CHAPTER 5230. PSYCHIATRIC REHABILITATION SERVICES
5230.4. Psychiatric rehabilitation processes and practices.
5230.5. Access to facility and records.
5230.11. Organizational structure.
5230.12. Inspections and licenses.
5230.13. Agency records.
5230.14. Physical site requirements.
5230.15. Agency service description.
5230.16. Coordination of care.
5230.21. Content of individual record.
5230.22. Documentation standards and record security, retention and disposal.
5230.23. Access to individual record.
ADMISSION, CONTINUED STAY AND DISCHARGE REQUIREMENTS
5230.31. Admission requirements.
5230.32. Continued stay requirements.
5230.33. Discharge requirements.
5230.41. PRS statement of rights.
5230.51. Staff qualifications.
5230.52. General staffing requirements.
5230.53. Individual services.
5230.54. Group services.
5230.56. Staff training requirements.
5230.57. Criminal history background check.
SERVICE PLANNING AND DELIVERY
5230.62. Individual rehabilitation plan.
5230.63. Daily entry.
5230.72. Discharge summary.
5230.81. Quality improvement requirements.
WAIVER OF STANDARDS
5230.91. Request for waiver.
The provisions of this Chapter 5230 issued under Articles IX and X of the Public Welfare Code (62 P. S. § § 901922 and 10011088), unless otherwise noted.
The provisions of this Chapter 5230 adopted May 10, 2013, effective August 9, 2013, 43 Pa.B. 2572, unless otherwise noted.
§ 5230.1. Purpose.
§ 5230.2. Scope.
§ 5230.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
(i) One of five dimensions relating to different aspects of the diagnosis of a psychiatric disorder or disability as organized in the DSM-IV-TR or subsequent revisions.
(ii) Axis I specifies clinical disorders, including major mental disorders.
BH-MCOBehavioral health managed care organizationAn entity that manages the purchase and provision of mental health and substance abuse services.
Best practiceService delivery practice based directly on principles and standards that are generally recognized by a profession and are documented in the professional literature.
CPRPCertified Psychiatric Rehabilitation PractitionerA person who has completed the required education, experience and testing, and who is currently certified as a Certified Psychiatric Rehabilitation Practitioner by the USPRA.
CPS certificateCertified Peer Specialist certificateA certificate awarded to a person who has successfully completed the Department-approved training in peer support services.
ClubhouseA PRS facility that is accredited by the ICCD.
Coordination of careDirect contact by a PRS agency with other mental health, physical health or human service formal and natural supports, to ensure continuity in service planning between service agencies.
County MH/ID administratorThe Mental Health/Intellectual Disability administrator who has authority in the geographic area.
Culturally competentThe ability to provide service in a manner that shows awareness of and is responsive to the beliefs, interpersonal styles, attitudes, language and behavior of an individual and family who are referred for or receiving service.
DSM-IV-TRDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
DepartmentThe Department of Human Services of the Commonwealth.
DischargeDiscontinuation of service to an individual.
EBPEvidence based practiceService delivery practice identified, recognized and verified by research and empirical data to be effective in producing a positive outcome and supporting recovery.
FTEFull-time equivalent37.5 hours per calendar week of staff time.
Face-to-faceContact between two or more people that occurs at the same location, in person.
Formal supportAn agency, organization or person who provides assistance or resources to others within the context of an official role.
Functional impairmentThe loss or abnormality of the ability to perform necessary tasks.
GEDGeneral Equivalency Diploma.
GoalThe purpose of the rehabilitation service as identified by the individual.
Human servicesPrograms or facilities designed to meet basic health, welfare and other needs of a society or group.
ICCDInternational Center for Clubhouse Development.
ICD-9International Classification of Diseases, Ninth Edition.
IRPIndividual rehabilitation planA document that describes the current service needs based on the assessment of the individual and identifies the individuals goals, interventions to be provided, the location, frequency and duration of services, and staff who will provide the service.
IndividualA person, 18 years of age or older who has a functional impairment resulting from mental illness, who uses PRS.
LPHALicensed practitioner of the healing arts
(i) An individual licensed by the Commonwealth to practice the healing arts.
(ii) The term is limited to a physician, physicians assistant, certified registered nurse practitioner and psychologist.
Legal entityA person, society, corporation, governing authority or partnership legally responsible for the administration and operation of a PRS facility or a PRS agency.
Mental health direct serviceWorking directly with an individual to provide a mental health service.
Natural supportA person or organization selected by an individual to provide assistance or resources in the context of a personal or nonofficial role.
OutcomeAn observable and measurable result of PRS.
PRSPsychiatric rehabilitation serviceA recovery-oriented service offered individually or in groups which is predicated upon the principles, values and practice standards of the ICCD, USPRA or other Nationally-recognized professional PRS association.
PRS agencyAn organization that operates a PRS facility licensed by the Department under this chapter.
PRS facilityThe premises licensed by the Department for the delivery of PRS.
Psychiatric rehabilitation principlesA list of core values inherent in psychiatric rehabilitation as defined by Nationally-recognized professional associations, including the USPRA, the ICCD and the Coalition for Community Living.
QI planQuality improvement planA document outlining the ongoing formal process to ensure optimal care and maximize service benefit as part of the licensing process.
USPRAThe United States Psychiatric Rehabilitation Association.
§ 5230.4. Psychiatric rehabilitation processes and practices.
(a) A PRS agency shall assist an individual to develop, enhance and retain skills and competencies in living, learning, working and socializing so that an individual can live in the environment of choice and participate in the community.
(b) A PRS agency shall use the PRS process in delivering PRS. The PRS process consists of three phases:
(1) Assessing phase.
(i) Developing a relationship and trust.
(ii) Determining individual readiness for rehabilitation.
(iii) Completing mutual assessment of needs.
(iv) Goal setting.
(2) Planning phase.
(i) Prioritizing needed and preferred skills and supports.
(ii) Planning for resource development.
(3) Intervening phase.
(i) Developing new skills.
(ii) Supporting existing skills.
(iii) Overcoming barriers to using skills.
(iv) Identifying or modifying an individuals resources to pursue a goal.
(c) A PRS agency shall ensure that the following practices are included in programming and staff training and in agency and individual record maintenance:
(1) Creating a culturally competent, recovery-oriented environment consistent with psychiatric rehabilitation principles.
(2) Engaging an individual in PRS.
(3) Assessing individual strengths, interests and preferences for PRS with an individual.
(4) Developing strategies to assist an individual in identifying, achieving and maintaining valued roles.
(5) Developing an IRP with an individual.
(6) Helping an individual increase awareness of community resources and identify preferred options for the rehabilitation process.
(7) Educating an individual about mental illness, wellness and living in recovery.
(8) Providing direct or indirect skills development.
(9) Assisting an individual in identifying, developing and utilizing natural supports.
(10) Reaching out and re-engaging an individual who discontinues service participation.
(d) PRS shall be provided to an individual regardless of involvement in other mental health services.
(1) PRS shall begin as soon as possible following diagnosis.
(2) A PRS agency shall collaborate and coordinate with other service agencies with the consent of the individual.
(e) A PRS agency shall follow EBP or best practices of the specific PRS approach identified in the agency service description.
(f) A PRS agency may offer PRS in a PRS facility or in the community, or both, as is consistent with an approved agency service description.
§ 5230.5. Access to facility and records.
(a) A PRS agency shall provide access to the PRS facility and records during inspection and, upon request, by the Department.
(b) A PRS agency shall grant access to private interviews with individuals upon request by the Department and with individual consent.
§ 5230.11. Organizational structure.
A PRS agency shall:
(1) Establish guidance from an advisory board that:
(i) Includes participation by individuals and families who utilize mental health services.
(ii) Is developed by the PRS agency or is the advisory board of the legal entity.
(2) Document that the members of the advisory board have been provided with an overview of PRS processes and practices.
§ 5230.12. Inspections and licenses.
(a) A PRS agency shall meet the requirements under Chapter 20 (relating to licensure or approval of facilities and agencies).
§ 5230.13. Agency records.
A PRS agency shall maintain records that contain copies of the following:
(1) Inspection reports, certifications or licenses issued by state and local agencies.
(2) The PRS statement of rights under § 5230.41 (relating to PRS statement of rights).
(3) Documentation of civil rights compliance.
(4) A detailed agency service description under § 5230.15 (relating to agency service description).
(5) PRS agency policies and procedures that address the following:
(i) The implementation of the PRS based upon the agency service description.
(ii) Nondiscrimination statement.
(iii) Compliance with other applicable State and Federal regulations, including the Americans with Disabilities Act of 1990 (42 U.S.C.A. § § 1210112213) and the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191, 110 Stat. 1936).
(iv) Engagement and outreach to an individual to maintain participation in the IRP.
(v) Complaint policies and procedures.
(vi) Individual crisis management.
(vii) Disaster preparedness.
(6) Human resources policies and procedures that address the following:
(i) Job descriptions for staff positions.
(ii) Criminal history background check requirements and protocol.
(iii) Transportation of individuals.
(iv) Evidence of staff credentials or qualifications.
(v) Records of orientation and training, including an annual training plan for staff.
(vi) Staff work schedules and time sheets.
(7) PRS daily schedules.
(8) A copy of contracts or letters of agreement with external funding sources including BH-MCOs or county MH/ID administrators.
(9) Letters of agreement with mental health services and community agencies.
(10) Quality improvement documents, including the following:
(i) QI plan.
(ii) Data gathering tools.
(iii) Annual review reports.
§ 5230.14. Physical site requirements.
A PRS agency shall provide:
(1) A physical location within the PRS facility for recordkeeping and other administrative functions of the PRS regardless of where service is provided.
(2) PRS as a service that is distinct from other mental health services that may be offered by the legal entity:
(i) In terms of service content.
(ii) In terms of physical space utilized.
(3) A site that is accessible to individuals.
(4) Space, equipment and supplies that are well-maintained and sufficient to deliver the services listed in the agency service description.
(5) Private interview space.
(6) Protocols that meet applicable Federal, State and local requirements for fire, safety and health, including protocols for the following:
(ii) Fire drills.
§ 5230.15. Agency service description.
(a) Prior to the initial licensing visit, and when changes occur to the agency service description, a PRS agency shall submit to the Department for prior approval an agency service description that includes the following:
(1) The governing body, advisory board and an agency table of organization.
(2) The philosophy of the PRS agency, incorporating psychiatric rehabilitation principles.
(3) The population to be served, including the following:
(i) Anticipated daily attendance.
(ii) Age range.
(iii) Diagnostic groups.
(iv) Plans to identify and accommodate special populations.
(v) Plans to identify and accommodate culturally diverse populations.
(4) The approach of PRS offered including EBPs and best practices utilized.
(5) A PRS facility identified as a clubhouse must be accredited by the ICCD within 3 years of licensing.
(6) The location of service, whether in a PRS facility or in the community, or a combination of both.
(7) Expected service outcomes for individuals.
(8) Staffing, including the following:
(i) Staffing patterns.
(ii) Staff to individual ratios.
(iii) Staff qualifications.
(iv) Staff supervision plans.
(v) Staff training protocols.
(9) Service delivery patterns, including frequency, duration and method (group or individual) of service delivery.
(10) The days and hours of PRS operation.
(11) The geographic limits of PRS operation.
(12) A description of the physical site, including copies of applicable licenses and certificates.
(13) A process for development of an IRP with an individual.
(14) Admission and discharge policies and procedures.
(15) The methods by which PRS staff and an individual will collaborate to identify and use the individuals preferred community resources.
(16) A process for developing and implementing a QI plan.
(17) A procedure for filing and resolving complaints.
(b) The Department may deny agency service descriptions and approaches that do not meet EBP or best practices standards.
§ 5230.16. Coordination of care.
(a) A PRS agency shall have written agreements to coordinate care with other service providers, including the following:
(1) Psychiatric inpatient facilities.
(2) Partial hospitalization programs.
(3) Psychiatric outpatient clinics.
(4) Crisis intervention programs.
(5) Case management programs.
(b) A PRS agency may have written agreements to coordinate care with other service providers as needed, including the following:
(1) Housing and residential programs.
(2) Drug and alcohol programs.
§ 5230.17. Confidentiality.
A PRS agency shall protect information about an individual in compliance with the Mental Health Procedures Act (50 P. S. § § 71017503), § § 5100.315100.39 (relating to confidentiality of mental health records), the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191, 110 Stat. 1936) and 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information).
§ 5230.21. Content of individual record.
A PRS agency shall develop and maintain a record for an individual served containing the following:
(1) Information that identifies the individual.
(2) Eligibility for PRS, including diagnosis.
(3) Referral source, reason for referral and recommendation by an LPHA.
(4) A signed set of documents providing the following:
(i) Individual consent to receive services.
(ii) Individual consent to release information to other providers.
(iii) Verification that the individual received and had an opportunity to discuss the oral and written versions of the PRS statement of rights under § 5230.41 (relating to PRS statement of rights).
(5) An assessment and updates.
(6) The IRP.
(7) Staff documentation of IRP outcomes.
(8) Staff documentation of coordination with other services and supports.
§ 5230.22. Documentation standards and record security, retention and disposal.
A PRS agency shall ensure that an individual record meets the following standards:
(1) The record must be legible throughout.
(2) The record must identify the individual on each page.
(3) Entries shall be signed and dated by the responsible staff.
(4) The record must indicate progress at each day of service, changes in service and response to services.
(5) Updates of the record shall be signed and dated.
(6) The record is kept in a permanent, secure location.
(7) The record shall be maintained for a minimum of 4 years.
§ 5230.23. Access to individual record.
An individual may review, provide written comments and sign daily entries in the individual record.
ADMISSION, CONTINUED STAY AND DISCHARGE REQUIREMENTS
§ 5230.31. Admission requirements.
(a) General rule. To be eligible for PRS, an individual shall meet the following:
(1) Have a written recommendation for PRS by an LPHA acting within the scope of professional practice.
(2) Have the presence or history of a serious mental illness, based upon medical records, which includes one of the following diagnoses by an LPHA:
(ii) Major mood disorder.
(iii) Psychotic disorder (not otherwise specified).
(iv) Schizoaffective disorder.
(v) Borderline personality disorder.
(3) As a result of the mental illness, have a moderate to severe functional impairment that interferes with or limits performance in at least one of the following domains:
(4) Choose to receive PRS.
(b) Assessment. A PRS agency shall identify and document the functional impairment of the individual in an assessment as required under § 5230.61(b)(1) (relating to assessment).
(c) Exception. Individuals who do not meet the serious mental illness diagnosis requirement under subsection (a) may receive services when the following conditions are met:
(1) The written recommendation by the LPHA includes a diagnosis of mental illness that is listed on Axis I in the DSM-IV-TR or ICD-9 or subsequent revisions.
§ 5230.32. Continued stay requirements.
(a) A PRS agency shall determine an individuals eligibility for continued stay during an IRP update required under § 5230.62(c) (relating to individual rehabilitation plan).
(b) An individuals eligibility for continued stay shall be determined by documentation of the following:
(1) An individual chooses continued participation in the PRS.
(2) A continued need for service based upon one or both of the following:
(i) As a result of a mental illness, there is a functional impairment or skill deficit that is addressed in the IRP.
§ 5230.33. Discharge requirements.
When a PRS agency documents one of the following criteria, discharge may occur. An individual:
(1) Has achieved goals and sustained progress as designated in the IRP.
(2) Has gained maximum rehabilitative benefit.
(3) Will not lose rehabilitation gain or an attained goal as a result of withdrawal of service.
(4) Has voluntarily terminated.
§ 5230.41. PRS statement of rights.
(a) An individual has the right to be treated with dignity and respect and to be free from physical and mental harm.
(b) An individual has the right to receive PRS in a culturally respectful and nondiscriminatory environment.
(c) An individual has the right to receive PRS in the least restrictive setting that fosters recovery and promotes growth.
(d) An individual has the right to access competent, timely and quality service to assist with fulfillment of a goal.
(e) An individual has the right to express a goal which is individualized and reflects informed choice concerning selection, direction or termination of service and service plan.
(f) An individual has the right to choose a service based on individual need, choice and acceptance and not dependent on compliance or participation with another treatment or rehabilitation service.
(g) An individual has the right to keep and use personal possessions in a manner that is reasonable to the service and location. Any necessary limitations shall be clearly communicated and defined, universally applied and documented.
(h) An individual has the right to offer an opinion and belief.
(i) An individual has the right to file a complaint related to PRS and to have the complaint addressed.
(j) An individual has the right to have the assistance of a personally chosen representative or advocate in expressing a complaint.
(k) An individual has the right to be able to contribute to, have access to, and control release of the individual record.
(l) An individual has the right to have information and records concerning service treated in a confidential manner, as required under the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191, 110 Stat. 1936).
(m) A PRS agency shall:
(1) Assure compliance with the PRS statement of rights.
(2) Develop and implement a written procedure for assuring compliance with the PRS statement of rights.
(3) Post the PRS statement of rights within the PRS facility.
(4) Notify an individual verbally and in writing and include a signed acknowledgement of rights in the individual record.
(5) Develop the IRP in compliance with individual rights.
§ 5230.42. Nondiscrimination.
A PRS agency may not discriminate against an individual or staff on the basis of age, race, sex, religion, ethnic origin, economic status, sexual orientation or gender identity or expression, or disability.
§ 5230.43. Complaints.
(a) The PRS agency shall have written policies and procedures for filing and resolving complaints.
(b) A PRS agency shall give verbal and written notice to an individual upon admission to the service, explaining complaint policies and procedures.
(c) A PRS agency shall offer assistance to an individual as needed to file a complaint.
§ 5230.51. Staff qualifications.
(a) A PRS director shall have one of the following:
(1) A bachelors degree and CPRP certification.
(2) A bachelors degree and at least 3 years work experience in mental health direct service, 2 years of which must be work experience in PRS. CPRP certification shall be attained within 2 years of hire as a PRS director.
(3) An associate of arts degree and CPRP certification if employed as the PRS director of a licensed PRS facility for at least 6 months immediately prior to May 11, 2013.
(b) A psychiatric rehabilitation specialist shall have one of the following:
(1) A bachelors degree and 2 years work experience in mental health direct service, 1 year of which must be work experience in PRS. CPRP certification shall be attained within 2 years from the date of hire as a psychiatric rehabilitation specialist.
(2) CPRP certification.
(c) A psychiatric rehabilitation worker shall have one of the following:
(1) A bachelors degree.
(2) An associates degree and 1 year work experience in mental health direct service.
(3) A CPS certificate and 1 additional year paid or volunteer work experience in mental health direct service.
(4) A high school diploma or GED and 2 years work experience in human services which must include 1 year of mental health direct service.
(d) A psychiatric rehabilitation assistant shall have a high school diploma or GED and 6 months experience in human services.
§ 5230.52. General staffing requirements.
(a) A PRS agency shall staff the service according to the following:
(1) The location of services is consistent with the agency service description.
(2) The service may range from individual service to group service.
(3) The service and the choice of service locations shall be determined by the IRP of the individual.
(b) A PRS agency shall employ a PRS director and a psychiatric rehabilitation specialist.
(c) When a service is delivered in a PRS facility, a PRS facility shall have an overall complement of one staff for every ten individuals, a (1:10) ratio.
(d) When a service is delivered, a PRS agency shall schedule a psychiatric rehabilitation specialist or psychiatric rehabilitation worker to be present.
(e) A PRS agency shall develop a schedule that includes a plan to maintain staffing requirements during:
(1) Staff absence.
(2) Deployment of staff for PRS delivered in the community.
(f) A PRS agency shall document staffing by maintaining work schedules, time records and utilization data.
(g) When a PRS agency operates more than one PRS facility, the PRS director shall be present at each licensed PRS facility an average of 7.5 hours per week in a calendar month.
(h) A minimum of 25% of the FTE staff complement shall meet the qualifications of a psychiatric rehabilitation specialist provided under § 5230.51(b) (relating to staff qualifications) within 1 year of initial licensing.
(i) A minimum of 25% of the FTE staff complement shall have CPRP certification within 2 years of initial licensing.
(j) Trained staff shall be available, or other accommodations made, to address the language needs of an individual, including American Sign Language and Braille.
§ 5230.53. Individual services.
§ 5230.54. Group services.
(a) A PRS agency shall provide group services in a PRS facility or in the community.
(1) When a group service is provided in a PRS facility, group size may vary as long as the requirement under § 5230.52(c) (relating to general staffing requirements) is met.
(2) When a group service is delivered in the community, one staff shall serve a group of no more than five individuals. Group size in the community may not exceed five individuals.
(b) Group services delivered in the community shall be limited to individuals who have IRP goals that specify the need for services in the community.
(c) A PRS agency shall consider personal preferences of an individual and shall inform an individual of the following:
(1) The location where the group is to meet.
(2) The purpose of providing service in a community setting.
(3) The roles of individuals and PRS staff.
(d) A PRS agency shall obtain individual consent to participate in group services in the community.
(e) A PRS agency may not require an individual to participate in group services in the community. Individual preference for one to one (1:1) ratio service in the community shall be honored.
(f) A PRS agency shall design group services delivered in the community to protect confidentiality in a public location.
(g) A PRS agency shall arrange for group discussion of the experience before and after service is conducted in the community. The group discussion shall occur in a setting which assures confidentiality.
§ 5230.55. Supervision.
(a) A PRS director shall supervise staff.
(b) A psychiatric rehabilitation specialist may perform supervisory functions as delegated by the PRS director, consistent with approved job descriptions for the two positions.
(c) A PRS director or psychiatric rehabilitation specialist designated as a supervisor shall meet with staff individually, face-to-face, no less than two times per calendar month.
(d) A PRS director or psychiatric rehabilitation specialist designated as a supervisor shall provide group supervision utilizing the following methods:
(1) Monitoring active PRS delivery.
(2) Discussing approaches to assist individuals in goal attainment.
(3) Conducting staff meetings.
§ 5230.56. Staff training requirements.
A PRS agency shall implement a staff training plan that ensures initial and ongoing training in PRS practices as specified under § 5230.4 (relating to psychiatric rehabilitation processes and practices).
(1) Staff providing services in a PRS agency shall complete a Department-approved 12-hour psychiatric rehabilitation orientation course no later than 1 year after hire. This course shall be credited to the annual training requirement listed under paragraph (2) for the calendar year in which it is completed.
(2) Staff providing services in a PRS agency shall complete 18 hours of training per calendar year with 12 hours specifically focused on psychiatric rehabilitation or recovery practices, or both.
(3) A PRS agency shall assure competency of new staff by providing an additional PRS service-specific orientation that includes the following:
(i) Six hours of training in the specific PRS model or approach outlined in the agency service description prior to new staff working independently. This training is required within the first year of employment.
(ii) Six hours of face-to-face mentoring for new staff prior to new staff delivering services independently. Mentoring shall be provided by a PRS director or psychiatric rehabilitation specialist designated as a supervisor and is required within the first year of employment.
(4) A PRS agency shall assure that training has learning objectives.
§ 5230.57. Criminal history background check.
(a) A PRS agency shall complete a criminal history background check for staff that will have direct contact with an individual.
(b) A PRS agency shall develop and consistently implement written policies and procedures regarding personnel decisions based on the criminal history background check.
SERVICE PLANNING AND DELIVERY
§ 5230.61. Assessment.
(a) A PRS agency shall complete an assessment of an individual prior to developing the IRP.
(b) The assessment shall be completed in collaboration with the individual and must:
(1) Identify the functioning of the individual in the living, learning, working and socializing domains.
(2) Identify the strengths and needs of the individual.
(3) Identify existing and needed natural and formal supports, including other health care facilities and social service agencies.
(4) Identify the specific skills, supports and resources the individual needs and prefers to accomplish stated goals.
(5) Identify cultural needs and preferences of the individual.
(6) Be signed by the individual and staff.
(7) Be updated annually and when one of the following occurs:
(i) The individual requests an update.
(ii) The individual completes a goal.
(iii) The individual is not progressing on stated goals.
§ 5230.62. Individual rehabilitation plan.
(a) A PRS staff and an individual shall jointly develop an IRP that is consistent with the assessment and includes the following:
(1) A goal designed to achieve an outcome.
(2) The method of service provision, including skill development and resource acquisition.
(3) The responsibilities of the individual and the staff.
(4) Action steps and time frame.
(5) The expected frequency and duration of participation in the PRS.
(6) The intended service location.
(7) Dated signatures of the individual, the staff working with the individual and the PRS director.
(b) A PRS agency shall complete an IRP by day 20 of attendance, but no more than 60 calendar days after initial contact.
(c) A PRS agency and an individual shall update the IRP at least every 90 calendar days and when:
(1) A goal is completed.
(2) No significant progress is made.
(3) An individual requests a change.
(d) An IRP update must include a comprehensive summary of the individuals progress that includes the following:
(1) A description of the service in the context of the goal identified in the IRP.
(2) Documentation of individual participation and response to service.
(3) A summary of progress or lack of progress toward the goal in the IRP.
(4) A summary of changes made to the IRP.
(5) The dated signature of the individual.
(6) Documentation of the reason if the individual does not sign.
(7) The dated signature of the PRS staff working with the individual and the dated signature of the PRS director.
§ 5230.63. Daily entry.
A PRS agency shall include an entry for the day service was provided in the record of an individual as follows:
(1) Indicates the date, time, duration, location and type of interaction.
(2) Documents service provided in the context of the goal.
(3) Documents the individual response to service.
(4) Includes the signature of the individual, or if the individual does not sign, documents the reason.
(5) Is signed and dated by staff providing the service.
§ 5230.71. Discharge.
(a) A PRS agency shall discuss discharge with an individual.
(b) A decision to discharge should be a joint decision between the individual and the PRS agency.
(c) When a decision to discharge is not a joint decision, the PRS agency shall document the reason for discharge.
(d) When a decision to discharge is reached, a PRS agency shall offer the individual the opportunity to participate in future service.
(e) When an individual voluntarily terminates from the PRS, a PRS agency shall plan and document next steps with the individual, including recommended service and referral.
(f) When it is necessary to discharge an individual from PRS due to the individuals disengagement, prior to discharge the PRS agency shall document:
(1) Attempts to reengage the individual.
(2) The circumstances and rationale for discharge.
§ 5230.72. Discharge summary.
(a) Upon discharge, a PRS agency shall complete a dated and signed discharge summary that must include a description of the following:
(1) Service provided.
(2) Outcomes and progress on goals.
(3) Reason for discharge.
(4) Referral or recommendation for future service.
(b) A PRS agency shall ensure that the discharge summary is:
(1) Completed no more than 30 days after the date of discharge.
(2) Reviewed and signed by the PRS director.
(3) Offered to the individual for review, signature and the opportunity to comment.
§ 5230.81. Quality improvement requirements.
(a) A PRS agency shall establish and implement a written QI plan that meets the following requirements:
(1) Provides for an annual review of the quality, timeliness and appropriateness of services, including the following:
(i) Outcomes for PRS.
(ii) Individual record reviews.
(iii) Individual satisfaction.
(iv) Use of exceptions to admission and continued stay requirements.
(v) Evaluation of compliance with the agency service description.
(2) Identifies reviewers, frequency and types of reviews and methodology for establishing sample size.
(b) A PRS agency shall document that individuals served participate in QI plan development and follow up.
(c) A PRS agency shall prepare a report that:
(1) Documents analysis of the findings of the annual review required under subsection (a).
(2) Identifies actions to address annual review findings.
(d) A PRS agency shall make the report available to the public.
WAIVER OF STANDARDS
§ 5230.91. Request for waiver.
(a) A PRS agency may submit a written request to the Department for a waiver of a specific requirement in this chapter.
(b) The Department reserves the right to grant or deny waiver of a specific requirement in this chapter.
(c) A waiver request will be considered only in exceptional circumstances.
(d) A waiver will be granted only when the health and safety of an individual and the quality of service are not adversely affected.
(e) The Department reserves the right to revoke a waiver if the conditions required by the waiver are not met.
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