R501-2-6. Direct Service Management

A. Direct service management, as described herein, is not applicable to social detoxification. The program shall have on file for public inspection a written eligibility policy and procedure, approved by a licensed clinical professional to include the following:

1. legal status,

2. age and sex of consumer,

3. consumer needs or problems best addressed by program,

4. program limitations, and

5. appropriate placement.

B. The program shall have a written admission policy and procedure to include the following:

1. appropriate intake process,

2. age groupings as approved by the Office of Licensing,

3. pre-placement requirements,

4. self-admission,

5. notification of legally responsible person, and

6. reason for refusal of admission, to include a written, signed statement.

C. Intake evaluation.

1. At the time of intake an assessment shall be conducted to evaluate health and family history, medical, social, psychological and, as appropriate, developmental, vocational and educational factors.

2. In emergency situations which necessitate immediate placement, the intake evaluation shall be completed within seven days of admission.

3. All methods used in evaluating a consumer shall consider age, cultural background, dominant language, and mode of communication.

D. A written agreement, developed with the consumer, and the legally responsible person if applicable, shall be completed, signed by all parties, and kept in the consumer's record, with copies available to involved persons. It shall include the following:

1. rules of program,

2. consumer and family expectations,

3. services to be provided and cost of service,

4. authorization to serve and to obtain emergency care for consumer,

5. arrangements regarding absenteeism, visits, vacation, mail, gifts, and telephone calls, when appropriate, and

6. sanctions and consequences.

E. Consumer treatment plan shall be individualized, as applicable according to the following.

1. A staff member shall be assigned to each consumer having responsibility and authority for development, implementation, and review of the plan.

2. The plan shall include the following:

a. findings of intake evaluation and assessment,

b. measurable long and short term goals and objectives,

1) goals or objectives clearly derived from assessment information,

2) goals or objectives stated in terms of specific observable changes in behavior, skills, attitudes or circumstances,

3) evidence that consumer input was integrated where appropriate in identifying goals and objectives, and

4) evidence of family involvement in treatment plan, unless clinically contraindicated,

c. specification of daily activities, services, and treatment, and

d. methods for evaluation,

3. Treatment plans

a. plans shall be developed within 30 days of consumer's admission by a treatment team and reviewed by a clinical professional if applicable. Thereafter treatment plans shall be reviewed by the licensed clinical professional if applicable as often as stated in the treatment plan.

4. All persons working directly with the consumer shall be appropriately informed of the individual treatment plan.

5. Reports on the progress of the consumer shall be available to the applicable Division, the consumer, or the legally responsible person.

6. Treatment record entries shall include the following:

a. identification of program,

b. date and duration of services provided,

c. description of service provided,

d. a description of consumer progress or lack of progress in the achievement of treatment goals or objectives as often as stated in the treatment plan, and

e. documentation of review of consumer's record to include the following:

1) signature,

2) title,

3) date, and

4) reason for review.

7. Transfer and Discharge

a. a discharge plan shall identify resources available to consumer.

b. the plan shall be written so it can be understood by the consumer or legally responsible party.

c. whenever possible the plan shall be developed with consumers participation, or legally responsible party if necessary. The plan shall include the following:

1) reason for discharge or transfer,

2) adequate discharge plan, including aftercare planning,

3) summary of services provided,

4) evaluation of achievement of treatment goals or objectives,

5) signature and title of staff preparing summary, and

6) date of discharge or transfer.

d. The program shall have a written policy concerning unplanned discharge.

8. Incident or Crisis Intervention records

a. The program shall have written policies and procedures which includes: reporting to program manager, documentation, and management review of incidents such as deaths of consumers, serious injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, strip searches and other situations or circumstances affecting the health, safety, or well-being of consumers.

b. records shall include the following:

1) summary information,

2) date, time of emergency intervention,

3) action taken,

4) employees and management responsible and involved,

5) follow up information,

6) list of referrals,

7) signature and title of staff preparing report, and

8) records shall be signed by management staff.

c. the report shall be maintained in individual consumer records.

d. when an incident involves abuse, neglect, serious illness, violations of the Provider Code of Conduct or death of a consumer, a program shall:

1) notify the Office of Licensing, legally responsible person and any applicable agency which may include law enforcement.

2) a preliminary written report shall be submitted to the Office of Licensing within 24 hours of the incident.