PROVIDER CERTIFICATION MANUAL 
FOR 
DELAWARE 
COMMUNITY MENTAL HEALTH CENTERS 
DEPARTMENT OF HEALTH AND SOCIAL SERVICES 
DIVISION OF SOCIAL SERVICES 
Interim Draft 9/1/94
TABLE OF CONTENTS 
PAGE 
OVERVIEW......................................................4 
1 CERTIFICATION FOR PROVIDER PARTICIPATION.................5 
1.1 Authority...........................................5 
1.2 Certification Criteria..............................5 
1.3 Standards...........................................7 
1.4 Ongoing Monitoring..................................9 
1.5 Suspension or Revocation of Certification..........10 
2 CLINICAL STAFF AUTHORIZED TO PROVIDE SERVICES...........12 
3 RECIPIENT ELIGIBILITY...................................12 
4 COVERED STANDARDS.......................................13 
5 SERVICE LIMITATIONS.....................................14 
6 COMMUNITY MENTAL HEALTH CENTERS CLINIC OPTION STANDARDS.16 
6.1 Program Organization and Operation.................16 
6.2 Program Staff......................................17 
6.3 Intake.............................................18 
6.4 Assessment.........................................19 
6.5 Treatment Planning.................................20 
6.6 Consumer Rights....................................20 
6.7 Management of Case.................................21 
6.8 Standard: Comprehensive Psychosocial Assessment...22 
6.9 Standard: Psychiatric Evaluation/Therapy..........27 
6.10 Standard: Emergency Services......................32
6.11 Standard: Medication Injection....................35 
6.12 Standard: Medication Check/Medical Monitoring.....37 
6.13 Standard: Counseling and Psychotherapy............41 
6.14 Standard: Group Counseling/Therapy................45 
7 ORGANIZATIONAL STANDARDS................................47 
8 ADMINISTRATIVE STANDARDS................................47 
8.1 Consumer Records...................................47 
8.2 Procedure Manual...................................57 
8.3 Financial Management...............................59 
8.4 Personnel Management...............................62 
8.5 Staff Development Plan.............................63 
8.6 Quality Assurance Program..........................65 
9 WAIVER OF PROVISIONS....................................66
OVERVIEW 
This manual contains the standards by which the Division of 
Substance Abuse and Mental Health certifies Comprehensive 
Community Mental Health Center Clinic programs for persons with 
psychiatric disabilities. Certification is required for provider 
enrollment with the Division of Social Services, Medical Assistance 
Program for Medicaid reimbursement through Title XIX of the 
Social Security Amendments. 
Through an Inter-Divisional Agreement the Division of Substance 
Abuse and Mental Health has been delegated authority for 
administration of certain provisions of the Medicaid program 
pertaining to optional clinic services. These provisions include 
the following: 1) certification of programs for provider enrollment; 
2) rate setting; and 3) quality assurance. Delegated 
quality assurance functions include program monitoring, utilization 
review, training and technical assistance. 
This Certification Manual addresses the provision of mental health 
clinic services on an outpatient basis. The clinic services are 
defined as preventative, diagnostic, therapeutic, rehabilitative, 
or palliative items or services that are provided to outpatients; 
are provided by a facility that is not part of a hospital but is 
organized and operated to provide medical care to outpatients; and 
are furnished under the direction of a physician. The Delaware 
Medical Assistance Program covers clinic services provided to 
eligible Medicaid recipients by eligible providers. 
1 CERTIFICATION FOR PROVIDER PARTICIPATION 
1.1 Authority - Through an Inter-Divisional Agreement, the 
Division of Social Services (DSS) Delaware Medical 
Assistance Program has delegated the function of certifying 
organizations for enrollment as providers of 
mental health clinic services to the Division of 
Substance Abuse and Mental Health (Division or DSAMH). 
1.2 Certification Criteria - Agencies designated by the 
Division as comprehensive community mental health 
centers are eligible for certification to provide 
community mental health clinic services. Comprehensive 
community mental health centers are public or private 
non-profit agencies that provide for the mental health 
needs of a geographically designated population, as 
determined by the Division, that provide the following 
services: 
1.2.1 24-hour mobile emergency services which shall 
be: 
1.2.1.1 Organized as a self-contained program, 
within a center, available to respond to 
the site of the emergency; 
1.2.1.2 Staffed on a 24-hour basis; and 
1.2.1.3 Provide access to community-based, face 
to face psychiatrist intervention at all 
times; 
1.2.2 Clinical liaison to the Delaware State 
Hospital and private psychiatric 
inpatient facilities, provided by a full 
time designated hospital liaison 
clinician who visits patients while in 
the hospital to coordinate their 
discharge and post discharge linkage to 
continuing care; 
1.2.3 Individual and group counseling and 
psychiatric services, provided to any 
resident of the service area who has a 
mental illness without regard to a 
consumer's ability to pay; 
1.2.4 Evaluation and, when appropriate, treatment 
services for consumers of the Department 
of Correction and the Division of 
Vocational Rehabilitation;
1.2.5 Case Management services to assist consumers 
in obtaining social security benefits and 
other entitlements and to provide 
outreach to consumers when needed; 
1.2.6 Case consultation and crisis intervention 
services to local school districts; 
1.2.7 Case consultation and crisis intervention 
services to local nursing facilities; 
1.2.8 24-hour assistance to law enforcement agencies 
in managing the psychiatric dimensions of 
emergency situations they encounter; 
1.2.9 Outreach to homeless persons who have a mental 
illness and service agreements to assist 
agencies that provide services to 
homeless persons. 
1.2.10 The Division bases its certification of 
programs and enrollment recommendation to DSS 
upon the organization's compliance with state 
level organizational, administrative and 
program standards, and with federal 
requirements for the administration of 
Medicaid services as contained in federal 
statutes, regulations and guidelines. 
1.2.2.1 The division may establish and apply 
minimum compliance guidelines to be used 
in making certification determinations. 
1.2.11 The Division uses a certification survey to 
measure compliance with organizational, 
administrative and program standards. The 
determination with regard to a program's 
certification Division to DSS is based on: 
1.2.11.1 Statements of the organization's 
authorized representatives; 
1.2.11.2 Documents provided to the Division by the 
organization; 
1.2.11.3 Documented compliance with 
organizational, program and 
administrative standards;
1.2.11.4 On-site observations by surveyors. 
1.3 Standard 
1.3.1Enrolled provider status under the Delaware Medical 
Assistance Program shall be obtained from DSS 
in accordance with the following procedure: 
1.3.1.1 Upon request to the Division, the 
organization shall receive a 
certification survey package and a date 
for a certification survey site visit 
from the Division. 
1.3.1.2 Recertification of enrolled providers 
shall be determined annually. The 
Division will forward a certification 
package containing a certification 
application and set a date for a 
certification survey within 90 days of 
the expiration of the provider's existing 
certification. 
1.3.1.3 The organization shall return the 
completed certification application 
contained in the certification package 
within 30 days of receipt. 
1.3.1.4 Upon receipt of the completed 
certification application, the Division 
will conduct a preliminary review to 
ensure that all pre-survey information is 
complete. If additional information is 
required, the Division will send a 
written request specifying the additional 
information needed. 
1.3.1.5 When all application form information is 
complete, the Division will conduct an 
on-site inspection of the applicant 
organization. 
1.3.1.6 Upon completion of the site visit, the 
Division surveyor will submit an 
inspection report to the Director 
describing the findings of the review of 
the certification application and the 
site visit. The inspection report, along 
with the application will form the basis
for the review process and certification 
determination. 
1.3.1.7 The Division shall complete its 
certification survey and make a 
certification determination within 60 
days of forwarding the certification 
package to the organization/enrolled 
provider. The Director of the Division 
shall notify the organization of its 
certification determination. 
1.3.1.8 The Division shall forward to the 
provider and to DSS notice of 
certification for provision of clinic 
services to Medicaid beneficiaries. 
1.3.1.9 Upon receipt of initial certification, 
the provider may enroll as a provider of 
clinic programs under Delaware's Medical 
Assistance Program (Medicaid) in 
accordance with policy and standards 
established by DSS for such enrollment. 
1.3.2To facilitate the determination by the Division of 
the organization's eligibility for 
certification, the organization shall make all 
necessary documentation available for the 
Division's review, including the following: 
1.3.2.1 Policies and procedures; 
1.3.2.2 Staff qualifications and work schedules; 
1.3.2.3 Documentation of clinical supervision; 
1.3.2.4 Consumer records; 
1.3.2.5 Consumer billing records; and 
1.3.2.6 Other documentation as requested by the 
Division. 
1.3.3The division surveyor may meet with the director, 
supervisors, staff members and consumers in 
the process of conducting a site visit to 
evaluate the applicant organization's 
adherence to the following standards: 
1.3.3.1 Organizational;
1.3.3.2 Administrative; and 
1.3.3.3 Program. 
1.4 Ongoing Monitoring - As an authorized representative of 
DSS, the Division has the right to access any information 
directly related to the provider's administration of the Medicaid 
program. The Division may conduct on-site visits to a 
provider and review consumer records periodically to 
monitor ongoing compliance with certification standards. 
The Division will notify a provider in writing of any 
deficiencies found during a monitoring visit. The 
provider shall submit a plan of correction of any 
deficiencies within 30 days of notification. 
1.4.1The Division shall provide quality assurance 
monitoring, technical assistance and 
utilization control through staff of the 
Division Management Information System/Quality 
Assurance Unit. 
1.4.1.1 The role of this unit is to review, 
define, and educate the mental health 
centers as to Medicaid policy. 
1.4.1.2 They also monitor for compliance and 
certification. 
1.4.2The Division's Management Information 
System/Quality Assurance Unit will conduct at 
least yearly on-site program reviews of 
Community Mental Health Centers to verify the 
following: 
1.4.2.1 Services reimbursed by Medicaid were 
actually furnished to consumers; 
1.4.2.2 Services were provided under supervision; 
1.4.2.3 Services were provided in accordance with 
an individual treatment plan; 
1.4.2.4 Services rendered were medically 
necessary. 
1.4.3The Division's Management Information 
System/Quality Assurance Unit will monitor 
and evaluate activities concerning utilization 
control through a program that:
1.4.3.1 Assesses the quality of community mental 
health services; 
1.4.3.2 Assesses the timeliness of services; 
1.4.3.3 Uses written criteria for evaluating the 
appropriateness and quality of Medicaid 
services; 
1.4.4Site visits will include, but not be limited to, 
review of the following: 
1.4.4.1 Consumer records; 
1.4.4.2 Treatment plans; 
1.4.4.3 Internal policies; 
1.4.4.4 Procedures; 
1.4.4.5 Documentation; 
1.4.4.6 Face to face interviews with staff, 
consumers and collaterals. 
1.4.5The Division will determine which sites will be 
reviewed and will determine which records will 
be reviewed. 
1.4.6Providers will be notified of the Divisions site 
visits at least one week in advance where 
possible. 
1.4.6.1 Unannounced site visits may also be 
conducted at the discretion of the 
Division. 
1.4.7In addition to monitoring by the Division, 
community mental health centers are subject to 
program audits by the Health Care Financing 
Administration (HCFA). 
1.5 Suspension or Revocation of Certification 
1.5.1The Division may suspend provider certification at 
any time upon 15 days written notice to the 
provider of the intent to suspend when the 
provider fails to satisfy or continue to meet 
the requirements for certification.
1.5.1.1 DSAMH shall advise the provider of the 
reason(s) for suspension. 
1.5.1.2 Upon receipt of the written notice of 
DSAMH's intent to suspend provider 
certification, the affected provider may 
request a hearing by the Division 
Director for the purpose of demonstrating 
that the reasons for suspension have been 
corrected. 
1.5.1.3 Failure of the provider to demonstrate 
the correction of the reasons for 
suspension within 60-days of receipt of 
the notice of intent to suspend shall 
result in the revocation of the 
provider's certification. 
1.5.1.3.1 The Division Director may extend 
the period of suspension without 
revocation by not more than 30- 
days. 
1.5.1.4 Upon revocation of a provider's 
certification, DSAMH shall notify DSS of 
such revocation and the concomitant 
failure of the provider to meet the 
requirements to be recognized as an 
enrolled provider under the Delaware 
Medical Assistance Plan. 
1.5.2 DSAMH may revoke a provider's certification and so 
advise DSS without prior written notice to the 
provider in the event that the provider has 
evidenced conduct which has caused or which 
can reasonably be expected to cause harm to 
program participants. 
1.5.2.1 DSAMH shall provide written notification 
of revocation to the affected provider 
within 5 working days of the effective 
date of such revocation. 
1.5.3Failure of DSAMH to timely reissue a Certification 
to a provider on the anniversary of an 
existing Certification shall be construed as, 
and have the effect of, the issuance of a 
Certification and the concurrent suspension of 
same unless such failure of DSAMH to reissue 
Certification is caused by action taken by 
DSAMH pursuant to 1.5.2.
1.5.3.1 No written notice of intent to suspend 
shall be required upon the failure of 
DSAMH to timely reissue a Certification 
on the anniversary of an existing 
Certification. 
2 CLINICAL STAFF AUTHORIZED TO PROVIDE SERVICES: The Delaware 
Medical Assistance Program will reimburse qualified providers 
for those services provided to eligible recipients of the 
Medical Assistance Program. The services must be rendered by 
members of the clinical staff who hold the credentials 
required by each covered billable activity. The categories 
of clinical staff and their definitions for community mental 
health centers clinic option are as follows: 
2.1 Physician: a person with a Medical Degree or Doctor of 
Osteopathy degree, is licensed to practice medicine in 
Delaware and has completed (or is enrolled in) an 
accredited residency training program in psychiatry, 
internal medicine or family practice. 
2.2 Clinician: a person with a doctoral or masters degree 
in psychology, counseling, social work, nursing, 
rehabilitation or related field from an accredited 
college or university (or a registered nurse with a 
certificate in mental health nursing from the American 
Nurses Association). 
2.3 Associate Clinician: a person with a bachelors degree 
in a human service field or a registered nurse. 
3 RECIPIENT ELIGIBILITY: Eligible recipients are Medicaid 
recipients who are certified by a community mental health 
center program physician as being in medical need of 
community mental health services in accordance with an 
assessment procedure approved by the Division of Substance 
Abuse and Mental Health. 
3.1 Determination of Consumer eligibility for Medicaid 
benefits is the sole responsibility of DSS. 
3.2 The Division audits recipients' records to determine 
whether the assessment procedure has been appropriately 
conducted and may disallow medicaid payment in the event 
that a determination of medical necessity by the 
physician does not appear to DSAMH to be supported by 
the assessment materials. 
3.3 Payment will be authorized for visits up to 45 days 
prior to the physician's certification of medical 
necessity if
those visits are for the purpose of providing emergency 
or comprehensive psychosocial assessment services. 
4 COVERED STANDARDS: Community Mental Health Center Clinic 
Option Services may be billed to the Delaware Medical 
Assistance Program for eligible Medicaid recipients for the 
following activities which are further defined in section 6: 
4.1 Comprehensive Psychosocial Assessment (Non MD) 
4.2 Psychiatric Evaluation/Therapy 
4.3 Emergency Services 
4.4 Medication Injection 
4.5 Medication Check/Medical Monitoring 
4.6 Counseling and Psychotherapy 
4.7 Group Counseling/Therapy 
5 SERVICE LIMITATIONS: The following limitations apply to 
coverage for Community Mental Health Centers clinic option: 
5.1 Appropriate Use: Services are reimbursable only when 
provided in accordance with a treatment plan approved by 
a physician in conjunction with the certification of 
medical necessity (as indicated by physician signature 
on the treatment plan). 
5.1.1 Exclusions to this general rule include 
emergency services. 
5.1.2 Services to collaterals are reimbursable under 
specific standards. 
5.1.2.1 A collateral is defined as a consumer's 
family member or others with significant 
ties to the consumer (includes guardians, 
advocates, significant other, etc.). 
5.1.3 Services can only be billed for the staff who 
actually provided the service to the 
consumer. 
5.1.4 ONLY one service provided by one staff can be 
billed for at the same time even if more 
than one staff are present during the 
delivery of the service.
5.1.5 All third party resources, when available, 
must be utilized prior to billing the 
Medical Assistance Program. 
5.2 Non-Covered Services: The following are not 
reimbursable: 
5.2.1Vocational and (non medically related) educational 
services; 
5.2.2Services which are solely recreational in nature; 
5.2.3Services delivered by telephone; 
5.2.4Services provided to consumer in an institute for 
mental disease; 
5.2.5 Services provided to consumer in a correctional 
institution. 
5.2.6Services provided off site. 
5.3 Service Utilization: Community mental health centers 
clinic option is a service predominantly provided within 
the context of consumer visits to the offices of the 
programs. The number of visits and frequency is based on 
consumer status and as outlined in the treatment plan. 
5.3.1 Exclusions to this general rule include 
emergency services provided by emergency 
services staff. 
5.3.2 Other exclusions include services furnished 
outside the offices of the program, by 
clinic personnel under the direction of a 
physician, to an eligible individual who 
does not reside in a permanent dwelling 
or does not have a fixed home or mailing 
address. 
5.4 Sub-Contracting of Services: Services billed to 
Medicaid must be provided by an employee or by a 
physician or other clinician under contract with the 
provider. 
5.4.1 Component services (e.g. emergency services, 
group therapy, etc.) of clinic option 
programs may not be subcontracted to 
independent provider organizations.
5.5 Physician Supervision: Services billed to Medicaid must 
be authorized by a physician's determination of medical 
necessity, must be supported by an individual treatment 
plan signed by the physician within 45 days and must be 
supervised by a physician in a manner prescribed by 
program standards of the Division. 
6 COMMUNITY MENTAL HEALTH CENTERS CLINIC OPTION STANDARDS 
6.1 Program Organization and Operation 
6.1.1 A community mental health center shall operate 
with on site staff during all regularly 
scheduled work days. Emergency services 
staff shall be available on site and 
mobile in the community on a 24 hour 
basis for 7 days per week. 
6.1.2 Staff of the mental health center clinic 
programs shall meet regularly to conduct 
treatment planning and treatment plan 
reviews. A schedule of upcoming 
treatment plans and reviews shall be 
maintained. A clinic supervisor shall 
lead treatment planning and review 
meetings. 
6.1.3 Each consumer shall have a treatment team 
consisting of at least the physician and 
one staff member who are primarily 
involved in his/her treatment plan. 
6.1.4 All staff listed on the treatment plan as 
responsible staff for delivery of 
services are considered an integral part 
of the treatment team. 
6.1.5 It shall be evident from review of clinical 
records and from observation of staff 
interactions with consumers that the 
provider is organized and operates in a 
manner consistent with the following 
principles: 
6.1.5.1 Minimizing disability by providing 
consumers with clinical interventions in 
the course of their interactions with the 
program;
6.1.5.2 Providing outreach, when appropriate, to 
ensure that consumers have access to and 
receive needed services; 
6.1.5.3 Maximizing consumer involvement and 
choice in all aspects of his/her 
treatment; 
6.1.5.4 Assisting consumers to develop and 
maintain supportive networks. 
6.2 Program Staff 
6.2.1 There shall be an overall director of the 
community mental health center who shall 
be a clinician with at least seven years 
of clinical/administrative experience in 
providing community mental health center 
services. 
6.2.2 There shall be an overall clinical supervisor 
who shall supervise the overall provision 
of services to consumers. The clinical 
supervisor shall be a clinician with at 
least five years of post-graduate 
experience in providing community mental 
health center services. 
6.2.3 Clinicians and associate clinicians shall have 
appropriate education, experience, and 
skills for the treatment activities they 
engage in and shall be supervised on a 
regular and consistent basis. 
6.2.4 A physician shall be available to the staff at 
all times. 
6.2.5 When volunteers or student interns are used, 
they shall be clinically supervised on a 
regular and consistent basis by 
clinicians. 
6.2.5.1 There shall be written procedures for the 
selection, orientation, in-service 
training and supervision of volunteers 
and students.
6.3 Intake 
6.3.1 During the intake process, the consumer shall 
be informed of: 
6.3.1.1 The program's services and aims; 
6.3.1.2 The manner in which the program operates 
to ensure that consumers receive the 
services they need; 
6.3.1.3 The program's expectations of consumers 
regarding their responsibilities; 
6.3.1.4 How consumers can obtain assistance 
during an emergency or whenever the 
program offices are closed; 
6.3.1.5 The program's provisions for maintaining 
confidentiality; 
6.3.1.6 Charges for which consumers or a third 
party may be billed; 
6.3.1.7 The process for appeal and review of 
problems consumers experience in regard 
to the quality and responsiveness of 
services provided by program staff; 
6.3.1.8 Their rights. 
6.4 Assessment 
6.4.1 A Comprehensive Medical/Psychosocial 
Evaluation approved by the Division as an 
assessment procedure shall be begun at 
the time of the consumer's admission to 
the program which shall be completed 
within 45 days. 
6.4.1.1 The evaluation shall be conducted by 
authorized staff. 
6.4.1.2 Assessment instruments shall conform to 
formats approved by the Division. 
6.4.1.3 Assessments shall be conducted with the 
active participation of the consumer and, 
when appropriate, collaterals, and shall 
be responsive to the consumer's goals.
6.4.2 Written assessment instruments shall be 
completed and explained to the consumer. 
The assessment shall include but not be 
limited to the following: 
6.4.2.1 Extent and effects of drug and/or alcohol 
use; 
6.4.2.2 Compliance with and response to 
prescribed medical (when 
appropriate)/psychiatric treatment; 
6.4.2.3 History of prior treatment for 
psychiatric problems and/or substance 
abuse; 
6.4.2.4 Current psychiatric symptomatology and 
mental status; 
6.4.2.5 Recent key life events; 
6.4.2.6 Vocational and educational functioning 
(when appropriate); 
6.4.2.7 Current social functioning; and 
6.4.2.8 Conditions of daily living. 
6.5 Treatment Planning 
6.5.1 A written treatment plan shall be developed 
within 45 days of the admission date. 
6.5.2 The treatment plan shall include long-range 
goals; objectives stated in measurable 
terms; and include criteria for 
termination of treatment. 
6.5.2.1 It shall include the specific treatment, 
modalities and interventions, and their 
frequency, planned to achieve treatment 
goals. 
6.5.2.2 Participation in the development of the 
treatment plan by consumers and 
collaterals shall be documented.
6.5.2.3 With the permission of the consumer, 
program staff shall engage the 
involvement of other service providers 
and members of the consumer's social 
network in formulating treatment plans 
when appropriate. 
6.5.3 The treatment plan shall be reviewed in full 
at least every six months. 
6.5.3.1 The date, results of the review and any 
changes in the treatment plan shall be 
recorded. 
6.5.3.2 Appropriate signatures will be obtained. 
6.6 Consumer Rights 
6.6.1 The provider shall establish a formal process 
for soliciting consumer's complaints and 
for reviewing treatment decisions by 
staff with which consumers disagree. 
6.6.2 The provider shall not establish any general 
conditions of program participation that 
limit a consumer's rights to selfdetermination. 
6.6.3 The provider shall comply with DHSS Policy 
Memorandum 46 regarding reporting and 
responding to allegations of abuse and 
neglect, and to incidents resulting in 
injury or death. 
6.6.4 The provider shall promote any self-help and 
mutual support efforts among consumers. 
6.6.5 Consumers shall be kept informed (as evidenced 
through written guidelines and through 
documentation in their clinical records) 
of their rights and responsibilities 
contained in written policies and 
procedures including reference to: 
6.6.5.1 Behavioral expectations and limitations;
6.6.5.2 Consumer grievances; 
6.6.5.3 Confidentiality; 
6.6.5.4 Fees; 
6.6.5.5 Appeals of decisions by program staff. 
6.7 Management of Case 
6.7.1 A member of the community mental health 
program's clinic staff shall be 
designated responsible for maintaining a 
primary treatment relationship with each 
consumer and shall: 
6.7.1.1 Maintain the clinical file for the 
consumer to include: 
6.7.1.1.1 assurance that written assessments 
are completed; 
6.7.1.1.2 preparation of treatment plans; 
6.7.1.1.3 documentation of services and 
response to treatment; 
6.7.1.1.4 order and completeness. 
6.7.1.2 Conduct and participate in treatment 
planning and case conferences with other 
staff and other agencies when 
appropriate; 
6.7.1.3 Maintain a therapeutic alliance with the 
consumer and serve as his/her primary 
therapist; 
6.7.1.4 Support and consult with the consumer's 
collaterals when appropriate. 
6.7.2 In addition to the above responsibilities of 
the clinician who serves as the manager 
of the case, all staff of the program 
shall share the following 
responsibilities, for which they are 
credentialed, for each consumer:
6.7.2.1 Document and keep other staff informed of 
all significant changes in the consumer's 
mental or social status as it effects 
treatment; 
6.7.2.2 Provide any of the above functions on 
behalf or in place of the primary 
therapist as conditions dictate. 
6.8 STANDARD: COMPREHENSIVE PSYCHOSOCIAL ASSESSMENT (NON 
MD) 
6.8.1DEFINITION: Comprehensive Psychosocial Assessment 
refers to services provided in face to face 
interaction with consumers and collaterals as 
diagnostic and evaluative methods to determine 
a consumers' current status and needs. They 
involve a professional determination of the 
nature and intensity of an individuals' 
problems, resources and assets. A complete 
assessment takes place when a consumer first 
comes in contact with the community mental 
health center. Appropriate components of the 
assessment should be repeated as reassessment 
in preparation for semi-annual treatment plan 
reviews and/or whenever a consumer experiences 
a significant change in psychosocial 
functioning. 
6.8.2MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for psychosocial assessment (non MD). 
6.8.3AUTHORIZED STAFF: Comprehensive Psychosocial 
Assessment (non MD) may be provided by a 
Clinician or Associate Clinician. 
6.8.3.1 Exclusions to this service are physicians 
who may, in fact, provide this type of 
treatment service but who will bill 
under Psychiatric Evaluation when 
applicable. 
6.8.3.2 Staff not listed above may also provide 
some of these services in certain 
circumstances but the service may not be 
billed.
6.8.3.3 If services are delivered by staff not 
listed the service should be documented 
in the consumer record according to the 
standard documentation guidelines. 
6.8.4PROGRAM GUIDELINES 
6.8.4.1 Assessments involve a wide range of tools 
and procedures and are acceptable if used 
in clinical practice, as deemed 
appropriate, by staff listed under 
authorized staff. 
6.8.4.2 Psychological testing, where indicated,is 
included in this standard. Examples of 
testing may include but are not limited 
to: 
6.8.4.2.1 Projective tests; 
Standardized personality 
inventories; 
Intellectual assessment; 
Tests for specific disorders; 
Rating scales; 
Questionnaires; 
Differential diagnostic tests. 
6.8.4.3 Assessments shall be furnished under the 
supervision of a physician. Physician 
shall confirm the review of a consumer's 
treatment and record by a signature and 
date on the treatment plan. This 
signature is required to confirm the 
diagnosis, medical necessity of 
treatment, and appropriateness of care. 
6.8.4.4 Staff may utilize this service to secure 
information from a collateral. Such face 
to face contacts are billable but must be 
utilized solely in connection with 
gathering information pertinent to a 
clinical assessment process. 
6.8.4.5 Court ordered evaluation and external 
requests for evaluation are included 
within this service. They must be face 
to face in order to be billed.
6.8.5SERVICES: May include but not be limited to: 
6.8.5.1 Interview; 
6.8.5.2 Medical History/Care; 
6.8.5.3 Psychiatric History; 
6.8.5.4 Social History; 
6.8.5.5 Substance Abuse/Use (includes alcohol); 
6.8.5.6 Mental Status; 
6.8.5.7 Testing; 
6.8.5.8 Questionnaires; 
6.8.5.9 Screening for admission to other 
services; 
6.8.5.10 Diagnostic Evaluation; 
6.8.5.11 Legal involvement(s) (when applicable). 
6.8.6DOCUMENTATION 
6.8.6.1 The acceptable abbreviation for this 
standard is Assess. 
6.8.6.2 Initial assessment of a consumer shall 
include but not be limited to the 
completion of the following: 
6.8.6.2.1 Consumer Rights; 
6.8.6.2.2 Applicable Releases; 
6.8.6.2.3 Delawares Community Mental Health 
Screening Instrument; 
6.8.6.2.4 Michigan Alcoholism Screening Test; 
6.8.6.2.5 Medical History ; 
6.8.6.2.6 Intake Data Base (Psycho Social 
History); 
6.8.6.2.7 Face Sheet (Stat Sheet);
6.8.6.2.8 Signed Consent to Treatment; 
6.8.6.2.9 Signed Consent for Medication; 
6.8.6.2.10 Treatment Plan; 
6.8.6.2.10.1 The treatment plan should 
be discussed and agreed 
to with consumer by 45th 
day following admission 
or by next visit 
thereafter. 
6.8.6.2.10.2 Consumer signature is 
required. 
6.8.6.2.10.2.1 If consumer, by 
nature of illness, 
is not cooperative a 
notation on the 
consumer signature 
line of the 
treatment plan 
should be made 
explaining the 
circumstances. 
6.8.6.2.10.2.2 At least every six 
months attempts 
should be made to 
both explain and 
encourage consumer 
participation in the 
treatment planning 
process throughout 
the consumers length 
of stay in community 
mental health center 
treatment. 
6.8.6.3 If a clinic document, test, or form is 
completed, reviewed with consumer and 
signed and dated it will suffice for 
documentation for billing purposes. 
6.8.6.3.1 An additional progress note to 
describe completion of said form 
does not need to be completed. 6.8.6.3.2 However, if, during the session 
other areas of concern or treatment 
issues are addressed a 
corresponding note should be placed 
in the consumer record. 
6.8.6.4 Yearly reassessment of a consumer shall 
include but not be limited to completion 
of the following updates: 
6.8.6.4.1 Comprehensive Psychosocial 
Assessment (Non MD); 
6.8.6.4.2 Psychiatric Evaluation; 
6.8.6.4.3 Treatment Plan. 
6.8.6.5 Assessment must be entered on the 
treatment plan if/when it is indicated 
following the completion of the initial 
assessment during the first 45 days of 
treatment. Examples include but are not 
limited to: 
6.8.6.5.1 Request from court for assessment 
due to recent consumer behavior 
that resulted in legal involvement. 
6.8.6.5.2 Consumer is being referred to 
another and more intensive program 
which requires an assessment be 
completed. 
6.8.6.5.3 Rule out diagnosis is being 
monitored. 
6.8.6.6 Documentation must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.8.7REIMBURSEMENT 
6.8.7.1 Assessment must be face to face to be 
billed. 
6.8.7.2 Bill in 10 minute units of service. 
6.8.7.3 Travel time is not reimbursable.
6.8.7.4 Telephone time is not billable. 
6.8.7.5 If staff normally assigned to the 
emergency services program of the 
Community Mental Health Center provide 
this service when they are not on duty 
for emergency services the service should 
be billed as comprehensive psychosocial 
assessment (non MD). If the staff are on 
duty for emergency services and are 
providing this service they should bill 
for emergency service. 
6.9 STANDARD: PSYCHIATRIC EVALUATION/THERAPY 
6.9.1DEFINITION: A face to face interaction between a 
physician and consumer or physician and a 
collateral. Contacts may include all 
interactions to provide clinical diagnostic, 
monitoring, treatment services, and 
prescription of pharmacotherapy. The scope of 
issues addressed in this service is based on 
consumer need. 
6.9.2MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for Psychiatric Evaluation. 
6.9.3AUTHORIZED STAFF: Psychiatric Evaluation shall be 
rendered by a physician, licensed to practice 
medicine or osteopathy within the State of 
Delaware. 
6.9.4PROGRAM GUIDELINES 
6.9.4.1 Each consumer should have a completed 
psychiatric evaluation, at a minimum, 
within 45 days of admission to the 
community mental health center or the 
next visit thereafter. 
6.9.4.1.1 Any exceptions must be clearly 
documented and explained in the 
progress note section of the 
consumer record. An example may be 
that the consumer has been 
hospitalized.
6.9.4.2 Each consumer should have a completed 
psychiatric evaluation, at a minimum, 
yearly regardless of whether or not 
medications are being prescribed. 
6.9.4.2.1 Any exceptions must be clearly 
documented and explained in the 
progress note section of the 
consumer record. Examples may be 
that the consumer refuses to 
authorize this service or that the 
consumer has been hospitalized. 
6.9.4.2.2 The evaluation should take place 
plus or minus 30 days from the one 
year time limit from the last 
evaluation. 
6.9.5SERVICES 
6.9.5.1 May include but not be limited to: 
Assessment Therapy 
Mental Status Testing 
Diagnosis Specialized Needs 
Initiate Medication(s) Monitoring 
Continue Medication(s) Treatment Planning 
Need for Referral Status in Response 
to Treatment 
6.9.6DOCUMENTATION 
6.9.6.1 The acceptable abbreviation for this 
standard is Psych Eval/Ther. 
6.9.6.2 Each consumer record documentation shall 
reflect the date the service was 
rendered. 
6.9.6.3 Psychiatric diagnosis form is part of the 
treatment plan. It may be completed by 
any staff but must be signed by Physician 
by 45th day of consumer admission or next 
visit thereafter. 
6.9.6.3.1 Evidencing data (symptoms/problems) 
MUST be included on each axis of 
the psychiatric data form.
6.9.6.4 A new Standardized Diagnosis Form must be 
completed whenever there is a change in 
diagnosis or a new treatment plan is 
generated. 
6.9.6.5 Medication orders should be documented on 
a medication order form. 
6.9.6.5.1 ALL medication orders need to be 
completely re-written each time 
there is a change in any one aspect 
of an order including but not 
limited to the following: 
6.9.6.5.1.1 Initiation; 
6.9.6.5.1.2 Discontinuance; 
6.9.6.5.1.3 Type; 
6.9.6.5.1.4 Strength; 
6.9.6.5.1.5 Frequency; 
6.9.6.5.1.6 Amount; and, 
6.9.6.5.1.7 Refill. 
6.9.6.5.2 If there are no medication changes 
over a period of three months, ALL 
orders need to be re-written at 
that time or at the next consumer 
visit to the physician if the visit 
does not coincide with the three 
month time frame. 
6.9.6.6 Written documentation in a format 
approved by the Division must be provided 
for each face to face contact. 
6.9.6.6.1 Information included should be 
relevant to topic of that visit. 
Examples include: 
6.9.6.6.1.1 Initial visit to 
psychiatrist: 
Documentation shall 
include but not be 
limited to review of
history, mental status 
exam, observations, 
impression, diagnosis, 
and plan. 
6.9.6.6.1.1.1 Documentation shall 
be on a Division 
approved Psychiatric 
Evaluation form. 
6.9.6.6.1.2 Follow up visit to 
psychiatrist: 
Documentation shall 
include but not be 
limited to consumer 
report of progress, 
content of session, 
psychiatrists' opinion of 
consumer status, 
affirmation of diagnosis, 
and continuation of plan 
as it relates to the 
treatment plan. 
6.9.6.6.1.2.1 Documentation shall 
be in a Division 
approved progress 
note format. 
6.9.6.7 Psychiatrist shall provide at least 
yearly reviews for consumers. 
6.9.6.7.1 Documentation shall be on a 
Division approved Psychiatric 
Evaluation form. 
6.9.6.7.2 Yearly documentation should include 
but not be limited to: 
6.9.6.7.2.1 Review of consumer 
progress that year; 
6.9.6.7.2.2 Changes noted; 
6.9.6.7.2.3 Mental status exam; 
6.9.6.7.2.4 Observation; 
6.9.6.7.2.5 Impression; 6.9.6.7.2.6 Diagnosis; and 
6.9.6.7.2.7 Plan. 
6.9.6.8 Psychiatrist shall provide documentation 
with an opinion of consumer progress each 
time there is a face to face visit. 
6.9.6.9 Each medication prescribed must have an 
informed consent presented initially and 
annually. It shall contain information 
about: 
6.9.6.9.1 The medication; 
6.9.6.9.2 Potential side effects; 
6.9.6.9.3 Purpose; 
6.9.6.9.4 Potential long term effects and; 
6.9.6.9.5 Precautions. 
6.9.6.9.6 If a consumer is unable or 
unwilling to sign the circumstances 
should be documented directly on 
the informed consent and a minimum 
of every six months in the progress 
notes. 
6.9.6.10 The physician rendering this service 
shall sign the documentation in the 
consumer record with his/her first 
initial, last name and credentials. 
6.9.6.11 Documentation must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.9.7REIMBURSEMENT 
6.9.7.1 Bill in 10 minute units of service. 
6.9.7.2 Face to face contacts with collaterals 
are billable under Psychiatric Evaluation 
when the contact pertains to consumer 
treatment issues and appropriate releases 
have been obtained. Examples include but 
are not limited to: 6.9.7.2.1 Psychiatrist sees a consumer's 
parents to gather or verify 
information regarding consumer 
behavior. 
6.9.7.2.2 Psychiatrist sees consumer's friend 
to explain and/or reinforce 
conflict resolution particular to 
consumer's treatment plan. 
6.9.7.2.3 Sister of consumer requests visit 
with psychiatrist to describe 
consumer's increased isolation, 
refusal of medication, increased 
response to internal stimuli and 
other signs and symptoms of 
decompensation. 
6.9.7.3 Travel time is not reimbursable. 
6.9.7.4 Telephone time is not reimbursable. 
6.10 STANDARD: EMERGENCY SERVICES 
6.10.1 DEFINITION: Emergency services are short term 
interactions provided to consumers 
experiencing an increase in personal distress 
which threatens to cause the admission of the 
consumer to a hospital, detoxification, or 
other crisis facility. They are provided when 
a consumer suffers an acute episode despite 
having received other clinic services or when 
a consumer initially enters the community 
mental health system due to a crisis in their 
life. Emergency services are available on a 
24 hour per day, 7 day per week basis on site 
or mobile in the community and by telephone. 
6.10.2 MEDICAL NECESSITY CRITERIA: This service is 
available to all consumers. A physician does 
not have to see a consumer prior to the 
delivery of this service. 
6.10.3 AUTHORIZED STAFF: Emergency services may be 
provided by a physician, clinician or 
associate clinician.
6.10.3.1 Emergency services may ONLY be provided 
by mental health professionals on duty in 
the emergency services department at the 
time of service delivery. 
6.10.3.2 A psychiatrist shall be available to 
emergency services staff at all times. 
6.10.4 PROGRAM GUIDELINES 
6.10.4.1 After an initial contact it is 
permissible to provide up to three 
additional face to face emergency 
services aimed at resolving the immediate 
crisis if clinically indicated. 
6.10.4.1.1The additional contacts should be 
provided within a 72 hour time 
frame of the initial contact. 
6.10.4.2 Repeated, frequent, and/or cyclical use 
of emergency services by an individual 
consumer should trigger a review of the 
consumer's treatment plan. 
6.10.4.3 All referrals shall be based on 
utilization of the least restrictive, 
clinically appropriate, and available 
alternative. 
6.10.4.4 It is not necessary to include emergency 
services in the treatment plan. 
6.10.5 SERVICES: May include but not be limited to: 
6.10.5.1 Evaluation and Assessment 
6.10.5.2 Counseling and Psychotherapy 
6.10.5.3 Medical Treatment 
6.10.5.4 Resource Coordination 
6.10.5.5 Conflict Resolution 
6.10.5.6 Crisis Intervention
6.10.6 DOCUMENTATION 
6.10.6.1 The acceptable abbreviation for this 
standard is Em Serv. 
6.10.6.2 Each face to face and telephone contact 
shall be documented on a Division 
approved emergency services contact form. 
6.10.6.3 Documentation shall include but not be 
limited to: 
6.10.6.3.1Date of service; 
6.10.6.3.2Name and staff title of individual 
providing the service; 
6.10.6.3.3Setting where services were 
rendered; 
6.10.6.3.4Time services rendered; 
6.10.6.3.5Amount of time to render service; 
6.10.6.3.6Complete description of services 
rendered; 
6.10.6.3.7Effect of services on consumer 
condition; 
6.10.6.3.8Events or circumstances leading to 
consumer need for emergency 
services; 
6.10.6.3.9Discharge/follow-up. 
6.10.6.4 Emergency contact sheet shall be placed 
in consumer record in chronological order 
in the progress note section within 24 
hours of actual service delivery. 
6.10.7 REIMBURSEMENT 
6.10.7.1 Emergency contacts must be performed by 
Emergency Services On Duty personnel in 
order to be billable.
6.10.7.2 Emergency services employees may bill for 
only one eligible consumer at any given 
time. 
6.10.7.2.1There is no provision for group 
emergency services or group 
crisis intervention. 
6.10.7.3 Telephone contacts are not billable. 
6.10.7.4 Face to face work with collaterals to 
resolve the emergency is billable. 
6.10.7.5 Travel time is not reimbursable. 
6.10.7.6 Bill for 10 minute units of service. 
6.11 STANDARD: MEDICATION INJECTION 
6.11.1 DEFINITION: A face to face interaction during 
which the prescribed medication as ordered by 
a physician and outlined in the treatment plan 
is administered, or in the case of an 
emergency, when the medication may not be 
included in the treatment plan. Medications 
are provided in order to restore, maintain 
and/or improve the consumer's role performance 
or mental status. 
6.11.2 MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for this service if physicians who, 
within the scope of their medical practice, 
believe the consumer would benefit from it. 
6.11.3 AUTHORIZED STAFF: Medication injection may be 
provided by a physician or registered nurse. 
6.11.4 PROGRAM GUIDELINES 
6.11.4.1 There must be a current physician order 
in the consumer's record. 
6.11.4.1.1The exception to this is in case of 
an emergency when medical 
staff should follow the 
procedures as outlined in 
their individual programs.
6.11.4.2 When the service is rendered by a nurse, 
a physician must be available in case of 
an emergency. 
6.11.4.3 The physician shall authorize medication 
injection. 
6.11.4.4 Physician shall confirm the review of a 
consumer's treatment and record by a 
signature and date on the treatment plan. 
This signature is required to confirm 
the diagnosis, medical necessity of 
treatment, and appropriateness of care. 
6.11.5 DOCUMENTATION 
6.11.5.1 The acceptable abbreviation for this 
standard is IM. 
6.11.5.2 Medication injection shall be included in 
the treatment plan for consumers whom the 
physician believes would benefit from 
this service. 
6.11.5.3 Division approved medication order forms 
shall be used. 
6.11.5.4 When the injection is given the specific 
service rendered shall be listed in the 
consumer record providing date and actual 
time the injection was given. 
6.11.5.5 The Physician or Registered Nurse shall 
sign his/her first initial, last name and 
credentials, in the consumer record when 
documenting each injection. 
6.11.5.6 The documentation shall address the 
following items in order to provide a 
pertinent clinical description, assure 
the service conforms to the service 
description, and authenticate the 
charges: 
6.11.5.6.1Medication Administered; 
6.11.5.6.2Dosage given (quantity; strength);
6.11.5.6.3Route (I.M., I.D., I.V.); 
6.11.5.6.4Injection Site; 
6.11.5.6.5Side effects or adverse reactions 
noted. 
6.11.5.7 Documentation must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.11.6 REIMBURSEMENT 
6.11.6.1 Bill in 10 minute units of service. 
6.11.6.2 Bill only for actual administration of 
the injection. 
6.11.6.2.1The medication will be billed for 
separately. 
6.12 STANDARD: MEDICATION CHECK/MEDICAL MONITORING 
6.12.1 DEFINITION: A face to face interaction 
between a consumer and medical personnel to 
monitor effects of medications prescribed; 
discuss new or ongoing physical problems; 
provide education regarding medication, 
nutrition, exercise or other medically related 
topics when the activities are described as an 
integral part of the treatment regimen in the 
treatment plan. 
6.12.2 MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for this service if physicians who, 
within the scope of their medical practice, 
believe the consumer would benefit from it. 
6.12.3 AUTHORIZED STAFF: Medication Check/medical 
monitoring may be provided by a physician or 
registered nurse. 
6.12.4 PROGRAM GUIDELINES 
6.12.4.1 Only the above authorized staff are 
eligible to provide this service and bill 
for it.
6.12.4.2 Other non-medical staff may document 
information reported to them by a 
consumer in regards to their 
medication/medical condition in the 
context of providing other services. 
6.12.4.2.1These staff are not eligible to 
bill for a medication check. 
6.12.4.3 Telephone contacts to determine 
medication effect or consumer medical 
condition are not billable services. 
They should, however, be documented in 
the consumer record. 
6.12.4.4 Medication dispensing should be billed 
for under this standard. 
6.12.4.5 A consumer does not have to be receiving 
medications to receive this service. 
6.12.4.6 Vital signs, monitoring weight 
fluctuations, and other medically related 
services are considered to be billable 
under this standard. 
6.12.4.7 A physician must be available in case of 
an emergency. 
6.12.4.8 Medication Check/Medical Monitoring shall 
be furnished under the supervision of a 
physician. The physician shall authorize 
medication check/medical monitoring. 
Physician shall confirm the review of a 
consumer's treatment and record by a 
signature and date on the treatment plan. 
This signature is required to confirm 
the diagnosis, medical necessity of 
treatment and appropriateness of care. 
6.12.5 SERVICES: May include but not be limited to: 
6.12.5.1 Administration of medications other than 
injectable; 
6.12.5.2 Assessment to determine need for consumer 
to see the physician;
6.12.5.3 Determine overt physiological effects 
related to the medications prescribed; 
6.12.5.4 Determine psychological effects of 
medications prescribed; 
6.12.5.5 Monitor compliance; 
6.12.5.6 Vital Signs; 
6.12.5.7 Explanation of laboratory findings or 
need for laboratory work to be 
completed; 
6.12.5.8 Conducting or arranging for any 
laboratory tests that may be ordered when 
such services are performed face to face 
with consumer; 
6.12.5.9 Medically related education; Examples 
include: 
6.12.5.9.1Information to help the consumer be 
informed as to the dosage, 
type, benefits, actions and 
potential side effects of 
medication(s) being 
prescribed. 
6.12.5.9.2Information to help the consumer 
live a healthy life such as 
use of tobacco products, 
alcohol, illegal substances, 
nutrition. 
6.12.6 DOCUMENTATION 
6.12.6.1 The acceptable abbreviation for this 
standard is Med Ck. 
6.12.6.2 Medication check/medical monitoring shall 
be included in the treatment plan for 
consumers whom the physician believes 
would benefit from the service. 
6.12.6.3 A separate entry in the consumer record 
shall correspond to each service delivery 
of medication check/medical monitoring.
6.12.6.4 Documentation shall address the following 
items: 
6.12.6.4.1Current medications consumer is 
taking (if applicable). 
6.12.6.4.2Side effects or adverse reactions 
the consumer is experiencing 
or has experienced. 
6.12.6.4.3Refusal of consumer to comply with 
medication administration as 
ordered. 
6.12.6.4.4Effect medications are having, or 
not having, on symptom 
control. 
6.12.6.4.5Staff assessment of consumer 
progress. 
6.12.6.5 The staff person rendering this service 
shall sign the documentation in the 
consumer record with his/her first 
initial, last name and credentials. 
6.12.6.6 Each consumer record documentation shall 
reflect the date the service was 
rendered. 
6.12.6.7 Results of any tests, vital signs, or 
weight taken must be recorded in the 
consumer record with corresponding date 
of service, explanation of service, and 
signature of staff providing service. 
6.12.6.8 Documentation must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.12.7 REIMBURSEMENT 
6.12.7.1 Bill in 10 minute units of service. 
6.12.7.2 Telephone contacts are not billable but 
should be documented in the consumer 
record.
6.13 STANDARD: COUNSELING AND PSYCHOTHERAPY 
6.13.1 DEFINITION: Counseling and psychotherapy is 
performed in face to face interaction with the 
consumer and/or collateral to listen to, 
interpret and respond to the consumer's 
expressions of physical, emotional, and/or 
cognitive functioning. Treatment focus is on 
the prevention of deterioration, remediation, 
development, and/or rehabilitation of the 
consumer's functional abilities within 
society. The scope of issues addressed within 
this service is based on consumer need as is 
the therapy modality utilized. The 
orientation of this service may be supportive, 
palliative, or therapeutic. 
6.13.2 MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for counseling and psychotherapy if a 
physician, within the scope of his/her medical 
practice, believes the consumer would benefit 
from participation. 
6.13.3 AUTHORIZED STAFF: Counseling and 
psychotherapy may be provided by a Clinician or 
Associate Clinician. 
6.13.3.1 Exclusions to this service are physicians 
who may, in fact, provide this type of 
treatment but who will bill under 
psychiatric evaluation/therapy when 
applicable. 
6.13.3.2 Psychotherapy may be provided by staff 
who are credentialed in specific 
modalities or learning and practicing 
under the supervision of one who is 
credentialed. 
6.13.3.3 Staff not listed as authorized staff may 
also provide this service in certain 
circumstances but the service may not be 
billed.
6.13.3.3.1If services are delivered by staff 
not listed the service should 
be documented in the consumer 
record according to the 
standard documentation 
guidelines. 
6.13.4 PROGRAM GUIDELINES 
6.13.4.1 Services are provided within the context 
of the goals of the consumer's treatment 
plan. 
6.13.4.2 Counseling and Psychotherapy shall be 
furnished under the supervision of a 
physician. The physician shall authorize 
counseling and psychotherapy. A 
physician shall sign and date the 
treatment plan and thereby confirm the 
diagnosis, medical necessity of 
treatment, and appropriateness of 
treatment. 
6.13.4.3 The purpose of counseling and 
psychotherapy is to help the consumer 
achieve and maintain psychiatric 
stability. 
6.13.4.4 Its broader purpose is to help consumers 
improve their physical and emotional 
health and to cope with or gain control 
over the symptoms of their illness and 
effects of their disabilities. 
6.13.4.5 Restoration of role functioning in the 
natural environment is the primary 
emphasis of all treatment related to 
counseling and psychotherapy. 
6.13.5 SERVICES: Counseling and Psychotherapy may 
include but is not limited to the following: 
6.13.5.1 Counseling 
6.13.5.2 Psychotherapy 
6.13.5.2.1There are several highly specific 
modalities of psychotherapy, 
each based on an empirically 
valid body of knowledge about 
human behavior. 
6.13.5.2.1.1 Provision of each 
requires specific 
training and/or 
credentials. 
6.13.5.2.2Although the nature of the 
consumer's needs and the 
specific modality of therapy 
determines its duration, 
psychotherapy has 
circumscribed goals, a 
definite schedule and a finite 
duration. 
6.13.5.2.2.1 Examples include but are 
not limited to: 
Psychodynamic therapy; 
Psychoeducational 
therapy; Family therapy; 
Cognitive therapy. 
6.13.5.3 Face to face counseling and psychotherapy 
sessions may be conducted to: 
6.13.5.3.1Assess the consumer's behavior; 
6.13.5.3.2Modify treatment goal(s); 
6.13.5.3.3Increase self esteem/self worth; 
6.13.5.3.4Decrease anxieties; 
6.13.5.3.5Decrease depression; 
6.13.5.3.6Develop appropriate behavior; 
6.13.5.3.7Develop interactional skills; 
6.13.5.3.8Allow/encourage consumer to 
verbalize; 
6.13.5.3.9Promote consumer awareness of 
goals. 6.13.6 DOCUMENTATION 
6.13.6.1 The acceptable abbreviation for this 
standard is Coun/Ther. 
6.13.6.2 Counseling and psychotherapy shall be 
included in the treatment plan for 
consumers whom a physician believes would 
benefit from this individual service. 
6.13.6.3 Each face to face interaction shall 
result in a progress note entry referring 
to the treatment plan goal(s) which the 
interaction addresses. 
6.13.6.4 The progress note shall outline the 
content of the session, consumer 
involvement in the session and the 
involvement of the staff in provision of 
service. 
6.13.6.5 The staff person rendering this service 
shall sign the documentation in the 
consumer record with his/her first 
initial, last name and credentials. 
6.13.6.6 Each consumer record documentation shall 
reflect the date the service was 
rendered. 
6.13.6.7 Staff are expected to provide 
documentation pertaining to each service 
delivery that includes their assessment 
of consumer progress. 
6.13.6.8 Each entry shall include a plan for 
description of continuation of treatment. 
6.13.6.9 Documentation must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.13.7 REIMBURSEMENT 
6.13.7.1 Counseling and Psychotherapy must be face 
to face in order to be billed. 
6.13.7.2 Bill in 10 minute units of service.
6.13.7.3 Face to face contacts with collaterals 
are billable under Counseling and 
Psychotherapy when the contact pertains 
to consumer treatment issues and 
appropriate releases have been obtained. 
6.13.7.4 Telephone contacts are not billable. 
6.13.7.5 Emergency service staff on duty in 
emergency service may not bill for this 
service. They should use the emergency 
service standard. If, however, an 
employee normally assigned to emergency 
service is providing counseling and 
psychotherapy within the context of 
another clinic program (not emergency 
services) they are eligible (if they meet 
authorized staff requirements) to both 
provide the service and bill accordingly. 
6.14 STANDARD: GROUP COUNSELING/THERAPY 
6.14.1 DEFINITION: Group Counseling/Therapy are face 
to face interactions with more than one 
consumer at the same time to provide mutual 
deliberations, support, response and/or 
interpretation of consumer issues. Group 
counseling/therapy is provided under the 
immediate guidance of authorized staff and is 
directed toward the restoration, enhancement, 
or prevention of deterioration of individual 
consumer functioning. Commonality of consumer 
issues provides a basis for authorized staff 
to establish group treatment. 
6.14.2 MEDICAL NECESSITY CRITERIA: All consumers are 
eligible for group counseling/therapy if a 
physician, within the scope of his/her medical 
practice, believes the consumer would benefit 
from participation. 
6.14.3 AUTHORIZED STAFF: Group counseling/therapy 
may be provided by a physician, clinician, or 
associate clinician.
6.14.4 PROGRAM GUIDELINES 
6.14.4.1 Services are provided within the context 
of the goals of the consumer's treatment 
plan. 
6.14.4.2 Group counseling/therapy shall be 
furnished under the supervision of a 
physician. The physician shall authorize 
group counseling/therapy. A physician 
shall sign and date the treatment plan 
and thereby confirm the diagnosis, 
medical necessity of treatment, and 
appropriateness of treatment. 
6.14.5 DOCUMENTATION 
6.14.5.1 The acceptable abbreviation for this 
standard is Group. 
6.14.5.2 Group counseling/therapy shall be 
included in the treatment plan for 
consumers whom a physician believes would 
benefit from this service. 
6.14.5.3 Each group service rendered shall be 
documented in an individual progress note 
in the consumer record which shall 
include the following: 
6.14.5.3.1Outline the content of the group 
session; 
6.14.5.3.2Consumer's involvement in the 
group; 
6.14.5.3.3Involvement of the staff in the 
provision of the group; and 
6.14.5.3.4Consumer's status in relation to 
treatment. 
6.14.5.4 The staff person(s) rendering this 
service shall sign the documentation in 
the consumer record with his/her first 
initial, last name and credentials.
6.14.5.5 Each consumer record documentation shall 
reflect the date the service was 
rendered. 
6.14.5.6 The progress note must be placed in the 
consumer record within 24 hours from the 
date of service. 
6.14.6 REIMBURSEMENT 
6.14.6.1 Group counseling/therapy must be face to 
face in order to be billed. 
6.14.6.2 Bill for 10 minute units of service. 
6.14.6.3 Interventions with collaterals are not 
included in this billable service. 
6.14.6.4 Telephone contacts are not billable. 
7 ORGANIZATIONAL STANDARDS 
7.1 The Community Mental Health program shall be managed by 
a Director and other supervisory staff who will elicit 
consumer and family participation in the process of 
setting and evaluating the values, mission, goals, 
objectives and service strategies of the program and to 
assist the program in representing its interest to the 
community in which it operates. 
7.2 The facility(ies) within which the community mental 
health center programs operate shall meet the following 
criteria: 
7.2.1 They shall meet all applicable fire and life 
safety codes; 
7.2.2 They shall have the appearance of a high 
quality therapeutic environment; 
7.2.3 They shall be accessible to the consumer's 
served; 
7.2.4 They shall provide a smoke free environment 
for non-smokers.
8 ADMINISTRATIVE STANDARDS 
8.1 Consumer Records 
8.1.1 There shall be a treatment record for each 
consumer that includes sufficient 
documentation of assessments, treatment 
plans and treatment to justify Medicaid 
participation and to permit a clinician 
not familiar with the consumer to 
evaluate the course of treatment. 
8.1.2 There shall be a designated consumer record 
manager who shall be responsible for the 
maintenance and security of consumer 
records. 
8.1.3 The record keeping format and system for 
purging shall provide for consistency, 
facilitate information retrieval and 
shall be approved by the Division. 
8.1.3.1 The format and system shall be available 
in up to date written policies and 
procedures. 
8.1.4 Consumer treatment records shall be kept 
confidential and safeguarded in a manner 
identical to the requirements of Section 
5161 of Title 16 of the Delaware Code 
governing the rights of mental health 
inpatients. The consumer record shall 
contain, at a minimum, the following: 
8.1.4.1 An up-to-date face sheet; 
8.1.4.2 Consumer consent to treatment and consent 
to any occasion of release of treatment 
information; 
8.1.4.3 Results of all assessment information, 
examinations, and tests. 
8.1.4.3.1 Assessments shall be completed on 
forms approved by the Division; 
8.1.4.4 Reports from referral sources and 
clinical consults;
8.1.4.5 Hospital discharge summaries; 
8.1.4.6 A treatment plan in a format approved by 
the Division. 
8.1.4.6.1 All mental health services covered 
by Medicaid, with the exception of 
emergency services and initial and 
yearly assessments involving 
specific and signed forms, must be 
provided in accordance with a 
comprehensive treatment plan. 
8.1.4.6.2 The treatment plan must document 
the medical necessity of the 
services prescribed as evidenced by 
the presence of the following: 
8.1.4.6.2.1 Symptoms (problems); 
8.1.4.6.2.2 Diagnosis (using DSM IIIR 
criteria, all axis); 
8.1.4.6.2.3 MD signature 
8.1.4.6.3 The DSM III-R diagnosis or current 
DSAMH approved diagnostic procedure 
and symptoms (problems) must be 
present on the treatment plan and 
must be the basis from which the 
plan is developed. 
8.1.4.6.4 There should be a clear connection 
between the services or treatment 
provided and the symptoms of the 
consumer as described in the 
treatment plan and the diagnosis. 
8.1.4.6.5 Medicaid regards a treatment plan 
as a prescription for services 
which the consumer then has filled 
by the staff of the center. 
8.1.4.6.5.1 Unsigned plans, or plans 
signed by an 
inappropriate individual, 
are invalid and any 
services provided to 
consumers based on them
are not reimbursable by 
Medicaid. 
8.1.4.6.6 In addition, the treatment plan 
should adhere to the following: 
8.1.4.6.6.1 Individual; 
8.1.4.6.6.2 Written; 
8.1.4.6.6.3 Comprehensive; 
8.1.4.6.6.4 Based on assessment of 
consumer; 
8.1.4.6.6.5 Be completed within 45 
days of admission or next 
visit thereafter; 
8.1.4.6.6.6 Identify strengths and 
limitations; 
8.1.4.6.6.7 Specify services 
necessary to meet the 
consumer's needs; 
8.1.4.6.6.8 Contain goals for the 
consumer to address 
emotional and/or physical 
health as well as growth 
and adaptive 
capabilities. 
8.1.4.6.6.8.1 Goals should be 
based on periodic 
assessment of the 
consumer. 
8.1.4.6.6.8.2 It is acceptable to 
group like needs 
identified in an 
assessment and 
develop a single 
goal to describe the 
group rather than 
have too many 
individual goals. 
8.1.4.6.6.9 Objectives for treatment 
that relate to the goals.
Objectives should be 
described in terms of 
being: 
8.1.4.6.6.9.1 Specific; 
8.1.4.6.6.9.2 Measurable; 
8.1.4.6.6.9.3 Time limited; 
8.1.4.6.6.9.4 Observable changes 
in behavior, skills 
and/or 
circumstances; 
8.1.4.6.6.9.5 Attainable. 
8.1.4.6.6.10 Expected length of 
treatment or achievement 
dates; 
8.1.4.6.6.11 Frequency and duration of 
service; 
8.1.4.6.6.12 Criteria for termination; 
8.1.4.6.6.13 Consumer participation; 
8.1.4.6.6.14 Names of staff 
responsible for 
individual services; 
8.1.4.6.6.15 Referrals for needed 
services; 
8.1.4.6.6.16 Signatures and 
credentials of all 
responsible staff 
involved in treatment 
plan service delivery; 
8.1.4.6.6.17 Dates of signatures, 
additions, deletions; 
8.1.4.6.6.18 Must be reviewed at major 
decision points in the 
consumer's course of 
treatment. These 
decision points include
but are not limited to 
the following: 
8.1.4.6.6.18.1 Time of admission; 
8.1.4.6.6.18.2 Change in diagnosis; 
8.1.4.6.6.18.3 Transfer between 
programs; 
8.1.4.6.6.18.4 Discharge; 
8.1.4.6.6.18.5 Major changes in 
consumer's life 
situation/condition; 
8.1.4.6.6.18.6 At least every six 
months; 
8.1.4.6.6.18.7 Frequent use or 
patterns of use of 
emergency services; 
8.1.4.6.7 Changes in a current treatment plan 
can be made by adding and deleting 
those changes on the same treatment 
plan form with a corresponding 
progress note explaining. 
8.1.4.6.8 The first review at the expiration 
of a treatment plan may be an 
update on the same existing 
treatment plan form. 
8.1.4.6.8.1 It requires all new 
signatures and dates 
indicating agreement 
to prescription of 
services. 
8.1.4.6.9 A new treatment plan must be 
developed annually. 
8.1.4.6.10If there are discrepancies between 
interventions prescribed and 
those actually delivered there 
must be documentation 
describing why it has occurred 
and what steps are
being taken to rectify the 
situation. 
8.1.4.6.10.1 Failure to document 
deviations from written 
prescriptions could 
result in audit 
exceptions. 
8.1.4.7 Documentation for each service provided 
shall include: 
8.1.4.7.1 Date of service provision; 
8.1.4.7.2 Signature and credentials of 
individual making entry; 
8.1.4.7.3 Summary of the intervention(s) and 
their relationship to the treatment 
plan documented in a clinical 
format; and 
8.1.4.7.4 Consumer's condition and response 
to the intervention(s). 
8.1.4.7.5 BE CLEARLY LEGIBLE. 
8.1.4.8 The consumer record should be organized 
in a way conducive to a clear understanding 
of the consumer's current status and 
treatment, as well as history. 
8.1.4.9 Progress note format should be uniform 
throughout the program in a manner 
approved by the Division. 
8.1.4.10 Progress notes should be entered into the 
consumer record within 24 hours of the 
provision of service. 
8.1.4.11 Documentation shall be on forms 
prescribed by the Division. 
8.1.4.12 Medication records (on forms prescribed 
or approved by the Division) shall allow 
for ongoing monitoring of all medication 
administered and the detection of adverse 
drug reactions. 8.1.4.12.1All medication orders and records 
in the consumer case record 
shall specify the following: 
8.1.4.12.1.1 Name of the medication; 
8.1.4.12.1.2 Dose; 
8.1.4.12.1.3 Route of administration; 
8.1.4.12.1.4 Injection site (when 
applicable); 
8.1.4.12.1.5 Frequency of 
administration; 
8.1.4.12.1.6 Side effects or adverse 
reactions noted (when 
applicable); 
8.1.4.12.1.7 Signature and credentials 
of the person prescribing 
and/or administering; 
8.1.4.13 Discharge documentation shall be in a 
format prescribed or approved by the 
Division to include the following: 
8.1.4.13.1Be completed and entered into the 
consumer record no later than 
90 days from last face to face 
visit. 
8.1.4.13.1.1 Any exceptions must be 
documented in a progress 
note and co-signed by a 
supervisor. 
8.1.4.13.2A description of the reasons for 
discharge indicating whether 
the discharge was planned, 
unplanned, and circumstance; 
8.1.4.13.3Overall observations about consumer 
initially, during treatment, 
at discharge;
8.1.4.13.4The consumer's status and condition 
at discharge; 
8.1.4.13.5Assessment of attainment of goals; 
8.1.4.13.6Final diagnosis; 
8.1.4.13.7A plan developed with the consumer 
regarding the consumer's 
continuing or future service 
needs where applicable; 
8.1.4.13.8Clear documentation of referral to 
other programs or agencies 
(when applicable) including, 
whenever possible: 
8.1.4.13.8.1 Date of referral; 
8.1.4.13.8.2 Telephone number; 
8.1.4.13.8.3 Address and contact 
person at referral; as 
well as 
8.1.4.13.8.4 Date of first scheduled 
appointment. 
8.1.4.18 Documentation that the consumer has been 
informed of client rights, including the 
right to contest treatment decisions and 
or practices or otherwise express 
grievances regarding program activities. 
8.1.4.18.1Consumers shall be provided with 
information regarding the 
process by which grievances 
can be addressed. 
8.1.4.18.2A record of all grievances filed 
with the program by a consumer 
shall be included in the 
program's records, together 
with a statement of 
disposition or resolution.
8.2 Procedure Manual 
8.2.1 The Community Mental Health programs shall 
maintain a written procedure manual for 
its staff. A mechanism shall be in place 
to ensure that the procedure manual is 
updated continuously and that the staff 
of the program are notified promptly of 
changes. The manual shall include: 
8.2.1.1 A statement of the program's values, 
mission and objectives; 
8.2.1.2 Referral policies and procedures that 
facilitate consumer referral; 
8.2.1.3 Detailed instructions for assessment, 
treatment planning and documentation 
procedures; 
8.2.1.4 Policies and procedures for medication 
management which shall include, but not 
be limited to: 
8.2.1.4.1 Prescribing; 
8.2.1.4.2 Storage; 
8.2.1.4.3 Handling; 
8.2.1.4.4 Distribution; 
8.2.1.4.5 Dispensing; 
8.2.1.4.6 Disposing; and 
8.2.1.4.7 Recording of medication and it's 
use by consumers. 
8.2.1.4.8 Such policies and procedures shall 
conform to all applicable rules, 
regulations and requirements of the 
(Delaware) Board of Nursing and, as 
applicable, the (Delaware) State 
Board of Pharmacy. 
8.2.1.4.9 The medication policy and procedure 
shall be reviewed and approved by
the program physician and 
registered nurse(s). 
8.2.1.5 Policies and procedures for handling oncall 
responsibilities and consumer 
emergencies; 
8.2.1.6 Detailed instructions for application to 
and communication with entitlement 
authorities; 
8.2.1.7 Policies and procedures for sharing of 
information about consumers with family 
members or others; 
8.2.1.7.1 Policy and procedure regarding 
confidentiality should include a 
signed statement by all personnel 
regarding their understanding and 
agreement to abide by the policy. 
8.2.1.8 Policies and procedures for the receipt, 
consideration and resolution of consumer 
complaints and/or grievances regarding 
treatment decisions and practices or 
other program activities. 
8.2.1.9 Policies and procedures regarding 
the management of consumer's funds for 
whom the program has been designated 
payee; 
8.2.1.10 Policies and procedures for student 
placements and supervision within the 
community mental health program. 
8.2.1.11 Admission and discharge criteria. 
8.2.1.12 Policies and procedures regarding duty to 
warn. 
8.2.1.13 Policies and procedures for acceptable 
handling of cases involving communicable 
disease. 
8.2.1.14 Policies and procedures for response to 
staff who are exposed to potential 
communicable disease while working in the 
mental health program.
8.2.1.15 Policies and procedures regarding 
documentation including clinical; 
financial; and personnel. 
8.2.1.16 Other policies and procedures as may be 
promulgated or required by the Division 
and/or DSS. 
8.3 Financial Management 
8.3.1 There shall be written policies and 
procedures regarding committing and 
handling financial resources of the 
program. 
8.3.2 The accounting system of the community mental 
health program shall be in accordance 
with generally accepted accounting 
practices. 
8.3.3 The Community Mental Health program shall 
submit an independent annual audit and 
management letter prepared by a certified 
public accountant to the Division within 
90 days of the end of the budget period. 
8.3.4 The program's budget shall be in a format 
prescribed by the Division and approved 
by the Division. Funding shifts within 
the budget shall be made in accordance 
with the financial policies of the 
Division. 
8.3.5 Procurement of equipment and services for the 
program shall be made in compliance with 
the Code of Federal Regulations. 
8.3.6 For Medicaid consumers, the fee paid by DSS, 
Delaware Medical Assistance Program will 
constitute full payment for services 
rendered. 
8.3.6.1 The community mental health program will 
bill for services rendered to non- 
Medicaid consumers according to the 
Medicaid approved rate. 
8.3.6.2 In addition, the program will seek third 
party reimbursement and will establish a
sliding fee scale for non-Medicaid 
consumers. 
8.3.6.3 The program's charges, sliding fee scale, 
collections policies and procedures and 
write-off policies and procedures shall 
be subject to approval by the Division. 
8.3.6.4 Non-Medicaid billings and revenue 
collected shall be reported to the 
Division. 
8.3.7 Fee for service reimbursement rates paid by 
Delaware Medical Assistance Program are 
based on the program's approved budget 
and actual costs; and are subject to 
approval by the rate setting committee as 
appointed by DSS; and 
8.3.7.1 Are subject to periodic monitoring and 
adjustment. 
8.3.8 The Community Mental Health program shall 
maintain insurance policies for property 
and liability in accordance with Division 
guidelines. 
8.3.9 The Community Mental Health program shall 
operate in accordance with a Financial 
Management Procedure Manual which shall 
address the following: 
8.3.9.1 Processing of funds: i.e., 
8.3.9.1.1 Procedures for receiving, recording 
and depositing incoming funds; and 
8.3.9.1.2 Procedures for disbursement of 
funds; 
8.3.9.2 Purchasing: i.e., 
8.3.9.2.1 Establishment and use of agency 
charge accounts; 
8.3.9.2.2 Transactions requiring prior 
approval; and 
8.3.9.2.3 Procedure for acquisition of goods 
and services requiring bids;
8.3.9.3 Payroll: i.e., 
8.3.9.3.1 Preparation process; 
8.3.9.3.2 Pay periods; 
8.3.9.3.3 Maintenance and approval of time 
sheets; 
8.3.9.3.4 Payroll register; 
8.3.9.3.5 Employee earnings; 
8.3.9.3.6 Payment of payroll taxes; 
8.3.9.3.7 Signatures required on payroll 
checks; and 
8.3.9.3.8 Maintenance of payroll records; 
8.3.9.4 Petty Cash: i.e., 
8.3.9.4.1 Allowable uses; 
8.3.9.4.2 Authorization; 
8.3.9.4.3 Maximum balance; 
8.3.9.4.4 Limits on transactions; 
8.3.9.4.5 Documentation and reconciliation 
and replenishment of petty cash; 
8.3.9.5 Internal Controls: 
8.3.9.5.1 Accurate and complete books of 
account; 
8.3.9.5.2 Separation of functional 
responsibilities; 
8.3.9.5.3 Financial reports; 
8.3.9.5.4 Proper documentation; 
8.3.9.5.5 Annual audit; and 
8.3.9.5.6 Bonding for employees handling 
financial transactions.
8.4 Personnel Management 
8.4.1 The Community Mental Health program shall 
maintain an up-to-date Personnel Policies 
and Procedures Manual and make it readily 
available for reference by the program 
staff. State operated programs shall 
comply with Merit Rules and Labor 
Contracts. The Manual will include: 
8.4.1.1 Policies and procedures regarding equal 
employment opportunity and affirmative 
action to include compliance with: 
8.4.1.1.1 The Americans with Disabilities Act 
and the Vocational Rehabilitation 
Act of 1973, Sections 503 and 504 
prohibiting discrimination against 
the handicapped; 
8.4.1.1.2 Title VII of the Civil Rights Act 
of 1964 prohibiting discrimination 
on the basis of race, color, creed, 
sex or national origin; 
8.4.1.1.3 Age discrimination Act of 1975 
prohibiting discrimination based on 
age; 
8.4.1.1.4 Section 402 of the Vietnam Era 
Veterans Readjustment Assistance 
Act of 1974 prohibiting 
discrimination against disabled 
Vietnam Era veterans. 
8.4.1.2 Policies and procedures for interviews 
and selection of candidates including 
verification of credentials and 
references; 
8.4.1.3 Policies and procedures for employee 
performance appraisal; 
8.4.1.4 A code of ethics; 
8.4.1.5 Conditions and procedures for termination 
of employment; 
8.4.1.6 Conditions and procedures for grievances 
and appeals;
8.4.1.7 A staff development plan; 
8.4.1.8 Maintenance and access to personnel files 
which shall contain employees' 
applications, credentials, job 
descriptions, and performance appraisals, 
job titles, training, orientation, 
salary, staff statement of 
confidentiality. 
8.4.1.9 Work hours including hours of program 
operation, shifts and overtime 
compensation. 
8.4.1.10 Agency policies regarding compensation 
including: 
8.4.1.10.1salary ranges, salary increases, 
and payroll procedures; 
8.4.1.10.2Use of personal automobile for 
program activities; 
8.4.1.10.3Reimbursement for work related 
expenses; 
8.4.1.10.4Description of employee benefits. 
8.5 Staff Development Plan 
8.5.1 The staff development plan shall include 
provisions for orientation of paid staff, 
student interns and volunteers and for 
continuing education. 
8.5.2 Orientation shall include the following: 
8.5.2.1 Review of these procedures; 
8.5.2.2 Review of the program's procedure and 
personnel manuals; 
8.5.2.3 Review of DHSS Policy Memorandum #46; 
8.5.2.4 Review of section 5161 of Title 16 of the 
Delaware Code regarding safeguarding 
confidentiality;
8.5.3 Staff Development shall include the following: 
8.5.3.1 An annual plan for continuing education 
both through on-site training and 
participation in state, regional and 
national programs; 
8.5.3.2 Provision for regularly scheduled 
clinical supervision by clinician level 
staff which teach and enhance the 
clinical skills of staff. In addition, 
the following should also be provided: 
8.5.3.2.1 Regularly scheduled staff meetings 
led by a supervisor during which 
assessments, treatment plans and 
progress toward treatment goals are 
reviewed and staff receive 
direction regarding clinical 
management of treatment issues. 
8.5.3.2.2 Regularly scheduled individual, 
face-to-face sessions between a 
supervisor and staff to review 
cases, assess performance and give 
feedback. 
8.5.3.2.3 Individual, side-by-side sessions 
during which the supervisor attends 
clinical sessions conducted by 
staff to assess performance, teach 
clinical skills, and give feedback. 
8.5.3.2.4 The frequency, duration, and 
specifics of all supervision should 
be described in the community 
mental health center's policy and 
procedure manual. 
8.5.3.2.4.1 Documentation of 
supervision should be 
maintained by each 
supervisor. At a minimum, 
it should contain: 
8.5.3.2.4.1.1 Date of supervision; 
8.5.3.2.4.1.2 Names of staff 
present;
8.5.3.2.4.1.3 Issues 
addressed/content of 
session; 
8.5.3.2.4.1.4 Assignments made; 
8.5.3.2.4.1.5 Resolutions of any 
issues. 
8.5.3.2.4.2 All supervision 
documentation must be 
available for review by 
site surveyors upon 
request. 
8.5.3.2.5 Regular staff conferences at which 
current principles and methods of 
treatment, rehabilitation and 
support services are presented. 
8.5.3.2.6 Provision of a method for staff to 
receive suggestions and/or feedback 
from multiple disciplines regarding 
cases difficult to treat and/or 
cases of unusual components. 
8.6 Quality Assurance Program 
8.6.1 The Community Mental Health program shall 
prepare an annual quality assurance plan 
which shall be subject to approval by the 
Division. A clinician employed by the 
program shall be designated quality 
assurance coordinator. The provider 
shall establish the following quality 
assurance mechanisms which shall be 
carried out in accordance with the 
quality assurance plan: a concurrent 
utilization review process; a 
retrospective quality assurance review 
process; a process for clinical care 
evaluation studies; and a process for 
self-survey for compliance with the 
certification procedures. 
9 Waiver of Provisions 
10.1. The Director of DSAMH, at his/her discretion, may 
issue a waiver of any of the requirements of 
these certification procedures upon the
good-cause-shown request of a program seeking 
certification/recertification. Such request 
for a waiver must demonstrate that the waiver 
will not in any substantial or material manner 
have a deleterious effect on the essential 
quality of services to the consumer. 
10.1.1 Waivers issued by the Director shall be in 
writing and shall specify the maximum duration 
of the waiver's effect. 
10.1.1.1 Any waiver issued by the Director may be 
rescinded at any time at the discretion 
of the Director and will be rescinded if 
deleterious effect on the essential 
quality of service to the consumer is 
evidenced. 
10.1.1.2 Extensions and/or renewals of any waiver 
shall be made at the Director's 
discretion.