Children's Treatment Services Level of Care Determinations 624-05-20-13

(Revised 10/1/2024 ML 3864)

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Family First Prevention Services Act (FFPSA) seeks to reduce the over-reliance of residential long-term placements, instead the federal regulation emphasizes children in foster care are to be placed in family settings, whenever possible. North Dakota implemented FFPSA qualified residential treatment program (QRTP) requirements on October 1, 2019. Since that time, Children and Family Services (CFS) has seen an increased need for children in foster care who present with complex behavioral health needs receiving treatment services in a family setting. Children in foster care are eligible to receive the ND Children’s Treatment Services Level of Care Determination, an assessment to determine placement based on the child’s mental and behavioral health needs. The streamlined assessment will ensure that children receive the right service, at the right level of care, for the right duration of time. The assessment will determine if the child is best served in Treatment Foster Care (TFC), a Qualified Residential Treatment Program (QRTP), a Psychiatric Residential Treatment Facility (PRTF) or deny the child by recommending the most appropriate setting.

 

Treatment Foster Care and QRTP placements are only available to:

  1. Children under the public custody of Human Service Zone, North Dakota Tribal Nation or Division of Juvenile Services; and

  2. Children who remain in custody of their parents and have been approved for placement and reimbursement by the HHS Behavioral Health Voluntary Treatment Program.

 

CANS Assessment

North Dakota is utilizing the Child and Adolescent Strengths and Needs (CANS) 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 a contracted Qualified Individual who will complete an assessment report, identifying the child's approved level of care.

 

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 in foster care are placed.

 

The Department holds a contract with an independent third-party vendor, who hires contracted employees to complete a formal assessment for the TFC, QRTP and PRTF levels of care. The Qualified Individuals are 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 a Utilization Review Clinician. The Qualified Individual will complete the assessment and provide a recommendation. The Utilization Review Clinician will review the recommendation along with supporting documentation to determine the level of care. Random cases will be reviewed and staffed with the Department of Health and Human Services Clinical Alignment Team.

 

The Qualified Individual will: 

  1. Receive the referral information including the Universal Application (SFN 824) or the Continued Stay Review Form (SFN 826) and all supporting documentation from the custodial agency worker.

  2. Receive the attestation from the treatment agency (PRTF, QRTP, or TFC) and documentation, if applicable.

  3. Interview the custodial agency worker, family and members of the child and family team, when appropriate. Required interviews must be completed withing these parameters: 

    1. Emergency placement is virtual only and the determination must be completed within 3 working days.

    2. Non-Emergency (face-to-face or virtual) and the determination must be completed within 7 working days.

    3. Facilitated face to face in a mutually convenient location. The custodial agency worker may grant approval to the Qualified Individual to complete a virtual assessment via a secure platform.

    4. Interview the treatment agency, when applicable.

  4. Assess the strengths and needs of the child using the CANS assessment tool.

  5. Determine whether the needs of the child can be met in the least restrictive environment with family or through placement in a foster home.

  6. Determine whether the needs of the child are consistent with goals specified in the case plan.

  7. Develop a list of child-specific short and long-term goals.

  8. Provide, in writing, a formal assessment report to the custodial agency worker within 3 working days if an emergency placement and 7 working days if a non-emergent placement from the completed referral date.

The Qualified Individual has the authority to make an approval or denial recommendation based on the ND treatment levels of care. The Qualified Individual cannot dictate which treatment placement a child can be placed; their role is to determine what is the least restrictive most appropriate level of care for the child based on their current symptoms or behaviors.

 

Case Worker Responsibility

The custodial case worker is responsible to seek least restrictive most appropriate placement settings for each child in foster care. 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.

Regarding the Children’s Treatment Services Level of Care Determination, the custodial case worker 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, therapy notes, diagnostic evaluation, treatment plan, specialist evaluation, IQ Testing, IEP, etc.

    1. If the required referral paperwork is not filled out and supporting documentation is not submitted with the application, the Qualified Individual has the authority to reject the referral due to insufficient information.

  2. Submit referral documentation to: 

    1. The treatment agency desired for placement and

    2. Assessment Pro

  3. Engage in discharge planning upon admission.

  4. Track the approval period timeframes.

  5. Track the child's placement maximums.

  6. Communicate with the child, as developmentally appropriate, about placement decisions being made to assist in meeting their permanency plan:

    1. The 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 time limited for treatment needs and services.

    3. If approved for QRTP, upon discharge the facility is required to provide 6 months post discharge support to ensure continuity of services.

  7. Specific to QRTP: Submit evidence at each court review and each permanency hearing held demonstrating that ongoing assessment of the strengths and needs of the child continues to support that the needs of the child cannot be met through placement in a family setting at this time. Custodial case workers 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 only 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.

  8. Submit the approved Assessment Report to the: 

    1. Treatment agency accepting placement to ensure appropriate and ongoing services are provided to meet the needs of the child and for reimbursement/ billing purposes, and

    2. CFS Field Service Specialist to ensure accurate placement approval dates in FRAME and for timely reimbursement of payment to the QRTP. FRAME Group Home Approvals (GHA) will be reviewed and approved for the period of time reflected in the QRTP assessment report. The GHA comments box must indicate the difficult of care level specified on the QRTP Assessment report.

 

Children Treatment Services Level of Care Determinations - Initial Screening

A custodial agency wanting to place a child into residential treatment (QRTP, PRTF) must first complete the screening to ensure the custodial agency has exhausted community-based resources to meet the needs of the child, before seeking residential treatment. If placed as an emergency basis in either QRTP or PRTF or seeking TFC placement, the screening is not required. For more information on symptoms and behaviors, see the Level of Care Chart for reference.

 

Approved screening

If the case has been reviewed and the screening indicates a yes in all 6 categories, the custodial agency can proceed to upload the SFN 824, screening and required supporting documents to Assessment Pro to initiate an assessment.

 

Denied Screening

If the case has been reviewed and is not yes in all 6 categories, the child is ineligible to move forward with a Children’s Treatment Services Level of Care Determination. The custodial agency should work with their local Human Service Center for further assessment and services.

 

Emergency Placements:

An emergency placement into a PRTF, QRTP or treatment foster home is allowable prior to a completed assessment by the Qualified Individual. It is the responsibility of the custodial agency worker to submit the Universal Application (SFN 824) and relevant supporting documentation to the treatment agency for immediate placement review and acceptance. (Child Welfare Workflow. Children Treatment Services) The custodial agency must immediately upload the Universal Application (SFN 824) and relevant supporting documentation to Assessment Pro, to initiate a Children's Treatment Service's Level of Care Determination. If a child is placed as an emergency placement, the assessment interview will be virtual and must be completed with 3 working days. The treatment agency will submit the treatment agency Attestation (SFN 831) and supporting treatment documentation completed upon admission directly to the vendor through Assessment Pro. It is imperative custodial agencies recognize the approval timeframes are different based on the child's approved level of care.

 

Emergency Placement Parameters

  1. If the child is placed as an emergency placement and is denied by the Qualified Individual, the child’s length of stay at the QRTP or treatment foster care level 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.

  2. Emergency placements "back-to-back" are prohibited. If the child was placed on an emergency basis and is denied, a child may not be reassessed for a period of 30 days from discharge from any level of care.

    1. Back-to-Back is further defined that an emergent 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 child runs to unsafe environments where the likelihood to be victimized is high.

    2. If and emergency placement is determined necessary in less than 30 days, the custodian must request permission from Children and Family Services (CFS) via cfslicensing@nd.gov. This will provide authorization to place a child back as an emergency placement. If reviewed and approved by the CFS, the agency worker will be notified and responsible to submit a reconsideration request.

 

Universal Application (SFN 824)

The state form is completed by the custodial agency worker detailing current and immediate need for out of home treatment. In addition to this form, the custodian must attach supporting information. This form must be submitted to the Qualified Individual and the treatment agency.

 

Continued Stay Review (SFN 826)

The state form is completed by the custodial agency worker for all children placed in a PRTF, QRTP or treatment foster home. The continued stay review form must be completed no greater than 20 calendar days prior to placement approval expiration and no less than 14 calendar days before the placement approval expires. The Qualified Individual will have 7 working days to review the request to continue in at a treatment level of care.

 

Continued Stay Review (CSR) Timeliness and Process

Upon receipt of the CSR form, the Qualified Individual will coordinate, and lead all continued stay review interviews to determine ongoing approval in a treatment level of care. Custodial agency workers may choose to invite the agency treatment staff to join in the 3 and 9 month continued stay phone interviews, as determined appropriate.

 

Childrens Treatment Services Level of Care Determination Attestation (SFN 831)

The state form is completed by the treatment agency who is managing the treatment plan and progress for children in their care. This form must be submitted by the treatment agency:

 

Discharge Planning

Custodial agencies and treatment agencies must ensure that discharge planning begins on the date of admission and should continue throughout the entirety of placement regardless of the child’s level of care. The discharge planning process should be person-centered and engage the child and child’s family to ensure continuity of services are provided when discharge occurs.

 

Managing Denials

The role of the Qualified Individual is to determine an approval or denial for treatment levels of care. If the determination results in a denial of TFC, QRTP or PRTF, the Qualified Individual will recommend a higher (acute hospitalization) or lower level of care (family home). If a custodial agency disagrees with a denial, the custodial agency can submit for a reconsideration.

 

Reconsiderations

A reconsideration request is only allowable when an assessment is denied for a treatment level of care. If requesting a reconsideration, the custodial agency worker must submit:

If only the reconsideration request form is submitted without supporting clinical/treatment information, the request will be denied. The Qualified Individual will review the information within 1 working day of receipt of the reconsideration and determine an approval or denial. While awaiting the decision of the reconsideration, custodial agency worker must simultaneously work to identify a plan, resources and supports to best meet the needs of the child.

 

14 Day Extension Request

The Qualified Individual contracted vendor generated a form for custodial agency workers to complete in order to request an extension for the QRTP or TFC approval period. Extension requests are prohibited for PRTF.

A request for an 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 allowed when a discharge location and date have been identified and an extension is requested to meet the discharge plan. This form cannot be used when a child is reaching placement maximums. The form can be found on the contracted vendor website.

 

Extension Request Beyond Placement Maximums

Treatment Foster Care: Children placed in a TFC level of care, who meet placement maximums may have a continued stay review completed to determine if TFC is still the least restrictive most appropriate placement option.

Qualified Residential Treatment Program: The custodial agency worker, with support of the child's collateral contacts and treatment agency must submit the SFN 826, Continued Stay Review Form at least 30 days prior to reaching placement maximums. In order to request a placement extension beyond the allocated state and federal maximum, the custodial agency worker must:

  1. Complete the SFN 826 in its entirety, detailing all necessary and required information;

  2. Write a summary indicating the child's needs and barriers to achieving treatment goals requiring a longer stay in treatment;

  3. Provide supporting documentation of progress and detailed discharge plans;

  4. Detail the requested/estimated amount of time required for treatment; and

  5. Submit the required paperwork to Children and Family Services (CFS) via cfslicensing@nd.gov with an email subject titled "Placement Extension Request Beyond Placement Maximums".

  6. The Clinical Alignment Team will review the request and respond accordingly within 5 working days of submission.

    1. If approved for extension, the custodial agency worker will be directed to submit the SFN 826 and supporting documentation to the contracted vendor for the initiation of a continued stay review assessment to determine appropriateness.

    2. If denied the child must discharge withing the placement maximums.

 

Dual Approvals - Children's Treatment Services LOC

Dual approvals are prohibited. Two CTS LOC assessments cannot occur at the same time for the same child. If a new referral is submitted outside of continued stay review timelines when a child is already approved for a CTS LOC, the second determination will supersede the initial determination and the child must discharge the current level of care 14-days from the date of the new determination.

 

For example, if the child is in a QRTP and the worker submits a new CTS LOC referral on day 30 of placement, there are 60 days of QRTP approval remaining. If the second assessment determines TFC is appropriate based on current symptoms and behaviors, the child would have 14-days from the date of determination to discharge from the QRTP.

 

 

Psychiatric Residential Treatment Facilities (PRTF)

The North Dakota Children’s Treatment Services Level of Care Determination may approve a PRTF placement for a child in foster care. North Dakota PRTF’s are not a foster care placement, rather are considered a medical placement. PRTF’s are licensed by the HHS Behavioral Health and may receive funding from commercial insurance or paid for by North Dakota Medical Services.

 

Placement Timeframes

A custodial agency with PRTF approval, must follow the continued stay review timeframes.

 

Emergency placement

An emergency placement into a PRTF is allowable prior to a completed assessment by the Qualified Individual. It is the responsibility of the custodial agency worker to submit the Universal Application (SFN 824) and relevant supporting documentation to the Qualified Individual and to the PRTF who accepted the child. The treatment agency will submit the Attestation (SFN 831) and supporting treatment documentation to assessment pro.

A child who is placed as an emergency in a PRTF and is approved will have their approval timeframes align with the date of admission. If a child is placed as an emergency in a PRTF and is denied, the child must discharge according to Medical Services timeframes.

 

Qualified Individual Contracted Vendor

ND has a contract with Maximus. All information regarding the Children’s Treatment Services Level of Care Determination is located at the website below.