SUTS Minimum Quality Drug Treatment Standards

County of Santa Clara Health System

Minimum Quality Drug Treatment Standards for Substance Use Prevention and Treatment for Block Grants (SABG)

Policy & Procedure (BHSD #1400) Click here to open the Policy in .pdf format

REFERENCE:

Title 9 CCR, Division 4, Chapter 8 – Certification of Alcohol and Other Drug Counselors
Title 22 CCR § 51341.1 – Drug Medi-Cal Substance Use Disorder Services, §
51000.24.5 – Substance Use Disorder Treatment Professional, § 51516.1 –
Reimbursement Rates for Drug Medi-Cal Substance Abuse Program Services
42 CFR, Chapter 1, Subchapter A, Part 2 – Confidentiality of Alcohol and Drug Abuse
Patient Records
45 CPR 96.127
Drug Medi-Cal Certification Standards for Substance Abuse Clinics (July 1, 2004)
Alcohol and/or Other Drug Program Certification Standards (May 1, 2017)
Drug Medi-Cal Provider Billing Manual (July 1, 2017)
DHCS Funding Hierarchy- Payment of First and Last Resort United States Code(USC)
Title 42 USC, Section 300x-21through 300x-66: Substance Abuse Prevention and
Treatment Block Grant California Health and Safety Code (HSC)
HSC, Division 10.5, Section 11750 – 11970: State Department of Health Care
Services
State of California, Youth Treatment guidelines 2002. Alcohol and/or Other Drug
Program Certification Standards
Department of Health Care Services Health and Human Services Agency State of
California May 1, 2017
Perinatal Practice Guidelines FY 2018-19
STC- Standard Terms and Conditions
IA - Intergovernmental Agreement
AOD Cert. Standards - Alcohol and/or Other Drug Program
DTS - Standards for Drug Treatment Programs (September 1982)
Title 9 - California Code of Regulations
Title 9 - Narcotic Treatment Programs
Title 22 - California Code of Regulations
Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
WIC - Welfare and Institutions Code
SUTS CPM - Substance Use Treatment Services Clinical Performance Measures 2018
BHSD Policy #1401 Admission and Re-Admission Criteria
BHSD Policy #1402 Clinical Guidelines
BHSD Policy #1404 Discharge Planning
BHSD Policy #1405 Intake
BHSD Policy #1406 Level of Care and Lateral Transfers
BHSD Policy #1407 Authorization for OPD Extension of Treatment
BHSD Policy #1408 Physical Examination
BHSD Policy #1409 Referral for Services
BHSD Policy #1410 Tarasoff Ruling – Duty to Warn
BHSD Policy #1411 Treatment Plan
BHSD Policy #1414 Progress Notes
BHSD Policy #1415 Treatment Status Report
BHSD Policy #1420 Policy for Maintaining an Alcohol and Drug-Free Environment
BHSD Policy #1421 Health and Safety
BHSD Policy #1422 Orientation for New Hires
BHSD Policy #1423 Personnel Files
BHSD Policy #1424 Job Description
BHSD Policy #1425 Code of Conduct
BHSD Policy #1426 Admission or Readmission
BHSD Policy #1427 Treatment
BHSD Policy #11400 Beneficiary Rights
BHSD Policy # 11300 Providing Language Services.

POLICY:

Behavioral Health Services Department (BHSD) will implement and adhere to the Minimum Quality Drug Treatment Standards for Substance Abuse Prevention and Treatment Block Grants (SABG), including those Personnel Policies (e.g., personnel files, job descriptions, volunteers/interns, codes of conduct) and Program Management Policies (e.g., admission/readmission, treatment). These can be found on the DHCS link.

BHSD will also provide copies of the Minimum Quality Drug Treatment Standards to all subcontractors on the BHSD website and monitor compliance standards of all subcontractors.

DEFINITIONS:

SABG: Federal Substance Abuse Prevention and Treatment Block Grant funding for substance abuse treatment and prevention activities.

PROCEDURE:

Responsible Party	Action Required
BHSD Management	Supervise the annual administrative audit, reviewing County employees, volunteers, and subcontractors for compliance with the Minimum Quality Drug Treatment Standards for SABG.
BHSD Personnel	Implement all Minimum Quality Drug Treatment Standards for Substance Abuse Prevention and Treatment for Block Grants (SABG) policies across BHSD systems, including subcontractors. BHSD personnel will administer the “Provider Evaluation Monitoring Tool” [Attachment A] annually to all County and Contractor programs. BHSD personnel will administer the Tool and note compliance deficiencies that would require an Administrative Corrective Action Plan (CAP) [Attachment B] to be completed and submitted within 30 days. BHSD personnel will sign the letter accompanied by the provider’s CAP and BHSD personnel will email a copy of the letter and CAP to the provider and DHCS. The CAP shall: Address each compliance deficiency; Include the date of response; Provide a specific description of how the deficiency will be corrected; Identify the staff person responsible for correcting the deficiency and ensuring future compliance; Specify the date of implementation of each deficiency; and as deficiencies are corrected, include relevant documentation which demonstrate the correction of a deficiency, if applicable. BHSD personnel will monitor the CAP and progress on the CAP every 30 days until the Contractor or County program meets compliance standards
BHSD and Subcontractor Program Managers	Have the responsibility to adhere to the Minimum Quality Drug Treatment Standards for SABG policies that define their scope of work as program managers. BHSD personnel must comply with administrative and clinical audits requirements, review the results and complete the administrative CAP within 30 days of receiving the notice of a CAP. The CAP shall address the required corrections. The CAP must be submitted with all supporting documents included as attachments.
BHSD Clinical Standards Coordinators	Oversee the DMC ODS Utilization Review (UR) [Attachment C]. A random selection of approximately 5% of client charts for the year will be audited for each provider. BHSD Clinical Standards Coordinators will compile the Utilization Review (UR) data with assistance from Research Outcomes and Measurement (ROM) and distribute results to each BHSD Program Manager with the request for a CAP [Attachment D], if necessary. BHSD Clinical Standards Coordinators will provide BHSD Program Managers and BHSD Management with a report that describes the system’s adherence to the Minimum Quality Drug Treatment Standards and propose methods to improve the quality of clinical performance, based on the findings of the audit.
BHSD Quality Improvement Coordinators (QIC)	BHSD QIC Teams will conduct the DMC-ODS Utilization Review by visiting each provider site. BHSD QIC teams shall monitor adherence to the Minimum Quality Drug Treatment Standards for Substance Abuse Prevention and Treatment for Block Grants (SABG) policies by ensuring that treatment for all clients includes, at a minimum: a) Comprehensive Assessment b) A Corresponding Treatment Plan c) Progress Notes d) Discharge Documentation

Attachments:

Provider Evaluation Monitoring Tool [Attachment A]

Administrative Corrective Action Plan Template [Attachment B]

DMC-ODS Utilization Review [Attachment C]

Corrective Action Plan [Attachment D]