justification for the discharge will be documented in an updated PCP and a Discharge 

Summary following a discussion with the clinical treatment team. A copy of the Discharge Summary is 

made available for the consumer and other members of the consumer’s healthcare team, such as the 

Primary Care Physician, upon written authorization (Authorization to Disclose Protected Health 

Information) by the consumer or his/her legally responsible party.

Protocol for Clinical Re-evaluations

RE-EVALUATIONS:

There are times throughout the course of treatment when consumers require re-evaluation as a means for the 

agency to provide the most appropriate service according to their individual therapeutic needs. Re-evaluations 

may not always occur in the form of a comprehensive clinical assessment such as a Diagnostic Assessment. 

However, when they do, the following will be observed by The Ship Group Community Services Care Service, 

Inc.:

THE SHIP GROUP COMMUNITY SERVICE LLC.

Policies & Procedures Manual

• A recipient may receive one Diagnostic Assessment per year according to NC DHHS 10A NCAC 27G .0104. 

In accordance with this guideline, The Ship Group Community Services will perform routine consumer reevaluations, at minimum, on an annual basis. Any additional Diagnostic Assessment that falls within a 1-year 

period must be authorized by the DHHS-approved LME or the statewide vendor prior to the delivery of the 

service. The exception is if/when the assessment performed is not classified or billed as a Diagnostic 

Assessment (i.e. Mental Health Assessment, Psychiatric Evaluation, Psychological Evaluation, Comprehensive 

Clinical Assessment).

• As a practice rule of thumb, clinicians will perform re-evaluations under the following circumstances:

1. Annually 

2. Service re-authorization 

3. When there is a significant change in clinical presentation, either generally, or relative to recent hospitalization or 

medication changes

4. When there is a significant change in safety concerns and/or risk to the consumer or for others as a result of the consumer’s 

actions

DOCUMENTATION OF RE-EVALUATION:

Documentation of re-evaluation may occur in progress notes and any of the following methods:

▪ Method: Clinical Addendum

Process: Addendum to current assessment may be completed when any of the circumstances noted above have 

been observed, as well as when there are changes in diagnoses or GAF score

▪ Method: Person-Centered Plan and TAR

Process: Conduct a Treatment Team Meeting and update the PCP and TAR accordingly. Be sure to provide details 

in the justification section(s) of the PCP and TAR. If a new service is added or an old service is taken away, then a 

new Service Order is required (MD, NP, PA, or PhD Psychologist signature for medical necessity).

▪ Method: Discharge/Transition/After-care Plan

Process: Assess the consumer’s current level of care needs and level of engagement relative to needs. If the 

consumer’s clinical presentation no longer coincides with continuing service criteria, the consumer wants to cancel 

services, or if the agency can no longer meet the therapeutic needs of the consumer, then the treatment team plans 

for transfer, discharge, or transition as appropriate.

Consumer Chart Index/Outline

1 – DEMOGRAPHICS

Staff Signature Log 

Client Face sheet 

Crisis Plan 

Map Quest Driving Directions (from office to consumer home and back)

Medicaid Card and/or other insurance carrier information

Social Security Card

2 – SERVICE AUTHORIZATIONS

MCO authorization notification

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Policies & Procedures Manual

3 – REFERRAL/SCREENING/ASSESSMENT

Completed referral form and additional background information

*Referral Acknowledgment Statement and Follow-up Letter

Primary Care Physician Referral if applicable, required for all consumers under the age of 21 unless the referral comes 

from the LME or a psychiatrist

Admission Screening or STR (Pre-admission Screening Assessment Tool)

* Triage Severity Determination

Comprehensive Clinical Assessment must address The Ship Group Community Services Care’s ability to meet the 

needs of the consumer

Target Population (included on The Ship Group Community Services Care’s Comprehensive Clinical Assessment 

form)

* Outside Referrals

* Psychiatric and/or Psychological Evaluation, if applicable

* LOCUS / CALOCUS 

 NCTOPPS print out

4 – INFORMED CONSENT

Verification of Consumer Choice

Signed Client Rights Form

Consent for Services *(may include Consent for Telemed/TelePsych/Telehealth)

Consent for Therapy if applicable

HIPAA / Notice of Privacy Acknowledgement

Authorization(s) to Disclose Protected Information

Acknowledgement of Receipt of Client Handbook

 Proof of Guardianship/other court orders/legal documents if applicable

5 – MEDICAL and LABORATORY 

Medication Profile 

Printed pharmacy information leaflet for each medication/vitamin/herbal supplement

*Physician/Medical Orders

*Laboratory Reports/Results if applicable 

*AIMS Monitoring 

*Physician and Medical Progress Notes/Reports

6 – PERSON-CENTERED PLANNING

LME Consumer “Admission/Discharge Form”

SAR or TAR

Updated PCP most current PCP should be first

Complete PCP

 Intro PCP

*Staple fax confirmation sheets to the back of the PCP before filing if applicable

7- TEAM NOTES

Monthly Summary 

Treatment Team Meeting / Child & Family Team Meeting Notes

Service Notes (from AP/QP/LP) Chart may possibly include a Volume 2 for other service notes.

Case Communication Forms

Clinical Team Meeting Notes

8 – DISCHARGE PLANNING

Discharge Summary

Discharge SAR or TAR

“LME Consumer Admission/ Discharge Form”

9- MISCELLANEOUS 

(i.e., Consumer Survey, other faxed cover sheets, General Correspondence, Transportation Release, Crisis Assistance, 

Transfer Documents, Signed Search and Seizure Policy Acknowledgement)