Current through Register Vol. 56, No. 18, September 16, 2024
(a) The
individualized recovery plan is designed to assist the consumer in organizing,
reviewing and modifying an array of treatment and rehabilitation services which
supports his or her identified path to recovery. The IRP shall be based on
specific areas of interest identified by the consumer and urgent problems or
barriers that have been prioritized from the comprehensive assessment.
1. It shall be formulated and implemented at
the completion of the comprehensive assessment, but no later than six weeks
from the consumer's admission to the program.
2. Areas identified in the comprehensive
assessment, but not initially addressed in the IRP at intake, should be
reviewed and formulated at subsequent IRP reviews or when re-prioritized by the
consumer and PA. The IRP shall reflect agreement and mutual understanding
between the consumer and the program staff on goals to be achieved by the
consumer and program activities to address these goals.
(b) The IRP, developed with the consumer,
shall include the following:
1. Language that
can be easily understood by the consumer;
2. The signatures of the consumer, primary
case coordinator or counselor and direct care staff supervisor;
3. The psychiatrist's or advanced practice
nurse's signature, which shall reflect the direction of the course of
treatment;
4. To assure family
participation in developing the IRP and revisions, the PA shall seek the input
of family members or close personal friends at each service planning milestone;
however, the PA may not disclose protected health information to family members
or close personal friends, except as follows:
i. Protected health information may be
disclosed to the extent permitted by a valid written authorization;
ii. If the consumer is present at the service
planning milestone, or otherwise available prior to, protected health
information may be disclosed at that meeting if it is directly relevant to the
family member's or close personal friend's involvement with the consumer's care
and one of the following apply:
(1) The
consumer agrees to disclosure of the information at the time of service
planning milestone;
(2) The
consumer is provided with an opportunity to object to the disclosure at the
service planning milestone and does not express an objection; or
(3) Based on the exercise of professional
judgment, the PA reasonably infers from the circumstances at the service
planning milestone that the consumer does not object to the disclosure. Absent
countervailing circumstances, the consumer's agreement to participate in the
service planning milestone with the family member or close personal friend
present indicates that the consumer does not object to disclosure of protected
health information that is directly relevant to the family member's or close
personal friend's involvement with his or her care; or
iii. If the opportunity to agree or object to
the use or disclosure cannot practicably be provided because of the
individual's incapacity or an emergency circumstance, the PA may, in the
exercise of his or her professional judgment, determine whether the disclosure
is in the best interests of the individual and, if so, disclose only the
protected health information that is directly relevant to the person's
involvement with the individual's health care;
5. The consumer's self-stated overall goals
related to chosen, valued role(s) and specific plans to achieve these roles,
with target dates for achievement, including further in-depth and ongoing
assessment in the identified areas;
6. Specific interventions, strategies and
activities to implement the IRP, including clear reference to necessary
off-site services to assist in the transfer of learning;
7. Identification of staff responsible for
implementing each intervention; and
8. A comment section under which the consumer
states in his or her own words any concerns, agreements, or disagreements with
either the development of or final IRP.
(c) Where protected health information is
disclosed pursuant to (b)4ii or iii above, the PA shall document the basis for
the disclosure. Disclosure in accordance with (b)4ii or iii above shall not
authorize or otherwise provide a basis for future disclosures not in compliance
with this section.
(d)
Notwithstanding (a), (b) and (c) above, the PA shall not disclose to a
consumer's family or close personal friends, psychotherapy notes related to
treatment of the consumer without the consumer's valid written authorization,
consistent with
45 CFR
164.508(a)2.
(e) The PA shall include consumer and family
(if the consumer consents) participation in service planning. The consumer's
signature on the IRP shall indicate that the consumer was involved in the
formulation of the plan or that the consumer reviewed and approved of the plan.
If the consumer is not involved in the development of the plan or the consumer
does not agree with any part of the plan, the consumer shall document his or
her lack of participation or disagreement in the comments section of the IRP.
1. If the consumer refuses to give written
authorization to release information, the team shall document in the consumer's
record that efforts were made at each milestone to obtain such
authorization.
(f) The
IRP shall reflect any other service in which the consumer participates and
coordinative efforts, if any, in achieving the treatment goals and
objectives.
(g) The PA shall train
staff in the formulation and implementation of an IRP.
(h) The comprehensive IRP shall be
periodically reviewed to determine the consumer's need for continued services
and revised as necessary.
1. The IRP shall be
reviewed and revised within three months of its development, every three months
for the first year, and every six months thereafter, unless goals or objectives
change due to new information from the in-depth and ongoing assessment or a
change in the consumer's circumstances. The IRP shall then be immediately
changed to reflect this new information. A review of ongoing skill and resource
assessments shall be made prior to the plan review. Documentation of the IRP
reviews shall include signatures of the consumer, direct care staff, supervisor
and psychiatrist.
2. IRP reviews
shall reflect the consumer's changing needs and progress toward goals.
Documentation shall include a determination of the need for continued PC
services and any revisions in service provision. Consideration of the expected
benefits of continued services and the risk of service termination shall be
included.
3. The PA shall update
the psychiatric evaluation at least every six months for every consumer
receiving partial care services.
4.
As the consumer progresses, treatment goals shall address a gradual reduction
in services or a transition to less intensive services.
5. Maintenance of functioning shall be a
legitimate service goal if it is appropriate to the consumer's needs.
(i) The PA shall write progress
notes in the consumer's record at least weekly, as follows:
1. The PA staff shall document development of
the IRP during the initial three-month period in the progress notes.
2. Each weekly progress note shall address:
i. The consumer's response to at least one
specific treatment intervention identified in the IRP;
ii. A summary of PC activities in which the
consumer participated during that week;
iii. The consumer's general level of
participation and clinical progress in the program for that week; and
iv. Significant events that occurred during
that week.
3. Within
every three-month period, the progress notes shall reflect the consumer's
progress towards all goals and objectives included within the IRP.
4. Progress notes shall contain documentation
by P.A. staff of all known current medications prescribed to address both
psychiatric and medical conditions. All medications and changes in the
medication regimen shall also be documented by P.A. staff on a medication
summary sheet.
5. Progress notes
shall be legibly written, signed and dated.
6. Progress within group and other PA
activities shall be documented through a weekly rating of the consumer's
progress and participation which may also include the consumer's perspective.
These ratings can be contained within the body of the weekly progress note in
the form of a written narrative or a rating scale which is distinct from any
overall progress or historical account of the week.
i. Overall progress and participation for the
week should be reflected in the weekly progress note.
