N.H. Admin. Code § He-P 830.16

Current through Register No. 45, November 7, 2024

Section He-P 830.16 - Required Services

(a) The licensee shall provide administrative services that include the appointment of a full-time, on-site administrator who:

(1) Is responsible for the day-to-day operations of the PRTP;

(2) Meets the requirements of He-P 830.18(j);

(3) Designates, in writing, an alternate administrator who shall assume the responsibilities of the administrator in his or her absence; and

(4) In the event the administrator will be absent for a period to exceed 30 consecutive days, the facility shall notify the department who the interim administrator will be and submit credentials to verify he or she meets the requirements of (2) above.

(b) Upon admission or within 24 hours following admission, the APRTP shall perform a comprehensive intake assessment of each client's needs and develop a preliminary treatment plan.

(c) The comprehensive intake assessment required by (b) above shall include, at a minimum, the following:

(1) A mental health status examination and medication review;

(2) An initial diagnostic impression;

(3) Safety risk assessment and presence or absence of communicable disease;

(4) A functional assessment of those specific skills and behaviors required for the client to be in a less restrictive setting;

(5) A statement by the treating licensed practitioner that the PRTP represents the appropriate level of treatment for the client;

(6) Serve as a basis for treatment plan;

(7) Historical and current information and assessments; and

(8) Medical, psychiatric, and social information containing the following:

a. For medical information:

1. A statement of the individual's general physical health status;

2. Medical history, including current weight, height, blood pressure, pulse, and smoking status;

3. When applicable, medical diagnosis, and the results or any medical or neurological screenings, examinations, or tests; and

4. The name and contact information for the individual's primary care physician;

b. For psychiatric information:

1. History of mental illness or serious emotional disturbance, including onset and severity;

2. Previous services and treatments, including medications and hospitalizations;

3. Individual's strengths;

4. Illness self-management skills;

5. Precipitating events for current psychiatric symptoms, as applicable;

6. Documentation of medical necessity for services;

7. Current diagnosis;

8. Medication orders;

9. Current medications; and

10. Results of formalized psychiatric or psychological tests, if applicable;

c. For social information:

1. Developmental history;

2. Educational history and current status, if applicable;

3. Family history and current family status;

4. History and current family status;

5. History of trauma, including domestic violence;

6. Results of a substance use screening tool;

7. Employment history including work skills and types, and lengths of employment;

8. Military history and veteran's status, if applicable;

9. Current living situation including type of environment and nature of relationship with any room/house mates or family;

10. Social and leisure time activities and skills;

11. Ability to develop and maintain friendships;

12. Involvement with or history of involvement with other social service agencies or the criminal justice system;

13. Guardianship, if applicable; and

14. Other legal documents.

(d) The intake assessment and updates shall be signed and dated by the person completing the assessment.

(e) A treatment plan shall:

(1) Be completed within 24 hours of the comprehensive assessment in (c) above;

(2) Be updated following the completion of each future assessment;

(3) Be made available to personnel who assist clients in the implementation of the plan; and

(4) Address the needs identified by the comprehensive assessment.

(f) The licensee shall provide each client, or their agent, the opportunity to participate in the development of the treatment plan.

(g) The treatment plan required by (e) above, shall contain, at a minimum, the following:

(1) The date the problem or need was identified;

(2) A description of the problem or need;

(3) The objectives, which shall be measurable, attainable, realistic, and timely;

(4) The interventions, which shall be specifically provided on behalf of the program to the clients;

(5) The client's clinical needs, treatment goals, and objectives;

(6) The client's strengths and resources for achieving goals and objectives as identified in (3) above;

(7) The strategy for providing services to meet those needs, goals, and objectives;

(8) The specification and description of the indicators to be used to assess the client's progress;

(9) The date of re-evaluation, review, or resolution;

(10) Psychiatric evaluation, including mental status and alcohol/substance abuse evaluations, as determined necessary by the treating licensed practitioner;

(11) Individual and group therapeutic activity directed towards stabilization of psychiatric crises or extended care;

(12) Family education, consultation, and therapy, as clinically indicated; and

(13) For children or youth clients, the determination made by a licensed practitioner, that the child or youth client is eligible for PRTF level of care.

(h) The treatment plan shall be reviewed at least every 30 days or as medically indicated.

(i) For each client, progress notes shall be written daily and include at a minimum:

(1) Any treatment plan goals addressed;

(2) Changes in the client's physical and mental status, as applicable;

(3) Changes in behavior, such as eating habits, sleeping pattern, and relationships; and

(4) Summary of protective care that has been provided.

(j) At the time of a client's admission, the licensee shall ensure that orders from a licensed practitioner are obtained for medications, and that special dietary requirements are documented.

(k) All personnel shall follow the orders of the licensed practitioner for each client and encourage clients to follow the practitioner's orders.

(l) The licensee shall have each client obtain a health examination by a licensed practitioner within 30 days prior to admission or within 72 hours following admission to the PRTP.

(m) The health examination in (l) above shall include:

(1) Diagnoses, if any;

(2) The medical history;

(3) Medical findings, including the presence or absence of communicable disease;

(4) Vital signs;

(5) Prescribed and over-the-counter medications;

(6) Allergies;

(7) Dietary needs;

(8) Pain assessment; and

(9) Safety risk assessment.

(n) Each client shall have at least one health examination every 12 months, unless the licensed practitioner determines that an annual physical examination is not necessary and specifies in writing an alternative time frame, or the client refuses in writing.

(o) A client may refuse all care and services.

(p) When a client refuses care or services that could result in a threat to their health, safety or well-being, or that of others, the licensee or their designee shall:

(1) Inform the client and guardian of the potential results of their refusal;

(2) Notify the licensed practitioner of the client's refusal of care; and

(3) Document in the client's record the refusal of care and the client's reason for the refusal if known.

(q) The licensee shall maintain an information data sheet in the client's record and promptly give a copy to emergency medical personnel in the event of an emergency transfer to another medical facility.

(r) The information data sheet in (q) above shall include:

(1) Full name and the name the client prefers, if different;

(2) Name, address and telephone number of the client's next of kin, guardian or agent, if any;

(3) Diagnosis;

(4) Medications, including last dose taken and when the next dose is due;

(5) Allergies;

(6) Functional limitations;

(7) Date of birth;

(8) Insurance information;

(9) Advanced directives including DNR or DNAR orders, if applicable; and

(10) Any other pertinent information not specified in (1)-(9) above.

(s) Services shall be age and developmentally appropriate.

(t) PRTP's shall offer psychotherapeutic services.

(u) Individual psychotherapy shall:

(1) Include therapy, crisis intervention, or assessment and monitoring necessary to determine the course and progress of therapy or to stabilize an individual experiencing an acute psychiatric episode; and

(2) Be verbal, with the therapist in direct, personal, involvement with the resident to the exclusion of other residents, individuals, and duties.

(v) Group psychotherapy, per person, shall include therapy or assessment and monitoring necessary to determine the course and progress of therapy that is performed in a direct, personal involvement with the resident in a setting with other residents or individuals.

(w) Group psychotherapy shall meet the following criteria:

(1) Limit clinical groups to no more than 8 individuals with one licensed counselor present and no more than 12 individuals when that licensed counselor is joined by a second licensed counselor;

(2) Sessions shall be scheduled often enough to provide effective treatment;

(3) The group focus shall be face to face dialogue of a verbal rather than performance nature; and

(4) Individual progress notes for each session shall be recorded in each recipient's record with specific attention directed toward goal achievement as stated in the resident's treatment plan.

(x) Family therapy shall be:

(1) The resident and their natural or surrogate family member(s); or

(2) The natural or surrogate family member(s) without the resident present.

N.H. Admin. Code § He-P 830.16

#10059, eff 12-23-11

Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12952, Effective 12/21/2019, Expires 6/18/2020.

Amended by Volume XLI Number 19, Filed May 13, 2021, Proposed by #13195, Effective 4/24/2021, Expires 4/24/2031.