Current through Register Vol. 56, No. 18, September 16, 2024
(a)
Each eligible consumer shall be admitted with a preliminary individualized
rehabilitation plan, to be developed with the consumer by the referring agency,
health care provider, or Division in consultation with the PA, based on the
medical necessity identified by the referring agency or the Division during the
eligibility determination process. The preliminary individualized
rehabilitation plan shall be followed in providing medically necessary services
for up to 60 calendar days after admission.
(b) No later than 60 days after the consumer
has been admitted, PA staff shall partner with the consumer to develop and
implement an individualized rehabilitation plan.
1. Within the parameters established by State
and Federal confidentiality laws, rules, and regulations, the PA shall consult
with identified providers and the consumer's significant others in developing
the individualized rehabilitation plan.
(c) At a minimum, each individualized
rehabilitation plan shall be based upon the preliminary and comprehensive
rehabilitation needs assessment and any other existing assessment, WRAP(R) and
advance directive for mental health care.
(d) All individualized rehabilitation plans
shall include the following information:
1.
The valued life role the consumer wants to achieve, the consumer's
rehabilitation and recovery goals, and time-framed, measurable
objectives;
2. The strategies and
interventions to be employed, as well as anticipated outcomes, and the
following information:
i. The expected
frequency and duration of any community support services to be
implemented;
ii. The location where
the community support service is to be delivered; and
iii. The type of practitioner to provide each
intervention, including the names and titles of staff;
3. Specific measurable criteria for measuring
change.
i. For the criteria to be measurable,
they shall include a desired behavioral change or skill attainment;
and
4. If psychotropic
medication or controlled substances are included in the individualized
rehabilitation plan, any arrangements appropriate to that consumer's ability to
self-administer such medications, assistance to be provided or arranged by the
community support service provider, and the procedure and location for storage
and retrieval of the medications.
(e) Each individualized rehabilitation plan
and subsequent revisions shall be signed and dated by:
1. A physician or licensed practitioner
authorized by State law to recommend a course of treatment;
2. Other appropriate team members, including
those assigned to interventions, the primary service coordinator, and the staff
supervisor; and
3. The consumer.
i. If the consumer declines to sign the
individualized rehabilitation plan, the PA shall document this fact.
(f) Review of the
individualized rehabilitation plan shall occur as follows:
1. A consumer may request a review and/or
revision of the individualized rehabilitation plan at any time.
2. In addition to any request by the
consumer, the PA shall review and, as necessary, revise the individualized
rehabilitation plan within three months of its development and every three
months thereafter.
3. The provider
agency shall partner with the consumer during any requested or scheduled review
of the individualized rehabilitation plan.
4. In addition to the requirements of (e)
above, documentation confirming reviews shall include the date of the review
and signature of the consumer, the PA staff member who conducted the review and
is assigned to coordinate services for the consumer, and that staff member's
supervisor.
