N.Y. Comp. Codes R. & Regs. tit. 14 § 589.9

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

Section 589.9 - Individual Service Plan and Case Record

(a) Individual service plans for Intensive Crisis Residence Programs and Residential Crisis Support Programs

(1) An individual service plan shall be developed and implemented with each recipient by the staff of the crisis residence within 24 hours of admission.

(2) The individual service plan shall be based on a comprehensive assessment of each recipient.

(i) For an Intensive Crisis Residence program, the assessment shall engage each recipient as an active partner in developing, reviewing and modifying a service plan that supports their progress toward recovery. The assessment shall include but not be limited to the recipient's personal preferences and desired life roles, physical, medical, emotional, social, residential, recreational and, when appropriate, vocational and nutritional needs. The assessment shall also include a risk assessment, and shall identify any need for medication management. If appropriate, this information, with the recipient's consent, may be obtained from the recipient's most recent mental health service provider(s) and coordinator.

(ii) For a Residential Crisis Support program, the assessment shall engage each recipient as an active partner in developing, reviewing and modifying a service plan that supports their progress towards recovery. The assessment shall include, but not limited to emotional, mental, social, residential, recreational and, when appropriate, vocational and nutritional needs. If appropriate, this information, with the individual's consent, may be obtained from the recipient's most recent mental health service provider(s).

(iii) Consideration of each recipient's needs shall include a determination of the type and extent of additional clinical examinations, tests and evaluations necessary for a complete assessment, if needed.

(3) The individual service plan shall address the needs of the recipient.

(i) The individual service plan shall identify all service needs of the recipient whether or not the services are provided directly by the crisis residence program.

(ii) The individual service plan shall address the manner in which the recipient's identified supports, which may include family, will be involved in the service planning and implementation.

(4) The individual service plan must be signed by a qualified mental health staff person and the recipient.

(5) The individual service plan must be developed in collaboration with the recipient and any collateral persons the recipient chooses to involve.

(6) The individual service plan must include discharge planning.

(b) Individual service plans for Children's Crisis Residence Programs

(1) An individual service plan is required for each recipient.

(2) The individual service plan shall be based on a comprehensive intake assessment of each recipient.

(3) Within 24 hours of admission of a child to a children's crisis residence program, an intake assessment must be completed by a qualified mental health staff person (QMHP) within their scope of practice and at a minimum a preliminary individual service plan must be developed.

(i) The intake assessment must include, at a minimum:

(a) an assessment of risk;

(b) a description of the current symptoms and/or behaviors which demonstrate eligibility for admission;

(c) the presenting problem, including factors contributing to the psychiatric crisis or risk;

(d) a description of the child's current needs and strengths; and

(e) a description of the skills needed to transition to the home or community.

(ii) The preliminary individual service plan must include, at a minimum:

(a) a description of the immediate need(s) to be addressed,

(b) the initial goal(s), service(s), intervention(s) and crisis plan to address the need(s) during the initial period after admission.

(4) Within 72 hours of admission the individual service plan must be completed, with the participation, as appropriate, of the child, the child's parent/guardian or other identified collaterals. Parent/guardian or other collaterals participating in the development of the plan must be specifically identified in the plan. If the QMHP developing the plan does not possess a license, the plan must be approved and signed by professional staff.

(5) The completion of the Individual Service Plan must include, at a minimum, the following additional components:

(i) the treatment goal(s) and objectives; the services, interventions, projected time periods to accomplish the goal(s); the parent/guardian, family members or other identified collaterals participating in treatment and discharge planning; the criteria for discharge and a description of the services and supports needed at the time of transition to the home or community; signatures of the child, participating family or collaterals indicating their agreement. If the child, family or identified collateral(s) is unable to participate, the reason for non-participation must be documented.

(ii) If applicable, the plan for provision of additional service(s) outside of the crisis residence program to further support and prepare the child for discharge, while in the program, must also be included in the individual service plan.

(iii) The development of the crisis plan must include the child and family as active participants, as appropriate. With the child's and/or parent/guardian's consent, the crisis plan may be shared with identified collaterals involved in the child's treatment or support.

(6) The individual service plan must be reviewed as needed and include participation of staff involved in the provision of services to the to the child and/or, if appropriate, the child's family or other collaterals. The service plan must be revised if there is a change to the child's goals or plan for discharge.

(c) Case Records.

(1) There shall be a complete case record maintained at one location or electronically for each recipient.

(2) Information in crisis residence program case records that is subject to the confidentiality protections of Mental Hygiene Law section 33.13 may be shared between facilities, agencies and programs responsible for the provision of services pursuant to an approved local or unified services plan (including programs that receive funding from the Office of Mental Health disbursed via a State aid letter); such Office and any of the psychiatric centers and programs that it operates; and facilities, agencies, and programs that are not licensed by such Office and are not participants in an approved local or unified services plan, but are responsible for the provision of services to any recipient pursuant to a written agreement with the Office as a party, provided, however, if a case record contains HIV or AIDS information that is protected by Public Health Law article 27-F, or information provided by a federally-funded alcoholism/substance abuse provider that is protected under 42 CFR part 2, such information shall only be redisclosed as permitted by such law or regulation.

(3) Each case record shall include:

(i) identifying information about the recipient and the recipient's identified supports;

(ii) admission information including source of referral, date of admission, rationale for admission, the date service commenced, presenting problem and initial treatment needs of the recipient;

(iii) summary of psychiatric, medical, emotional, social and residential needs. Special consideration shall be given to the role of the recipient's identified supports in each area of assessment;

(iv) summary of reports of all mental and physical diagnostic examinations and assessments, including findings and conclusions, if available;

(v) summary of reports of all special studies performed, including but not limited to X-rays, clinical laboratory tests, psychological tests, and electroencephalograms, if available;

(vi) the individual service plan;

(vii) daily progress notes, related to the goals and objectives of the service plan, including the signature of the staff member who provided the service;

(viii) a discharge summary; and

(ix) documentation that, upon admission, all recipients were educated in self-preservation procedures, regarding emergency evacuation and fire safety procedures.

(4) Records must be retained for a minimum period of six years from the date of the last service provided to a recipient or, in the case of a minor, for at least six years after the last date of service or three years after he/she reaches majority, whichever time period is longer.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 589.9

Amended New York State Register June 26, 2019/Volume XLI, Issue 26, eff. 6/26/2019