N.Y. Comp. Codes R. & Regs. tit. 14 § 512.8

Current through Register Vol. 46, No. 43, October 23, 2024

Section 512.8 - Documentation

(a) Case records.

(1) There shall be a complete case record maintained for each person admitted to a PROS program. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:

(i) any case record entries shall be legible and non-erasable;

(ii) case records shall be periodically reviewed for quality and completeness; and

(iii) all entries in case records shall be dated and signed by appropriate staff.

(2) The case record shall be available to all staff who are providing services to the individual, and to any staff who have need for access, consistent with State and Federal confidentiality requirements.

(3) The case record shall include the following information:

(i) any pre-admission screening notes;

(ii) identifying information and history;

(iii) mental illness diagnosis;

(iv) required assessments based on enrollment in specific PROS components;

(v) for individuals receiving clinical treatment component services from the PROS program, an assessment of the individual's psychiatric and physical needs, and dated and signed records of all medications prescribed;

(vi) for individuals who are receiving integrated dual disorder treatment from the PROS program and clinical treatment services from a source other than the PROS program, documentation that the services provided by the clinic are integrated with those provided by the PROS program, including, at a minimum, the ongoing exchange of information, documentation of progress and outcomes related to the services provided by the clinic, and the name of the treating psychiatrist or nurse practitioner at such clinic who will be collaborating with a designated member of the PROS clinical staff;

(vii) reports of any mental and physical diagnostic exams, tests and consultations;

(viii) screening and admission note;

(ix) attestation form;

(x) initial services recommendation plan;

(xi) the individualized recovery plan (IRP), IRP service addition form, and all reviews of the IRP;

(xii) documentation satisfying the requirements in subdivision (d) of this section;

(xiii) dated progress notes;

(xiv) any referrals to other programs and services;

(xv) any consent forms; and

(xvi) discharge plan and/or summary, as appropriate.

(4) Case records may include relevant history and assessment documents completed by other providers of service.

(5) For persons who are discharged from a PROS program and referred to another provider, the discharge summary shall be transmitted to the receiving program within two weeks.

(6) Case records shall be retained for a minimum of six years following an individual's discharge from the program.

(b) Individualized recovery plan (IRP).

(1) Each individual's IRP shall include, at a minimum, the following:

(i) a description of the individual's strengths as identified in the summary of findings provided in each required assessment;

(ii) a description of the barriers created by the individual's mental illness that prevent the individual's achievement of his or her stated goals, as identified in the summary of findings provided in each required assessment;

(iii) a statement of the individual's recovery goals and program participation objectives;

(iv) an individualized course of action to be taken, including the specific services to be provided, the expected frequency of service delivery, the expected duration of the course of service delivery, and the anticipated outcome;

(v) for individuals receiving IR, ORS or clinical treatment services, the IRP shall identify the reasons why these services are needed, in addition to CRS services, to achieve the individual's recovery goals;

(vi) criteria to determine when goals and objectives have been met so that the individual can move forward in his or her recovery process;

(vii) the identification of any collaterals who will assist the individual in his or her recovery;

(viii) a relapse prevention plan, which includes a description of the individual's preferences regarding treatment and any PROS services that may be used in the event of a crisis;

(ix) any other advance directives or preferences expressed by the individual;

(x) description and goals of any linkage and coordination activities with other service providers;

(xi) for PROS participants receiving treatment services from a clinic licensed pursuant to Part 599 of this Title, a description of how such services are integrated with the individual's IRP; and

(xii) required signatures obtained within seven days of the date that the IRP is developed, as follows:

(a) the PROS participant's signature; in situations where the individual is out of contact with the program due to hospitalization or other issue, signature should be obtained upon the individual's return to the program;

(b) the signature of the clinical staff member who prepared the IRP;

(c) if the clinical staff member who prepared the IRP is not a member of the professional staff, the signature of the professional staff member supervising or participating in the IRP process shall also be included; and

(d) for persons receiving clinical treatment, the IRP shall include a physician's signature or the signature of a nurse practitioner in psychiatry.

(2) The inclusion of all required staff's signatures on the IRP is a representation that the identified PROS services are deemed to be medically necessary.

(3) An IRP is considered completed when all required staff signatures are provided. The latest date of signature is the IRP's official completion date.

(4) Services may be provided on an interim basis and be considered part of the IRP by completing a service addition form or documenting the need for a new service or change in a service on a progress note. If the new or revised service continues after scheduled periodic review of the IRP, the service must be identified on the IRP. The service addition form or the progress note must include the following:

(i) the name of the service(s) to be provided and the reason for the service(s) addition;

(ii) the signature of the individual and a member of the clinical staff; and

(iii) for clinical treatment services, the signature of the psychiatrist or nurse practitioner in psychiatry.

(c) Progress notes.

(1) Progress notes shall be maintained for each individual and shall be dated, signed by a clinical member of the PROS program staff, and indicate the period of time covered by the note.

(2) Progress notes shall include, at a minimum:

(i) a summary of services received subsequent to the last progress note;

(ii) a description of the progress made toward the goals identified in the IRP subsequent to the last progress note; and

(iii) identification of any necessary changes to the IRP and services related to such changes.

(3) Progress notes shall be completed, at a minimum, once each month.

(4) A progress note must also be completed for any significant event and/or unexpected incident.

(d) Supporting documentation.

(1) The PROS program shall maintain documentation for each participant indicating:

(i) duration of on-site and off-site program participation per day;

(ii) types and numbers of PROS services provided per day; and

(iii) upon request, capacity to provide the number of PROS units per person, per day, per month.

(2) The PROS program shall maintain a daily program schedule that includes scheduled meal periods and planned recreational activities.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 512.8