Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0077 - Mental Health and Substance Use Disorder Services
Chapter 2 - BEHAVIORAL HEALTH SERVICE PROVIDER CERTIFICATION
Section 2-11 - Client Case Records

Universal Citation: WY Code of Rules 2-11

Current through September 21, 2024

(a) A provider shall maintain a client case record for each client admitted for services.

(b) A provider shall maintain all client case records in accordance with professional standards of practice, including storage of records in a secure and designated area.

(c) Client case records must include the following documentation and reflect the following applicable services utilizing ASAM criteria, according to the unique needs of each individual client:

(i) Consent to receive treatment signed by the client or legal guardian;

(ii) A statement signed by the client or legal guardian affirming that confidentiality was explained to them and that they understand what information is protected and under what circumstances information can or cannot be released;

(iii) A form signed by the client or legal guardian acknowledging receipt and affirming that they understand the procedures for filing a complaint;

(iv) A form signed within the last year by the client or legal guardian acknowledging receipt and affirming that they understand client rights;

(v) A form signed by the client or legal guardian acknowledging receipt, understanding, and acceptance of provider policies and procedures governing the treatment process;

(vi) Clinical assessments, based on the following criteria:
(A) A provider serving adults shall utilize an evidence-based assessment tool which includes comprehensive information regarding the client's biopsychosocial and spiritual needs;

(B) A provider serving adolescents shall utilize a bio-psychosocial assessment tool which, at a minimum, includes the following domains: medical, criminal, substance use, family, psychiatric, developmental and academic history; intellectual capacity; physical and sexual abuse history; spiritual needs; peer, environmental, and cultural history; and, assessment of suicidal and homicidal ideation;

(C) A provider shall utilize the ASAM criteria including the dimensional criteria for each domain in the assessment process;

(D) A provider shall adequately assess the client's need for case management services according to subsection (ix) of this section; and

(E) When a client is transferred from another provider which completed the assessment, a receiving provider shall complete a transfer note showing that the assessment information was reviewed. Further, a provider shall determine if the client's needs are congruent with this assessment, make needed adjustments to treatment recommendations, and note the adjustment in the client file;

(vii) Diagnosis and diagnostic summary utilizing diagnostic tools which are standard for the field and which are acknowledged by the Department and payer sources;

(viii) Treatment plans, which must:
(A) Be completed when treatment is initiated and updated at a minimum of every ninety (90) calendar days;

(B) Be developed utilizing the assessment information, including the diagnosis and ASAM criteria;

(C) Integrate mental health needs if included as part of the assessment and diagnosis, if identified as part of the assessment process, or at any point during the course of treatment; and

(D) Include:
(I) Evidence the client or guardian participated in the development of the treatment plan, signed the treatment plan, and received a copy of the treatment plan;

(II) Outcome driven goals and measurable objectives;

(III) Changes in the client's symptoms and behaviors that are expected during the course of treatment in the current level of service, expressed in measurable and understandable terms;

(IV) The desired improved functioning level of the client utilizing the assessment; and

(V) Documentation of appropriate actions taken following specific program infractions, which do not require immediate termination, with appropriate timeframes for clients to address infractions prior to terminating the client;

(ix) A case management plan, based on the following criteria;
(A) A provider shall provide case management services directly or through written formal agreement among multiple agencies or providers;

(B) Upon determination from the client's primary qualified clinical staff that the case management services would benefit the client, case management services must include collaboration with other available agencies, providers, and services to meet individual client needs based on ongoing assessments when applicable; and

(C) Special emphasis must be placed on coordinating with other entities including, but not limited to, education institutions, vocational rehabilitation, recovery supports, and workforce development services to enhance the client's skill base, chances for gainful employment, housing, community resource supports, and other options for independent functioning;

(x) Progress notes, which must:
(A) Document the symptoms and condition of the client, response to treatment, and progress or lack of progress toward specific treatment goals;

(B) Be detailed enough to allow a qualified clinical staff to follow the course of treatment;

(C) Be completed as they occur for individual, IOP, and group therapy sessions. The dates of services shall be documented as part of each individual or group therapy session progress note; and

(D) Be signed by the staff providing services to the client. If the staff is not a qualified clinical staff the progress notes shall also be signed by a qualified clinical supervisor;

(xi) Releases of client confidential information completed in full and signed by the client or legal guardian and the provider;

(xii) Referrals;

(xiii) Quality of care reviews by the client's treatment team of clinical documentation for the purpose of reviewing the client's progress in treatment and the services provided to ensure the most appropriate level of care is provided, to coordinate needed services outside the provider, and for internal quality assurance;

(xiv) Correspondence relevant to the client's treatment, including all letters and dated notations of telephone conversations conducted by provider staff;

(xv) Documentation of any prescribed medication, to include:
(A) The client was fully apprised about the medication;

(B) The assessment for the medication;

(C) Each prescribed medication;

(D) Medication monitoring; and

(E) If the client is receiving Medication Assisted Treatment (MAT) through a different MAT practitioner, documentation of collaboration and attempts to collaborate with the MAT practitioner;

(xvi) Evidence the client was given information regarding communicable diseases, referred for screening, and provided linkages to appropriate counseling; and

(xvii) Documentation of continued stay, transition, and discharge planning, including the ASAM level of care recommendation. Discharge summaries must contain a summary of pertinent case record information and any plan for continuing care, referral, or admission to another level of care.

Disclaimer: These regulations may not be the most recent version. Wyoming 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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