West Virginia Code of State Rules
Agency 78 - Human Services
Title 78 - LEGISLATIVE RULE DEPARTMENT OF HUMAN SERVICES BUREAU FOR SOCIAL SERVICES
Series 78-03 - Minimum Licensing Requirements for Residential Child Care and Treatment Facilities for Children and Transitioning Adults and Vulnerable and Transitioning Youth Group Homes and Programs in West Virginia
Section 78-3-13 - Initial Assessment and Plan of Care
Universal Citation: 78 WV Code of State Rules 78-3-13
Current through Register Vol. XLI, No. 38, September 20, 2024
13.1. Multidisciplinary Team.
In all instances in which there is a legally designated Multidisciplinary Team (MDT), the organization's assessments and care plans shall be provided to the DHHR representative of the MDT for the purpose of maintaining consistency in assessment, treatment and placement planning. The MDT is responsible by statute for overseeing the assessment and case planning process for all children who are in the custody of the Department. The organization shall supply a representative to the MDT who is familiar with the child, his or her current status and his or her progress in treatment. The Department of Health and Human Resources designee assigned as the child's representative to the MDT is responsible for approving plans of care designed by the organization. This approval shall include permissions for treatment.
13.2. Initial Assessment.
Each child or transitioning adult that enters residential treatment shall have a thorough assessment and a subsequent plan of care, if considered appropriate by a health care professional.
13.2.1. For children and transitioning adults
who have comprehensive assessments completed within six months prior to
admission, further assessments are not required, unless circumstances have
significantly changed, or the assessments are incomplete.
13.2.2. The organization shall have a
comprehensive assessment procedure for children entering the organization's
care. Clinical assessments shall be completed by an appropriately licensed or
certified clinical professional or an individual under supervision for the
licensure. Other assessments may be completed by employees meeting the
requirements of their scope of practice. All assessments comprising the
comprehensive assessment shall be completed prior to the development of the
plan of care and shall include as appropriate and available:
13.2.2.a. Demographic information including
custody status;
13.2.2.b.
Presenting problems and reason for referral;
13.2.2.c. A history of treatment;
13.2.2.d. A medical history;
13.2.2.e. A social history;
13.2.2.f. The potential need for use of
restrictive behavior management interventions;
13.2.2.g. A developmental history;
13.2.2.h. An educational or vocational
history;
13.2.2.i. A legal
history;
13.2.2.j. A substance
abuse history;
13.2.2.k. A mental
status examination;
13.2.2.l. An
assessment of independent living and adaptive living skills;
13.2.2.m. A summary of the child's
strengths;
13.2.2.n. A summary of
family strengths and weaknesses; and
13.2.2.o. A summary of presenting problems or
potential focus for treatment as identified through the assessment.
13.2.3. When appropriate to the
needs of the person served, the assessment shall include:
13.2.3.a. A review of adaptive behavior or a
functional assessment, or both.
13.2.3.b. A review of the need for assistive
technology, auxiliary aids and services and other special
accommodations;
13.2.3.c.
Nutritional and dietary needs;
13.2.3.d. Special or unique behavioral
issues; and
13.2.3.e. A review of
academic, cognitive, and vocational testing or assessments, if
available.
13.2.4. Each
assessment shall consider any unique aspects of the person's racial, ethnic,
and cultural background, and the need for any special service approaches
resulting from that assessment.
13.2.5. The assessment shall result in a
written integrated summary of findings and recommendations that shall guide the
organization's treatment efforts. The integrated summary of findings shall
include:
13.2.5.a. Recommendations for dental,
visual, and other health screenings or treatment;
13.2.5.b. A diagnosis, stated in terms as
provided is the most recent version of the Diagnostic and Statistical Manual of
Mental Disorders, if applicable;
13.2.5.c. Recommendations for further
assessment as appropriate;
13.2.5.d. Recommendations for clinical
behavioral health treatment, if applicable;
13.2.5.e. Recommendations for interventions
to be made in the home environment, as necessary and appropriate;
13.2.5.f. Preliminary recommendations for
placement and aftercare upon discharge;
13.2.5.g. Recommendations for family
visitation unless contraindicated clinically or legally; and
13.2.5.h. Any recommendations for rights
restrictions.
13.2.6.
The organization shall have a policy establishing timelines for completion of a
full assessment that shall take into account urgency of child need, expected
duration of treatment, and timelines for plan of care. The timelines shall
facilitate provision of an appropriate range of services at the earliest
opportunity depending on the unique needs of the individual and the expected
duration of services. Exceptions to those timelines shall be fully documented
and justified in the clinical record.
13.2.7. When the organization is required to
accept assessments from another organization or subcontracting entity, it shall
review each assessment for sufficiency and conduct additional assessments if
the product does not meet the standard.
13.2.8. The organization shall have a written
practice to incorporate families into the assessment and service-planning
process unless clinically or legally contra-indicated.
13.3. Initial Plan of Care.
13.3.1. The organization shall develop an
initial plan of care within 72 hours of placement that includes the following:
13.3.1.a. List of medications prescribed
prior to admission and continued until the assessment process is
completed;
13.3.1.b. A summary of
assessments needed for the development of a full diagnostic and treatment
perspective and recommendations;
13.3.1.c. A description of specific,
short-term individual or group interventions to be provided prior development
of a master plan of care;
13.3.1.d.
A description of educational services to be provided prior to the development
of a master plan of care, if any;
13.3.1.e. A description of any behavioral
interventions or protocols considered likely to be necessary prior to the
completion of the master plan of care; and
13.3.1.f. A description of acute or chronic
medical problems that may require treatment prior to the completion of the
master plan of care.
13.3.2. The initial plan of care shall be
developed whenever possible by a team representative of the professionals
performing the assessments, the child (if cognitively capable of
participating), the guardian, and the parents of the child if appropriate. The
plan shall include a written description of the services to be provided. The
initial plan of care shall be approved in writing by the parent or legal
guardian and the individual served if that individual is considered
sufficiently mature to understand the document. The organization shall obtain
the guardian's consent for treatment if the guardian is not present for the
development of the initial plan of care. If the organization is required to
have the DHHR's consent and does not within 10 business days, the organization
must document all reasonable efforts to obtain the consent, including
contacting the appropriate chain of command.
13.3.3. If the expected length of stay is 30
days or less, the initial plan of care shall guide the team's efforts
throughout the child's stay with the organization and shall be modified as
necessary and appropriate. If, however, the expected length of stay is to be
greater than 30 days, the team shall meet prior to the end of that time period
to develop a master plan of care.
13.3.4. If a child requires a specific
therapeutic support plan or a protocol for employees to use in dealing with an
inappropriate behavior, the plan or protocol shall be in writing, shall be in
terms that make it clear to direct care employees and shall have the consent of
the parent or guardian. The plan shall include:
13.3.4.a. The behaviors to be monitored and
modified;
13.3.4.b. The precise
action to be taken by employees if the behavior occurs; and
13.3.4.c. Documentation employees are
responsible for supplying, if any.
13.4. Master Plan of Care.
13.4.1. The plan of care planning and review
team shall be an interdisciplinary team consisting of the employees involved in
providing services to the child (including at a minimum a licensed or certified
master's level professional), the parents, the guardian (if other than parent),
and the child him or herself, if the child is of sufficient developmental age
to appreciate the content of the review. Unless clinically or legally
contraindicated in writing, both parents shall be considered members of the
care planning team regardless of the identification of a guardian. The child or
guardian may request the presence of any other individuals they feel may add to
the process. However, the organization is not responsible for bearing any costs
related to the presence of other resources. Teachers or other external
providers of service while the child is receiving services from the
organization should be invited to team meetings and considered part of the
team. The organization is responsible for ensuring that all members of the team
receive adequate notification of team meetings, both by telephone, if possible,
and in writing. The organization shall document its efforts to obtain
participation by team members and any lack of attendance. The organization
shall also document efforts to obtain informed consent for treatment from the
parent or legal guardian if the guardian does not attend the team meeting. If
the organization is required to have the DHHR's consent and does not within 10
business days, the organization must document all reasonable efforts to obtain
the consent, including contacting the appropriate chain of command.
13.4.2. The master plan of care shall:
13.4.2.a. Use the summary and recommendations
of the assessment process;
13.4.2.b. Contain plans for maintaining or
strengthening the relationship between the person served and his or her family
if clinically and legally appropriate;
13.4.2.c. Identify the ultimate goal of
services (e.g., return to home, foster care, independent living, post-secondary
education, etc.);
13.4.2.d.
Identify the services the organization intends to provide to meet the needs of
the child and child's family as revealed by the comprehensive assessment,
including a list of general goals tied to the problems identified in the
assessment; and desired measurable objectives for each goal stated in terms
that are understandable to the child and guardian;
13.4.2.e. Contain a description of the
interventions to be provided in order to achieve the stated objectives,
including:
13.4.2.e.1. List of medications
prescribed by the child's medical practitioner. Medications may be altered by
the physician or qualified medical practitioner during the interval between
development and review of the care plan without modification of the care plan
itself, however, notes made and signed by the physician or qualified medical
practitioner shall be present in the record to document what changes were made
and why within one week of alteration of a medication regimen; and
13.4.2.e.2. A description of therapeutic
interventions intended to achieve the outcomes to include behavior support
plans or therapy plans, or both, as necessary and appropriate;
13.4.2.f. Identify the title or
position of persons responsible for providing each intervention;
13.4.2.g. Identify the frequency of the
intervention;
13.4.2.h. Identify
any outside providers, such as therapists, that the organization has arranged
to treat the child and the goals of the interventions;
13.4.2.i. Include educational, vocational,
and health services, including dietary, provided to the client; and
13.4.2.j. A proposed discharge
plan.
13.5. Review of Master Plan of Care.
13.5.1. The
organization shall have a procedure regarding regular review of the plan of
care. The procedure shall dictate schedules of review of the plan depending on
the average or projected length of stay for the child. At no time shall the
schedule allow a period of review to extend more than 90 days except as
permitted in sections for each provider type.
13.5.2. Reviews shall always be performed
prior to discharge and at critical treatment junctures.
13.5.3. The review shall be the result of a
conference of all members of the child's care team including the guardian.
Participation by team members and guardians may be telephonic, video
conferencing, or, when appropriate, submitted in writing and included in the
progress summary (e.g., by educational employees). The organization is
responsible for documenting efforts to notify each team member in a timely
fashion of the review.
13.5.4.
Changes to the plan of care shall be the result of recommendations by the
interdisciplinary team and shall be dated and approved in writing by the
members of the team including the child (as developmentally appropriate) and
his or her guardian.
13.5.5.
Reviews shall be conducted by the interdisciplinary team and shall be in
writing. They shall consist of:
13.5.5.a. A
review of each outcome objective and its current status;
13.5.5.b. Identification of problems that are
preventing progression;
13.5.5.c.
Suggestions for dealing with those problems;
13.5.5.d. Modifications to be made to the
care plan;
13.5.5.e. A review of
any therapeutic service provided by an outside provider, to include a written
report from that provider if he or she is not present for the review
meeting;
13.5.5.f. A summary of all
interventions provided to date;
13.5.5.g. A review of any incidents in which
the recipient of service may have been involved since the prior
review;
13.5.5.h. A review of the
discharge plan and the permanency plan; and
13.5.5.i. A review of the effectiveness of
each psychotropic medication the child is taking at the time of the
review.
13.6. Permanency Plans.
The organization shall assist the MDT in the development of a permanency plan for each recipient of service, when required by statute.
Disclaimer: These regulations may not be the most recent version. West Virginia 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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
