QRTP Placements 624-05-20-17

(NEW 1/15/21 ML #3606)

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PI 21-22

 

 

Family First Prevention Services Act (FFPSA) seeks to restrict the use of residential settings and instead emphasizes placement of foster children in family settings. Federal regulations grant authority to states to place in approved foster care settings; one being a qualified residential treatment program (QRTP). A QRTP shall use a trauma-informed treatment model and employ registered or licensed nursing staff and other licensed clinical staff to engage in short term treatment. The QRTP placement is only available to:

1. Children under the public custody of a Human Service Zone, Tribe or Division of Juvenile Services and
2. Children, not in public custody, who have been approved for placement and reimbursement by the NDDHS Voluntary Treatment Program.

CANS Assessment

North Dakota has elected to utilize the Child and Adolescent Strengths and Needs assessment which is a multi-purpose tool developed to support decision making, level of care and service planning, while monitoring outcomes. The CANS assessment will be completed by the Qualified Individual and an assessment report will be provided to the custodial case manager.

• If interested in learning more about the CANS tool “Standard CANS Comprehensive 2.0”, it is available at: https://praedfoundation.org/general-manuals-cans/

Qualified Individual

The term ‘Qualified Individual’ means a trained professional or licensed clinician who is not an employee of the state child welfare program and who is not connected to, or affiliated with, any public agency or placement setting in which children are placed.

 

The Department contracted with an independent third-party vendor, Maximus Ascend, known to ND as “Ascend” in efforts to hire contracted employees to complete a third-party formal assessment for the QRTP level of care. The contracted employees hired by Ascend will be located throughout North Dakota and assigned cases based on geographic area and ability to meet timeliness standards. All Qualified Individual assessment efforts will be monitored and reviewed by an Ascend Utilization Review Clinician located in the headquarter office of Tennessee. The Qualified Individual will complete the assessment and provide a recommendation to Ascend. The Ascend Utilization Review Clinician will review the recommendation along with supporting documentation to determine the child’s level of care eligibility based on the North Dakota algorithm. Random cases will be reviewed and staffed by Ascend with the Department of Human Services QRTP Clinical Alignment Team (Administration from DHS Children and Family Services and Field Services).

 

The Qualified Individual will:

1. Receive the referral information including the Universal Application (SFN 824) and all supporting documentation from the custodial case manager via fax.
2. Work in conjunction with the custodial case manager, family and members of the child and family team to complete interviews timely.
3. If the child is placed as an emergency placement the Qualified Individual will also speak with the QRTP therapist and/or QRTP treatment coordinator.
4. Meet with the custodial case manager in a mutually convenient location where the child is also able to participate in the interview for assessment, likely the case manager’s office or in the QRTP if already placed. If the assessment visit is being completed onsite at a QRTP, the QRTP shall ensure and provide the Qualified Individual with a private office space in order to complete the assessment and interviews in private.

1. If a child is placed out of state, Ascend can complete the CANS assessment via, Skype, FaceTime or Telephone call.
2. The Department has granted one out of state exception; if a North Dakota child is placed in the Moorhead, Minnesota Detention Center a Qualified Individual can arrange to visit the child in the detention center location. This exception was granted based on a contract for detention center services in the Fargo-Moorhead area.

5. Complete required interviews within 5 working days of the referral date.
6. Assess the strengths and needs of the child using Child and Adolescent Needs and Strengths (CANS) assessment tool.
7. Determine whether the needs of the child can be met with family members or through placement in a family foster home or, if not, recommend a type of setting that would provide the most effective and appropriate level of care for the child in the least restrictive environment.
8. Determine whether the needs of the child are consistent with goals for the child, as specified in the case plan for the child.
9. Develop a list of child-specific short and long-term goals.
10. Provide, in writing, a formal QRTP Assessment Report to the custodial case manager within 10 working days of the referral date.

The Qualified Individual has the authority to make an approval or denial determination based on the ND Qualified Residential Treatment Program (QRTP) level of care. The Qualified Individual cannot dictate which QRTP a child can be placed; their role is to determine if the QRTP level of care is appropriate.

 

Grandfathered in Youth

Youth will be “grandfathered in” to a North Dakota licensed QRTP if placement occurred prior to October 1, 2019. The youth will receive a formal baseline CANS assessment initiated by Ascend. Ascend will contact the custodial case manager with the details regarding arrangements to complete the required assessment. Upon notice from Ascend, the custodial case manager will be responsible to:

1. Submit a new Universal Application (SFN 824)
2. Submit supporting documentation and rationale as to why the QRTP level of care is the most appropriate.

Grandfathered in youth will either be determined:

1. Approved for the QRTP Level of Care,

1. The 90-day approval period starts on the date of the QRTP level of care determination.
2. The placement maximum date starts effective October 1, 2019.

2. Denied for the QRTP Level of Care,

1. A new placement must occur within the 30-days from the date of the QRTP denial.
2. If the custodial case manager chooses to seek a reconsideration of the denial and the denial is upheld, the 30-day time frame starts on the date the initial denial was made. If the appeal was overturned, the 90-day approval starts on the date the initial determination was made.

Emergency Placement

An emergency placement into a QRTP is allowable prior to a completed assessment by the Qualified Individual. It is the responsibility of the custodial case manager to submit the Universal Application (SFN 824) and relevant supporting documentation to Ascend and the desired QRTP’s for admission acceptance.

• If the child is placed as an emergency placement and is approved by the Qualified Individual for the QRTP level of care, the child’s 90-day approval period starts on the date of admission.
  
  
  
  
• If the child is placed as an emergency placement and is denied by the Qualified Individual, the child’s length of stay in a QRTP is not to exceed 30 days from date of admission. The Department will allow reasonable discharge planning and payment to occur, not to exceed 30 days.
  
  
  
  
• Emergency placements “back to back” are prohibited. If the child was placed on an emergency basis and is denied, a child may not re-enter the QRTP as an emergency placement. Back to Back is further defined that an emergency placement cannot occur for 30 days from discharge unless an onset or increase of high-risk behaviors are present. High-risk behaviors include danger to self or others, self-injurious behaviors, sexual aggression, fire setting and runaway if present with additional dangerous behaviors, or the youth runs to unsafe environments where the likelihood to be victimized is high. If an emergency placement is determined necessary in less than 30 days, the custodian must request permission from the central office via dhscfs@nd.gov. This will provide authorization to place a child back into a QRTP as an emergency placement. If reviewed and approved by the central office, the case manager will be notified and responsible to submit a reconsideration request to Ascend.
  
  
  
  
• Although the custodial case manager is primarily responsible to work directly with Ascend, the QRTP is expected to ensure an approval is granted for a child to remain in that level of care. If the QRTP does not receive notice that the placement has been approved within 15 days of admission, the QRTP should be asking the custodial case manager for the assessment report.

Placement Approvals into QRTP

A child who has been approved and placed at the QRTP will be granted an approval for a 90-period beginning at the date of placement. The custodial case manager does not need pre-approval from either Ascend or the Court before placement can occur.

• 30-day window: The approval to be placed in a QRTP is valid up to 30 days; meaning a child must be placed in the QRTP within 30 days of receiving the approval from the Qualified Individual. If the QRTP placement is not available for more than 30 days, a new SFN 824 and CANS assessment must be completed.
  
  
  
  
• Pending Approval: There may be cases where the child is in need of acute hospitalization to stabilize prior to a QRTP treatment stay. The CANS assessment may indicate a pending approval for a QRTP, not to exceed 10 days. If the child successfully discharges from acute hospitalization the pending approval would allow transition into a QRTP upon discharge. The custodial case manager would need to notify Ascend of the acute discharge via fax to ensure the pending approval remains valid.
  
  
  
  
• Bed Hold: If a child who has been approved and placed at QRTP is in need of temporary psychiatric hospitalization, the temporary acute care is allowable. If the QRTP is willing to accept the child back into placement, the facility is allowed a 14-day bed hold for reimbursement to the QRTP and a new assessment is not required.
  
  
  
  
• Transition: A child may be transitioned from one QRTP to another if it is determined in the best interest for their treatment. The current Ascend QRTP approval will follow the child to their new QRTP location, while the placement maximums and approval timeframes remain.

Placement Maximums

QRTP placement is closely regulated by federal regulations and the age of the child. A foster child 13 years of age and older shall not exceed placement into a QRTP for more than 12 consecutive months (365 days) or 18 non-consecutive months (545 days). A foster child age 12 and younger shall not exceed placement in a QRTP for more than 6 consecutive months (180 days).

• A child who has been placed at a QRTP for 12 consecutive months may not re-enter a QRTP facility for a period of 90 days unless high-risk behaviors are present. High-risk behaviors include danger to self or others, self-injurious behaviors, sexual aggression, fire setting and runaway if present with additional dangerous behaviors, or the youth runs to unsafe environments where the likelihood to be victimized is high. If placement is determined necessary in less than 90 days, the custodian must request permission from the central office via dhscfs@nd.gov. This will provide authorization to place a child back into a QRTP. If reviewed and approved by the central office, the case manager will be notified and responsible to submit the universal application and supporting documentation to Ascend.
  
  
  
  
• Example: If a 12-year-old is placed at the QRTP and turns 13 during their placement stay, those days already placed at a QRTP are part of their placement maximums of 12 consecutive months because the child is now 13. The placement maximums in this example begin the date the child entered the QRTP when he/she was 12. The child is 12 and six months of placement is expiring, however the child will soon turn age 13 and has a valid QRTP approval that extends beyond the child’s 13th birthday, a placement extension request must still be made to the Department. This is a notification of the current placement, birthday of the child, approval to continue treatment and a request to extend until the 13th birthday to fill the gap.

The placement maximums are specific to the QRTP level of care, not individual facilities. It is important that case managers are aware of and track the placement maximums, while recognizing the importance of referring children to a QRTP only if he/she needs treatment. If the length of stay is greater than the federal requirements, state approval from the ND Department of Human Services Executive Director is required. This process for a placement extension will be requested by the custodial case manager at least 30 days prior to reaching placement maximums.

 

In order to request a placement extension, the custodial case manager must:

1. Complete the SFN 826;
2. Write a summary indicating the child’s needs and barriers to achieving treatment goals requiring a longer stay in the facility;
3. Provide supporting documentation of progress and discharge plans;
4. Detail the requested/estimated amount of time required to complete the treatment; and
5. Submit the required paperwork to the Department via dhscfs@nd.gov with an email subject titled “QRTP Placement Extension Request”.
6. The QRTP Clinical Alignment Team will review the request within 3 working days of submission.

1. If determined unnecessary to submit to the Executive Director, the custodial case manager will receive notice to discharge.
2. If determined necessary to submit to the Executive Director, the custodial case manager will receive a final decision of placement extension.

Case Manager Responsibility

The custodial case manager is responsible to seek least restrictive most appropriate placement settings for each child in foster care. It is the responsibility of the custodial case manager to ensure all referral information and supporting documentation is provided to Ascend and the desired QRTP. If the required referral paperwork is not filled out and supporting documentation is not submitted with the application, Ascend has the authority to reject and send back or be denied due to insufficient information.

 

The custodial case manager is responsible to:

1. Complete the referral paperwork in its entirety inclusive of the Universal Application (SFN 824) and supporting documentation. Supporting documentation may include a recent psychiatric evaluation, diagnostic evaluation, treatment plan, specialist evaluation, IQ Testing, IEP, etc.
2. Submit referral documentation to:

1. Each QRTP desired for placement and
2. Fax to Ascend at 877-431-9568 to begin the assessment; each fax must include, an Ascend Referral Fax Cover Sheet. A copy of the cover sheet can be obtained from the Ascend website.
3. If the child was placed at a QRTP on an emergency, the SFN 824 to Ascend shall also include any intake assessments completed onsite by the QRTP.

3. Engage in discharge planning upon admission to the QRTP.
4. Track the length of stay a child is in a QRTP during the approval periods. If a child remains in a QRTP after an approval period ends, the QRTP is at risk of non-payment and the custodial agency will be responsible for reimbursement.
5. Submit evidence at each court review and each permanency hearing held with respect to the child demonstrating that ongoing assessment of the strengths and needs of the child continues to support the determination that the needs of the child cannot be met through placement in a family setting at this time. Custodial case managers want to ensure the court grants general placement and care authority in the court order, this allows the flexibility to move a child to a higher or lower level of care as appropriate. If the court order limits the child’s placement to only a family setting or a QRTP level of care, the case will need to go before a judge to be granted authority to move the child if a different level of care is warranted.
6. Seek least restrictive family setting placements ongoing. Federal regulation specifically indicates that the unavailability of a family foster home is not a sufficient reason to place a child in a QRTP. Federal regulations emphasize that a shortage or lack of foster family homes is not an acceptable reason for determining that the needs of the child cannot be met in a lower level of care.
7. Communicate with the child, as developmentally appropriate, about the placement decisions being made to assist in meeting their permanency plan.

1. The client may request to remain at the QRTP level of care, however, level of care determination is made specific to the appropriateness of a treatment setting and not equivalent to the comfortability of a child’s placement preference.
2. Residential settings are intended to be limited for treatment needs and services. It is important for the child to know the QRTP (whom they have a relationship with) will be providing aftercare services for up to six months. This requirement of aftercare services offers continuity of care and connections to not only the QRTP, but service providers and supports locally in the child’s community.

8. Submit the approved QRTP Assessment Report to:

1. The QRTP facility accepting placement to ensure appropriate and ongoing services are provided to meet needs of the child, and
2. The Field Service Specialist to ensure accurate placement approval dates in FRAME and for timely reimbursement of payment to the QRTP. Group Home Approvals will be approved for the timeframe in which the QRTP assessment report reflects. However, if the court order expires prior to the 90-day approval, the group home approval cannot exceed the court order expiration date.
3. Discharge option placement provider, TFC agency or foster parent upon request.

Universal Application (SFN 824)

The state form is completed by the custodial case manager detailing current and immediate need for out of home treatment. In addition to this form; the custodian must attach additional supporting information to determine placement to best meet the needs of the child. This form must be submitted to Ascend and the desired QRTP.

• The state form must be completed electronically.
• The state form is fillable and savable for future editing.

Continued Stay Review (SFN 826)

The state form is completed by the custodial case manager for all children placed in a QRTP for treatment. The continued stay review form must be completed no greater than 30 calendar days prior to placement approval expiration and no less than 20 calendar days before the placement approval expires. The Qualified Individual will have 10 working days to review the request to continue in a QRTP.

• The state form must be completed electronically.
• The state form is fillable and savable for future editing.

Continued Stay Review (CSR) Timelines and Process

• 3 months = A document review. The Ascend utilization Reviewer will conduct a phone interview with the custodial case manager.
• 6 months = A full review. The Qualified Individual will conduct in-person interviews with the custodial case manager, the youth, the QRTP treatment coordinator and any other relevant parties.
• 9 months = A document review. The Ascend utilization Reviewer will conduct a phone interview with the custodial case manager.
• 12 months = A full review. The Qualified Individual will conduct in-person interviews with the custodial case manager, the youth, the QRTP treatment coordinator and any other relevant parties.

Ascend will coordinate and lead all continued stay reviews to determine ongoing approval in the QRTP level of care.

 

Approval Extension Request Form

Ascend, as the contracted Qualified Individual vendor, generated a form for custodial case managers to complete in order to request an extension for the QRTP approval period. The extension may be granted for a period of up to 14 days. If approval is needed for longer than 14 days, the continued stay review (SFN 826) shall be completed. The Extension Request Form is only required when a discharge plan and discharge date has been identified and an extension is requested to meet the discharge plan. The form can be found on the Ascend website.

 

Reconsiderations- Submit to Ascend

If a child receives a denial for the QRTP level of care, it is the responsibility of the custodial case manager to reconvene necessary parties to identify local or in-state resources to meet the child’s needs. If it is determined, information needed for the QRTP approval was missing, the custodial case manager may choose to submit a reconsideration request to Ascend.

 

If requesting a reconsideration, the custodial case manager must:

• Submit a reconsideration request form found online on the Ascend website;
• Any documentation not previously submitted resulting in the denial or any new supporting information or documentation;
• Detailed rationale as to why the QRTP level of care is most appropriate; and
• Submit to Ascend within 5 working days of receiving the initial denial.

Ascend will review the information within 5 working days of receipt of the reconsideration and determine an approval or denial for QRTP. While awaiting the decision of the reconsideration, custodial case managers must simultaneously work to identify a community care plan, resources and supports to best meet the needs of the child.

 

DHS Temporary Approval

QRTP Clinical Alignment Team may consider granting a temporary approval on a case by case basis in efforts to not disrupt a child’s treatment. A temporary approval will allow the custodial case manager permission to submit a second “reconsideration request” to Ascend detailing new information before the required discharge.

 

Ex. Youth has completed the assessment process with Ascend and was recommended a higher level of care. During the window to discharge, there were no higher level of care beds available. While attempting to locate appropriate level of care placement, the youth began engaging in treatment at the QRTP and has stabilized in efforts to remain at the QRTP level of care in lieu of transition. With a DHS temporary approval, a custodial case manager may submit a second reconsideration to Ascend with new information regarding the child’s engagement at the QRTP. Such reconsiderations are prohibited from being submitted to Ascend without temporary approval form DHS.

 

In order to request a DHS temporary approval, the custodial case manager must:

1. Write a summary indicating the child’s recent change in treatment engagement;
2. Provide supporting documentation of clinical treatment team notes and recommendations;
3. Submit to dhscfs@nd.gov with an email subject titled “DHS Temporary Approval Request”.
4. The QRTP Clinical Alignment Team will review the request within 3 working days of submission.

1. If determined unnecessary to submit to Ascend, the custodial case manager will receive notice to discharge.
2. If determined necessary to submit to Ascend, the custodial case manager will receive a final decision of temporary approval to complete a second reconsideration.

Managing QRTP Denials

The role of Ascend is to determine an approval or denial into a QRTP. If the determination results in a denial of QRTP, Ascend will recommend higher or lower categories of care. If a lower level of care is recommended, the custodial case manager may seek any combination of lower levels of care to meet the child’s needs in the least restrictive environment.

 

If a case is denied the QRTP level of care, the custodial case manager shall reconvene necessary parties to identify local or in-state resources to meet the child’s needs; which may include members of the Child and Family Team. If necessary, the custodial case manager may submit all supporting documentation to the Regional Review Team Coordinator. The Regional Review Team Coordinator will determine if the case requires a Regional Review Team meeting. Regional Review Team members shall ensure all resources have been exhausted to transition or accommodate the individual in the least restrictive environment.

 

Regional Review Teams operate under clinical administration of the regional Human Service Centers. The custodial case manager shall refer to the Human Service Center office affiliated with the county in which the case originated.

 

On occasion, local teams may be unable to identify sufficient resources and services to meet the child’s needs. The Regional Review Team Coordinator may request a State Review Team meeting. The Regional Review Team Coordinator shall submit all supporting documentation provided by the case manager including:

1. Rationale as to why QRTP remains the least restrictive level of care;
2. The submitted Universal Application (SFN 824), which received the denial;
3. Current supporting information, inclusive of mental health evaluations, treatment plan, diagnostic evaluations, specialist evaluations, completed IQ Testing, IEP, previous placement setting tried and failed, as well as current options sought including all in state and out of state placement options; and
4. Email such documentation to the State Review Team Coordinator at SRT@nd.gov with an email subject line indicting ‘Region #: QRTP Denial’

The State Review Team Coordinator will communicate with the QRTP Clinical Alignment Team to review denials and determine if the case does rise to the level of a formal state review. The QRTP Clinical Alignment Team will meet within 3 working days of receiving the request. If warranted, the State Review Team will meet within 3 working days of the QRTP Clinical Alignment Team receiving the denial request.

 

The Department of Human Services recognizes the need for staffing cases when local resources/supports are insufficient to meet identified needs. However, local agencies and Human Service Zones are required to engage families, case plan, develop resources, identify service gaps, while recruiting and retaining viable placement resources to meet local needs. The intention of the State Review Team is to not identify placements, rather to support regions in promoting resiliency by providing technical assistance and access to financial resources and supports if a community care plan is developed to meet the complex needs of a child.

 

QRTP Aftercare Services

When a child is approved and admitted for treatment, the child is required to be provided aftercare services by the QRTP facility per NDAC 74-03-40 post discharge.

 

• If a child was grandfathered in on October 1, 2019 and remained placed beyond 30 days the child does meet the eligibility of a treatment resident and is eligible for aftercare services.
• If a child is placed as an emergency placement and denied for QRTP level of care, the child does not meet the eligibility of a treatment resident and the facility is not required to provide the aftercare services.

Aftercare services shall include coordinating of services, supporting the current placement location (relative, foster home, parent, etc.), tracking of client outcomes and other tasks as defined by the QRTP. The outcomes will be collected by the QRTP in conjunction with the youth and the family for six-months post-discharge.

 

Out of State Placements

Foster children placed in a residential facility out-of-state prior to October 1, 2019 may remain in placement until treatment is complete. The out-of-state facility remains eligible because the residential facility is licensed in that state of jurisdiction and approved by that state’s IV-E plan; making the placement reimbursable with foster care funding.

 

Placement length of stay maximums do not apply to out of state facilities as the child is not placed in a licensed QRTP.

 

The Department does not prohibit children from being placed outside of the state of North Dakota, however it is highly discouraged to place a child away from their connections and reunification or permanency plan options. If seeking an out of state placement, Interstate Compact for the Placement of Children (ICPC) must be followed. Before seeking out of state residential placement, in-state QRTP facilities must deny the child for admission. The current list of approved out of state facilities is located online at the Children and Family Services website.

 

Ascend Contact Information

Fax: (877)-431-9568

Phone: (844) 933-3772

Email: ND_FFPSA@MAXIMUS.com

Website: https://maximusclinicalservices.com/svcs/north_dakota_ffpsa

• Fax Coversheet
• Desk Reconsideration Request Form
• Extension Request Form
• Trainings and Education