§ 5221.33. Intensive case management recordsstatement of policy.
To satisfy the recordkeeping requirements in § § 5221.31(4) and 5221.41 (relating to responsibilities of providers; and recordkeeping), intensive case management records should contain, at a minimum, the following:
(1) Intake information. The following shall be included:
(i) Identifying information to include the consumers name, address, date of birth, social security number and third-party resources.
(ii) Referral Form, to include date, source and reason for referral to intensive case management and DSM III-R, or subsequent revision, diagnosis.
(iii) Verification of eligibility to receive intensive case management, such as past treatment records, psychiatric or psychological evaluation, letter summarizing treatment history, Individual Education Plan (IEP), and the like.
(2) Assessments and evaluations.
(i) The following assessments and evaluations should be made:
(A) Medical history, taken within the past 12 months, or documentation of the intensive case managers efforts to assist the consumer in obtaining a physical examination.
(B) Assessment of the consumers strengths, needs and interests.
(C) Summaries of hospitalizations, incarcerations or other out-of-home placements while enrolled in intensive case management, including the place and date of admission, the reason for admission, length of stay and discharge plan.
(D) Children only: IEP, school testingfor example, psychological evaluationsguidance counselor reports, and the like, or documentation of the intensive case managers efforts to obtain the information if not in the record.
(E) Outcome information required for annual Consolidated Community Reporting System reportingthat is, consumer level of functioning, independence of living and vocational/educational status.
(ii) The following applies to clauses (A), (C) and (D):
(A) If the intensive case management provider is part of a multiple service agency which maintains the assessments and evaluations in clauses (A), (C) and (D) in another file, the information other than that required to establish eligibility for intensive case management does not need to be duplicated for the intensive case management record.
(B) These reports are considered to be part of the intensive case management record, and shall be made available if the intensive case management record is requested.
(3) Written service plan. The initial plan shall:
(i) Be developed within 1 month of registration and reviewed at least every 6 months.
(ii) Reflect documented assessment of the consumers strengths and needs.
(iii) Identify specific goals, objectives, responsible persons, time frames for completion and the intensive case managers role in relating to the consumer and involved others.
(iv) Be signed by the consumer, the family if the consumer is a child, the intensive case manager, the intensive case management supervisor and others as determined appropriate by the consumer and the intensive case manager. If the signatures cannot be obtained, attempts to obtain them should be documented.
(4) Documentation of services. The following shall be included:
(i) Case notes. The case notes shall:
(A) Be legible.
(B) Verify the necessity for the contact and reflect the goals and objectives of the intensive case management service plan.
(C) Include the date, time and circumstance of contacts, regardless of whether or not a billable service was provided.
(D) Identify the consumer by name or case number on both sides of each page on which there is writing on both sides. The consumers name and case number should appear together earlier in the file.
(E) Be dated and signed by the individual providing the service.
(ii) Documentation of referral for other services.
(iii) Encounter forms.
(5) Discharge information. The following shall be included:
(i) A termination summary, including a reason for admission to intensive case management, the services provided, the goals attained, the goals not completed and why and a reason for closure. The summary shall:
(A) Contain the signature of the consumer, the family if the consumer is a child, and involved others, if obtainable, to verify agreement of the termination.
(B) Contain the signature of the county administrator or designee if the consumer (or family, if the consumer is a child) does not consent to the termination.
(iii) A recommended after-care plan.
The provisions of this § 5221.33 adopted September 10, 1993, effective upon publication and apply retroactively to August 31, 1993, 23 Pa.B. 4312.
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