BEHAVIORAL HEALTH COUNSELING THERAPY SERVICE/AOD INDIVIDUAL COUNSELING
PurposeTo codify the Mid-Ohio Psychological Services, Inc. policies concerning the delivery of Behavioral Health Counseling Therapy Service and AOD Individual Counseling and establish the responsibilities of both clinical staff and support staff for the delivery of this service.
Policy
It is the policy of Mid-Ohio Psychological Services, Inc. to provide the highest quality, cost effective Behavioral Health Counseling Therapy/AOD Individual Counseling services available. This service is provided by qualified mental health practitioners and supported by competent clerical staff, all of whom are sensitive to the needs of the consumer.
It is the responsibility of the Executive Director, Associate Director and Operations Director, to oversee the delivery of Behavioral Health Counseling Therapy/AOD Individual Counseling Services. The Executive Director is responsible for codifying the procedures for this service and for ensuring compliance by all staff with the established procedures, reporting any discrepancies to the appropriate staff personnel.
It is the responsibility of all clinical staff and support staff to provide immediate feedback to the Executive Director or Associate Director when any problems arise in the delivery of this service or when any areas for improvement are identified.
It is the responsibility of the Quality Assurance Committee to review the provision of this service through established procedures to ensure the thoroughness, appropriateness, and effectiveness of service delivery.
Procedures
Admission
All admissions to the Mid-Ohio Psychological Services, Inc. must first enter through the Mental Health Assessment/AOD Assessment process before initiating Behavioral Health Counseling Therapy/AOD Individual Counseling. The time period involved in initiating Behavioral Health Counseling Therapy/AOD Individual Counseling depends on the nature of the problem, scheduling limits, hours of operation, and client attendance. Behavioral Health Counseling Therapy/AOD Individual Counseling services should be provided within 30 days of the time the service is requested.
Intake
Intake usually begins when a client calls with a presenting problem. Support staff are to complete an Initial Telephone Contact Form or a referral source must complete a Referral to MOPS Form. The Initial Telephone Contact Form and/or Referral to MOPS Form will be reviewed by the Site Supervisor or their designee and the case will be assigned to a clinician for assessment according to established guidelines. During the initial phone intake, every effort will be made to determine the existence of any special needs including assistance with language, physical challenges or the potential impediments to the completion of an assessment and every effort will be made to address these concerns at no cost to the client.
The receptionist will make arrangements for the individual to be seen by a counselor for their Mental Health Assessment/AOD Assessment session, setting the appointment with appropriate consideration to the person’s work schedule, place of residence, availability of transportation, and other valid circumstances; however, it is requested that, when possible, the assessment be conducted within seven working days of the initial contact. At this point, the client will be informed of relevant fees for service. The client is given/mailed an appointment card indicating the time, date, and day of the session, as well as the name of the counselor the client is scheduled to see. The Receptionist notes the client’s name in the computer scheduler for the time, date, and type of session (Mental Health Assessment/AOD Assessment). If the client is in acute distress and in need of emergency services, the client will be referred to the community Emergency Services program as established by the Mental Health Board.
When the client initially comes into the agency, they are asked to complete the Physical Health Assessment (self report) Form, Psycho-Social History (self report) Form, appropriate Outcomes Form, and Billing Authorization Form and to review the Client Guidelines and Client Rights Statement. The client must complete these forms and sign the Authorization for Services portion of the Client Guidelines form prior to receiving any services. These materials may be mailed to the client prior to the client first arriving to the office, when time permits. The client must sign a statement indicating that they have received and reviewed the Client Guidelines and Client Rights Statement. If a client is a minor or is under legal guardianship, the parent/legal guardian must sign the Client Guidelines, Client Rights Statement, and Authorization for Billing forms to provide authorization for services. Upon completion of these forms, the person is then registered with the agency and the case is entered into the computer system where an individualized client number is assigned to the case.
Client case numbers are based on the current year, month, date, and numerical sequence (Example: For a person who registered on April 6, 1991 and is the third client to register that day, their individualized client I.D. number will be 91-04-06-03). The Master Log will then serve as a tracking device that follows the client’s involvement in the agency through termination of service(s). The billing clerk then enters the client information into the practice management software. An Individualized Client Record (ICR) is then organized, into which all of that client’s records are placed and maintained. At this time, the ICR will have at least the Phone Intake (or Referral to MOPS Form), Physical Health Assessment (self report) form, Psycho-Social History (self report) form, andAuthorization for Billing and the signed portion of the Client Guidelines (Authorization for Services) and Client Rights Statement. The Records Clerk will then organize the file, arranging to established procedures. The file will then be affixed an identification label with the client’s last name, first name, and middle initial, as well as his/her individualized case number. The file is to be stamped with “CONFIDENTIAL” on its front cover.
Mental Health Assessment/AOD AssessmentAll clients must receive a Mental Health Assessment/AOD Assessment prior to receiving Behavioral Health Counseling Therapy/AOD Individual Counseling. The Mental Health Assessment/AOD Assessment is either conducted according to the policies and procedures of this agency or is obtained from another agency through the transfer of an Integrated Client Record. After the first session, a Plan of Action or Individual Service Plan (ISP) must be completed. The Mental Health Assessment/AOD Assessment is complete when an ISP has been established or when it has been determined that mental health services are not necessary at this time. The ISP must be signed by the client, the participating clinicians, and the clinical supervisor. Mental Health Assessment/AOD Assessments should be completed by the second session but must be completed within the first four sessions or 30 days, whichever comes first.
During the Mental Health Assessment/AOD Assessment, all the materials in the ICR are to be reviewed, appropriate collateral material obtained (with signed release of information forms), appropriate testing conducted, a complete psychosocial history gathered, and a mental status examination administered. The clinician must also complete the MACSIS Intake Form and the appropriate Outcome Measure (as appropriate).
The case notes for Mental Health Assessment/ AOD Assessment sessions must include a section addressing clinical formulation. This clinical formulation section to the case note must include supporting data, evidence of signs and symptoms, and reasoning for the diagnosis that is being provided.
Outpatient TreatmentBehavioral Health Counseling Therapy/AOD Individual Counseling may begin when an ISP has been completed and the client has been assigned a counselor. Outpatient treatment is designed to address the issues identified on the ISP through face-to-face interaction with the counselor and client or client family member.
In the event of a client-counselor conflict, and the client has difficulty with the initially assigned counselor, the client may request re-assignment to another counselor. The client is required to inform his/her initial counselor of the problem and request a different counselor. If the counselor cannot resolve the conflict, he/she will present the client’s request to the clinical staff in the clinical staffing. The clinical staff will determine the appropriateness of the client’s request and if it is approved, will re-assign the case. In the case of a re-assignment, a Case Transfer form must be completed. When the request is denied, the counselor will inform the client at their next scheduled session. If the client still is not satisfied, the counselor will make arrangements for the client to be seen by Client’s Rights Officer or Executive Director along with the counselor to attempt to resolve the conflict.
Case notes
Case notes must include the client name, record ID, date of the session, type of session, start and end time of the session, and the time spent in the session. Case notes for the initial two sessions should begin with a summary of why the client is being seen and a brief mental status examination. All subsequent case notes should begin by addressing any discrepancies in the client’s presentation. As a general rule, case notes should include a description of client progress or lack of progress since the last session in relation to treatment goals and objectives, and any changes in a client’s cognitive, affective, or behavioral functioning. They should include a brief summary on the purpose of the session, what occurred in the session, and what is planned for the next session. The signature and credentials of the person making the entry should follow each case note entry as well as the date the case note was signed. All activities concerning a client should be documented by a case note. Case notes are preferably dictated but may be typed by the clinician. If dictated, case notes must be turned in at the end of the business day for transcription. The person completing transcription shall record their initials, the date the note was dictated, and the date the note was transcribed at the bottom of the case note.
Termination
While the client remains active in treatment/assessment, it is the responsibility of the assigned counselor to ensure the maintenance of the file and to report on the client’s involvement to the referral source (when appropriate). If a client fails to appear for a session or fails to reschedule an appointment, it is the responsibility of the support staff to initiate the following procedures:
1. Notify the clinician of the situation.
2 . Attempt to contact the client to clarify their intentions and document said attempt. This attempt should include at least one attempt to phone and one attempt to send a Missed Appointment Notification form.
3. Initiate a Termination Summary form, filling in the appropriate sections including # of sessions, name, attempts to reinitiate, etc.
4. Have the counselor complete the Termination Summary form, MACSIS–Case Closure Form, Outcome Case Closure and have the clinical supervisor sign off.
5. Place the ICR in the temporary inactive file.
6. After a reasonable amount of time, place the ICR in the file archives.
Re-Admission
Any client who has not been in counseling contact with the program without prior notification for over six months will be required to be re-evaluated. The type of re-evaluation will be determined by the counselor conducting the initial interview. It may involve re-administering an evaluation device or may simply be a screening session. The client will not pick up where he/she left off in treatment as had been outlined on the Individual Service Plan or Plan of Action. Consequently, the client’s case will be re-staffed by the counselor conducting the re-evaluation, and the appropriate recommendations will be made by the clinical staff relative to the results of the evaluation. It is also possible that the initial diagnostic impression may be upgraded as a result of new or additional information.
In the event of a client applying for readmission after his/her case had been terminated the same case number will be maintained in the computer practice management system, however, the client will be assigned a new treatment episode/file number utilizing the same numbering system used to assign case numbers.
Any previous records that had not been destroyed (less than 10 years old) may be copied and placed in the new chart. The old chart is to be maintained intact as an independent clinical chart.
Client Transfer
When a client is transferred from one staff member or service areas to another within the agency, the following information is to be recorded on the Client Transfer Form: the dated signature of the staff member transferring the person, the name of the staff to which the person is being transferred, and the effective date of the transfer. The case notes shall reflect that the reason(s) have been explained to the person served, and, if appropriate, parent or guardian that the person being transferred participated in the transfer decision. The person’s response to the transfer decision shall be documents in the case notes.
Interagency Referral
When a client is transferred to or from another agency, the following information shall be documented in the Individual Client Record: the name and dated signature of the staff member making the interagency referral, the name of the individual or agency to whom the interagency referral is being made, the effective date of the interagency referral, the authorization for release of information according to division F of section 5122.31 of the Ohio Revised Code, and progress and/or consultation reports requested from the agency to which the person is referred. The ICR will reflect the reason(s) for the referral, including documentation that the reason(s) have been explained to the person being referred, and if appropriate, parent or guardian, and that the person being transferred participated in the referral decision. The person’s response to the referral shall be documented in the client record as well. When a person is referred to a psychiatric hospital, a copy of the Individual Service Plan shall be provided to the hospital treatment team with consent of the person served, or the person’s parent or guardian, when appropriate.
Mid-Ohio Psychological Services, Inc. maintains a close working relationship with other human service providers in and around Fairfield County area. MOPS takes a holistic approach to the treatment of mental disorders, looking at the needs of the whole person, and not just one or two aspects of its clientele. To better meet these varied needs, MOPS has linked its services with the services of other resources in the area, and have implemented procedures of referral to these service providers.
A. MOPS encourage its clients involved in outpatient treatment to either see a personal physician or to find a personal physician for at least a general examination.
B. In the event of an immediate emergency medical need, MOPS will link the client with Fairfield Medical Center Emergency Room, Emergency Services (or other local hospital for services rendered outside of Fairfield County).
C. In the event of any client needing inpatient psychiatric care out-of-county, the MOPS can make the necessary arrangements to have the person admitted through Emergency Services.
D. Medical Emergencies are to be referred to the Fairfield Medical Center (or other local hospital for services rendered outside of Fairfield County) for further assessment and stabilization. In life threatening medical emergencies, the MOPS staff will call 911.
E. Any other referrals for services are made by the Mid-Ohio Psychological Service, Inc. whose responsibility it is to link the client with the agency or agencies that can best provide the needed service(s). The referrals can be made via direct phone contact and an appointment made for the client, or the client can be given the name and address of the service provider to contact.