Tag Archives: treatment

Confusion Over Sober Home Certification Spurs Misinformation Campaign in Florida

Prior to 2016, there was no law in Florida governing the relationship between sober homes and treatment programs.  Certification of recovery residences was voluntary, under the premise (and misunderstanding of legislative staffers in the State’s capitol in Tallahassee) that sober living and treatment programs were entirely separate creatures.

In other states, that may be the case and sober living has historically enjoyed an autonomy (such as the reputable Oxford House International charter model) which led to multitudes of success stories of people finding their own path to recovery and sustained sobriety.

But as Florida cemented itself as a “treatment destination”, the concept of the “sober home “ or “recovery residences” began to turn from an altruistic endeavor to a concern over where and how to house patients while they were in treatment.

By coming to Florida for treatment, patients clearly need a place to stay when not in clinical session. Under the “Florida Model” of outpatient services favored by insurance carriers and as adopted by Florida law under the “Partial Hospitalization” (PHP) level of care, housing is to be provided by the treatment provider.

For many years, the PHP model worked quite well and it simply made sense that a patient needed to be provided a place to sleep that was safe, secure, and drug/alcohol free. “Recovery support services” within the home were never required.

These homes, referred to as the “Community Housing” component of a “Day or Night Treatment with Community Housing” license, may or may not provide any form of peer-supported living. It is at the discretion of the provider.

And that is where the problem comes in, as far as the Fair Housing Act is concerned. Such a home is, by all definitions, a “house,” but is it a “boarding house?” A “dormitory?” A “hotel for addicts” while in treatment?

The Fair Housing Act (FHA) only protects “dwellings.”  It also protects the right of all persons to “choose their own ‘home’.”

The FHA does supersede local zoning codes that wrongfully differentiate between homes for people related by blood or marriage and homes where people live “as the functional equivalent of a biological family” that has a known therapeutic benefit.  The FHA and ADA, however, does not allow a Recovery “Bed & Breakfast” to exist wherever it wants to.

For the past 40+ years in Florida, there have been and continue to be numerous “stand alone” sober living environments (many in Delray Beach, for instance) that have faithfully served as the lifeline between newfound sobriety and living a life in recovery, surrounded by a “recovery community”.  The NY Times even lauded Delray Beach for being “an oasis of sobriety” for long-term sober living and support, calling Delray Beach a Recovery Capitol [“Delray Beach, a funky outpost of sobriety between Fort Lauderdale and West Palm Beach, is the epicenter of the country’s largest and most vibrant recovery community, with scores of halfway houses, more than 5,000 people at 12-step meetings each week, recovery radio shows, a recovery motorcycle club and a coffeehouse that boasts its own therapy group.”].

Those were “recovery residences” to be rightfully protected by the FHA.

But as the Pill Mill Epidemic became replaced with the Opioid Epidemic across the country, people quickly flocked to Google and other informational websites to try to find out what “sobriety” was and where to find it.

Newly-christened addiction treatment entrepreneurs, due in large part to the Great Recession of 2008, began snapping up residential real estate across Southeast Florida in order to provide these supposed “sober living homes” to meet the growing demand.

Then, with the passage of the Patient Protection and Affordable Care Act of 2010, the requirement that insurance carriers pay health care benefits to include addiction treatment fueled the growth of the industry. However, the barrier to entry was (and remains) rather low, and the housing component remains a necessary part in order to have somewhere to “keep” patients while not providing them with clinical services.

Thus, the “Sober Home” problem began as boarding houses for people brand-new to recovery replaced reputable sober living.

In addition, some newer providers of PHP level of services decided to market their housing as the selling point for coming to South Florida; clinical services were secondary, if mentioned at all. To that point, the only requirement to enjoying such a [free] life of leisure was attendance at the housing provider’s off-site clinical treatment location.

This new reality caused local elected officials to plea to the federal government to revisit the Fair Housing Act and the Americans with Disabilities Act, stating that those laws never intended for residential neighborhoods to become de facto hospital districts for persons just released from post-relapse Detoxification services and newly placed into PHP programs. At a minimum, they argued, there should be some modicum of standard for such housing no different than Assisted Living or any other form of supervised group living arrangement.  Stated otherwise, the FHA and ADA do not trump those regulations; why does sober living associated with a treatment program get a free pass?

To begin to bring some level of objectivity to the field, the Florida Association of Recovery Residences (FARR), a sister-organization to the National Alliance of Recovery Residences (NARR), began to seek voluntary certification of sober living residences so that the established homes could differentiate themselves from the new upstarts.

And by 2015, the Florida Legislature elected to formalize that process by directing DCF to identify an entity to credential Recovery Residences.  While voluntary in nature, all licensed treatment providers could not make any refer to a sober living residence if that home was not certified.

Being the only game in town, FARR applied to be the credentialing agency and was thereafter delegated the authority to serve in that administrative capacity.

However, the problem of unregulated sober homes only continued to flourish, as the clear nexus between the locations of overdose deaths and unregulated “sober homes” became abundantly clear.

More had to be done, and faster.

By 2016, the Florida Legislature asked the Palm Beach County State Attorney’s Office to begin conducting a fact-finding mission to determine, fairly and objectively, what was actually “happening on the ground.”

The results were mind-blowing.

After a Grand Jury investigation and report from the separate Sober Homes Task Force Proviso Committee found rampant fraud and abuses of patients by the treatment, housing and marketing industries, further laws were recommended and ultimately adopted.

These new laws, adopted in 2017, sought amongst other protections to clarify unequivocally that treatment centers and sober living residences were regulated by different entities, and that any referral to any sober living residence by a treatment center, whether owned by the treatment center or not, was now to be regulated.

As of July 1, 2018, all sober living residences to which treatment centers were to make a referral of any type had to be certified.

In order to address the long-standing relationship between treatment providers and housing components under the PHP level of care, the Florida Legislature gave all providers until July 1, 2018 (a full year) to become certified.

The reason for the year-long delay was for purposes of fundamental fairness – treatment providers needed to both have their sober living residences certified by FARR as well as secure the services of a Certified Recovery Residence Administrator (CRRA) through approval  by the Florida Certification Board.

Even then, the statute provides that DCF may only begin fining violations as of June 2019.

Still, notwithstanding the well-publicized passage of this law in early 2017 and its signature by Governor Rick Scott by May of that year, many providers continued to claim confusion, based upon misinformation circulated by “consultants” or typical “word of mouth” rumors which are all-too-rampant in the addiction treatment space.

Still, many providers DID follow the law and sought FARR certification long before the deadline of July 1st.

One such provider was Amethyst Recovery Center in St. Lucie County, Florida.

However, Amethyst was ultimately denied FARR certification for its recovery residences, clearly compromising its ability to continue its PHP program.

In response, attorneys for Amethyst filed what is referred to as a “Petition for Declaratory Statement” with DCF, seeking clarification as to whether the housing component of a PHP program must be FARR certified.

Most recently, DCF issued a clearly worded notice on May 29, 2018 to all providers, reaffirming the plain language of the statute that any referral to made to any non-FARR certified recovery residence after July 1, 2018 would be a violation of state statute.

While the outcome of Amethyst’s Petition is now in the hands of DCF, and maybe ultimately the courts, the law has not been suspended, particularly at the local level, where various cities now require FARR certification as a condition of obtaining local zoning approval.

So why are we even commenting on this issue if it is so apparently undecided?

Candidly, we take great offense at the apparent opportunism that some are exhibiting, claiming the “confusion” is due to “random, misleading emails from organizations within the drug and alcohol treatment industry” as to whether PHP housing must be FARR certified, which confusion has been “fueled by the new questionable laws that were passed.”

Such statements are not only wrong, they are irresponsible.

It doesn’t take a lawyer to know that the Florida Legislature said what it meant, and meant what it said. Either one is living under a rock, or is in denial about the state of affairs of sober living in Florida and the country as a whole.

But putting all of that aside, what everyone is missing is the most obvious – certification is an additional burden placed upon treatment providers that compromises their ability as to where they can house their patients, for which insurance refuses to pay.

Since that housing is not reimbursed by insurance, any additional regulatory burden comes out of the treatment center’s bottom line.

But the other side of the argument is even more pressing – the FHA and, by compliment, the ADA, guarantees “fair” housing choices for those who desire to live in a  sober living environment.

PHP patients, by the very nature of PHP housing as well as Res. 5 housing, inherently do NOT choose their own housing. No differently than a hospital patient does not pick and choose which bed to be placed in after surgery.

Moreover, the FHA and ADA only protect “dwellings” which term has a specific federal definition under those laws.

A treatment provider has no inherent federal protections to select a single-family home in a residential neighborhood as a place to house their patients while the residents are in a Partial Hospitalization level of care.

Under long-standing and prevailing law developed under the Fair Housing Act, treatment providers do not enjoy superior rights to zoning laws to house their patients wherever they choose, any more than Hospitals or Institutions do.

However, a “Recovery Residence” does enjoy higher protections, because it can be objectively determined that peer-supported community based living is taking place both inside and outside of the home.

While I understand and an sympathetic to what Amethyst and similar providers are concerned with, their challenge of the law may be causing them to walk right into a trap.

Here is the issue, boiled down to a plain reading of the statutes and rules:

397.311(26)(a)3, Fla. Stat. – “Day or night treatment with community housing” means a program intended for individuals who can benefit from living independentlyin peer community housingwhile participating in treatment services for a minimum of 5 hours a day for a minimum of 25 hours per week.

397.311(37), Fla. Stat. – “Recovery residence” means a residential dwelling unit, or other form of group housing, that is offered or advertised through any means, including oral, written, electronic, or printed means, by any person or entity as a residence that provides apeer-supported, alcohol free, and drug-free living environment.

Rule 65D-30.0081(1) – “Day or night treatment with community housing is appropriate for clients who do not require structured, 24 hours-a-day, 7 days-a-week residential treatment. This component allows clients to live in a supportive, community housing location while participating in treatment.”

Without FARR certification, what objective criteria are we going to use to demonstrate that a treatment center is providing peer community housing, rather than simply providing a “boarding house” to patients while in treatment?

A decision by DCF that PHP or Res. 5 housing need not be FARR certified would give local governments the ammunition they need (and have been desperately waiting for) to say that those “medical boarding houses” can no longer exist in single-family residences or even multi-family zoning districts, but rather may only be in zoning districts for transient housing for medical patients.

A Recovery Residence can be a person’s “home” even if residency is temporary such as at a PHP level of care, but only if the home can meet specific standards proving that unrelated cohabitation is necessary for therapeutic reasons, and which proof can be objectively qualified and quantified.  The US Department of Justice and the Department of Housing and Urban Development agree on this point.

Perhaps most realistic, I do not know of a civil rights attorney in the nation who is going to go into battle over whether PHP housing has the right to exist in any residential neighborhood if there is no ability to demonstrate through evidence that the cohabitation is necessary for therapeutic reasons. Certification of FARR Level 3 and 4 housing creates a rebuttable presumption that the resident medically benefits from such sober living. Simply housing patients in a home while because they need a place to stay while in clinical treatment does not meet that standard.

Perhaps it should. But under the law, it does not.

There is a saying that “bad facts make bad law.” Providers who object to housing oversight and meeting minimum housing standards are further entrenching policymakers that the industry itself is not mature enough to be trusted and that it places profit above patient protection.

On the other hand, those familiar with the Parity Act need to find a way to take a stand that sober living is the “yin” to clinical treatment’s “yang” and the refusal to pay for credible recovery residential services is no different than paying for medical treatment but not the necessary post-surgical residential rehabilitation care.

Either way, within the treatment and housing space, it always seems that the realities of the demands of free market enterprise to conflicts with healthcare policy on an all-too-frequent basis.  Perhaps recently announced collaboration between SAMHSA and NARR will drive the federal government to bring some sanity to an otherwise insane industry without making access to care inaccessible. But in the meantime, the law is what the law says, not what we want it to be.

Recommitting to the Mission

Dear Friends and Subscribers:

First, Happy Holidays to all. This is my favorite time of year, mostly because this is when the new Star Wars movies come out.

But it is also a time of reflection, appreciation, gratitude, and recommitting ourselves to your own life’s purpose and mission.

As we all move into 2018, while the treatment and recovery residence business communities have taken their unfair share of lumps in the press (since it is widely accepted as fact that far more good comes from the Recovery Business Community, than bad), we must continue to press on to change the narrative that people with Substance Use Disorders are not second-class/disposable human beings; that while “recovery” may begin in treatment, it is only fully realized in a supportive recovery community setting; and that we are all in this together – the afflicted, the first responders, citizens, government officials, parents, normies, lawyers, doctors, legislators, DCF, AHCA, DOH, and on and on.

But to that point of “recommitment of purpose,” I must admit a rather large failing that I have. I tend to want to see only the good in people and therefore tend to trust more than perhaps I should.

I have been deceived, actually lied to, manipulated, and used as a tool by clients who (I came to learn too late), never really wanted to heal our nation, but rather whose sole and exclusive purpose was to make money off of the pain.

That said, if I was ever to get a tattoo, it would say “It’s ok to do ‘well’ by doing ‘good’.”

I am a firm believers that profit motivation drives innovation, creativity, and the new discoveries that have always made our state and nation the greatest place on Earth.

I fully, 100%, support the private sector as the solution to getting our way out of this addiction crisis, which is far beyond a public health emergency. It is a national crisis that simply shows no sign of receding. It may sadly become to new “normal,” much like mass gun shootings in malls, movie theaters, churches, and schools.

However, and lately, I find myself getting worn down from it all. I become, admittedly, cranky. I become cantankerous. I become distrustful. I become jaded. I become angry and mean and resentful.

Then I am reminded of that saying attributed to the Buddhist faith that: “Holding onto anger is like drinking poison and expecting the other person to die.”

Maybe I missed out by not being addicted and going through recovery.

I find that those friends who have had to endure the life crucible of addiction and recovery to be at a different and oftentimes better place that I am. And very likely the reason why the Recovery Community is the best “community” that I have ever encountered in my lifetime as a native third-generation South Floridian.

As the New Year and holidays are upon us, I wish each of you nothing but the best and only ask in return that you, too, recommit yourself to the purpose and mission and privilege of working with and among these most exceptional people.

Will Addiction Treatment Be Eliminated from Obamacare Requirements?

The federal Centers for Medicare & Medicaid Services (CMS) proposed a federal rule late Friday aimed at giving states more flexibility in interpreting the Affordable Care Act’s “Essential Health Benefits” mandate as a way “to lower the cost of individual and small group health plans.”

Perhaps most notably, CMS’ proposed rule would allow states to alter their essential health benefits benchmark plan annually, beginning as early as 2019.

The Affordable Care Act set forth ten (10) categories of essential health benefits, including mental health and substance use disorder treatment.

“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.”

The agency in 2017 proposed standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. The CMS said it would eliminate standardized options for 2019 to maximize innovation. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the proposed rule states.

The Trump administration hopes to relax the ACA’s requirements and provide as much state flexibility as possible through administrative action, following the collapse of congressional Republican efforts this year to make those changes legislatively.

However, the EHB benchmark plans for mental health/substance abuse must comply with the Mental Health Parity and Addiction Equity Act of 2008 (“Parity Act”).

While we do not believe that any state can eliminate or reduce benefits for drug and alcohol treatment, by reducing benefits for other medical health care counterparts, they could strategically and effectively compromise reimbursements, even under the Parity Act.

The 2019 Notice of Benefit and Payment Parameters (PDF), released Friday.

The Positive Economic Impact of the Treatment Industry and Recovery Community

The health care industry is the job engine of many parts of the U.S., aided by funding as a result of the Affordable Care Act.

Florida, California, Texas, and other states are no different, specifically and including the number of well-paying jobs for professionals and para-professionals in the drug and alcohol treatment industry.

While some cities would prefer not to have treatment providers and recovery residences in their jurisdiction, that really cutting off the proverbial nose to spite one’s face.

We don’t have the numbers (yet) but no one will doubt the major economic driver that the treatment and housing industry is for the South Florida region.

According to a newly-released report by the New York Times in relation to Republican efforts to “repeal and replace” the Affordable Care Act:

“Whatever happens, the economy of every state will be affected. Across the country, the health care industry has become a ceaseless job producer — for doctors, nurses, paramedics, medical technicians, administrators and health care aides. Funding that began flowing in 2012 as a result of the Affordable Care Act created at least a half-million jobs, according to an analysis by Goldman Sachs.”.

Similarly, universities such as Florida Atlantic, University of Miami, and Nova Southeastern, that have strong social work and other behavioral clinical programs, rely upon the robust treatment industry and recovery community for employment for their graduating students.

An economic impact review by the American Hospital Association concluded that workers’ earnings combined with their spending on groceries, clothing and the like generate millions of dollars per year in economic activity and helped create thousands of jobs beyond their own. “The goods and services hospitals purchase from other businesses create additional economic value for the community. With these “ripple effects” included, each hospital job supports about two additional jobs, and every dollar spent by a hospital supports roughly $2.30 of additional business activity.”

Similar results apply to the robust treatment and housing industry within Palm Beach County and throughout Florida, as well as the rest of the nation.

In the effort to regulate the treatment and housing industry, we have used chemotherapy to rid the scourge of bad players from the playing field. However, in doing so, we may have found that many good providers have been scared off too, fearful that regulators and law enforcement are using this is a pre-text at the behest of the electorate, where one may be able to “beat the rap” but will be unable to “beat the ride.”

In the meantime, recognition of the positive economic benefit that this industry has on Florida and the entire nation should be further studied, recognized, and supported.

The alternative is to eliminate the entire system, and to leave those suffering with no alternatives whatsoever.

The Continued Evolution of Treatment

“Intensified post-treatment support at Caron illustrates potential of monitoring”

Caron has been offering and continues to extend to patients one year of post-treatment support free of charge, with monthly phone contact from the treatment facility designed to ease the transition between treatment and life back in the community. Caron leaders were observing that at around the six-month mark, a worrisome number of individuals were falling out of touch with the organization, for a number of possible reasons. “In some cases, it could be associated with the shame of relapsing,” says Knepper.

Read about it here!

The Future of Substance Abuse Treatment

I just received the attached from Addiction Professional Magazine, which, in my opinion, is a must read about the antiquated system of substance abuse treatment models that are employed and how existing RESEARCH needs to be reviewed and implemented.

Quote: [Integration] is not a gift to the mental health and substance abuse field. We¹re not being given something just because it’s fair, just because it’s our time, or just because there¹s a Democratic administration. You can¹t run the rest of healthcare if you don¹t manage substance use and mental health.

Me: Housing is an integral part of this equation as well. The best treatment outcomes occur when safe and secure housing exists. It’s a human necessity.

This is a great article that discusses Integration:
Integration demands highest standard of care

Wellington town hall meeting to address ‘sober homes’

Anyone with an interest should absolutely attend this meeting. Don’t let it be a one-decided discussion. Let them see the “Faces of Recovery” as well as hear from you that you and those you compassionately serve will not tolerate being treated as a second-class citizen due to your/their disability. I am reminded the following poem “First they came” is a famous statement and provocative poem attributed to pastor Martin Niemöller about the cowardice of German intellectuals following the Nazis’ rise to power and the subsequent purging of their chosen targets, group after group.

First they came for the Socialists, and I did not speak out– Because I was not a Socialist.

Then they came for the Trade Unionists, and I did not speak out– Because I was not a Trade Unionist.

Then they came for the Jews, and I did not speak out– Because I was not a Jew.

Then they came for me–and there was no one left to speak for me.

Get details here!

OIG’s 2014 plan promises scrutiny for behavioral health

By Dennis Grantham, Editor-in-Chief of Behavioral Healthcare

In a recent story, “Compliance programs stress effectiveness” (Behavioral Healthcare, Nov./Dec. 2013 issue), Fabio van der Merwe, director of quality improvement and compliance at DeKalb Community Services Board (Atlanta, Ga.) noted that each year, the Office of the Inspector General (OIG) for the Department of Health and Human Services releases an annual work plan.
This plan, he says, “puts compliance officers ‘on notice’ as to the focus of federal Medicare and Medicaid enforcement activity for the coming year.” In its recently unveiled 2014 work plan, the OIG committed to continuing a range of investigative activities involving behavioral health.

Read the full article here.

Letter from DCF RE: Patient Brokering

Many of you have called me regarding letters you may have received from DCF regarding Patient Brokering. Please be aware that the letter has been sent to all providers and not to anyone specifically accused of any wrongdoing.

That said, you should remain vigilant that you are closely monitoring any activity by your staff that could be construed to violate s. 817.505, Fla. Stat., the Patient Brokering Act. I have attached a copy for your records.

For purposes of the Act, the repeat question I receive is regarding how to effectively and legally use marketing companies to obtain referrals for new patients. The provision in the statute which addresses that point can be found within subsection (i) which allows for:

Payments by a health care provider or health care facility to a health, mental health, or substance abuse information service that provides information upon request and without charge to consumers about providers of health care goods or services to enable consumers to select appropriate providers or facilities, provided that such information service:

1. Does not attempt through its standard questions for solicitation of consumer criteria or through any other means to steer or lead a consumer to select or consider selection of a particular health care provider or health care facility;

2. Does not provide or represent itself as providing diagnostic or counseling services or assessments of illness or injury and does not make any promises of cure or guarantees of treatment;

3. Does not provide or arrange for transportation of a consumer to or from the location of a health care provider or health care facility; and

4. Charges and collects fees from a health care provider or health care facility participating in its services that are set in advance, are consistent with the fair market value for those information services, and are not based on the potential value of a patient or patients to a health care provider or health care facility or of the goods or services provided by the health care provider or health care facility.

Should you have any questions or concerns about your compliance with this provision, please don’t hesitate to give us a call.

Insurance Fraud – More Fraud in the Substance Abuse Drug Screening Urinalysis Industry

Meant to include this one earlier, brought to our attention from our friends over at PathologyBlawg.com

A chain of opiate addiction recovery centers, headquartered in Harrodsburg, Ky., and a Russell Springs, Ky., clinical laboratory, along with two physician owners, agreed to pay the U.S. Government millions of dollars to resolve civil allegations that they fraudulently billed federal health care programs for medically unnecessary and excessive urine tests.

Strangely, DOJ and the states Attorney Generals don¹t see to be concerned about the same abuse in the private insurance sector.

However, something to chew on – are medical plans obtained through the Federal Healthcare Exchange (or a state exchange) elevated to a federal health care program. I assume the answer is “no” as a mere result of legal definition, but we will wait and see.

Still, the fox appears to be the only one watching the hen house.

Check out these articles:
Kentucky Addiction Treatment Center, Clinical Laboratory and Two Physician Owners to Pay $15.75 Million to Resolve Allegations of Fraudulent Urine Drug Testing

Attorney states cash kickbacks from urine drug screen lab are perfectly legal

Blue Cross Accuses Drug Test Co. Of $36M Fraud Scheme