Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VII - Mental Health Manual
Subpart D - Nonresidential Agencies/Facilities/Services
Chapter 5221 - MENTAL HEALTH INTENSIVE CASE MANAGEMENT
RESPONSIBILITIES
Section 5221.33 - Intensive case management records-statement of policy
Universal Citation: 55 PA Code ยง 5221.33
Current through Register Vol. 54, No. 44, November 2, 2024
To satisfy the recordkeeping requirements in §§ 5221.31(4) and 5221.41 (relating to responsibilities of providers; and recordkeeping), intensive case management records should contain, at a minimum, the following:
(1) Intake information. The following shall be included:
(i) Identifying
information to include the consumer's name, address, date of birth, social
security number and third-party resources.
(ii) Referral Form, to include date, source
and reason for referral to intensive case management and DSM III-R, or
subsequent revision, diagnosis.
(iii) Verification of eligibility to receive
intensive case management, such as past treatment records, psychiatric or
psychological evaluation, letter summarizing treatment history, Individual
Education Plan (IEP), and the like.
(2) Assessments and evaluations.
(i) The following
assessments and evaluations should be made:
(A) Medical history, taken within the past 12
months, or documentation of the intensive case manager's efforts to assist the
consumer in obtaining a physical examination.
(B) Assessment of the consumer's strengths,
needs and interests.
(C) Summaries
of hospitalizations, incarcerations or other out-of-home placements while
enrolled in intensive case management, including the place and date of
admission, the reason for admission, length of stay and discharge
plan.
(D) Children only: IEP,
school testing-for example, psychological evaluations-guidance counselor
reports, and the like, or documentation of the intensive case manager's efforts
to obtain the information if not in the record.
(E) Outcome information required for annual
Consolidated Community Reporting System reporting-that is, consumer level of
functioning, independence of living and vocational/educational
status.
(ii) The
following applies to clauses (A), (C) and (D):
(A) If the intensive case management provider
is part of a multiple service agency which maintains the assessments and
evaluations in clauses (A), (C) and (D) in another file, the information other
than that required to establish eligibility for intensive case management does
not need to be duplicated for the intensive case management record.
(B) These reports are considered to be part
of the intensive case management record, and shall be made available if the
intensive case management record is requested.
(3) Written service plan. The initial plan shall:
(i) Be developed
within 1 month of registration and reviewed at least every 6 months.
(ii) Reflect documented assessment of the
consumer's strengths and needs.
(iii) Identify specific goals, objectives,
responsible persons, time frames for completion and the intensive case
manager's role in relating to the consumer and involved others.
(iv) Be signed by the consumer, the family if
the consumer is a child, the intensive case manager, the intensive case
management supervisor and others as determined appropriate by the consumer and
the intensive case manager. If the signatures cannot be obtained, attempts to
obtain them should be documented.
(4) Documentation of services. The following shall be included:
(i) Case notes. The case notes shall:
(A) Be legible.
(B) Verify the necessity for the contact and
reflect the goals and objectives of the intensive case management service
plan.
(C) Include the date, time
and circumstance of contacts, regardless of whether or not a billable service
was provided.
(D) Identify the
consumer by name or case number on both sides of each page on which there is
writing on both sides. The consumer's name and case number should appear
together earlier in the file.
(E)
Be dated and signed by the individual providing the service.
(ii) Documentation of referral for
other services.
(iii) Encounter
forms.
(5) Discharge information. The following shall be included:
(i) A termination summary, including a reason
for admission to intensive case management, the services provided, the goals
attained, the goals not completed and why and a reason for closure. The summary
shall:
(A) Contain the signature of the
consumer, the family if the consumer is a child, and involved others, if
obtainable, to verify agreement of the termination.
(B) Contain the signature of the county
administrator or designee if the consumer (or family, if the consumer is a
child) does not consent to the termination.
(iii) A recommended after-care
plan.
Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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