Current through Register No. 40, October 3, 2024
(a) The licensee
shall provide administrative services that include the appointment of a
full-time, on-site administrator who:
(1) Is
responsible for the day-to-day operations of the PRTP;
(2) Meets the requirements of
He-P
830.18(j);
(3) Designates, in writing, an alternate
administrator who shall assume the responsibilities of the administrator in his
or her absence; and
(4) In the
event the administrator will be absent for a period to exceed 30 consecutive
days, the facility shall notify the department who the interim administrator
will be and submit credentials to verify he or she meets the requirements of
(2) above.
(b) Upon
admission or within 24 hours following admission, the APRTP shall perform a
comprehensive intake assessment of each client's needs and develop a
preliminary treatment plan.
(c) The
comprehensive intake assessment required by (b) above shall include, at a
minimum, the following:
(1) A mental health
status examination and medication review;
(2) An initial diagnostic
impression;
(3) Safety risk
assessment and presence or absence of communicable disease;
(4) A functional assessment of those specific
skills and behaviors required for the client to be in a less restrictive
setting;
(5) A statement by the
treating licensed practitioner that the PRTP represents the appropriate level
of treatment for the client;
(6)
Serve as a basis for treatment plan;
(7) Historical and current information and
assessments; and
(8) Medical,
psychiatric, and social information containing the following:
a. For medical information:
1. A statement of the individual's general
physical health status;
2. Medical
history, including current weight, height, blood pressure, pulse, and smoking
status;
3. When applicable, medical
diagnosis, and the results or any medical or neurological screenings,
examinations, or tests; and
4. The
name and contact information for the individual's primary care
physician;
b. For
psychiatric information:
1. History of mental
illness or serious emotional disturbance, including onset and
severity;
2. Previous services and
treatments, including medications and hospitalizations;
3. Individual's strengths;
4. Illness self-management skills;
5. Precipitating events for current
psychiatric symptoms, as applicable;
6. Documentation of medical necessity for
services;
7. Current
diagnosis;
8. Medication
orders;
9. Current medications;
and
10. Results of formalized
psychiatric or psychological tests, if applicable;
c. For social information:
1. Developmental history;
2. Educational history and current status, if
applicable;
3. Family history and
current family status;
4. History
and current family status;
5.
History of trauma, including domestic violence;
6. Results of a substance use screening
tool;
7. Employment history
including work skills and types, and lengths of employment;
8. Military history and veteran's status, if
applicable;
9. Current living
situation including type of environment and nature of relationship with any
room/house mates or family;
10.
Social and leisure time activities and skills;
11. Ability to develop and maintain
friendships;
12. Involvement with
or history of involvement with other social service agencies or the criminal
justice system;
13. Guardianship,
if applicable; and
14. Other legal
documents.
(d) The intake assessment and updates shall
be signed and dated by the person completing the assessment.
(e) A treatment plan shall:
(1) Be completed within 24 hours of the
comprehensive assessment in (c) above;
(2) Be updated following the completion of
each future assessment;
(3) Be made
available to personnel who assist clients in the implementation of the plan;
and
(4) Address the needs
identified by the comprehensive assessment.
(f) The licensee shall provide each client,
or their agent, the opportunity to participate in the development of the
treatment plan.
(g) The treatment
plan required by (e) above, shall contain, at a minimum, the following:
(1) The date the problem or need was
identified;
(2) A description of
the problem or need;
(3) The
objectives, which shall be measurable, attainable, realistic, and
timely;
(4) The interventions,
which shall be specifically provided on behalf of the program to the clients;
(5) The client's clinical needs,
treatment goals, and objectives;
(6) The client's strengths and resources for
achieving goals and objectives as identified in (3) above;
(7) The strategy for providing services to
meet those needs, goals, and objectives;
(8) The specification and description of the
indicators to be used to assess the client's progress;
(9) The date of re-evaluation, review, or
resolution;
(10) Psychiatric
evaluation, including mental status and alcohol/substance abuse evaluations, as
determined necessary by the treating licensed practitioner;
(11) Individual and group therapeutic
activity directed towards stabilization of psychiatric crises or extended
care;
(12) Family education,
consultation, and therapy, as clinically indicated; and
(13) For children or youth clients, the
determination made by a licensed practitioner, that the child or youth client
is eligible for PRTF level of care.
(h) The treatment plan shall be reviewed at
least every 30 days or as medically indicated.
(i) For each client, progress notes shall be
written daily and include at a minimum:
(1)
Any treatment plan goals addressed;
(2) Changes in the client's physical and
mental status, as applicable;
(3)
Changes in behavior, such as eating habits, sleeping pattern, and
relationships; and
(4) Summary of
protective care that has been provided.
(j) At the time of a client's admission, the
licensee shall ensure that orders from a licensed practitioner are obtained for
medications, and that special dietary requirements are documented.
(k) All personnel shall follow the orders of
the licensed practitioner for each client and encourage clients to follow the
practitioner's orders.
(l) The
licensee shall have each client obtain a health examination by a licensed
practitioner within 30 days prior to admission or within 72 hours following
admission to the PRTP.
(m) The
health examination in (l) above shall include:
(1) Diagnoses, if any;
(2) The medical history;
(3) Medical findings, including the presence
or absence of communicable disease;
(4) Vital signs;
(5) Prescribed and over-the-counter
medications;
(6) Allergies;
(7) Dietary needs;
(8) Pain assessment; and
(9) Safety risk assessment.
(n) Each client shall have at
least one health examination every 12 months, unless the licensed practitioner
determines that an annual physical examination is not necessary and specifies
in writing an alternative time frame, or the client refuses in writing.
(o) A client may refuse all care
and services.
(p) When a client
refuses care or services that could result in a threat to their health, safety
or well-being, or that of others, the licensee or their designee shall:
(1) Inform the client and guardian of the
potential results of their refusal;
(2) Notify the licensed practitioner of the
client's refusal of care; and
(3)
Document in the client's record the refusal of care and the client's reason for
the refusal if known.
(q) The licensee shall maintain an
information data sheet in the client's record and promptly give a copy to
emergency medical personnel in the event of an emergency transfer to another
medical facility.
(r) The
information data sheet in (q) above shall include:
(1) Full name and the name the client
prefers, if different;
(2) Name,
address and telephone number of the client's next of kin, guardian or agent, if
any;
(3) Diagnosis;
(4) Medications, including last dose taken
and when the next dose is due;
(5)
Allergies;
(6) Functional
limitations;
(7) Date of
birth;
(8) Insurance
information;
(9) Advanced
directives including DNR or DNAR orders, if applicable; and
(10) Any other pertinent information not
specified in (1)-(9) above.
(s) Services shall be age and developmentally
appropriate.
(t) PRTP's shall offer
psychotherapeutic services.
(u)
Individual psychotherapy shall:
(1) Include
therapy, crisis intervention, or assessment and monitoring necessary to
determine the course and progress of therapy or to stabilize an individual
experiencing an acute psychiatric episode; and
(2) Be verbal, with the therapist in direct,
personal, involvement with the resident to the exclusion of other residents,
individuals, and duties.
(v) Group psychotherapy, per person, shall
include therapy or assessment and monitoring necessary to determine the course
and progress of therapy that is performed in a direct, personal involvement
with the resident in a setting with other residents or individuals.
(w) Group psychotherapy shall meet the
following criteria:
(1) Limit clinical groups
to no more than 8 individuals with one licensed counselor present and no more
than 12 individuals when that licensed counselor is joined by a second licensed
counselor;
(2) Sessions shall be
scheduled often enough to provide effective treatment;
(3) The group focus shall be face to face
dialogue of a verbal rather than performance nature; and
(4) Individual progress notes for each
session shall be recorded in each recipient's record with specific attention
directed toward goal achievement as stated in the resident's treatment
plan.
(x) Family therapy
shall be:
(1) The resident and their natural
or surrogate family member(s); or
(2) The natural or surrogate family member(s)
without the resident present.
#10059, eff
12-23-11
