Sec. 10.21.22.08. Evaluation and Planning Services

A. Assessment. Within 30 days of initiation of RRP services, staff, in collaboration with the individual, shall complete an RRP assessment that includes:

(1) The rehabilitation service requirements noted in the PRP assessment; and

(2) An assessment of the individual's:

(a) Need for RRP services;

(b) Behaviors, if any, that are potentially dangerous to self or others;

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

(d) History, if any, of requiring intermittent intensive levels of support in order to remain in the community; and

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

B. Individualized Rehabilitation Plan (IRP).

(1) Initial IRP. Within 30 days of initiation of RRP services and based on the assessment in §A of this regulation, staff shall specify in the IRP:

(a) RRP goals; and

(b) The range of:

(i) Frequency of residential services; and

(ii) Intensity of staff support, as described in Regulation .09D of this chapter.

(2) If the individual's service needs change, the RRP staff shall:

(a) Provide and document in the individual's record the services required by the change;

(b) Notify relevant staff of the change initiated; and

(c) Incorporate this information in the next IRP review.

(3) IRP Review. As frequently as necessary, as determined by an individual's rehabilitation coordinator, and at a minimum of every 6 months, the rehabilitation coordinator 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 individual's progress; and

(iii) Changes in interventions, including staff responsibility;

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

(i) Relevant program staff; and

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

(4) Signature of the IRP and Reviews. Staff shall obtain the individual's written or tape-recorded agreement or disagreement with the plan and, in addition, the following shall sign the plan and reviews:

(a) The rehabilitation coordinator; and

(b) Staff responsible for implementing the plan.

C. Continuing Evaluation. The RRP director shall ensure that RRP staff document in the individual's PRP record contact notes and, at least monthly, progress summary notes of services, including any change in intensity of staff support, delivered at the RRP.

D. Documentation. RRP staff shall document the assessment, IRP, contact notes, and progress summary notes for residential services in either:

(1) The PRP record; or

(2) In documents separate from the PRP record, if the PRP record references the separate documents.