Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
Go to Manual Table of Contents
Go to Next Manual Section
Go to Previous Manual Section
Return to Home Page

Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

5.4.1 Introduction
Persons who have been determined to have a Serious Mental Illness (SMI) have specific rights, remedies and protections in accordance with Arizona law. These include, but are not limited to, the right to self-determination, freedom of choice, and the right to participate to the fullest extent possible in all phases of their treatment. Individual service planning and inpatient treatment/discharge planning are fundamental aspects of an individual’s comprehensive treatment. The appeal and grievance/investigation processes are the primary mechanisms which preserve and enforce the rights of individuals determined to have a SMI.

In some instances, persons determined to have a SMI may have other conditions that can affect their ability to participate effectively in these processes. The Tribal/Regional Behavioral Health Authorities (T/RBHAs) and subcontracted providers are required to identify those persons in need of Special Assistance and facilitate the provision of Special Assistance. It is critically important that T/RBHAs and subcontracted providers regularly screen and identify persons who have been determined to have a SMI, who are also unable to communicate and/or participate effectively. T/RBHAs and providers must ensure that the person designated to provide Special Assistance is involved throughout treatment and in particular at key stages.

Go to top

5.4.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php.  The following terms are referenced in this section:

ADHS/DBHS Office of Human Rights

Disenrollment

Episode of Care

Human Rights Committee

Qualified Clinician

Serious Mental Illness

Special Assistance

Title XIX

5.4.3 Procedures

5.4.3-A. Criteria for identifying the need for Special Assistance
A person who has been determined to have a SMI is in need of Special Assistance if he or she is unable to do any of the following:

  • Communicate preferences for services;
  • Participate effectively in individual service planning (ISP) or inpatient treatment
  • discharge planning (ITDP); or
  • Participate effectively in the appeal, grievance, or investigation processes;

And the person’s limitations are due to any of the following:

  • Cognitive ability/intellectual capacity (such as cognitive impairment, borderline intellectual functioning, or diminished intellectual capacity);
  • Language barrier (an inability to communicate, other than the need for an interpreter/translator); or
  • Medical condition (including, but not limited to traumatic brain injury, dementia or severe psychiatric symptoms).

A person who is subject to a general guardianship has been found to be incapacitated under A.R.S. 14-5304 and therefore automatically satisfies the criteria for Special Assistance.  Similarly, if a T/RBHA or subcontracted provider recommends a person with a SMI for a general guardianship or a guardianship is in the legal process (in accordance with R9-21-206 and A.R.S. 14-5305), the person automatically satisfies the criteria for Special Assistance. 

The existence of any of the following circumstances for an individual should prompt the T/RBHA and subcontracted provider to more closely review the individual’s need for Special Assistance:

  • Developmental disability involving cognitive ability;
  • Residence in a 24 hour setting;
  • Limited guardianship or the T/RBHA or subcontracted provider is recommending and/or pursuing the establishment of a limited guardianship; or
  • Existence of a serious medical condition that affects his/her intellectual and/or cognitive functioning (such as dementia, traumatic brain injury (TBI), etc.)

5.4.3-B. Persons qualified to make a Special Assistance Determination

The following may deem a person to be in need of Special Assistance:

  • A qualified clinician providing treatment to the person;
  • A case manager of a T/RBHA or subcontracted provider
  • A clinical team of a T/RBHA or subcontracted provider;
  • A T/RBHA;
  • A program director of a subcontracted provider; including Arizona State Hospital (AzSH);
  • The Deputy Director of ADHS/DBHS; or
  • A hearing officer assigned to an appeal involving a person determined to have an SMI.

5.4.3-C. When to Screen for Special Assistance

T/RBHAs and their subcontracted providers must on an ongoing basis screen whether persons determined to have a SMI are in need of Special Assistance.  Minimally this screening must occur at the following stages:

  • Assessment and annual updates;
  • Development of or update to the Individual Service Plan (ISP);
  • Upon admissions to a psychiatric inpatient facility;
  • Development of or update to the Inpatient Treatment and Discharge Plan (ITDP);
  • Initiation of the grievance or  investigation processes;
  • Filing of an appeal; and
  • Existence of a condition which may be a basis for a grievance, investigation or an appeal, and/or the person’s dissatisfaction with a situation that could be addressed by one or more of these processes.

T/RBHAs and their subcontracted providers shall document in the clinical record each time a person is screened for Special Assistance, indicating what factors were considered and the conclusion reached.  If it is determined that the person is in need of Special Assistance, they must notify the Office of Human Rights (OHR) by completing PM Form 5.4.1 Notification of Persons in Need of Special Assistance in accordance with the procedures outlined below.

Before submitting PM Form 5.4.1, T/RBHAs and their subcontracted providers shall check if the person is already identified as in need of Special Assistance.  A notation of Special Assistance designation and a completed PM Form 5.4.1 should already exist in the clinical record.  However, if it is unclear, subcontracted providers must review T/RBHA data or contact the T/RBHA to inquire about current status.  T/RBHAs are required to maintain a database on persons in need of Special Assistance and share data with subcontracted providers on a regular basis, at a minimum quarterly.

Go to top

5.4.3-D. Notifying the Office of Human Rights
If the person is not correctly identified as Special Assistance, the T/RBHAs and subcontracted providers must notify the Office of Human Rights (OHR) using PM Form 5.4.1 Notification of Person in Need of Special Assistance (Part A), within five working days of identifying a person in need of Special Assistance. If the person’s Special Assistance needs require immediate assistance, the notification form must be submitted immediately, with a notation indicating the urgency. If the person is under a guardianship or one is in process, the documentation of such must also be submitted to OHR. However, if the documentation is not available at the time of submission of the PM Form 5.4.1 notification, the form should be submitted within the required timeframes, followed by submittal of the guardianship documentation.

The Office of Human Rights (OHR) administration (Office Chief or Lead Advocate) reviews the notification form to confirm that a complete description of the necessary criteria is included. In the event necessary information is not provided, OHR contacts the staff member submitting the form to obtain clarification. OHR responds to the T/RBHA and subcontracted provider by completing Part B of PM Form 5.4.1, within five working days of receipt of notification and any necessary clarifying information from the T/RBHA. If the need for Special Assistance is urgent, OHR will respond as soon as possible, but generally within one working day of receipt of the notification form.

The notification process is complete only when OHR returns the form, with Part B completed, to the T/RBHAs and subcontracted providers.  The T/RBHAs and subcontracted providers should follow up with OHR if no contact is made or Part B is not received within five working days.

Designation of the Agency/Person Providing Special Assistance
OHR designates which agency/person will provide Special Assistance when processing a PM Form 5.4.1 notification.  When the agency/person providing Special Assistance changes, OHR processes an “updated Part B” to document the change.

If the person or agency currently identified as providing Special Assistance is no longer actively involved, the T/RBHAs or subcontracted providers must notify OHR.  If an OHR advocate is also assigned, notification to the advocate is sufficient.

 

5.4.3-E. No longer in need of Special Assistance
The T/RBHAs or subcontracted providers must notify the OHR within ten days of an event or a determination that an individual is no longer in need of Special Assistance using Part C of the original PM Form 5.4.1 (with Parts A and B completed when first identified), noting:

  • The reasons why Special Assistance is no longer required;
  • The effective date;
  • The name and title of the staff person completing the form; and
  • The date the form is completed.

The following are instances that should prompt T/RBHAs or subcontracted providers to submit a Part C:

  • The original basis for the person meeting Special Assistance criteria is no longer applicable and the person does not otherwise meet criteria
  • T/RBHA or subcontracted provider must first discuss the determination with the person or agency providing Special Assistance to obtain any relevant input; this includes when a person is determined to no longer be a person with a SMI (proper notice and appeal rights must be provided and the time period to appeal must have expired).
  • The person passes away;
  • The person’s episode of care is ended with the T/RBHA (Non-Title XIX persons with a SMI will also be disenrolled) and the person is not transferred to another T/RBHA.1 The T/RBHAs or subcontracted providers must first perform all required re-engagement efforts, which includes contacting the person providing Special Assistance, per PM 3.8 Outreach, Engagement, Re-engagement and Closure and proper notice and appeal rights must be provided and the time period to appeal must have expired;

Upon receipt of Part C of PM Form 5.4.1, the OHR administration reviews the content to confirm accuracy and completeness and send it back to the agency that submitted it, copying any involved T/RBHA or subcontracted provider.

5.4.3-F. Requirements of T/RBHAs and Subcontracted Providers to Help Ensure the Provision of Special Assistance

T/RBHAs and subcontracted providers must maintain open communication with the person/agency (guardian, family member, friend, OHR advocate, etc.) assigned to meet the person’s Special Assistance needs.  Minimally, this involves providing timely notification to the person providing Special Assistance to ensure involvement in the following stages:

  • ISP planning and review
    • Including any instance when the person makes a decision about service options and/or denial/modification/termination of services; and
    • ISP development and updates must be in accordance with PM 3.9, Assessments and Service Planning
  • ITDP planning (which includes any time the person is admitted to a  psychiatric inpatient facility) and involvement throughout the stay and discharge;
  • Appeal process: this includes circumstances that may warrant the filing of an appeal, so all notices of action (NOAs) or notices of decisions (NODs) issued to the person/guardian must also be copied to the person designed to meet Special Assistance needs; and
  • Investigation, or grievance process including circumstances when initiating a request for investigation/grievance may be warranted.

In the event that such procedures are delayed in order to ensure the participation of the person providing Special Assistance, the T/RBHAs and subcontracted providers must document the reason for the delay in the clinical record and ensure that the person receives the needed services in the interim.

T/RBHAs and subcontracted providers shall provide relevant details and a copy of the original PM Form 5.4.1, Notification of Person in need of Special Assistance (both Parts A and B) to the receiving entity and when applicable case manager when a person in need of Special Assistance is:

  • admitted to an inpatient facility;
  • admitted to a residential treatment setting; or
  • is transferred to a different T/RBHA, case management provider site or case manager.

T/RBHAs and subcontracted providers must periodically review whether the person’s Special Assistance needs are being met by the person or agency designated to meet those needs. If a concern arises, the T/RBHA and subcontracted provider should initially address the problem with the person providing Special Assistance.  If the issue is not promptly resolved, they must take further action to address the issue, which may include contacting OHR administration for assistance. 

5.4.3-G. Confidentiality

T/RBHAs, AzSH and subcontracted providers shall grant access to clinical records of persons in need of Special Assistance to the OHR in accordance with all federal and state confidentiality laws. (For further clarification see Section 4.1 Disclosure of Behavioral Health Information).

5.4.3-H. Documentation and Supporting Requirements

T/RBHAs and their subcontracted providers must maintain a copy of the completed PM Form 5.4.1, (both Parts A, B and updated B, if any) in the person’s comprehensive clinical record. In the event a person was identified as no longer needing Special Assistance and a Part C of the notification form was completed, the T/RBHAs and subcontracted providers must maintain a copy of the PM Form 5.4.1 in the comprehensive clinical record.

T/RBHAs, and subcontracted providers must also clearly document in the clinical record (i.e. in the assessment, ISP, ITDP, face sheet) and case management/client tracking system if an individual is identified as Special Assistance, the person assigned currently to provide Special Assistance, the relationship, contact information of phone number and mailing address.

To support the T/RBHAs and OHR in maintaining accurate and up-to-date information on persons in need of Special Assistance, subcontracted providers are required to follow the T/RBHAs quarterly procedures for data updates about currently identified/active persons in need of Special Assistance.  

5.4.3-I. Other Requirements

The Human Rights Committee (HRC) must make periodic visits to individuals in need of Special Assistance placed in residential settings to determine whether the services meet their needs, and their satisfaction with their residential environment.

T/RBHAs must ensure that all applicable T/RBHA and provider staff are trained on the requirements related to Special Assistance.

5.4.4 References
The following citations can serve as additional resources for this content area:

5.4.5 PM Forms


1Submission of a Part C is not needed when a person transfers to another T/RBHA, as the Special Assistance designation follows the person.

Go to top

5.4 Special Assistance for Persons Determined to have a Serious Mental Illness
Last Revised: 12/20/2013
Effective Date: 12/20/2013

Gila River Health Care Corporation address and phone