R501-13-8. Direct Service Management

A. The program shall have a written eligibility, admission and discharge policy and procedure to include the following:

1. intake process,

2. self-admission,

3. notification of the responsible person,

4. reasons for admission refusal which includes a written, signed statement, and

5. reasons for discharge or dismissal.

B. Intake Assessment

1. Before a program admits a consumer, a written assessment shall be completed to evaluate current health and medical history, legal status, social, psychological and, as appropriate, developmental, vocational or educational factors.

2. In emergency drop-in care situations which necessitate immediate placement, the assessment shall be completed on the same day of service in all situations.

3. All methods used during intake shall consider age, cultural background, dominant language, and mode of communication.

4. During intake, the consumer's legal status, according to State Law, shall be determined as it relates to the responsible person who may have legal authority to make decisions on the consumer's behalf.

C. Consumer Agreement

A written agreement, developed with the consumer, the responsible person and the Director or designee, shall be completed, signed by all parties, and kept in the consumer's record. It shall include the following:

1. rules of program,

2. consumer and family expectations as appropriate and agreed upon,

3. services to be provided and not provided and cost of service, including refunds,

4. authorization to serve and to obtain emergency medical care, and

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

D. Individual Consumer Service Plan

1. A program staff member in collaboration with the Director, shall be assigned to each consumer and have responsibility and authority for development, implementation, and review of the individual consumer service plan.

2. The plan shall include the following:

a. findings of the intake assessment and consumer records,

b. individualized program plan to enhance consumer well-being,

c. specification of daily activities and services,

d. methods for evaluation, and

e. discharge summary.

3. Individual consumer service plans shall be developed within three working days of admission and evaluated within 30 days of admission and every 90 days thereafter or as changes occur.

4. All persons working directly with the consumer shall review the individual consumer service plan.

E. Incident or Crisis Intervention Reports

1. There shall be written reports to document consumer death, injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, and other situations or circumstances affecting the health, safety, or well-being of a consumer while in care.

2. The report shall include the following:

a. summary information,

b. date and time of emergency intervention,

c. list of referrals if any,

d. follow-up information, and

e. signature of person preparing report and other witnesses confirming the contents of the report.

3. The report shall be completed within 48 hours of each occurrence and maintained in the individual consumer's record.

4. When an incident or crisis involves abuse, neglect or death of a consumer, the Director or designee shall document the following:

a. a preliminary written report within 24 hours of the incident, and

b. immediate notification to the Office, the consumer's legally responsible person, the nearest Human Services office, and as appropriate a law enforcement authority.