Florida Administrative Code
65 - DEPARTMENT OF CHILDREN AND FAMILIES
65E - Mental Health Program
Chapter 65E-4 - COMMUNITY MENTAL HEALTH REGULATION
Section 65E-4.014 - Standards for Client Records, Treatment and Quality Assurance
Universal Citation: FL Admin Code R 65E-4.014
Current through Reg. 50, No. 187; September 24, 2024
(1) Introduction - This chapter establishes client record, treatment and quality assurance standards for mental health clients receiving state supported services from community mental health providers, exclusive of alcohol and drug abuse services, throughout Florida.
(2) Definitions - The definitions provided in this section are limited to this Rule 65E-4.014, F.A.C.
(a) CCMS - The Department of Children and
Family Services Continuity of Care Management System as described in Section
394.4573, F.S.
(b) Screening - The preliminary determination
of the type, extent and immediacy of the service needs of the individual
seeking help.
(c) Intake - The
determination of a client's service and treatment needs.
(d) Evaluation - A specific study of a
client's pertinent functional areas such as socioeconomic, cultural, medical,
psychological, psychiatric, educational, vocational, and environmental. This
information is necessary to determine a client's problems and the services
needed.
(e) Assessment - The
determination of a client's current and potential strengths, problems and
needs, by utilizing current intake, diagnosis and evaluation information in
order to identify service needs.
(f) Planning - The development of a client's
service plan or treatment plan which includes an assessment, the setting of
client goals, and the identification of necessary services and resources, based
upon identified needs.
(g) Quality
Assurance Program - A systematic approach designed to evaluate the quality of
care of an agency on an ongoing basis and to promote and maintain efficient,
effective mental health services.
(h) Utilization Review - A case-by-case
assessment of the utilization of an agency's services as recorded in client
records.
(i) Peer Review - Review
of staff members' professional work by a comparably trained and qualified
individual performing similar tasks, taking into account client
characteristics, accuracy of assessment, appropriateness of treatment, duration
of treatment, adequacy of planning, and relevant follow-up
procedures.
(j) Case Management -
Activities aimed at assessing client needs, planning services, linking the
service system to a client, coordinating the various system components,
monitoring service delivery and evaluating the effects of service
delivery.
(k) Primary Therapist or
Treatment Coordinator - The provider's treatment staff member responsible for
the coordination of treatment and services to the client who is not assigned a
CCMS case manager due to not meeting CCMS priority criteria.
(l) Rehabilitation - An education-based
process which provides the opportunities for mentally ill persons to attain the
physical, emotional and intellectual skills needed to function successfully in
living, learning, work and social environments. The process includes developing
the resources needed to support or strengthen clients' ability to function in
these environments.
(m) Service
Provider or Provider or Agency - Any agency under contract with the Department
of Children and Family Services, in which all or any portion of the program or
services set forth in Section
394.675, F.S., are carried
out.
(n) Service Plan - The
document developed with the CCMS client by the case manager which depicts goals
or objectives for the attainment of services and resources. For non-CCMS
clients, service or resource goals or objectives may be established on the
treatment plan or on a separate service plan.
(o) Treatment - Services, provided to persons
individually or in groups, which include rehabilitation, counseling, supportive
therapy, chemotherapy, psychotherapy or any other accepted therapeutic,
educational or supportive process.
(p) Treatment Plan - An individual document
or identifiable section of the service plan developed by treatment staff and
the client which depicts goals or objectives for the provision of services
within specific treatment environments. Examples of treatment environments
include but are not limited to day treatment, vocational, residential,
outpatient and activities of daily living programs.
(3) Client Record System.
(a) A service provider must develop an
individualized record for each client it serves except for those clients seen
on a brief emergency basis, and for whom no further services are indicated. The
detail and comprehensiveness of each record will depend upon the amount of
contact the agency has with the client. The information in subparagraphs
65E-4.014(3)(b)
1. and 9., F.A.C., must be obtained for every client. The necessity for all
other information will vary depending upon the service needs of the
client.
(b) Record Information -
The provider must obtain from or develop for each client it serves the
following information:
1. Name, address,
telephone number, marital status, sex, race, date of birth, names and addresses
of client's next of kin or guardian, referral source, presenting problem and
financial eligibility information as specified by the department,
2. The name of the individual having primary
responsibility for the client's treatment,
3. Assessment information,
4. Information on results from diagnosis and
evaluation,
5. Service plan,
6. Progress notes,
7. Medication profile,
8. As necessary, a time-specific statement
authorizing release of confidential information, signed and dated by the client
or guardian, which designates the agency to receive the information,
9. Termination reports,
10. Treatment plan and treatment plan
updates; and,
11. Legal
status.
(c) Progress
notes, activity notes or status reports shall be prepared at least monthly for
clients having a service plan or treatment plan unless the plan indicates less
frequent need. Content shall include:
1. Dates
of contact with client, and as needed, client's family, friends, and involved
service or resource agencies,
2.
Description of client progress, or lack thereof, relative to the service plan
or treatment plan; and,
3.
Description of any modification to the service plan or treatment plan resulting
from such factors as changes in client's needs, changes in resources and new
assessment findings.
(d)
Termination Reports - A termination report must be filed in the record within 4
weeks after official termination of services. For clients not requiring
additional services and for whom services are being terminated, the report
shall contain the following:
1. Reason for
termination - Non-CCMS cases with no contact over a 90-day period must be
closed or terminated except in those cases where the service plan or treatment
plan does not indicate the need for such frequent contact. Examples of reasons
to close a case are refusal of services, no longer in need of services,
referred to another agency, left the area and deceased,
2. Evaluation of impact of agency's services
on each client's service plan or treatment plan goals or objectives,
3. Signature of individual preparing report
and date of preparation; and,
4.
For a client whose case is being closed and who is being referred to another
agency for further services that are not provided by the referring agency, the
report must also include the reason for referral.
(e) Policies and Procedures for Client
Records - Service providers shall have written policies and procedures
regarding client records which insure the following:
1. Client records are current and accurate,
2. Client records are stored in a
locked room or container,
3. The
information in client records is safeguarded against loss, defacement,
tampering or use by unauthorized persons,
4. Confidentiality of the information
contained in a client's record and communication between staff members and
clients is protected as stated in subsection
394.4615, F.S., and Rule
65E-5.038, F.A.C.,
5. Records shall
be removed from the jurisdiction and safekeeping of the provider only in
accordance with written policies and procedures as required by law,
6. Training in verbal and written
confidentiality requirements is provided to all staff as part of new staff
orientation and ongoing staff development,
7. There is a master filing system which
includes a comprehensive record of each client's involvement in every aspect of
the program,
8. Client records are
maintained minimally for 7 years after the date of the last entry,
9. The client record system is directed,
staffed and equipped to facilitate processing, checking, indexing, filing,
retrieval and review of all client records; and,
10. There is adequate space, equipment and
supplies, compatible with the needs of the client record services to enable the
personnel to function effectively and to maintain client records readily
accessible.
(4) Screening and Intake Procedures - Providers must have written screening and intake procedures which minimally assure that:
(a) A single telephone number is established
that is manned 24 hours daily, 7 days per week through which a client may
secure information and referral for initial intake with an appropriate
provider;
(b) Upon initial request
for service, a screening is done to determine the immediacy of the client's
needs;
(c) Screening services are
conducted by staff members specifically trained to perform this function, in
order to ascertain the appropriateness of the agency's services to meet the
needs of the client;
(d) For cases
determined to be non-emergency, initial intake services are offered as
immediately as appropriate to meet the needs of the client;
(e) When the services offered by the agency
are found to be inappropriate for the needs of a potential client, the agency
shall secure a timely referral for the person to a more appropriate agency or
service and make all reasonable efforts to confirm that the client has been
accepted for service. If no referral is established, the agency shall, with the
consent of the client, notify Children and Family Services district CCMS staff
to assist them in identifying service gaps in the community;
(f) During the intake process, all potential
clients have explained to them the nature of the services offered, the
procedures, fees, and hours involved, and their choices, rights, and
responsibilities while receiving services; and,
(g) A smooth and effective transition occurs
from intake to initiation of services. For clients who are not eligible for
assignment to a CCMS case manager, a primary therapist or treatment coordinator
must be assigned.
(5) Evaluation Procedures - Each agency will have a written procedure describing the process whereby evaluation services will be initiated and completed for clients.
(6) Assessment and Treatment Plan Development - The assessment and treatment plan must be completed, and the actions specified in the plan must be initiated for each active client within 30 days after completion of intake.
(a) The assessment must, with input from the
client, include:
1. Description and evaluation
of presenting problem,
2.
Information from the intake and evaluation; and,
3. Description of the client's current and
potential strengths and problems, the client's family and friends, pertinent
service agencies with whom the client has been involved, and other social
support systems that may contribute to the course of
treatment.
(b) Treatment
plan goals or objectives must be derived from the initial assessment of the
client's needs and strengths.
1. Each goal or
objective must be developed with the client, be achievable, have a reasonable
time frame for achievement and be stated in terms of observable and measurable
outcomes.
2. For each goal or
objective, the actions needed to attain that goal and the responsible
individual or individuals must be listed.
3. A minimum of one goal or objective shall
be developed with the client for each treatment environment serving the client.
Social programs, networks and clubs are exempt from this requirement.
4. For clients who are assessed to be in need
of services or resources external to the provider and who do not meet CCMS
criteria for the assignment of a case manager, externally related service or
resource goals or objectives shall be developed by the primary therapist or
treatment coordinator on either the treatment plan or service plan.
a. If the agency does not offer the services
needed, the primary therapist for the non-CCMS client must refer and link the
client to appropriate agencies which provide the needed services. A copy of the
relevant parts of the service plan or treatment plan and other relevant client
information shall be submitted to referral agencies when authorized by the
client or guardian.
b. If the
service needed is not available in the community, this information shall be
reported to district CCMS staff.
5. Dates and results of follow-up contacts by
the primary therapist must be entered into the client
record.
(7) Quality Assurance Program, including Utilization and Peer Review Systems.
(a) Service providers are required to have an
established, ongoing quality assurance program.
(b) Each service provider must describe in
writing its quality assurance program to include:
1. Composition of review committees,
2. Procedures to be followed in
reviewing cases,
3. Criteria and
standards used in the review process and procedures for their development; and,
4. Procedures to be followed to
assure dissemination of the results.
Rulemaking Authority 394.78 FS. Law Implemented 394.4573, 394.75, 394.78 FS.
New 11-3-82, Formerly 10E-4.14, Amended 4-20-89, 5-23-96, Formerly 10E-4.014, Amended 12-20-98.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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