DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Substance Abuse and Mental Health

PROPOSED

PUBLIC NOTICE

6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions

In compliance with the Administrative Procedures Act (29 Del.C. Ch. 101) and under the authority of 16 Del.C. § 5004, the State of Delaware Department of Health and Social Service's Division of Substance Abuse and Mental Health ("the Division") is proposing amending regulations governing credentialed mental health screeners ("screeners").

A person may make suggestions or provide compilations of data, testimony, briefs, or other materials concerning the Division's proposal by written submission to the Division of Substance Abuse and Mental Health. The Division will receive submissions made before 4:30 p.m. on July 3, 2023, by mail to 1901 North DuPont Highway, New Castle, DE 19720-0906, by fax to (302) 255-4427, and by email to joe.aronson@delaware.gov. Please identify in the subject line: 6002 Credentialed Mental Health Screeners.

The Division's determination to adopt this proposal will include analysis and consideration of submissions received.

SUMMARY

This notice advises the public that the Division proposes amendments to regulations governing credentialed mental health screeners.

Statutory Authority

16 Del.C. §5004(k) authorizes the Division "to establish regulations consistent with this chapter," adopt "rules regarding the disclosure by credentialed mental health screeners… of potential conflicts of interest," and issue this proposal.

Background

Enacted in 2014, 79 Del. Laws Ch. 442 amended Delaware's existing involuntary commitment laws and established a new involuntary commitment process. The new law codified at 16 Del.C. ch. 50, required that an individual be emergently detained before being provisionally admitted as a precursor to a probable cause hearing and potential involuntary commitment.

Under 16 Del.C. § 5004(b), "an emergency detention may only be initiated by a credentialed mental health screener." Under 16 Del.C. § 5001(2), a credentialed mental health screener is a licensed psychiatrist or one of the following whom the Division credentials:

Summary of the Proposal

The proposed regulation ("the regulation") seeks to update the current regulation to establish precise requirements and procedures for conducting screenings, registering psychiatrists, and credentialing screeners.

The regulation amends 16 DE Admin. Code § 6002 and does all of the following:

Fiscal Impact

The Division anticipates the regulation will have a de minimus fiscal impact.

6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions

Title 16, Chapter 51 of the Delaware Code states that only psychiatrists and 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 themselves out to the public as credentialed mental health screener unless the persons 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.

“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 organization’s practice standards and guidelines. 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 assuring that this psychiatrist agrees and countersigns the decision made. An 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 of current licensure to practice medicine in Delaware.

3.1.2 No mental health screener credentialing is required.

3.1.3 A psychiatrist may authorize detention for a psychiatric evaluation of any person, over or under age 18.

3.2 Board Certified Emergency Physicians

3.2.1 Each physician applicant must submit qualifications; and

3.2.2 Each physician must supply evidence of current licensure to practice medicine in Delaware and current Board Certification by the American Board of Emergency Medicine.

3.2.3 Each physician will receive and be required to review an information packet on statewide resources for clients in crisis.

3.2.4 A credentialed Board Certified Emergency Physician may authorize detention for a psychiatric evaluation of any person, over or under age 18.

3.3 Physicians

3.3.1 Each physician applicant must submit qualifications; and

3.3.2 Each physician must supply evidence 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.

3.3.4 A credentialed physician may authorize detention for a psychiatric evaluation of any person, over or under age 18.

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 non-state health care facilities 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 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.

3.4.2.2 Advanced Practice Nurse. Each applicant shall document 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, and employment under a formal protocol with a Delaware licensed physician

3.4.2.3 Licensed Psychologist. Each applicant shall document 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.

3.4.2.4 Licensed Clinical Social Worker

3.4.2.4.1 Each applicant shall document 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.

3.4.2.5 Licensed Professional Counselor of Mental Health

3.4.2.5.1 Each applicant shall document 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

3.4.2.6 Licensed Marriage and Family Therapist

3.4.2.6.1 Each applicant shall document 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.

3.4.2.7 Licensed Physician Assistant.

3.4.2.7.1 Each applicant shall document current licensure by in the State of Delaware as a Physician Assistant in good standing, as set forth in 24 Del.C. Ch. 17, and employment under the delegated authority of a licensed physician.

3.4.3 A credentialed Licensed Non-Physician Mental Health Professional may authorize detention for a psychiatric evaluation of a person age 18 or older.

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, 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; or if working with a Delaware Health Care Facility as an employee or contracted staff member;

3.5.1.2 Such person has at least a bachelors or masters degree in a mental health related field if working as a State employee or contractor; or if working with a Delaware Health Care Facility as an employee or contracted staff member; and

3.5.1.3 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.

3.5.2 A credentialed Unlicensed Mental Health Professional may authorize detention for a psychiatric evaluation of a person age 18 or older.

4.1 Application for Credentialing

4.1.1 An individual who wishes to be credentialed as a MH Screener under Chapter 51 shall complete an Application for Credentialing as a Mental Health Screener to DSAMH.

4.1.1.1 The application shall include 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 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

4.2.1.1 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 not required to undergo this re-credentialing process are licensed physicians whose specialty is psychiatry and physicians who maintain Board Certification 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 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 applicants 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 For licensed applicants training guidelines for applicants 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 For unlicensed applicants training guidelines for applicants 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 specified 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 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 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;

5.2.4.3 Satisfactory score on the credentialing examination

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.

5.3.2 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 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.

6.1 Conflict of Interest Statement:

The intent of the law is to ensure that no person is detained for any reason other than experiencing symptoms associated with a mental condition that may result in danger to 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 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.

7.1 The following outlines circumstances under which a credential may be suspended or revoked. DSAMH will monitor individuals and general facilities performing credentialed mental health screenings and detaining individuals for 24 hours under this regulation as specified in Section 6.0. Nothing in Section 6 relieves credentialed mental health screeners 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 any credentialed MH Screeners 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 the Mental Health Screener credential.

7.1.2 Suspension or revocation of a professional license will result in the immediate revocation of the MH Screener credential.

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 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 the outcome of an independent review of forms and documentation as specified in Section 6.0. The review’s specific purpose will be to confirm 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 a screening credential suspended or revoked can appeal this decision by writing to the DSAMH Director. 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.

6002 Credentialed Mental Health Screeners

The Division of Substance Abuse and Mental Health, within the Department of Health and Social Services, promulgates this regulation under the authority of 16 Del.C. §5004.

The following words and terms, when used in this regulation, have the following meaning:

"Advanced Practice Registered Nurse" or "APRN" means as defined under 24 Del.C. §1902(b).

"Baccalaureate Social Worker" or "BSW" means as defined under 24 Del.C. §3902(5).

"Certificate to practice medicine" or "medical license" means as defined under 24 Del.C. §1702(2).

"Credentialed mental health screener" or "screener" means as defined under 16 Del.C. §5001(2).

"Designated psychiatric treatment facilities" or "facility" means as defined under 16 Del.C. §5001(6).

"Division" means the Division of Substance Abuse and Mental Health.

"Institutional License" or "training license" means a medical license as outlined under 24 Del.C. §1722(a)(2).

"Licensed clinical social worker" or "LCSW" means as defined under 24 Del.C. §3902(18).

"Licensed marriage and family therapist" or "LMFT" means as defined under 24 Del.C. §3051(c).

"Licensed mental health professional" or "LMHP" means any of the following:

"Licensed professional counselor of mental health" or "LPCMH" means as defined under 24 Del.C. §3031(2).

"Physician" means as defined under 24 Del.C. §1702(10). The term includes an allopathic Doctor of Medicine and surgery or a Doctor of Osteopathic Medicine and Surgery with a valid license to practice medicine working in a United States Department of Veterans Affairs medical center in the State.

"Physicians Assistant" or "PA-C" means as defined under 24 Del.C. §1770A(4).

"Psychiatric-mental health advanced practice registered nurse" or "PMH-APRN" means an APRN certified as a psychiatric-mental health nurse practitioner by the American Nurses Credentialing Center.

"Psychiatrist" means as defined under 16 Del.C. §5001(15).

"Psychiatry resident" means an individual who holds a training license and is enrolled in an accredited residency training program in psychiatry.

"Psychologist" means as defined under 24 Del.C. §3502(7).

"Relative" means an individual related to another by consanguinity or affinity within the third degree.

"Screening" means the emergency assessment of an individual's mental condition to determine the need for involuntary observation or treatment or both by a screener under 16 Del.C. Ch. 50.

"Unlicensed mental health professional" or "UMHP" means an individual who is not a psychiatrist, physician, PMH-APRN, or LMHP.

"Victim" means as defined under 11 Del.C. §9401(7).

This regulation sets forth the requirements and procedures for conducting screenings, registering psychiatrists, and credentialing screeners.

This regulation applies to all screeners.

5.1 Except as otherwise provided under subsections 5.2 and 5.3 of this regulation, an individual must not conduct a screening.

5.2 A psychiatrist registered by the Division may conduct a screening.

5.3 An individual credentialed by the Division may conduct a screening.

6.1 Before registering with the Division to perform screenings, a psychiatrist must do all of the following:

6.1.1 Possess a valid medical license.

6.1.2 Complete an accredited residency training program in psychiatry.

6.2 Before applying for credentialing, a physician must possess a valid medical license.

6.3 Before applying for credentialing, a PMH-APRN must possess a valid license and a valid psychiatric-mental health nurse practitioner certification from the American Nurses Credentialing Center.

6.4 Before applying for credentialing, an LMHP must do all of the following:

6.4.1 Possess at least 1 of the following:

6.4.1.1 Valid licensure as an LCSW.

6.4.1.2 Valid licensure as an LPCMH.

6.4.1.3 Valid licensure as a PA-C and valid certification in psychiatry by the National Commission on Certification of Physician Assistants.

6.4.1.4 Valid licensure as a psychologist.

6.4.1.5 A valid training license and proof of enrollment in an accredited residency training program in psychiatry.

6.4.2 Have at least 2 years of direct experience providing clinical services to individuals with mental health conditions.

6.5 Before applying for credentialing from the Division, a UMHP must practice under the supervision of a psychiatrist and do at least 1 of the following:

6.5.1 Have a bachelor's degree in a mental health-related field from an accredited educational institution and at least 4 years of direct experience providing clinical services to individuals with mental health conditions.

6.5.2 Have at least a master's degree in a mental health-related field from an accredited educational institution and at least 2 years of direct experience providing clinical services to individuals with mental health conditions.

7.1 Except as otherwise provided under this subsection, the Division may not register a psychiatrist. The Division shall register a psychiatrist that does all of the following:

7.1.1 Meets the qualifications under Section 6.0 of this regulation.

7.1.2 Applies to the Division by completing the Division's application form and submitting documentation proving that the psychiatrist is qualified under Section 6.0 of this regulation.

7.2 Except as otherwise provided under subsections 7.3, 7.4, and 7.5 of this regulation, a psychiatrist's registration is valid for 10 years from the date the Division registers the psychiatrist.

7.3 If a psychiatrist applies to renew their registration before it expires, their registration is valid until the Division approves or rejects the application.

7.4 Whenever a psychiatrist does not comply with federal, state, or local law, regulation, or policy, the Division may deregister the psychiatrist.

7.5 Whenever a psychiatrist registered with the Division does not meet the requirements under Section 6.0 of this regulation, the Division shall deregister the psychiatrist.

7.6 The Division shall notify a psychiatrist immediately after deregistering the psychiatrist.

7.7 A psychiatrist may appeal deregistration to the Division Director. An appeal must be made in writing no later than 10 days after the Division deregisters the psychiatrist under subsection 7.4 or 7.5 of this regulation. No more than 30 days after receiving the appeal, the Division Director shall review the appeal, make a final determination, and notify the psychiatrist of the determination.

8.1 Except as otherwise provided under this subsection, the Division may not credential an individual. The Division shall credential an individual that does all of the following:

8.1.1 Meets the qualifications under Section 6.0 of this regulation.

8.1.2 Applies to the Division by completing the Division's application form and submitting documentation proving that the individual is qualified under Section 6.0 of this regulation.

8.1.3 Completes the Division-required training.

8.1.4 Achieves a satisfactory score on the Division's examination.

8.2 Except as otherwise provided under subsections 8.3, 8.4, and 8.5 of this regulation, a credential is valid for 2 years from the date of issuance by the Division.

8.3 If a screener applies to renew their credential before it expires, the credential is valid until the Division approves or rejects the application.

8.4 The Division may suspend or revoke a screener's credential whenever the individual fails to comply with federal, state, or local law, regulation, or policy.

8.5 Whenever a screener does not meet the requirements under Section 6.0 of this regulation, the Division shall revoke the screener's credential.

8.6 The Division shall notify a screener immediately after suspending or revoking the screener's credential.

8.7 A screener may appeal a revocation or suspension of their credential to the Division Director. An appeal must be made in writing no later than 10 days after the Division suspends or revokes the screener's credential under subsection 8.4 or 8.5 of this regulation. No more than 30 days after receiving the appeal, the Division Director shall review the appeal, make a final determination, and notify the screener of the determination.

A screener must conduct a screening per 16 Del.C. Ch. 50, this regulation, and the Division's policies.

10.1 Whenever a screener conducts a screening, the screener shall disclose any existing or potential conflict of interest relating to the individual undergoing screening.

10.2 Conflicts of interest include the following:

10.3 A disclosure under this section must be made in writing on the form provided by the Division.