New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 589 - Operation Of Crisis Residence
Section 589.9 - Individual Service Plan and Case Record
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 589.9
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Individual service plans for Intensive Crisis Residence Programs and Residential Crisis Support Programs
(1) An individual service plan shall be
developed and implemented with each recipient by the staff of the crisis
residence within 24 hours of admission.
(2) The individual service plan shall be
based on a comprehensive assessment of each recipient.
(i) For an Intensive Crisis Residence
program, the assessment shall engage each recipient as an active partner in
developing, reviewing and modifying a service plan that supports their progress
toward recovery. The assessment shall include but not be limited to the
recipient's personal preferences and desired life roles, physical, medical,
emotional, social, residential, recreational and, when appropriate, vocational
and nutritional needs. The assessment shall also include a risk assessment, and
shall identify any need for medication management. If appropriate, this
information, with the recipient's consent, may be obtained from the recipient's
most recent mental health service provider(s) and coordinator.
(ii) For a Residential Crisis Support
program, the assessment shall engage each recipient as an active partner in
developing, reviewing and modifying a service plan that supports their progress
towards recovery. The assessment shall include, but not limited to emotional,
mental, social, residential, recreational and, when appropriate, vocational and
nutritional needs. If appropriate, this information, with the individual's
consent, may be obtained from the recipient's most recent mental health service
provider(s).
(iii) Consideration of
each recipient's needs shall include a determination of the type and extent of
additional clinical examinations, tests and evaluations necessary for a
complete assessment, if needed.
(3) The individual service plan shall address
the needs of the recipient.
(i) The individual
service plan shall identify all service needs of the recipient whether or not
the services are provided directly by the crisis residence program.
(ii) The individual service plan shall
address the manner in which the recipient's identified supports, which may
include family, will be involved in the service planning and
implementation.
(4) The
individual service plan must be signed by a qualified mental health staff
person and the recipient.
(5) The
individual service plan must be developed in collaboration with the recipient
and any collateral persons the recipient chooses to involve.
(6) The individual service plan must include
discharge planning.
(b) Individual service plans for Children's Crisis Residence Programs
(1) An individual service plan is required
for each recipient.
(2) The
individual service plan shall be based on a comprehensive intake assessment of
each recipient.
(3) Within 24 hours
of admission of a child to a children's crisis residence program, an intake
assessment must be completed by a qualified mental health staff person (QMHP)
within their scope of practice and at a minimum a preliminary individual
service plan must be developed.
(i) The intake
assessment must include, at a minimum:
(a) an
assessment of risk;
(b) a
description of the current symptoms and/or behaviors which demonstrate
eligibility for admission;
(c) the
presenting problem, including factors contributing to the psychiatric crisis or
risk;
(d) a description of the
child's current needs and strengths; and
(e) a description of the skills needed to
transition to the home or community.
(ii) The preliminary individual service plan
must include, at a minimum:
(a) a description
of the immediate need(s) to be addressed,
(b) the initial goal(s), service(s),
intervention(s) and crisis plan to address the need(s) during the initial
period after admission.
(4) Within 72 hours of admission the
individual service plan must be completed, with the participation, as
appropriate, of the child, the child's parent/guardian or other identified
collaterals. Parent/guardian or other collaterals participating in the
development of the plan must be specifically identified in the plan. If the
QMHP developing the plan does not possess a license, the plan must be approved
and signed by professional staff.
(5) The completion of the Individual Service
Plan must include, at a minimum, the following additional components:
(i) the treatment goal(s) and objectives; the
services, interventions, projected time periods to accomplish the goal(s); the
parent/guardian, family members or other identified collaterals participating
in treatment and discharge planning; the criteria for discharge and a
description of the services and supports needed at the time of transition to
the home or community; signatures of the child, participating family or
collaterals indicating their agreement. If the child, family or identified
collateral(s) is unable to participate, the reason for non-participation must
be documented.
(ii) If applicable,
the plan for provision of additional service(s) outside of the crisis residence
program to further support and prepare the child for discharge, while in the
program, must also be included in the individual service plan.
(iii) The development of the crisis plan must
include the child and family as active participants, as appropriate. With the
child's and/or parent/guardian's consent, the crisis plan may be shared with
identified collaterals involved in the child's treatment or support.
(6) The individual service plan
must be reviewed as needed and include participation of staff involved in the
provision of services to the to the child and/or, if appropriate, the child's
family or other collaterals. The service plan must be revised if there is a
change to the child's goals or plan for discharge.
(c) Case Records.
(1) There shall be a complete case record
maintained at one location or electronically for each recipient.
(2) Information in crisis residence program
case records that is subject to the confidentiality protections of Mental
Hygiene Law section
33.13 may be shared between facilities,
agencies and programs responsible for the provision of services pursuant to an
approved local or unified services plan (including programs that receive
funding from the Office of Mental Health disbursed via a State aid letter);
such Office and any of the psychiatric centers and programs that it operates;
and facilities, agencies, and programs that are not licensed by such Office and
are not participants in an approved local or unified services plan, but are
responsible for the provision of services to any recipient pursuant to a
written agreement with the Office as a party, provided, however, if a case
record contains HIV or AIDS information that is protected by Public Health Law
article 27-F, or information provided by a federally-funded
alcoholism/substance abuse provider that is protected under 42 CFR part 2, such
information shall only be redisclosed as permitted by such law or
regulation.
(3) Each case record
shall include:
(i) identifying information
about the recipient and the recipient's identified supports;
(ii) admission information including source
of referral, date of admission, rationale for admission, the date service
commenced, presenting problem and initial treatment needs of the
recipient;
(iii) summary of
psychiatric, medical, emotional, social and residential needs. Special
consideration shall be given to the role of the recipient's identified supports
in each area of assessment;
(iv)
summary of reports of all mental and physical diagnostic examinations and
assessments, including findings and conclusions, if available;
(v) summary of reports of all special studies
performed, including but not limited to X-rays, clinical laboratory tests,
psychological tests, and electroencephalograms, if available;
(vi) the individual service plan;
(vii) daily progress notes, related to the
goals and objectives of the service plan, including the signature of the staff
member who provided the service;
(viii) a discharge summary; and
(ix) documentation that, upon admission, all
recipients were educated in self-preservation procedures, regarding emergency
evacuation and fire safety procedures.
(4) Records must be retained for a minimum
period of six years from the date of the last service provided to a recipient
or, in the case of a minor, for at least six years after the last date of
service or three years after he/she reaches majority, whichever time period is
longer.
Disclaimer: These regulations may not be the most recent version. New York 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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