Washington Administrative Code
Title 246 - Health, Department of
FACILITY STANDARDS AND LICENSING
Chapter 246-341 - Behavioral health agency licensing and certification requirements
BEHAVIORAL HEALTH-GENERAL REQUIREMENTS
Section 246-341-0640 - Individual service record content
Universal Citation: WA Admin Code 246-341-0640
Current through Register Vol. 24-18, September 15, 2024
A behavioral health agency is responsible for the components and documentation in an individual's individual service record content unless specified otherwise in certification or individual service requirements.
(1) The individual service record must include:
(a) Documentation
the individual received a copy of counselor disclosure requirements as required
for the counselor's credential.
(b)
Identifying information.
(c) An
assessment which is an age-appropriate, strengths-based psychosocial assessment
that considers current needs and the individual's relevant behavioral and
physical health history according to best practices, completed by a person
appropriately credentialed or qualified to provide the type of assessment
pertaining to the service(s) being sought, which includes:
(i) Presenting issue(s);
(ii) An assessment of any risk of harm to
self and others, including suicide, homicide, and a history of self-harm and,
if the assessment indicates there is such a risk, a referral for provision of
emergency/crisis services;
(iii)
Treatment recommendations or recommendations for additional program-specific
assessment;
(iv) A diagnostic
assessment statement, including sufficient information to determine a diagnosis
supported by the current and applicable Diagnostic and Statistical
Manual of Mental Disorders (DSM-5), or
Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood
(DC:0-5);
(v) A placement decision, using ASAM criteria
dimensions, when the assessment indicates the individual is in need of
substance use disorder services.
(d) Individual service plan that:
(i) Is completed or approved by a person
appropriately credentialed or qualified to provide mental health, substance
use, co-occurring, or problem gambling disorder services;
(ii) Addresses issues identified in the
assessment and by the individual or, if applicable, the individual's parent(s)
or legal representative;
(iii)
Contains measurable goals or objectives and interventions;
(iv) Must be mutually agreed upon and updated
to address changes in identified needs and achievement of goals or at the
request of the individual or, if applicable, the individual's parent or legal
representative;
(v) Must be in a
terminology that is understandable to the individuals and the individual's
family or legal representative, if applicable.
(e) If treatment is not court-ordered,
documentation of informed consent to treatment by the individual or
individual's parent, or other legal representative.
(f) Progress and group notes including the
date, time, duration, participant's name, response to interventions or
clinically significant behaviors during the group session, and a brief summary
of the individual or group session and the name and credential of the staff
member who provided it.
(g) If
treatment is for a substance use disorder, documentation that ASAM criteria was
used for admission, continued services, referral, and discharge planning and
decisions.
(h) Discharge
information as follows:
(i) A discharge
statement if the individual left without notice; or
(ii) Discharge information for an individual
who did not leave without notice, completed within seven working days of the
individual's discharge, including:
(A) The
date of discharge;
(B) Continuing
care plan; and
(C) If applicable,
current prescribed medication.
(2) When the following situations apply, the individual service record must include:
(a)
Documentation of confidential information that has been released without the
consent of the individual under:
(i)RCW
70.02.050;
(ii) The Health Insurance Portability and
Accountability Act (HIPAA);
(iii)RCW
70.02.230 and
70.02.240 if the individual
received mental health treatment services; and
(iv) 42 C.F.R. Part 2.
(b) Documentation that any mandatory
reporting of abuse, neglect, or exploitation consistent with chapters 26.44 and
74.34 RCW has occurred.
(c) If
treatment is court-ordered, a copy of the order.
(d) Medication records.
(e) Laboratory reports.
(f) Properly completed authorizations for
release of information.
(g) If the
individual engages in services or is referred to a new service provider, the
individual service record should include documentation that copies of documents
pertinent to the individual's course of treatment were forwarded to the new
service provider with the individual's consent or if applicable, the consent of
the individual's parent or legal representation.
(h) If a report is required by a third-party,
a copy of any report required by third-party entities such as the courts,
department of corrections, department of licensing, and the department of
health, and the date the report was submitted.
(i) Documentation of coordination with any
systems or organizations the individual identifies as being relevant to
treatment, with the individual's consent or if applicable, the consent of the
individual's parent or legal representation.
(j) A crisis plan, if one has been developed
or obtained.
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