QRTP Placements 624-05-20-17

(Revised 10/1/2023 ML #3756)

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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 to engage in short term treatment. The QRTP placement is only available to:

1. Children under the public custody of a Human Service Zone, Tribal Nation or Division of Juvenile Services; and
2. Children, not in public custody, who have been approved for placement and reimbursement by the HHS 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 the contracted Qualified Individual and an assessment report, identifying the child's difficulty of care level, will be provided to the custodial case manager.

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 holds a contract with an independent third-party vendor, who hires contracted employees to complete a third-party formal assessment for the QRTP level 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 child’s approval/denial status and difficulty of care level based on the pre-determined North Dakota QRTP algorithm. Random cases will be reviewed and staffed with the Department of Health and Human Services QRTP Clinical Alignment Team (Administration from HHS 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.

2. Receive the QRTP attestation and documentation related to the child’s treatment stay (emergency placement or continued stay).

3. Work timely in conjunction with the custodial case manager, family and members of the child and family team to complete interviews.

4. If the child is placed as an emergency placement the Qualified Individual will also speak with the QRTP therapist and/or QRTP treatment coordinator.

5. 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 to complete the assessment and interviews.

   1. If a child is placed out of state, the CANS assessment can be completed via a secure virtual platform.

   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 close proximity to Fargo and a contract for detention center services in the Fargo-Moorhead area.

   3. In special circumstances, if a child is unable to meet face-to-face, the custodial case manager may request the Qualified Individual complete a virtual assessment.

6. Complete required interviews within 5 working days of the referral date.

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

8. 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.

9. Determine whether the needs of the child are consistent with goals for the child, as specified in the case plan.

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

11. 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.

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 the Qualified Individual and the desired QRTP’s for placement acceptance. The QRTP will submit the QRTP Attestation and supporting treatment documentation directly to Maximus Ascend.

1. 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.
   
   
2. 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.
   
   
3. 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 Children and Family Services (CFS) via cfslicensing@nd.gov. This will provide authorization to place a child back into a QRTP as an emergency placement. If reviewed and approved by the CFS, the case manager will be notified and responsible to submit a reconsideration request.
   
   
4. Although the custodial case manager is primarily responsible to work directly with the Qualified Individual, 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. Custodial case managers must also provide a copy of the assessment report including the difficulty of care level to the QRTP for billing purposes.

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 before placement can occur.

1. Initial 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.
   

2. Bed Hold: If a child who has been approved and placed at a QRTP needs of temporary psychiatric hospitalization, the temporary acute care is allowable. The QRTP is allowed reimbursement for a 14-day bed hold and a new assessment is not required, so long as the approval has not expired.
   

3. Transition: A child may be transitioned from one QRTP to another if it is determined in the best interest for their treatment. The child will require a new QRTP assessment to approve or deny the placment into a new QRTP location. The placement maximums and approval timeframes remain.
   

4. Post-Discharge: A child who discharges from a QRTP, but still has a period of time allowed within their 90-day approval time frame may be re-admitted if determined necessary for treatment but, a new SFN 824 and CANS assessment must be completed.

5. A child who is placed in a QRTP and who is denied must discharge within the approval time frames. The custodial agency and QRTP who allow a child to remain placed without valid QRTP approval is in non-compliance with state licensing and federal regulation.

6. “Back-to-Back” placements are prohibited. If the child was approved and is later denied, the child may not remain in or re-enter the QRTP for 30 days post discharge.

7. A child who remains placed in a QRTP without valid approval may not be reassessed for a period of 30 days post-discharge.

8. Turning 18: A child who has current QRTP approval that extends beyond their 18th birthday, must discharge QRTP placement on their 18th birthday, unless otherwise approved by the department. If a custodial case manager believes the child shall remain placed past their 18th birthday, the custodial case manager must receive approval from Children and Family Services. This approval requirement does not apply to the Division of Juvenile Services cases placed in a QRTP prior to their 18th birthday.

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 has reached their placement maximum and 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 Children and Family Services (CFS) via cfslicensing@nd.gov. This will provide authorization to place a child back into a QRTP. If reviewed and approved by the CFS the custodial case manager will be notified and responsible to submit the universal application and supporting documentation.

Turning age 13 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 (both in and out of state), 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 Health and Human Services Commissioner 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 beyond the allocated federal maximum, the custodial case manager 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 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 Children and Family Services (CFS) via cfslicensing@nd.gov with an email subject titled “QRTP Placement Extension Request”.

6. The QRTP Clinical Alignment Team will review the request and respond accordingly within 3 working days of submission.

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 the Qualified Individual and the desired QRTP. 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.

 

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. The QRTP desired for placement and

   2. The Qualified Individual contracted vendor to begin the assessment

3. Engage in discharge planning upon admission to the QRTP.

4. Track the 90-day approval period timeframes.

5. Track the child’s placement maximums (6 months or 12/18 months based on age). The dates in any QRTP located in or out of state are considered part of placement maximum days and cannot exceed the federal placement maximums defined above.

6. 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 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 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.

7. 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.

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

   1. The child 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 time limited for treatment needs and services. It is important for the child to know the QRTP is required to provide 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 local supports in the child’s community.

9. Submit the approved QRTP Assessment Report to the:

   1. QRTP facility 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.

   3. Discharge placement provider; example TFC agency or foster care provider 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 supporting information. This form must be submitted to the Qualified Individual 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.

1. The state form must be completed electronically.

2. The state form is fillable and savable for future editing.

Continued Stay Review (CSR) Timelines and Process

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

1. 3 months = A document review. The Utilization Reviewer will conduct a phone interview with the custodial case manager.

2. 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.

3. 9 months = A document review. The Utilization Reviewer will conduct a phone interview with the custodial case manager.

4. 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.

Qualified Individual Extension Request Form

The Qualified Individual contracted 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 contracted vendor website.

 

Reconsiderations

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.

 

If requesting a reconsideration, the custodial case manager must:

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

The Qualified Individual 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 plan, resources and supports to best meet the needs of the child.

 

HHS 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 (prior to the child's current QRTP approval expiration) permission to submit a second “reconsideration request” detailing new information before the required discharge date.

 

Example. Youth has completed the assessment process 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 a placement transition. With a HHS temporary approval, a custodial case manager may submit a second reconsideration with new information regarding the child’s engagement at the QRTP. Such reconsiderations are prohibited from being submitted without temporary approval from Children and Family Services.

 

In order to request a HHS 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 cfslicensing@nd.gov with an email subject titled “QRTP-HHS Temporary Approval Request”.
4. The QRTP Clinical Alignment Team will review and respond to the request within 3 working days of submission.

Managing QRTP Denials

The role of the Qualified Individual is to determine an approval or denial into a QRTP. If the determination results in a denial of QRTP, the Qualified Individual will recommend a higher or lower level 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. Regional Review Teams organize local agency collaboration and engage families, case planning, resource development, identification of service gaps, while recruiting and retaining viable placement resources to meet local needs. If State Review Team is required, the intention is to not case manage the case nor identify placements, rather to support, provide technical assistance and access to financial resources.

 

QRTP Aftercare Services

When a child is approved and admitted for QRTP treatment, the child is required to be provided aftercare services by the QRTP facility per NDAC 75-03-40 post discharge.

 

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 at six-months post-discharge.

 

Out of State Placements

North Dakota foster children in need of out-of-state placement may only be placed in a Qualified Residential Treatment Program (QRTP) facility that meets the federal standards. Foster care funding will only support the reimbursement of placement in a QRTP residential level of care. Placement maximums also apply to children placed in an out of state 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 QRTP placement, all 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.

For children under the custody of another state, seeking placement in a ND QRTP: The sending state must complete the ICPC and payment paperwork before placement can occur in efforts to ensure the QRTP assessment is paid for by the sending state and the ND QRTP is reimbursed the ND daily rate for service.

 

QRTP Payments

The Department will authorize all eligible QRTP payments directly to the QRTP facility based on billing. A child is prohibited from being placed at a QRTP without an approval, with the exception of emergency placements not to exceed 30 days.

 

If the child is placed at a QRTP and their approval expires, the child must be discharged from the placement location effective the date of expiration. It is imperative that custodial case managers monitor the approval timeframes, if a child remains in a QRTP without approval, the payment will 100% be the responsibility of the custodial agency and the days in a QRTP placement will go against the child’s placement maximum. Such placements will be elevated to the Executive Office for review of noncompliance.

 

Qualified Individual Contracted Vendor

ND has contracted with Maximus Ascend. All information including desk reconsideration request form, extension request form and trainings are located at the website below.

 

Assessment Pro Login: www.assessmentpro.com

Phone: (844) 933-3772

Email: ND_FFPSA@MAXIMUS.com

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