W. Va. Code R. § 78-3-13

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 78-3-13 - Initial Assessment and Plan of Care

13.1. Multidisciplinary Team.

In all instances in which there is a legally designated Multidisciplinary Team (MDT), the organization's assessments and care plans shall be provided to the DHHR representative of the MDT for the purpose of maintaining consistency in assessment, treatment and placement planning. The MDT is responsible by statute for overseeing the assessment and case planning process for all children who are in the custody of the Department. The organization shall supply a representative to the MDT who is familiar with the child, his or her current status and his or her progress in treatment. The Department of Health and Human Resources designee assigned as the child's representative to the MDT is responsible for approving plans of care designed by the organization. This approval shall include permissions for treatment.

13.2. Initial Assessment.

Each child or transitioning adult that enters residential treatment shall have a thorough assessment and a subsequent plan of care, if considered appropriate by a health care professional.

13.2.1. For children and transitioning adults who have comprehensive assessments completed within six months prior to admission, further assessments are not required, unless circumstances have significantly changed, or the assessments are incomplete.

13.2.2. The organization shall have a comprehensive assessment procedure for children entering the organization's care. Clinical assessments shall be completed by an appropriately licensed or certified clinical professional or an individual under supervision for the licensure. Other assessments may be completed by employees meeting the requirements of their scope of practice. All assessments comprising the comprehensive assessment shall be completed prior to the development of the plan of care and shall include as appropriate and available:

13.2.2.a. Demographic information including custody status;

13.2.2.b. Presenting problems and reason for referral;

13.2.2.c. A history of treatment;

13.2.2.d. A medical history;

13.2.2.e. A social history;

13.2.2.f. The potential need for use of restrictive behavior management interventions;

13.2.2.g. A developmental history;

13.2.2.h. An educational or vocational history;

13.2.2.i. A legal history;

13.2.2.j. A substance abuse history;

13.2.2.k. A mental status examination;

13.2.2.l. An assessment of independent living and adaptive living skills;

13.2.2.m. A summary of the child's strengths;

13.2.2.n. A summary of family strengths and weaknesses; and

13.2.2.o. A summary of presenting problems or potential focus for treatment as identified through the assessment.

13.2.3. When appropriate to the needs of the person served, the assessment shall include:

13.2.3.a. A review of adaptive behavior or a functional assessment, or both.

13.2.3.b. A review of the need for assistive technology, auxiliary aids and services and other special accommodations;

13.2.3.c. Nutritional and dietary needs;

13.2.3.d. Special or unique behavioral issues; and

13.2.3.e. A review of academic, cognitive, and vocational testing or assessments, if available.

13.2.4. Each assessment shall consider any unique aspects of the person's racial, ethnic, and cultural background, and the need for any special service approaches resulting from that assessment.

13.2.5. The assessment shall result in a written integrated summary of findings and recommendations that shall guide the organization's treatment efforts. The integrated summary of findings shall include:

13.2.5.a. Recommendations for dental, visual, and other health screenings or treatment;

13.2.5.b. A diagnosis, stated in terms as provided is the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, if applicable;

13.2.5.c. Recommendations for further assessment as appropriate;

13.2.5.d. Recommendations for clinical behavioral health treatment, if applicable;

13.2.5.e. Recommendations for interventions to be made in the home environment, as necessary and appropriate;

13.2.5.f. Preliminary recommendations for placement and aftercare upon discharge;

13.2.5.g. Recommendations for family visitation unless contraindicated clinically or legally; and

13.2.5.h. Any recommendations for rights restrictions.

13.2.6. The organization shall have a policy establishing timelines for completion of a full assessment that shall take into account urgency of child need, expected duration of treatment, and timelines for plan of care. The timelines shall facilitate provision of an appropriate range of services at the earliest opportunity depending on the unique needs of the individual and the expected duration of services. Exceptions to those timelines shall be fully documented and justified in the clinical record.

13.2.7. When the organization is required to accept assessments from another organization or subcontracting entity, it shall review each assessment for sufficiency and conduct additional assessments if the product does not meet the standard.

13.2.8. The organization shall have a written practice to incorporate families into the assessment and service-planning process unless clinically or legally contra-indicated.

13.3. Initial Plan of Care.

13.3.1. The organization shall develop an initial plan of care within 72 hours of placement that includes the following:

13.3.1.a. List of medications prescribed prior to admission and continued until the assessment process is completed;

13.3.1.b. A summary of assessments needed for the development of a full diagnostic and treatment perspective and recommendations;

13.3.1.c. A description of specific, short-term individual or group interventions to be provided prior development of a master plan of care;

13.3.1.d. A description of educational services to be provided prior to the development of a master plan of care, if any;

13.3.1.e. A description of any behavioral interventions or protocols considered likely to be necessary prior to the completion of the master plan of care; and

13.3.1.f. A description of acute or chronic medical problems that may require treatment prior to the completion of the master plan of care.

13.3.2. The initial plan of care shall be developed whenever possible by a team representative of the professionals performing the assessments, the child (if cognitively capable of participating), the guardian, and the parents of the child if appropriate. The plan shall include a written description of the services to be provided. The initial plan of care shall be approved in writing by the parent or legal guardian and the individual served if that individual is considered sufficiently mature to understand the document. The organization shall obtain the guardian's consent for treatment if the guardian is not present for the development of the initial plan of care. If the organization is required to have the DHHR's consent and does not within 10 business days, the organization must document all reasonable efforts to obtain the consent, including contacting the appropriate chain of command.

13.3.3. If the expected length of stay is 30 days or less, the initial plan of care shall guide the team's efforts throughout the child's stay with the organization and shall be modified as necessary and appropriate. If, however, the expected length of stay is to be greater than 30 days, the team shall meet prior to the end of that time period to develop a master plan of care.

13.3.4. If a child requires a specific therapeutic support plan or a protocol for employees to use in dealing with an inappropriate behavior, the plan or protocol shall be in writing, shall be in terms that make it clear to direct care employees and shall have the consent of the parent or guardian. The plan shall include:

13.3.4.a. The behaviors to be monitored and modified;

13.3.4.b. The precise action to be taken by employees if the behavior occurs; and

13.3.4.c. Documentation employees are responsible for supplying, if any.

13.4. Master Plan of Care.

13.4.1. The plan of care planning and review team shall be an interdisciplinary team consisting of the employees involved in providing services to the child (including at a minimum a licensed or certified master's level professional), the parents, the guardian (if other than parent), and the child him or herself, if the child is of sufficient developmental age to appreciate the content of the review. Unless clinically or legally contraindicated in writing, both parents shall be considered members of the care planning team regardless of the identification of a guardian. The child or guardian may request the presence of any other individuals they feel may add to the process. However, the organization is not responsible for bearing any costs related to the presence of other resources. Teachers or other external providers of service while the child is receiving services from the organization should be invited to team meetings and considered part of the team. The organization is responsible for ensuring that all members of the team receive adequate notification of team meetings, both by telephone, if possible, and in writing. The organization shall document its efforts to obtain participation by team members and any lack of attendance. The organization shall also document efforts to obtain informed consent for treatment from the parent or legal guardian if the guardian does not attend the team meeting. If the organization is required to have the DHHR's consent and does not within 10 business days, the organization must document all reasonable efforts to obtain the consent, including contacting the appropriate chain of command.

13.4.2. The master plan of care shall:

13.4.2.a. Use the summary and recommendations of the assessment process;

13.4.2.b. Contain plans for maintaining or strengthening the relationship between the person served and his or her family if clinically and legally appropriate;

13.4.2.c. Identify the ultimate goal of services (e.g., return to home, foster care, independent living, post-secondary education, etc.);

13.4.2.d. Identify the services the organization intends to provide to meet the needs of the child and child's family as revealed by the comprehensive assessment, including a list of general goals tied to the problems identified in the assessment; and desired measurable objectives for each goal stated in terms that are understandable to the child and guardian;

13.4.2.e. Contain a description of the interventions to be provided in order to achieve the stated objectives, including:

13.4.2.e.1. List of medications prescribed by the child's medical practitioner. Medications may be altered by the physician or qualified medical practitioner during the interval between development and review of the care plan without modification of the care plan itself, however, notes made and signed by the physician or qualified medical practitioner shall be present in the record to document what changes were made and why within one week of alteration of a medication regimen; and

13.4.2.e.2. A description of therapeutic interventions intended to achieve the outcomes to include behavior support plans or therapy plans, or both, as necessary and appropriate;

13.4.2.f. Identify the title or position of persons responsible for providing each intervention;

13.4.2.g. Identify the frequency of the intervention;

13.4.2.h. Identify any outside providers, such as therapists, that the organization has arranged to treat the child and the goals of the interventions;

13.4.2.i. Include educational, vocational, and health services, including dietary, provided to the client; and

13.4.2.j. A proposed discharge plan.

13.5. Review of Master Plan of Care.

13.5.1. The organization shall have a procedure regarding regular review of the plan of care. The procedure shall dictate schedules of review of the plan depending on the average or projected length of stay for the child. At no time shall the schedule allow a period of review to extend more than 90 days except as permitted in sections for each provider type.

13.5.2. Reviews shall always be performed prior to discharge and at critical treatment junctures.

13.5.3. The review shall be the result of a conference of all members of the child's care team including the guardian. Participation by team members and guardians may be telephonic, video conferencing, or, when appropriate, submitted in writing and included in the progress summary (e.g., by educational employees). The organization is responsible for documenting efforts to notify each team member in a timely fashion of the review.

13.5.4. Changes to the plan of care shall be the result of recommendations by the interdisciplinary team and shall be dated and approved in writing by the members of the team including the child (as developmentally appropriate) and his or her guardian.

13.5.5. Reviews shall be conducted by the interdisciplinary team and shall be in writing. They shall consist of:

13.5.5.a. A review of each outcome objective and its current status;

13.5.5.b. Identification of problems that are preventing progression;

13.5.5.c. Suggestions for dealing with those problems;

13.5.5.d. Modifications to be made to the care plan;

13.5.5.e. A review of any therapeutic service provided by an outside provider, to include a written report from that provider if he or she is not present for the review meeting;

13.5.5.f. A summary of all interventions provided to date;

13.5.5.g. A review of any incidents in which the recipient of service may have been involved since the prior review;

13.5.5.h. A review of the discharge plan and the permanency plan; and

13.5.5.i. A review of the effectiveness of each psychotropic medication the child is taking at the time of the review.

13.6. Permanency Plans.

The organization shall assist the MDT in the development of a permanency plan for each recipient of service, when required by statute.

W. Va. Code R. § 78-3-13