La. Admin. Code tit. 67 § V-7113

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-7113 - Admission and Discharge

A. Admission

1. Policies and Procedures

a. The provider shall have and adhere to written policies and procedures that shall include, at a minimum, the following information regarding an admission to the facility:

i. the application process and the possible reasons for rejection of an application;

ii. pre-admission screening assessment;

iii. the age and sex of residents and children of residents to be served;

iv. the needs, problems, situations, or patterns best addressed by the provider's program;

v. criteria for admission;

vi. authorization for care of the resident and child of a resident;

vii. authorization to obtain medical care for the resident and child of a resident;

viii. criteria for discharge;

ix. procedures for insuring that placement within the program are the least restrictive alternative, appropriate to meet the resident's needs.

b. No resident shall be admitted from another state unless the provider has first complied with all applicable provisions of the Interstate Compact on Juveniles, the Interstate Compact on Placement of Children, and the Interstate Compact on Mental Health. Proof of compliance shall be obtained prior to admission and shall be kept in the resident's file.

c. When refusing admission to a resident or child of a resident, the provider shall notify the referring party of the reason for refusal of admission in writing. If his/her parent(s) or legal guardian(s) referred the resident, he/she shall be provided written reasons for the refusal. Copies of the written reasons for refusal of admission shall be kept in the provider's administrative file.

2. Pre-Admission Screening

a. The provider shall receive an assessment of the applicant from the placing agency prior to admission that identifies services that are necessary to meet the resident's needs and verifies that the resident cannot be maintained in a less restrictive environment within the community. This assessment shall be maintained in the resident's record. The provider shall conduct the pre-admission screening within 24 hours of admission to assess the applicant's needs and appropriateness for admission and shall include the following:

i. current health status and any emergency medical needs, mental health, and/or substance abuse issues;

ii. allergies;

iii. chronic illnesses or physical disabilities;

iv. current medications and possible side effects;

v. any medical illnesses or condition that would prohibit or limit the residents activity or behavior plan;

vi. proof of legal custody or individual placing agency agreement;

vii. other therapies or ongoing treatments;

viii. family information; and

ix. education information. b. Information gathered from the preadmission screening shall be confirmed with resident and legal guardian (if applicable).

3. Admission Assessment

a. An admission assessment shall be completed or obtained within three business days of admission to determine the service needs and preferences of the resident. This admission assessment shall be maintained in the resident's record. Information gathered from the preadmission screening and the admission assessment shall be used to develop the interim service plan for the resident.

B. Service Plan

1. Within 15 days of admission, the provider, with input from the resident, his/her parents, if appropriate and legal guardian shall develop an interim service plan using information gathered from the pre-admission screening and the admission assessment. This interim service plan shall include:

a. the services required to meet the resident's needs;

b. the scope, frequency, and duration of services;

c. monitoring that will be provided; and

d. who is responsible for providing the services, including contract or arranged services.

2. Within 30 days of admission, the provider shall have documentation that a resident has an individual service plan developed that is comprehensive, time-limited, goal-oriented, and addresses the needs of the resident. The service plan shall include the following components:

a. a statement of goals to be achieved for the resident and his/her family;

b. plan for fostering positive family relationships for the resident, when appropriate;

c. schedule of the daily activities including training/education for residents and recreation to be pursued by the program staff and the resident in attempting to achieve the stated goals;

d. any specific behavior management plan:

i. the provider shall obtain or develop, with the participation of the resident and his/her legal guardian or family, an individualized behavior management plan for each resident receiving service. Information gathered from the pre-admission screening and the admission assessment will be used to develop the plan. The plan shall include, at a minimum, the following:

(a). identification of the residents triggers;

(b). the residents preferred coping mechanisms;

(c). techniques for self-management;

(d). anger and anxiety management options for calming;

(e). a review of previously successful intervention strategies;

(f). a summary of unsuccessful behavior management strategies;

(g). identification of the residents specific targeted behaviors;

(h). behavior intervention strategies to be used;

(i). the restrictive interventions to be used, if any;

(j). physical interventions to be used, if any; and

(k). specific goals and objectives that address target behaviors requiring physical intervention;

e. any specialized services provided directly or arranged for will be stated in specific behavioral terms that permit the problems to be assessed and methods for insuring their proper integration with the resident's ongoing program activities;

f. any specific independent living skills needed by the resident which will be provided or obtained on behalf of the resident by the facility staff;

g. overall goals and specific objectives that are time limited;

h. methods for evaluating the resident's progress;

i. use of community resources or programs providing service or training to that resident, and shall involve representatives of such services and programs in the service planning process whenever feasible and appropriate. Any community resource or program involved in a service plan shall be appropriately licensed or shall be a part of a reputable program;

j. any restriction to residents' "rights" deemed necessary to the resident's individual service plan. Any such restriction shall be expressly stated in the service plan, shall specifically identify the right infringed upon, and the extent and duration of the infringement, and shall specify the reasons such restriction is necessary to the service plan, and the reasons less restrictive methods cannot be employed;

k. goals and preliminary plans for discharge;

l. identification of each person responsible for implementing or coordinating implementation of the plan;

m. mental health screening; and

n. developmental and psychological assessments.

3. The service plan shall be developed by a team including, but not limited to, the following:

a. service plan manager;

b. representatives of the direct care staff working with the resident on a daily basis;

c. the resident;

d. the resident's parent(s), if indicated;

e. the residents legal guardian(s); and

f. any other person(s) significantly involved in the resident's care on an ongoing basis.

4. All team participants shall sign and date the completed service plan.

5. The service plan shall be monitored by the team on an ongoing basis to determine its continued appropriateness and to identify when a resident's condition or preferences have changed. A team meeting shall be held at least quarterly. The quarterly review shall be signed and dated by all team participants.

6. The provider shall ensure that all persons working directly with the resident are appropriately informed of the service plan and have access to information from the resident's records that is necessary for effective performance of the employee's assigned tasks.

7. The provider shall document that the resident, parent(s), where applicable, and the legal guardian have been invited to participate in the planning and quarterly review process. When they do not participate, the provider shall document the reasons for nonparticipation.

8. All service plans including quarterly reviews shall be maintained in the residents record.

C. Discharge

1. The provider shall have a written policy and procedure for all discharges. The discharge procedure shall include at least the following:

a. projected date of discharge;

b. responsibilities of each party (provider, resident, family) with regard to the discharge and transition process;

c. transfer of any pertinent information regarding the resident's stay at the facility; and

d. follow-up services, if any and the responsible party.

2. Emergency discharges initiated by the provider shall take place only when the health and safety of a resident or staff might be endangered by the resident's further stay at the facility. The provider shall have a written report detailing the circumstances leading to each unplanned discharge within seven calendar days of the discharge. The discharge summary is to be kept in the resident's record and shall include:

a. the name and home address of the resident, the resident's parent(s), where appropriate, and the legal guardian(s);

b. the name, address, and telephone number of the provider;

c. the reason for discharge and, if due to resident's unsuitability for provider's program, actions taken to maintain placement;

d. a summary of services provided during care including medical, dental, and health services;

e. a summary of the resident's progress and accomplishments during care; and

f. the assessed needs that remain to be met and alternate service possibilities that might meet those needs.

3. When a discharge is planned, the provider shall compile or obtain a complete written discharge summary within seven days of discharge. The discharge summary is to be kept in the resident's record and shall include:

a. the name and home address of the resident, the resident's parent(s), where appropriate, and the legal guardian(s);

b. the name, address, and telephone number of the provider;

c. the reason for discharge and, if due to resident's unsuitability for provider's program, actions taken to maintain placement;

d. a summary of services provided during care including medical, dental, and health services;

e. a summary of the resident's progress and accomplishments during care; and

f. the assessed needs that remain to be met and alternate service possibilities that might meet those needs.

La. Admin. Code tit. 67, § V-7113

Promulgated by the Department of Social Services, Office of Community Service, LR 36:818 (April 2010), amended by the Department of Children and Family Services, Division of Programs, Licensing Section, LR 38:984 (April 2012), Amended by the Department of Children and Family Services, Licensing Section, LR 43272 (2/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:477 and R.S. 46:1401 et seq.