Sec. 10.21.21.06. Evaluation and Planning Services

A. Review of Somatic Status.

(1) According to the provisions outlined in this section and upon an individual's enrollment into the program, a staff member assigned by the program director shall document in the individual's medical record:

(a) Pertinent past and current medical history including:

(i) The individual's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases;

(ii) Relevant medical treatment, including medications; and

(iii) Needed somatic care follow-up, if any; and

(b) When the individual does not have a primary care provider and if indicated, the plan, including the time frame, for the individual's referral to a primary care provider for evaluation and treatment.

(2) When indicated, the individual's rehabilitation coordinator shall communicate with the individual's primary care provider and document the communication in the individual's medical record.

(3) When indicated, the individual's rehabilitation coordinator shall discuss with the individual the need for medical and dental care, facilitate access to care, and document the communication in the individual's medical record.

B. Rehabilitation Assessment.

(1) Within 30 calendar days of initiation of PRP services, RRP services, or both, staff assigned by the program director to conduct assessments shall complete a face-to-face rehabilitation assessment with the individual and, with proper consent, family or others designated by the individual.

(2) The assigned staff shall document in the rehabilitation assessment, at a minimum:

(a) The individual's strengths, skills, wants, and needs in the following areas:

(i) Independent living;

(ii) Housing;

(iii) Employment;

(iv) Self-administration and management of medications;

(v) Mobility and transportation;

(vi) Social relationships and leisure activities;

(vii) Education and vocational training;

(viii) Adaptive equipment or resources; and

(ix) Other factors that may pose a challenge to the individual's successful recovery and rehabilitation;

(b) Current resources and support system;

(c) As relevant, a review of the individual's legal status and forensic history, if any;

(d) The individual's history of substance abuse, if any;

(e) Behaviors, if any, that are potentially dangerous to the individual or others; and

(f) For individuals receiving RRP services, the individual's:

(i) Need for RRP services;

(ii) Ability to perform basic self-care and to maintain personal safety; and

(iii) Need for changing intensity of intervention based on the episodic nature of mental illness.

C. Individual Rehabilitation Plan (IRP).

(1) Initial IRP. Within 30 calendar days of initiation of PRP or RRP services and based on the rehabilitation assessment described in §B of this regulation, the individual and the individual's rehabilitation coordinator shall prepare an initial IRP:

(a) In collaboration with:

(i) And with proper consent, family or others designated by the individual, and others involved in the individual's care; and

(ii) When appropriate and with proper consent, other mental health service providers, as available; and

(b) That includes, at a minimum:

(i) The individual's recovery and rehabilitation expectations and responsibilities;

(ii) A description of needed and desired program services and interventions, and staff responsible for implementation;

(iii) A description of how the needed and desired skills and supports will help the individual to manage the individual's psychiatric disorder and to support recovery;

(iv) Rehabilitation goals in measurable terms, and target dates for each goal;

(v) When appropriate, identification of, recommendations for, and collaboration with, other services to support the individual's recovery and rehabilitation, including but not limited to mental health treatment, residential services, self-help organizations, and somatic care; and

(vi) For individuals receiving RRP services, the frequency of residential services and intensity of staff support.

(2) Individual Treatment and Rehabilitation Plan (ITRP). With the individual and in collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP.

(3) Rehabilitation Plan Review. At a minimum of every 6 months, the rehabilitation coordinator, with the individual, shall:

(a) Review and record in the individual's medical record:

(i) The individual's progress toward the accomplishment of previously identified rehabilitation goals;

(ii) Goal changes, based on a review of the progress; and

(iii) Changes in interventions, as appropriate; and

(b) Communicate promptly the results of the review to:

(i) Relevant program staff; and

(ii) With proper consent, family or others designated by the individual, and community mental health programs providing services to the individual.

(4) Signature of the IRP or ITRP and Reviews.

(a) The following shall sign that they agree with the IRP or ITRP and reviews:

(i) The individual; and

(ii) The individual's rehabilitation coordinator.

(b) With proper consent, family or others designated by the individual, including the individual's caregivers, may sign the IRP or ITRP and reviews.

(c) If the individual is unwilling to sign agreement with the IRP or ITRP and reviews, the individual's rehabilitation coordinator shall:

(i) Verify the individual's verbal agreement with the IRP or ITRP and reviews; and

(ii) Document the rationale for the individual's refusal to sign.

(d) In addition, for an ITRP, at least two licensed mental health professionals, who collaborate about the individual's treatment, shall sign the ITRP and ITRP reviews, including:

(i) The individual's treatment coordinator; and

(ii) If the individual is receiving medication prescribed through an outpatient mental health center (OMHC), the OMHC psychiatrist.

(5) Upon completion of an IRP, ITRP, or review, an individual's rehabilitation coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's receipt or decline of the offer in the individual's medical record.

D. Continuing Evaluation.

(1) Contact Notes. Staff shall document in the individual's medical record:

(a) Each contact with or about the individual, including, at a minimum:

(i) The date and location of service;

(ii) The start time and either the duration or end time, unless the information is in a readily accessible billing document;

(iii) The individual's chief medical complaint or reason for the visit;

(iv) The delivery of services specified by the IRP or ITRP;

(v) A brief description of the service provided; and

(vi) A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title; and

(b) For individuals receiving RRP services, any change in intensity of staff support delivered at the RRP.

(2) Monthly Summary Notes. At a minimum, each month the rehabilitation coordinator shall record in the individual's medical record, either a contact note or a progress summary note that includes:

(a) An assessment of the individual's progress toward goal achievement that incorporates the perspective of both the individual served and staff involved;

(b) Changes in the individual's status; and

(c) A summary of the rehabilitation services and interventions provided.

(3) If not documented in §D(1) or (2) of this regulation, the rehabilitation coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's rehabilitation.

(4) The rehabilitation coordinator shall document that the individual's wants and needs and progress are promptly communicated to:

(a) Staff involved in the implementation of the IRP; and

(b) With proper consent, family or others designated by the individual, and community mental health programs providing services to the individual.