A.
Assessment and Evaluation
1. The Provider
shall conduct an initial assessment and evaluation in accordance with
§107.5-1.A within seventy-two (72) hours of admission, with a full
comprehensive assessment and evaluation completed within fourteen (14) days of
admission to the facility.
2. The
assessment and evaluation must consist of direct and indirect encounters.
Direct encounter shall include a psychological assessment and medical
evaluation (to include medication review) directly with the member. Indirect
encounters consist of record review and may include conversations with the
member's parent/guardian (as applicable), teachers, other professionals
involved, and natural supports (as applicable). Direct and indirect encounters
must inform the medical, psychological, social, behavioral and developmental
aspects of the member's situation, and reflects the need for inpatient
psychiatric care. Assessment and evaluation will be conducted to the extent
necessary to determine the member's current disposition and treatment
recommendations.
3. Documents
submitted to the PRTF by the CCON team in accordance with 107.04-02.B may be
used to satisfy parts of the documentation requirements for the initial and/or
full comprehensive assessment.
4.
The assessment must contain documentation of the member's current status, the
reason for referral to the service, history, strengths and needs in the
following domains: personal, family, social, emotional, psychiatric,
psychological, medical, drug and alcohol (including screening for co-occurring
services), legal, permanency/housing, financial, vocational, educational,
leisure/recreation, transition needs (when applicable), potential need for
crisis intervention, physical/sexual and emotional abuse (including trauma
history). The assessment must review cultural needs including issues of
literacy and English and language barriers, and the need for interpretation and
other needed services. The assessment should also take into consideration the
member's expressed desires.
5. The
assessment shall contain documentation of developmental history, sources of
support that may assist the member to sustain treatment outcomes including
natural and community resources and state and federal entitlement programs. The
assessment shall address physical and environmental barriers to treatment and
current medications. Domains addressed must be clinically pertinent to the
service being provided.
6. For a
member with substance abuse, the documentation must also contain age of onset
of alcohol and drug use, duration, patterns and consequences of use, family
usage, types and response to previous treatment.
7. The provider will review the member's CANS
assessment as a part of the full comprehensive assessment and will review the
CANS ongoing in coordination with the member's treatment plan intervals
described below in 107.07-07.B.2.
8. The assessment must be summarized to
include a clinical formulation that summarizes the strengths and needs of the
member and family (when applicable) that informs treatment, service intensity,
and recommendations for service. The formulation will include intended
intervention modalities. The assessment must include a diagnosis using the most
recent version of the
Diagnostic and Statistical Manual of Mental
Health Disorders (DSM) or the Diagnostic Classification of Mental
Health and Development Disorders of Infancy and Early Childhood (DC 0-5), as
appropriate. The assessment must be signed, credentialed and dated by the
appropriate personnel conducting the assessment.
B. Treatment Plan
1. All members must have an active Treatment
Plan, which must:
a. Be developed and
implemented in a timely manner; an initial treatment plan must be developed and
implemented within 72 hours of admission while a more comprehensive treatment
plan must be developed and implemented within 14 days of admission.
b. Be developed by the Treatment Planning
Team as described in Section 107.07-04 of this policy;
c. Be developed based on the Assessment
completed in accordance with Section 107.07-07.A;
d. Reflect the needs and strengths identified
in the member's CANS assessment;
e.
Be designed to achieve the member's discharge from inpatient status at the
earliest possible time;
f. Describe
the functional level of the member;
g. Prescribe an integrated program of
therapies, activities, and experiences designed to meet the member's treatment
objectives, and include any orders for:
ii. Treatments and
Therapy; and
iii. Social services;
and
iv. Special procedures
recommended for the health and safety of the member.
h. Include plans for continuing care,
including review and modification of the Treatment Plan;
i. Include clear short and long-term goals
and treatment objectives that are specific, measurable and are time limited to
include target dates, and include the frequency, intensity, and duration of
each described intervention;
j.
Describe the rationale for utilizing the prescribed treatment and
services;
k. Specify treatment and
service responsibility, including both staff and member responsibilities in
meeting the member's treatment objectives;
l. Be developed in consultation with the
member, the member's parents or legal guardians (where appropriate), or others
who will be caring for the member following discharge from the PRTF, including
but not limited to family, school officials, and community service providers;
and
m. Include a list of needs
identified in the assessment process that are not addressed in the Treatment
Plan and an explanation of why the identified needs are not
addressed;
n. Include a discharge
plan which must:
i. Identify individualized
discharge criteria that are related to the goals and objectives described in
the Treatment Plan;
ii. Identify
the individuals responsible for implementing the plan, including staff who can
assist the member in making referrals for other resources;
iii. Identify natural and other supports
necessary for the member and family to maintain the safety and well-being of
the member, and to sustain progress made during the course of treatment;
iv. Be reviewed by the treatment
planning team every review meeting and no less than every thirty (30) days;
v. Identify any service
recommendations and reasons for recommending that service;
vi. Address behavior planning, including
interventions and resources necessary to carry out the plan without supports;
and
vii. Contain a list of
resources tailored to the member's individualized needs and situation necessary
for parents, guardians, and natural supports to increase the likelihood of a
successful and sustainable discharge.
2. The Treatment Plan must:
a. Be entered in the member's medical record
upon initial completion and upon any alteration;
b. Consider any additional assessments in the
development of the Treatment Plan;
c. Be reviewed every 30 days, or sooner as
clinically indicated by the treatment planning team to:
i. Determine that services being provided are
required on an inpatient basis and
ii. Recommend changes in the plan as
indicated by the member's overall adjustment as an inpatient;
d. Document plan approval as shown
by the signature of the member (when applicable), parent/guardian (when
applicable), any staff with credential(s) involved in creating the treatment
plan, and the medical director with credential(s). All signatures will be dated
at the time of signature. In extenuating circumstances, verbal approval by the
parent/guardian may be obtained in lieu of signature which must be documented
in the member record with the staff member who received the approval (and
signature/date), and the reason why signature could not be obtained;
e. Be provided to the member and the member's
parent/guardian (if applicable) within five (5) working days from the date of
final plan approval.
C. Results of any assessments conducted must
be included in the member record.
D. Progress Notes:
1. Providers must maintain written progress
notes for each service discipline provided by the PRTF, in chronological order.
There must be one milieu note per shift and all medication/therapy services (as
defined under covered services Section 107.05-01.D) must be documented
individually. 2. All entries in the progress note must include the service
provided, the provider's signature and credentials, the date on which the
service was provided, the duration of the service, and the progress the member
is making toward attaining the goals or outcomes identified in the Treatment
Plan.