DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Division of Substance Abuse and Mental Health
Final
ORDER
6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions
NATURE OF THE PROCEEDINGS
Delaware Health and Social Services ("Department") / Division of Substance Abuse and Mental Health (DSAMH) initiated proceedings to promulgate new regulations regarding the process by which individuals can be detained for behavioral health assessment and treatment. The Department's proceedings to promulgate new regulations were initiated pursuant to 29 Delaware Code, Section 10114, with authority prescribed by 29 Delaware Code, Section 7971.
The Department published its notice of proposed regulatory change pursuant to 29 Delaware Code Section 10115 in the December 2012 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by December 31, 2012, at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.
SUMMARY OF PROPOSAL
The proposed establishes the Division of Substance Abuse and Mental Health's regulations for the eligibility criteria and means by which individuals qualify to attain credentialing as a mental health screener.
Background
House Bill 311 significantly updates the laws under which a person can be held involuntarily for up to 24 hours for a mental health evaluation. In place of the current system where a person is transported in handcuffs by police to a hospital emergency department, the bill allows a psychiatrist or credentialed mental health screener to evaluate a person anywhere and then transport that person to the most appropriate location for evaluation or treatment in the most appropriate and least restrictive manner. The changes in this bill will be phased in over a year to ensure that the greatly expanded, community-based services are fully operational before the complete change in procedure takes place. Credentialed Mental Health Screeners are to be in use by July, 2013.
In addition to providing people with a wider array of appropriate treatment options, these changes will free law enforcement from unnecessary transportation duties and long waits in hospital waiting rooms. This bill expands the number and kind of professional staff who are credentialed to involuntarily detain someone for a mental health evaluation, increases the immunity afforded to doctors, and expands immunity to other professionals involved in the process. In addition to moving Delaware towards best practices in this field and protecting the civil rights of Delawareans, these changes will enable the State to attain compliance with the terms set forth in Settlement Agreement United States v. State of Delaware, C.A. No. 11-591-LPS. This regulation delineates what who may be eligible, what information must be contained in the application to become credentialed as a Mental Health Screener, establishes the authority for the format for the training and delineates how the credentialed status must be maintained and how it may be suspended or revoked.
Summary of Proposal
This regulation sets forth methods used to determine eligibility for training and credentialing as a mental health screener. Effective July 1, 2013, new policy is added to the Division of Substance Abuse and Mental Health at DSAMH 6002 to provide mental health screener credentialing requirements.
Fiscal Impact Statement
The proposed regulation imposes no additional costs on DSAMH. Credentialing of Mental Health Screeners is required as a piece of Delaware's legislative and other efforts to improve the State's behavioral health care system in keeping with the U.S. Department of Justice Olmstead Settlement Agreement, entered into in July, 2011. The proposed regulation completes the promulgation of changes in the laws governing how the State acts to preserve the civil and human rights of individuals who may be recommended for involuntary detention under 16 Del. C. Chapter 51 as amended by HB 311 in July, 2012.
SUMMARY OF COMMENTS RECEIVED WITH AGENCY RESPONSE AND EXPLANATION OF CHANGES
The Governor's Advisory Council for Exceptional Citizens, the Developmental Disabilities Council, and the State Council for Persons with Disabilities and CLASI offered the comments and recommendations summarized below. DSAMH noted that the comments received from the former two entities were identical in content and that the latter's comments largely mirrored those of the former two. Both in response to comments and pursuant to DSAMH review, non-substantive changes were made several places in the regulations. For purposes of reference, DSAMH has considered each comment as it was presented in the first of the three respondents' letters and responds as follows:
Comment:
1. The regulation is inaccurate in some contexts???[with regard to conflicting old and new language]
2. (same concern)
Agency Response: We understand. However, these regulations are being written in support of the new language. The amended language and the existing language were to be concurrently effective for one year, that is, until July, 2013. Therefore, there is no conflict: until such a time as there are credentialed Mental Health Screeners, the old language still applies. The language applies to children as well as adults; in Title 16 Chapter 51 references to children remained unchanged in consultation with the Kids Department.
Comment:
3. The title to ??1.0 (Mental Health Screener Credentialing) is inappropriate..The title to the overall regulation identifies two topics: 1) credentialing of MH screeners; and 2) payment for voluntary admission. ???It would be much clearer if the regulation were divided into two prominent subparts with headings???
Agency Response: Amended general title of the regulation.
6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions
Comment:
4. In ??1.0, substitute ???professionals??? for ???people??? to conform to Title 16, Del.C. ??5122(a)(9)
5. In ??1.0, ???substitute ???regulation??? for ???chapter???.
6. In ??1.0???the reference to ???himself or herself??? is outdated.
Agency Response: Amended, as follows. Note that the Division supports the use of gender neutral language.
1.0 Mental Health Screener Credentialing
Title 16, Chapter 51 of the Delaware Code states that only psychiatrists and people professionals credentialed by the Delaware Department of Health & Social Services (DHSS) as a Mental Health Screener (MH Screener) have the authority to detain or abrogate a detainment of a person involuntarily for a psychiatric evaluation. No persons shall hold himself or herself themselves out to the public as a credentialed mental health screeners unless the persons is are credentialed in accordance with this chapter. The Division of Substance Abuse and Mental Health (DSAMH) is the DHSS Division responsible for implementing and enforcing this law.
Comment:
7. In ??2.0, the definition of ???Credentialed Mental Health Screener??? uses a plural pronoun with a singular antecedent. However, the entire reference to ???or their designee??? should be stricken.
Agency Response: Amended, as follows.
???Credentialed Mental Health Screener??? means an individual who has applied for and been approved to be credentialed as a mental health screener under Chapter 51 by the DSAMH or their designee.
Comments:
8. In ??2.0, substitute ???Correction??? for ???Corrections??? to conform to Title 29 Del.C. Ch 89.
9. In ??2.0, definition of ???Crisis experience in a mental health setting ???is grammatically weak???
Agency Response: Comment 8 apparently refers to language in an earlier draft that was amended before the last draft was published (Word appears as corrected in the published version). Amended to address Comment 9, as follows.
???Crisis experience in a mental health setting??? means a crisis experience in a mental health setting is defined as direct experience providing acute crisis services to people with mental health disorders in settings that include, but are not limited to, psychiatric assessment centers, hospital emergency rooms, crisis walk in settings, admission departments of psychiatric or general service hospitals, mobile crisis departments, drop in centers and certain settings found in the Department of Corrections
Comments:
10. In ??2.0, definition of ???Licensed Mental Health Professionals,??? the grammar merits correction???
11. In ??2.0, definition of ???Licensed Mental Health Professionals,??? Council questions the requirement that a licensed registered nurse have ???a bachelor???s degree in nursing (BSN)??? since this is not a requirement by the licensing state???.
Agency Response: The panel of experts convened to consider these regulations held that there is considerable difference between a 2-year and a 4-year nursing degree. Licensed individuals working under the supervision of a psychiatrist are not precluded from becoming credentialed. Amended to correct the grammar, as follows:
???Licensed Mental Health Professionals??? means individuals who are licensed by the State of Delaware and who are otherwise eligible to be credentialed as a mental health screener under Chapter 51. The term includes: licensed physicians (MD/DO) whose practice specialty is other than psychiatry; licensed registered nurses with a bachelor???s degree in nursing (BSN); licensed advanced practice registered nurses (APN); licensed physician assistants (PA-C); licensed clinical psychologists (PhD/Psy.D); licensed clinical social workers (LCSW); licensed mental health counselors (LMHC); and licensed marriage and family therapists (LMFT).
Comment:
12. In ??2.0, the definition of ???Supervision of unlicensed mental health professionals by a psychiatrist??? is problematic.
Agency Response: Amended to clarify, as follows. The Division notes that ???organization??? in this context refers to contracted provider or government agencies.
???Supervision of unlicensed mental health professionals by a psychiatrist??? means any unlicensed mental health professionals who need to work under a psychiatrist licensed to practice medicine will perform this work under their organization???s agency's by-laws practice standards and guidelines. and The This includes requirements that the credentialed mental health screener discuss the individual-in-care's issues on the phone or through telepsychiatry with the supervising psychiatrist at the time of the detainment decision, and assureing that this psychiatrist agrees and countersigns the decision made. An faxed electronically transmitted copy or original detainment form with the supervising psychiatrist???s signature will need to be placed in the client's medical record at the facility or site where the detainment occurred within 24 hours.
Comment:
13. In ??3.2.2, strike ???that such person is licensed and substitute ???that he is licensed??? or ???of a current license???.
Agency Response: Amended, as follows:
3.2.2 Each physician must supply evidence that such person is licensed of current licensure to practice medicine in Delaware and is current Board Certifiedication by the American Board of Emergency Medicine.
Comment:
14. In ??3.4.1, it is inconsistent to require five years of experience for DSAMH employees but only two years of experience for employees of any other public or private health care facility.
15. In ??3.4.2, there is no provision for a public agency apart from DSAMH (e.g. Veterans Hospital) ???vouching??? for the years of experience.
16. In ??3.4.1.2, there is a plural pronoun (???their???) with a singular antecedent (???facility???).
Agency Response: Comments 14 and 15 apparently refer to language in an earlier draft that was amended before the last draft was published; grammar corrected as requested by comment 16. See below:
3.4.1 Each applicant must submit qualifications and supply evidence that:
3.4.1.1 If employed by DSAMH or a self-employed professional not affiliated with any Delaware health care facility, the applicant has five (5) years??? experience in mental health clinical and/or crisis settings as an employed or as a contracted professional.
3.4.1.2 If employed or contracted by any Delaware health care facility, the applicant has at least two (2) years experience in mental health clinical and/or crisis settings as an employed or as a contracted professional, and that that non-state health care facilityies will take responsibility for the years of experience required for their staff to be credentialed.
Comments:
17. In ??3.4.2.1 There is a plural pronoun (???they???) with a singular antecedent (???applicant???). ???Council again questions the categorical requirement that a licensed RN have a BSN degree.
18. In ??3.4.2, the multiple references to ???relating to Professions and Occupations??? are unnecessary and should be deleted.
19. In ??3.4.2, strike the multiple references to ???that such person is licensed??? and substitute ???that he is licensed??? or ???of a current license???.
20. The GACEC recommends deletion of ??3.4.2.4.2 as unnecessary. ???
21. The GACEC recommends deletion of ??3.4.2.5.2 as unnecessary???.
22. Council recommends deletion of ??3.4.2.6.2 as superfluous???.
Agency Response: With the exception of the requirement for the 4-year nursing degree which was the recommendation of the expert panel, the Division agrees with most comments and amended the section, as follows:
3.4.2 Licensed Non-Physician Mental Health Professionals must meet the following qualifications:
3.4.2.1 Registered Nurse. Each applicant shall document that they are licensed in current licensure by the State of Delaware as a Registered Nurse with a BSN degree and in good standing, as set forth in 24 Del.C. Ch. 19, relating to Professions and Occupations.
3.4.2.2 Advanced Practice Nurse. Each applicant shall document that such person is licensed in current licensure by the State of Delaware as an Advanced Practice Nurse in good standing, as set forth in Title 24 Del.C. Ch. 19, relating to Professions and Occupations and is working employment under a formal protocol with a Delaware licensed physician
3.4.2.3 Licensed Psychologist. Each applicant shall document that such person is licensed in current licensure by the State of Delaware as a Licensed Clinical Psychologist in good standing, as set forth in 24 Del.C. Ch. 35 relating to Professions and Occupations.
3.4.2.4 Licensed Clinical Social Worker
3.4.2.4.1 Each applicant shall document that such person is licensed in current licensure by the State of Delaware as a Licensed Clinical Social Worker in good standing, as set forth in 24 Del.C. Ch. 39 relating to Professions and Occupations.
3.4.2.4.2 Each applicant shall document that such person has passed the American Association of State Social Work Boards.
3.4.2.5 Licensed Professional Counselor of Mental Health
3.4.2.5.1 Each applicant shall document that such person is licensed in current licensure by the State of Delaware as a Licensed Professional Counselor of Mental Health in good standing, as set forth in 24 Del.C. Ch. 30 relating to Professions and Occupations.
3.4.2.5.2 Each applicant shall document that such person is certified by the National Board for Certified Counselors, Inc. (NBCC), or the Academy of Clinical Mental Health Counselors (ACMHC), or other national mental health specialty certifying organization acceptable to the Board.
3.4.2.6 Licensed Marriage and Family Therapist
3.4.2.6.1 Each applicant shall document that such person is licensed in current licensure by the State of Delaware as a Licensed Marriage and Family Therapist in good standing, as set forth in 24 Del.C. Ch. 30 relating to Professions and Occupations.
3.4.2.6.2 Each applicant shall document that such person has passed the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) standardized examination or other examination acceptable to the Board.
3.4.2.7 Licensed Physician Assistant.
3.4.2.7.1 Each applicant shall document that such person is licensed in current licensure by the State of Delaware as a Physician Assistant in good standing, as set forth in 24 Del.C. Ch. 17, relating to Professions and Occupations and is working employment under the delegated authority of a licensed physician.
Comments:
23. Section 3.5.1 requires unlicensed mental health professionals applying for screener status to pay both an application fee and credentialing fee. There is no analog for licensed professionals. It is unclear if the latter professionals are also expected to pay such fees.
24. Since the standards are identical, ????3.5.1.1 and 3.5.1.2 could be merged.
25. In ????3.5.2.4 and 3.5.1.4, it is inconsistent to allow an unlicensed State employee to qualify with a Bachelor???s degree while requiring a Master???s degree for a private sector employee???
Agency Response: Comments accepted; amended, as follows:
3.5 Unlicensed Mental Health Professionals under Direct Supervision of a Psychiatrist
3.5.1 Each unlicensed mental health professional who is applying to become credentialed as a mental health screener must submit qualifications, pay the application fee, pay the credentialing fee, and supply evidence that:
3.5.1.1 Such person has had two (2) years of clinical and/or crisis experience if working as a State employee or contractor; 3.5.1.2 Such person has at least two (2) years of clinical and/or crisis experience or if working with a Delaware Health Care Facility as an employee or contracted staff member;
3.5.1.32 Such person has at least a bachelor???s or master???s degree in a mental health related field if working as a State employee or contractor; 3.5.1.4 Such person has a master???s degree in a mental health related field or if working with a Delaware Health Care Facility as an employee or contracted staff member; and
3.5.1.53 Such person has committed to completing forty (40) hours of crisis services in an employed position under direct supervision of a psychiatrist or credentialed mental health screener following completion of the mental health screener training and satisfactory score on the mental health screener credentialing exam.
Comment:
26. While the credentials sections address clinical experience, they are completely silent on expertise in utilizing police power and involuntary detention procedures. The statute contemplates the screeners promptly ???taking into custody??? individuals whose behavior constitutes a danger to self or others. See Title 16 Del.C. ??5122(b). The statute also contemplates the screener transporting the individual involuntarily to another screener or facility. See Title 16 Del.C. ??5122(c). The former Attorney General opposed granting police power to mental health personnel in the commitment context based on concerns about lack of training and capacity to detain violent individuals. Council queries whether physical fitness standards should be included in the credentialing criteria? Obviously, the ability to physically detain an unruly individual is contemplated by the statute and some individuals may initially appear cooperative but change their ???affect??? quickly. Training would also be essential.
Agency Response: The Division respectfully submits that mental health crisis experience necessarily involves contact with unruly or otherwise uncooperative individuals. Crisis mental health professionals receive training in nonviolent intervention and de-escalation techniques; they also work in concert with law enforcement, hospital constabulary and others in situations where there may a risk of violence. The ???taking into custody??? of an individual is a process that may involve both law enforcement and mental health professionals or it may not; much depends on the professional judgment of those involved in the incident at hand. Likewise, transport may be handled in a variety of different manners, depending on the professionals??? assessment of the risks involved, with the ultimate goal of providing care in the least restrictive, least traumatic manner safely possible.
Comments:
27. Definitions should be compiled in the front of the regulation. ???It is unusual and confusing to have both a ??2.0 definitions section and a ??4.0 definitions section. Alternatively, Section 4.0 contains substantive standards rather than ???definitions??? and could be converted to a ???contents of initial application??? section and ???reapplication standards??? section. The format of ??4.0 could then be converted to the following: ???An initial application for approval as an [sic] MH Screener shall include the following:??????. The 2-year term of approval should then be inserted. Finally, a section could then require a reapplication to be filed at least X days prior to the expiration of the 2-year term. Otherwise, the regulation would literally permit a reapplication to be filed on the 2-year expiration date.
28. In ??4.0, delete ???or their designee???. See Par.7 above
29. In ??4.0, the reference to ???group??? is inappropriate since there are two sets of exempt professionals
Agency Response: Section 4 has been amended, as follows, to address these comments:
4.0 Applications Process for Credentialing and Re-credentialing
Definitions
4.1 ???Application for Credentialing???
4.1.1 means An individuals who wishes to be credentialed as a credentialed MH Screener to be able to perform detainments under Chapter 51 will need to fill out shall complete an Application for Credentialing as a Mental Health Screener to DSAMH.
4.1.1.1 The application shall that includes a resume, school transcripts, current work history including experience in working with people in mental health crises, current employment, and all contact information, including Delaware license numbers and titles, and such other credentials or proof of certification as may be necessary to meet requirements set forth in section 3 above.
4.2 ???Application for Renewal of Credentialing???
4.2.1 means All Delaware credentialed mental health screeners except as noted in 4.2.1.2 below will be required to re-apply every two (2) years, 60 days prior to the second anniversary date of the issued credential, for renewal of the credential to DSAMH. or their designee and to
4.2.1.1 The application for renewal shall require the submission of send in their applicable CEU's, as well as such other credentials or proof of continuing licensure, credentials or certification as may be necessary to meet the requirements set forth in section 3 above to be re-credentialed.
4.2.1.2 The only professionals that will not be required to do undergo this re-credentialing process are licensed physicians whose specialty is psychiatry and physicians who are maintain Board Certifiedication Emergency Physicians.
4.2.1.2.1 DSAMH will provide any changes in state mental health or associated resources to these licensed psychiatric and emergency medicine physicians in a timely manner and when these services become available or are changed in any way.
Comments:
30. In ??5.1, first definition, substitute ???credentialed??? for ???credential???.
31. Consistent with Par. 27 above, it is unusual and confusing to have a ??2.0 definitions section, ??4.0 definitions section, and ??5.0 definitions section
32. In Section 5.0, there is no operative sentence. The section consists of definitions and an outline. There is no sentence similar to ???(T)he following standards will apply to the credentialing and re-credentialing of MH screeners??????
33. The grammar in ??5.1, first definition, is incorrect???.
34. The grammar in ??5.1, second definition, is incorrect???
35. In ??5.0, the third definition is a putative substantive standard, not a definition.
36. In ??5.2.1.1, Council suspects the word specific was intended to be ???specified???.
37. In ??5.2, the multiple references to ???specified above??? should be converted to ???specified in ??5.1 for clarity.
38. Punctuation is missing from the end of ??5.3.2.2.
39. There is a lack of parallel form in ????5.2.4.4, 5.3.1.3, 5.3.2.3, and 5.3.3.3.
Agency Response: Section 5 has been amended to address the concerns voiced in the comments above, as follows:
5.0 Training, Credentialing and Re-credentialing Requirements for Licensed and Unlicensed Mental Health Professionals
5.1 Definitions Training
The following standards will apply to the credentialing and recredentialing of Mental Health Screeners and sets forth the minimum qualifications and training requirements.
5.1.1 For licensed physicians other than psychiatrists??? means training guidelines for applicants who are licensed physicians other than psychiatrists will include content that may change over time and is up to DSAMH to direct, including acceptable CEUs generally related to psychiatric or crisis work.
5.1.2???Training Guidelines for credentialed mental health screener, For licensed applicants??? means training guidelines for applicants who are licensed professionals will include content that may change over time and is up to DSAMH to direct, including acceptable CEUs generally related to psychiatric or crisis work.
5.1.3???Training Guidelines for credentialed mental health screener, For unlicensed applicants??? means unlicensed applicants will be trained under the same training guidelines as for applicants who are licensed; plus in addition, applicants will be required to participate in 40 hours of supervised crisis internship in a mental health setting. This will include content that may change over time and is up to DSAMH to direct, including acceptable CEUs generally related to psychiatric or crisis work.
5.2 Credentialing
5.2.1 Board Certified Emergency Physicians.
5.2.1.1 Compliance with qualifications specificed in ??3 above;
5.2.1.2 Compliance with training guidelines as specified in ??5.1 above.
5.2.2 Licensed physicians other than psychiatrists and Board Certified Emergency Physicians:
5.2.2.1 Compliance with qualifications specified in ??3 above;
5.2.2.2 Compliance with training guidelines as specified in ??5.1 above. Including completion of 4 hours of training by the DHSS Division of Substance Abuse and Mental Health; and
5.2.2.3 Satisfactory score on the credentialing examination.
5.2.3 Licensed Mental Health Professionals
5.2.3.1 Compliance with qualifications specified in ??3 above;
5.2.3.2 Compliance with training guidelines as specified in ??5.1 above, including completion of 40 hours of training by DSAMH; and
5.2.3.3 Satisfactory score on the credentialing examination.
5.2.4 Unlicensed Mental Health Professionals
5.2.4.1 Compliance with qualifications specified in ??3 above;
5.2.4.2 Compliance with training guidelines as specified in ??5.1 above, including completion of 40 hours of mental health screener training by DSAMH; and completion of 40 hours of crisis services under direct supervision of a psychiatrist or credentialed mental health screener;
5.2.4.3 Satisfactory score on the credentialing examination.; and
5.2.4.4 Completion of 40 hours of crisis services under direct supervision of a psychiatrist or credentialed mental health screener.
5.3 Re-Credentialing
5.3.1 Licensed Physicians other than psychiatrists and Board Certified Emergency Physicians:
5.3.1.1 Compliance with qualifications specified in ??3 above; and
5.3.1.2 Compliance with training guidelines as specified in ??5.1 above, including completion of 4 hours of training by DSAMH every two years.
5.3.1.3 DSAMH will accept CEU???s that are generally related to psychiatric or crisis work.
5.3.2 Licensed Mental Health Professionals
5.3.2.1 Compliance with qualifications specified in ??3 above; and
5.3.2.2 Compliance with training guidelines as specified in ??5.1 above, including completion of 4 hours of training by DSAMH every two years
5.3.2.3 DSAMH will accept CEU???s that are generally related to psychiatric or crisis work.
5.3.3 Unlicensed Mental Health Professionals
5.3.3.1 Compliance with qualifications specified above; and
5.3.3.2 Compliance with training guidelines as specified in ??5.1 above, including completion of 8 hours of training by DSAMH every two years
5.3.3.3 DSAMH will accept CEU's that are generally related to psychiatric or crisis work.
Comment:
40. Section 6.0 (???Data???) is not within the scope of the title to the regulation which is limited to credentialing and payment for voluntary patients. Moreover, the lengthy narrative form is not written in regulatory form an dis extremely difficult to follow.
41. In ??6.0, substitute ???detentions??? for ???detainments??? to conform to the statute and ??7.0???
42. Section 7.0 has a plural pronoun (???their???) with a singular antecedent (???client???).
43. In ??7.0, substitute ???self??? for ???that person???.
Agency Response: The Division hopes that this comment is based on language in an earlier version. The regulation sections 6 and 7 have been amended (and combined), as follows, to clarify the role of record keeping in the credentialing process as necessary part of performance monitoring, compliance with the detention statute and prevention of conflicts of interest.
6.0 Data
6.0 Credentialed Mental Health Screener Performance
6.1 Essential Conflict of Interest Statement
The intent of the law is to ensure that no client person is detained for any reason other than their having experiencing symptoms associated with a mental health condition that may result in danger to that person self or others, and that any conflicts of interest as set forth in 16 Del.C. ??5122 are disclosed on the DSAMH Crisis Intervention Assessment Tool and 24-hour Detention Emergency Admission form filed with DSAMH within 24 hours of signature of the detention order. DSAMH will collect and monitor all assessments, detentions and non-detentions performed by credentialed mental health screeners, whether a conflict of interest is disclosed or not, for purposes of ensuring that the intent of this law is met.
6.12 Record Keeping, Forms and Documentation
The following standards will apply to the Forms and Documentation required to monitor and report on the performance of credentialed mental health screeners as it pertains to compliance with conflict of interest disclosure in actions to detain, or undo a detainmentention, of an individual under this statute.
6.2.1 Credentialed mental health screeners will be required to complete a DSAMH Crisis Intervention Assessment Tool and 24-Hour Emergency Admission Form for the purpose of ensuring a standardized approach to assessing the needs of clients in crisis and documenting the decision premised upon that assessment. These forms will become part of the client???s records as well as be submitted to DSAMH. Data will be required on all detainments and sent to DSAMH as soon as possible and within 24 hours by the credentialed MH Screener that signs the detainmentention order. These detainments will be reviewed on a case by case basis going forward.
6.23 Data Review and Reporting
Detention Orders, Assessment Tools and Emergency Admissions forms will be reviewed and the data collected will be recorded in a database. that will be documented daily in relation to detainments: DSAMH, as part of DHSS, will record a number of variables into a database. This database will include administrative information, such as the client MCI number, the date of contact, where the contact occurred, what staff member was lead in this response by name, the nature of the crisis, what was done including alternatives to inpatient care, who signed the detainment order, where the individual went once the detainment detention order was signed, and who transported the client; and clinical information as collected on the DSAMH Crisis Intervention Assessment Tool and 24-Hour Emergency Admission Form. In addition, if a detainment detention order was not signed, this database needs to documentation as to where the client went, to whom referred for care, what the plans were for follow-up, and transportation. DSAMH will also require a permanent data base that can render information on detainments every month going forward by April 2013.
6.3.1 Reports from the DSAMH database that will be publicly generated monthly on Delaware detainments: showing aggregated data reports will be generated on detainments in Delaware.
6.3.2 Detainment data will be reviewed to monitor for anomalies in detainment rates to assure mental health screener performance improvement and compliance.
Comment:
44. Section 9.0 consists of a single 78-word sentence. Consider ???breaking out??? the last three concepts as subparts???
Agency Response: Amended, as follows:
9.0 Payment for Voluntary and Involuntary Admissions.
Payment to hospitals for voluntary and involuntary admissions of clients in crisis will be made pending approval by a psychiatrist designated by the Secretary of Health and Social Services. Approval will depend on following the conduct outcome of an independent review of forms and documentation as specified in Section 6.0. The review???s specific purpose will be to and confirmation that: the admission represents the most appropriate and least restrictive treatment for the client in crisis; that the duration of stay for the admitted client is reviewed and deemed appropriate; and, that the State is the payer of last resort.
Comment:
45. In ??10.0, there are three instances of use of plural pronouns (???their???) with a singular antecedent (???individual???).
Agency Response: Amended, as follows:
10.0 Appeal Process.
Any individual who has been denied credentialing as a mental health screener or who has had a their screening credential suspended or revoked can appeal this decision by writing to the DSAMH Director with their Such an appeal, based on knowledge and facts of this event, must be made within twenty (20) days of the denial. A response by the DSAMH Director will be forthcoming within thirty (30) days.
Comment:
46. The GACEC respectfully requests clarification that the Division has not overlooked conducting criminal background checks in connection with the certification [sic], particularly in the context of unlicensed screeners since they would not have been vetted through the licensing process.
Agency Response: Licensure of professionals precludes requiring a separate Division criminal background check. The only unlicensed credentialed mental health screeners will be State mobile crisis employees.
FINDINGS OF FACT:
The Department finds that the proposed changes as set forth in the March 2013 Register of Regulations should be adopted.
THEREFORE, IT IS ORDERED, that the proposed new regulation to update the Division of Substance Abuse and Mental Health (DSAMH) to add policy regarding the process to credential mental health screeners is adopted and shall be final effective July 1, 2013.
Rita M. Landgraf, Secretary, DHSS
6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions
Title 16, Chapter 51 of the Delaware Code states that only psychiatrists and [people professionals] credentialed by the Delaware Department of Health & Social Services (DHSS) as a Mental Health Screener (MH Screener) have the authority to detain or abrogate a detainment of a person involuntarily for a psychiatric evaluation. No person shall hold [himself or herself themselves] out to the public as [a] credentialed mental health screener unless the person[s is are] credentialed in accordance with this chapter. The Division of Substance Abuse and Mental Health (DSAMH) is the DHSS Division responsible for implementing and enforcing this law.
As used in this subchapter:
[???Continuing Education Units (CEUs)??? means a measure used in continuing education programs, particularly for those required in a licensed profession, in order for the professional to maintain the license. In the case of unlicensed professionals who do not qualify for CEUs, the equivalent for the purpose contact hours or certificates of attendance issued in lieu of CEUs for continuing behavioral health training and education.]
???Credentialed Mental Health Screener??? means an individual who has applied for and been approved to be credentialed as a mental health screener under Chapter 51 by the DSAMH [or their designee].
???Crisis experience in a mental health setting??? [means a crisis experience in a mental health setting] is defined as direct experience providing acute crisis services to people with mental health disorders in settings that include, but are not limited to, psychiatric assessment centers, hospital emergency rooms, crisis walk in settings, admission departments of psychiatric or general service hospitals, mobile crisis departments, drop in centers and certain settings found in the Department of Corrections.
???Licensed Mental Health Professionals??? means individuals who are licensed by the State of Delaware and who are otherwise eligible to be credentialed as a mental health screener under Chapter 51 include licensed physicians (MD/DO) whose practice specialty is other than psychiatry; licensed registered nurses with a bachelor???s degree in nursing (BSN); licensed advanced practice registered nurses (APN); licensed physician assistants (PA-C); licensed clinical psychologists (PhD/Psy.D); licensed clinical social workers (LCSW); licensed mental health counselors (LMHC); and licensed marriage and family therapists (LMFT).
???Supervision of unlicensed mental health professionals by a psychiatrist??? means an unlicensed mental health professionals who need to work under a psychiatrist licensed to practice medicine will perform this work under their [agency's by-laws organization???s practice standards and guidelines. and the This includes] requirements that the credentialed mental health screener discuss the individual in care's issues on the phone or through telepsychiatry with the supervising psychiatrist at the time of the detainment decision and assur[eing] that this psychiatrist agrees and countersigns the decision made. A[n faxed electronically transmitted copy] or original detainment form with the supervising psychiatrist???s signature will need to be placed in the client's medical record at the facility or site where the detainment occurred within 24 hours.
???Unlicensed mental health professional??? means an individual who works under the direct supervision of a psychiatrist but does not hold a professional license issued by the State of Delaware.
3.1 Psychiatrists
3.1.1 The psychiatrist must supply evidence [that he or she is licensed of current licensure] to practice medicine in Delaware.
3.1.2 No mental health screener credentialing is required.
3.2 Board Certified Emergency Physicians
3.2.1 Each physician applicant must submit qualifications; and
3.2.2 Each physician must supply evidence [that such person is licensed of current licensure] to practice medicine in Delaware and [is current] Board Certifi[edcation] by the American Board of Emergency Medicine.
3.2.3 Each physician will [be required to] receive and [be required to] review an information packet on statewide resources for clients in crisis.
3.3 Physicians
3.3.1 Each physician applicant must submit qualifications; and
3.3.2 Each physician must supply evidence [that such person is licensed of current licensure] to practice medicine in Delaware.
3.3.3 Each physician will be required to attend four hours of training to be credentialed as a MH Screener.
3.4 Licensed Non-Physician Mental Health Professionals
3.4.1 Each applicant must submit qualifications and supply evidence that:
3.4.1.1 If employed by DSAMH or a self-employed professional not affiliated with any Delaware health care facility, the applicant has five (5) years??? experience in mental health clinical and/or crisis settings as an employed or as a contracted professional.
3.4.1.2 If employed or contracted by any Delaware health care facility, the applicant has at least two (2) years experience in mental health clinical and/or crisis settings as an employed or as a contracted professional, and that [that] non-state health care facilit[yies] will take responsibility for the years of experience required for their staff to be credentialed.
3.4.2 Licensed Non-Physician Mental Health Professionals must meet the following qualifications:
3.4.2.1 Registered Nurse. Each applicant shall document [that they are licensed in current licensure by] the State of Delaware as a Registered Nurse with a BSN degree and in good standing, as set forth in 24 Del.C. Ch. 19[, relating to Professions and Occupations].
3.4.2.2 Advanced Practice Nurse. Each applicant shall document [that such person is licensed in current licensure by] the State of Delaware as an Advanced Practice Nurse in good standing, as set forth in Title 24 Del.C. Ch. 19[, relating to Professions and Occupations] and [is working employment] under a formal protocol with a Delaware licensed physician
3.4.2.3 Licensed Psychologist. Each applicant shall document [that such person is licensed current licensure by] in the State of Delaware as a Licensed Clinical Psychologist in good standing, as set forth in 24 Del.C. Ch. 35 [relating to Professions and Occupations].
3.4.2.4 Licensed Clinical Social Worker
3.4.2.4.1 Each applicant shall document [that such person is licensed current licensure by] in the State of Delaware as a Licensed Clinical Social Worker in good standing, as set forth in 24 Del.C. Ch. 39 [relating to Professions and Occupations].
[3.4.2.4.2 Each applicant shall document that such person has passed the American Association of State Social Work Boards.]
3.4.2.5 Licensed Professional Counselor of Mental Health
3.4.2.5.1 Each applicant shall document [that such person is licensed current licensure by] in the State of Delaware as a Licensed Professional Counselor of Mental Health in good standing, as set forth in 24 Del.C. Ch. 30 [relating to Professions and Occupations].
[3.4.2.5.2 Each applicant shall document that such person is certified by the National Board for Certified Counselors, Inc. (NBCC), or the Academy of Clinical Mental Health Counselors (ACMHC), or other national mental health specialty certifying organization acceptable to the Board.]
3.4.2.6 Licensed Marriage and Family Therapist
3.4.2.6.1 Each applicant shall document [that such person is licensed current licensure by] in the State of Delaware as a Licensed Marriage and Family Therapist in good standing, as set forth in 24 Del.C. Ch. 30 [relating to Professions and Occupations].
[3.4.2.6.2 Each applicant shall document that such person has passed the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) standardized examination or other examination acceptable to the Board.]
3.4.2.7 Licensed Physician Assistant.
3.4.2.7.1 Each applicant shall document [that such person is licensed current licensure by] in the State of Delaware as a Physician Assistant in good standing, as set forth in 24 Del.C. Ch. 17[, relating to Professions and Occupations] and [is working employment] under the delegated authority of a licensed physician.
3.5 Unlicensed Mental Health Professionals under Direct Supervision of a Psychiatrist
3.5.1 Each unlicensed mental health professional who is applying to become credentialed as a mental health screener must submit qualifications, [pay the application fee, pay the credentialing fee,] and supply evidence that:
3.5.1.1 Such person has had two years of clinical and/or crisis experience if working as a State employee or contractor;
[3.5.1.2 Such person has at least two (2) years of clinical and/or crisis experience or] if working with a Delaware Health Care Facility as an employee or contracted staff member;
3.5.1.[32] Such person has at least a bachelors or masters degree in a mental health related field if working as a State employee or contractor;
[3.5.1.4 Such person has a master???s degree in a mental health related field or] if working with a Delaware Health Care Facility as an employee or contracted staff member; and
3.5.1.[53] Such person has committed to completing forty (40) hours of crisis services in an employed position under direct supervision of a psychiatrist or credentialed mental health screener following completion of the mental health screener training and satisfactory score on the mental health screener credentialing exam.
[Definitions
4.1] ???Application for Credentialing???
[4.1.1 means An individuals] who wish[es] to be credentialed as a [credentialed] MH Screener [to be able to perform detainments] under Chapter 51 [will need to fill out shall complete an Application for Credentialing as a Mental Health Screener to DSAMH.
4.1.1.1 an The application that shall includes their a] resume, school transcripts, current work history including experience in working with people in mental health crises, current employment, and all contact information including Delaware license numbers and titles[, and such other credentials or proof of certification as may be necessary to meet requirements set forth in section 3 above].
[4.2] ???Application for Re-credentialing???
[4.2.1 means aA]ll Delaware credentialed mental health screeners [except as noted in 4.2.1.2 below] will be required to re-apply every two [(2)] years[, 60 days prior to the second anniversary date of the issued credential, for renewal of the credential] to DSAMH [or their designee and to
4.2.1.1 send in their The application for renewal shall require the submission of] applicable CEU's[, as well as such other credentials or proof of continuing licensure, credentials or certification as may be necessary to meet the requirements set forth in section 3 above] to be re-credentialed.
[4.2.1.2] The only professionals [that will] not [be] required to [do undergo] this re-credentialing process are licensed physicians whose specialty is psychiatry and physicians who [are maintain] Board Certifi[edcation] Emergency Physicians.
[4.2.1.2.1] DSAMH will provide any changes in state mental health or associated resources to this group in a timely manner and when these services become available or are changed in any way.
5.1 [Definitions Training
The following standards will apply to the credentialing and re-credentialing of Mental Health Screeners and sets forth the minimum qualifications and training requirements.
5.1.1 For licensed physicians other than psychiatrists??? Training Guidelines for credential mental health screener, licensed physicians other than psychiatrists??? means] training guidelines for applicants [who are licensed physicians other than psychiatrists] will include content that may change over time and is up to DSAMH to direct[, including acceptable CEUs generally related to psychiatric or crisis work].
[5.1.2 ???Training Guidelines for credentialed mental health screener, For licensed applicants??? means] training guidelines for applicants [who are licensed professionals] will include content that may change over time and is up to DSAMH to direct[, including acceptable CEUs generally related to psychiatric or crisis work].
[5.1.3 ???Training Guidelines for credentialed mental health screener, For unlicensed applicants??? means unlicensed applicants will be trained under the same training guidelines as for applicants who are licensed plus applicants will be required to participate in 40 hours of supervised crisis internship in a mental health setting. This will include content that may change over time and is up to DSAMH to direct, including acceptable CEUs generally related to psychiatric or crisis work].
5.2 Credentialing
5.2.1 Board Certified Emergency Physicians.
5.2.1.1 Compliance with qualifications specifi[ced in ??3] above;
[5.2.1.2 Compliance with training guidelines as specified in ??5.1 above.]
5.2.2 Licensed physicians other than psychiatrists and Board Certified Emergency Physicians:
5.2.2.1 Compliance with qualifications specified above;
5.2.2.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 4 hours of training by the DHSS Division of Substance Abuse and Mental Health; and
5.2.2.3 Satisfactory score on the credentialing examination.
5.2.3 Licensed Mental Health Professionals
5.2.3.1 Compliance with qualifications specified [in ??3] above;
5.2.3.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 40 hours of training by DSAMH; and
5.2.3.3 Satisfactory score on the credentialing examination.
5.2.4 Unlicensed Mental Health Professionals
5.2.4.1 Compliance with qualifications specified above;
5.2.4.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 40 hours of mental health screener training by DSAMH;
5.2.4.3 Satisfactory score on the credentialing examination[; and
5.2.4.4 Completion of 40 hours of crisis services under direct supervision of a psychiatrist or credentialed mental health screener.]
5.3 Re-Credentialing
5.3.1 Licensed Physicians other than psychiatrists and Board Certified Emergency Physicians:
5.3.1.1 Compliance with qualifications specified [in ??3] above; and
5.3.1.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 4 hours of training by DSAMH every two years.
[5.3.1.3 DSAMH will accept CEU???s that are generally related to psychiatric or crisis work.]
5.3.2 Licensed Mental Health Professionals
5.3.2.1 Compliance with qualifications specified above; and
5.3.2.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 4 hours of training by DSAMH every two years
[5.3.2.3 DSAMH will accept CEU???s that are generally related to psychiatric or crisis work.]
5.3.3 Unlicensed Mental Health Professionals
5.3.3.1 Compliance with qualifications specified above; and
5.3.3.2 [Compliance with training guidelines as specified in ??5.1 above, including Cc]ompletion of 8 hours of training by DSAMH every two years
[5.3.3.3 DSAMH will accept CEU's that are generally related to psychiatric or crisis work.
6.1 Forms and Documentation required to detain, or undo a detainment, of an individual under this statute: Credentialed mental health screeners will be required to complete a DSAMH Crisis Intervention Assessment Tool and 24-Hour Emergency Admission Form for the purpose of ensuring a standardized approach to assessing the needs of clients in crisis and documenting the decision premised upon that assessment. These forms will become part of the client???s records as well as be submitted to DSAMH. Data will be required on all detainments and sent to DSAMH as soon as possible and within 24 hours by the credentialed MH Screener that signs the detainment order. These detainments will be reviewed on a case by case basis going forward.
6.2 Data that will be documented daily in relation to detainments: DSAMH, as part of DHSS, will record a number of variables into a database. This database will include administrative information, such as the client MCI number, the date of contact, where the contact occurred, what staff member was lead in this response by name, the nature of the crisis, what was done including alternatives to inpatient care, who signed the detainment order, where the individual went once the detainment order was signed, and who transported the client; and clinical information as collected on the DSAMH Crisis Intervention Assessment Tool and 24-Hour Emergency Admission Form. In addition, if a detainment order was not signed, this database needs to document where the client went, to whom for care, what the plans were for follow-up, and transportation. DSAMH will also require a permanent data base that can render information on detainments every month going forward by April 2013.
6.3 Reports that will be publicly generated monthly on Delaware detainments: Aggregated data reports will be generated on detainments.
7.0 6.1 Essential] Conflict of Interest Statement:
The intent of the law is to ensure that no [client person] is detained for any reason other than [their having experiencing symptoms associated with] a mental condition that may result in danger to [that person self] or others, and that any conflicts of interest as set forth in 16 Del.C. ??5122 are disclosed on the [DSAMH Crisis Intervention Assessment Tool and] 24-hour [detention Emergency Admission] form filed with DSAMH within 24 hours of signature of the detention order. DSAMH will collect and monitor all assessments, detentions and non-detentions [performed by credentialed mental health screeners], whether a conflict of interest is disclosed or not, for purposes of ensuring that the intent of this law is met [and that admissions are appropriate].
[6.2 Record Keeping, Forms and Documentation. The following standards will apply to the Forms and Documentation required to monitor and report on the performance of credentialed mental health screeners as it pertains to compliance with conflict of interest disclosure in actions to detain, or undo a detainment, of an individual under this statute.
6.2.1 Credentialed mental health screeners will be required to complete a DSAMH Crisis Intervention Assessment Tool and 24-Hour Emergency Admission Form for the purpose of ensuring a standardized approach to assessing the needs of clients in crisis and documenting the decision premised upon that assessment. These forms will become part of the client???s records and sent to DSAMH as soon as possible and within 24 hours by the credentialed MH Screener that signs the detainment order.
6.3 Data Review and Reporting. Detainment Orders, Assessment Tools and Emergency Admissions forms will be reviewed and the data collected will be recorded in a database. This database will include administrative information, such as the client MCI number, the date of contact, where the contact occurred, what staff member was lead in this response by name, the nature of the crisis, what was done including alternatives to inpatient care, who signed the detainment order, where the individual went once the detainment order was signed, and who transported the client; and clinical information, if a detainment order was not signed, documentation as to where the client went, to whom referred for care plans for follow-up, and transportation.
6.3.1 Reports from the DSAMH database will be publicly generated monthly showing aggregated data on detainments in Delaware.
6.3.2 Detainment data will be reviewed to monitor for anomalies in detainment rates to assure mental health screener performance improvement and compliance.
[87].1 [The following outlines circumstances under which a credential may be suspended or revoked.] DSAMH will monitor individuals and general facilities [who performing] credentialed mental health screenings and [who detaining] individuals for 24 hours under this regulation [as specified in Section 6.0. Nothing in Section 6 relieves. C c]redentialed mental health screeners [are expected of the requirement] to keep their own records on their work to detain or not detain individuals that they assess. Copies of the screening form are sufficient documentation if the individual mental health screener or organization that supports these screeners keeps this information protected and confidential under federal law. Compliance with federal laws on this documentation is the responsibility of the individual who has been credentialed as a [Mental Health] Screener.
[7.1.1 Failure of All any] credentialed MH Screeners [need] to be aware of[, and operate in compliance with,] the federal [and state] laws pertaining to protection of health records[. Failure to comply with this requirement will result in immediate suspension of th[ise Mental Health Screener] credential.
[8.2 7.1.2 If Suspension or revocation of] a professional license [is revoked or suspended will result in the immediate revocation of,] the MH Screener credential[ is immediately revoked].
[7.1.3 Loss of psychiatric supervision.] For unlicensed mental health professionals who cease to work under the supervision of a psychiatrist licensed to practice medicine, the [Mental Health] Screener credential is immediately revoked.
[7.2] Compliance with notification of this revocation is the responsibility of the individual who has been credentialed as a [Mental Health] Screener.
[7.3] Reinstatement of [the Mental Health Screener credential of] an individual [with a revoked credential for whom a credential has been suspended or revoked] will be at the discretion of DSAMH, in light of circumstances surrounding the original [suspension or] revocation.
Payment to hospitals for voluntary and involuntary admissions of clients in crisis will be made pending approval by a psychiatrist designated by the Secretary of Health and Social Services[. Approval will depend on following the conduct outcome] of an independent review [of forms and documentation as specified in Section 6.0. The review???s specific purpose will be to and confirmation that:] the admission represents the most appropriate and least restrictive treatment for the client in crisis[,;] that the duration of stay for the admitted client is reviewed and deemed appropriate, and that the State is the payer of last resort.
Any individual who has been denied credentialing as a mental health screener or who has had [their a] screening credential suspended or revoked can appeal this decision by writing to the DSAMH Director[. with their Such an appeal,] based on [their] knowledge and facts of this event[, must be made] within twenty (20) days of the denial. A response by the DSAMH Director will be forthcoming within thirty (30) days.
