Current through Register Vol. 54, No. 45, November 9, 2024
Section 257.4 - Case management(a)Statement of policy. As a component of the Comprehensive Drug and Alcohol Treatment and Prevention Plan, each SCA shall, in cooperation with service providers, develop a plan for the provision of a case management system for all individuals entering or currently a client of drug or alcohol treatment services provided by that SCA. The case management system shall be in accordance with the provisions set forth in this section.(b)Performance. The SCA shall have the following responsibilities: (1) The SCA shall be responsible for the planning and implementation of the case management system. The SCA shall perform the following functions: (i) Supervise, coordinate, monitor and ensure the performance of case management activities.(ii) Periodically review client service plans for continuity of service, continued appropriateness of service, and utilization of available resources. The SCA may review random samples for conformance with written policies or guidelines, or both, for service plans developed by the SCA in cooperation with service providers.(2) The SCA shall perform or delegate the performance of the following functions to treatment service providers: (i) Development of a comprehensive confidential personal history, including any significant medical, social, occupational and family information.(ii) Arrangement for the provision of needed medical, functional, psychological, psychiatric, social or vocational diagnostic assessments.(iii) Thorough exploration of service needs and discussion with the client concerning service options to which he may be referred.(iv) Preparation of a written service plan utilizing all appropriate available service resources and listing the services, to be provided. This plan shall be developed in cooperation with and agreed to by the service provider and the client. The service plan shall also include referral to any services not specifically for drug and alcohol clients, for example legal services and dental services, for which the client may be eligible.(v) Prompt arrangement for delivery of the requested services.(vi) If a client has been referred for services, liaison, follow-up, or advocacy, as appropriate, to promote client satisfaction, continued delivery of services, and continuity of services.(vii) Case consultation, as appropriate.(viii) Assignment of a client number for UDCS reporting forms and the completion of UDCS forms and intake forms as appropriate.(ix) Determination of liability and preparation of abatement requests for those cases where liability payment cannot be collected.(3) Each treatment service provider shall perform the following functions: (i) Development and periodic review of individual treatment and rehabilitation plans which document the specific activities to be provided by the service provider as specified in §262.6(b)(2) (relating to general standards for treatment activities).(ii) Assignment of a primary counselor to assure that services are provided according to treatment and rehabilitation plans.(iii) Performance of any case management activities delegated to the provider by the SCA as set forth in subsection (b)(2).(4) As set forth in § 254.20 (relating to appeals), an aggrieved party shall have the right to appeal an SCA decision to the Council.(c)Client records. Client records shall be managed in accordance with the following: (1) Clearly stated written policies shall be developed cooperatively by the SCA and service providers and utilized in the performance of case management stating the following: (i) The types and form of records gathered on each applicant for services.(ii) The types and form of ongoing records to be kept on each individual.(2) A complete client record shall be maintained on each individual whose case is managed which shall include, but not be limited to, the following:(i) Significant medical, social, occupational and family history.(ii) The client's treatment plan.(iii) Records of any significant client contacts.(iv) Records of any referral contacts.(v) Consent forms for the release of client information.(vi) Records of any client-related consultation, conversations and so forth with service providers.(vii) Records of the release of any client information and copies of any client-related correspondence.(viii) Records or referral follow-up.(ix) Documentation of monitoring of the service plan.(d)Confidentiality. To insure confidentiality the following safeguards shall be taken: (1) All client records shall be confidential in accordance with Federal and State laws or regulations. (i) Client records shall be secured within a locked storage container.(ii) Only those individuals actually performing case management functions, including SCA staff performing case management functions, may have access to the client records. This includes clerical personnel assigned the responsibility of case management files.(2) Client records may be released for treatment purposes if written informed and voluntary consent has been obtained from the client, in accordance with § 255.5 (relating to projects and coordinating bodies: disclosure of client orientation information). (i) Informed and voluntary consent shall be obtained from the client for disclosure of client information necessary for the performance of case management functions.(ii) Informed and voluntary consent shall be obtained from the client for the release of information to a treatment project to which the client is referred during an agreed upon and specified period of time.(iii) A copy of any client consent shall be given to the client and the original maintained in the client records.(iv) When client information is disclosed to an authorized person or organization the information shall not be redisclosed.(e)Client rights. Client rights shall be defined as follows: (1) A person receiving care or treatment under the provisions of or subject to the provisions of section 7 of the act of April 14, 1972 ( P. L. 221, No. 63) (71 P. S. § 1690.107) shall retain all civil rights and liberties except as provided by law. No client shall be deprived of any civil right solely by reason of treatment.(2) The case management system shall not discriminate on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.The provisions of this §257.4 adopted September 9, 1977, 7 Pa.B. 2604.