Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 488 (January 27, 2024).

Pennsylvania Code



5320.51.    Treatment plan.
5320.52.    Review and periodic reexamination.
5320.53.    Medication.
5320.53a.    Clarification of the term ‘‘written’’—statement of policy.
5320.54.    Seclusion and restraints.

§ 5320.51. Treatment plan.

 The interdisciplinary treatment team shall:

   (1)  Complete an initial assessment on admission by the interdisciplinary team of the resident’s mental, physical and social needs including a mobility assessment.

     (i)   Reflect the reason for the resident’s admission.

     (ii)   Indicate what less restrictive alternatives to an LTSR were considered and why they were not utilized.

   (2)  Develop an initial treatment plan, within 72 hours, based on the initial assessment by the interdisciplinary team.

   (3)  The plan, developed with the participation of the resident or a designee, shall identify the problem areas, initial goals and objectives for the resident to meet, modalities of treatment, and responsible staff indicated in helping the resident meet their goals.

   (4)  Develop a comprehensive treatment plan within 10 days of admission. The plan shall:

     (i)   Be formulated, to the extent feasible, with the participation of the resident. With the resident’s consent, designated persons could participate in the planning process.

     (ii)   Be based upon diagnostic evaluation of the resident’s medical, psychological, social, cultural, behavioral, familial, educational, vocational and developmental strengths and needs.

     (iii)   Set forth measurable, time limited treatment goals and objectives and prescribe an integrated program of therapies, activities, experiences and appropriate education designed to meet these goals and objectives.

     (iv)   Specify the person responsible for carrying out the modalities described in the plan.

     (v)   Result from the collaborative recommendation of the resident’s interdisciplinary treatment team.

     (vi)   Be easily understood by a lay person and a copy of the current treatment plan shall be available for review by the person in treatment.

     (vii)   Address major psychiatric, psychosocial, medical, behavioral and rehabilitative needs of the resident and the manner in which they are to be met, including those needs to be addressed by contractors who are not employed by the LTSR.

§ 5320.52. Review and periodic reexamination.

 The interdisciplinary treatment team shall review treatment plans at least every 30 days or more frequently as the resident’s condition changes. A report of the review and findings and the resident’s progress toward meeting program goals and objectives shall be documented by the interdisciplinary team in the resident’s record.

   (1)  The interdisciplinary treatment team shall maintain a record of each reexamination and review to include:

     (i)   A report of the reexamination.

     (ii)   A brief description of the treatment provided to the person during the period preceding the reexamination and the results of that treatment.

     (iii)   Continuation or revision of the individual treatment plan for the next period.

     (iv)   Criteria for discharge and recommendation for discharge if these criteria have been met.

   (2)  Changes to the treatment plan and the reasons for the changes shall be made by the interdisciplinary treatment team and recorded in the resident’s record as a progress note or on another form specifically designed for that purpose.

   (3)  The record shall include information required by §  5100.16 (relating to review and periodic reexamination).

   (4)  Reassessment of each resident’s mental, physical and social needs, including a mobility assessment as follows:

     (i)   Annually.

     (ii)   If the condition of the resident materially changes prior to the annual assessment.

     (iii)   At the request of the county administrator or the Department if there is cause to believe that an additional assessment is required.

§ 5320.53. Medication.

 (a)  The provider shall establish and implement written medication policies and procedures that conform to Pennsylvania law. Medication administration policies and procedures shall address:

   (1)  How the education of residents regarding their medication will be accomplished.

   (2)  How residents who need assistance with medication precribed by a physician for self-administration receive it.

     (i)   For residents who need assistance, the least assistance necessary should be provided within the context of a planned program toward self-administration of medication.

     (ii)   Assistance with self-medication including handling the medication containers or taking medication out of its container for the resident is considered medication administration and shall be done by licensed medical staff.

   (3)  How medications and treatments shall be administered by the licensed medical staff person who prepared the dose for administration.

   (4)  Documentation of the written orders provided by the attending physician for each resident receiving medication.

   (5)  Recording of physicians’ orders in each resident’s clinical record that is reviewed, renewed and signed by the physician every 30 days.

   (6)  Documentation of the reason a prescribed medication was not given and notice of same to the prescribing physician.

   (7)  The taking and recording of telephone orders by only licensed medical staff, pharmacists or other individuals authorized by law to accept a physician’s telephone orders for medication.

     (i)   Oral orders are recorded immediately on the resident’s record, dated and signed by the person receiving the order.

     (ii)   Oral orders are countersigned by the prescribing physician within 48 hours.

   (8)  Training by a physician or other licensed medical staff person that will cover, at minimum, medications used by the residents, their purposes and function, major side effects and recognition of signs that the medication is not being taken or is being misused.

 (b)  The circumstances under which the provider stores medication for residents shall include the following limitations:

   (1)  Only medications which are prescribed for self-administration or that will be administered by an individual appropriately licensed to administer medication is stored in the LTSR.

   (2)  Medications stored in the LTSR are kept in a locked container in a locked room.

   (3)  Each prescription medication ordered for a resident is kept in the original prescription container labeled by the dispensing pharmacist for the sole use of the resident.

   (4)  If over-the-counter drugs are maintained in the facility, they will bear the original label and the name of the resident for whom the drug is ordered.

 (c)  Pharmaceutical services shall include:

   (1)  A written quarterly review of the drug regimen of each resident by a licensed pharmacist and the findings submitted to the program director and prescribing physicians.

   (2)  A pharmacist or licensed medical staff annual review of the provider’s medication policies and procedures including inspection of the medication storage areas. A written report of the review including inservice training recommendations, if any, is submitted to the program director.

   (3)  A policy developed or approved by a pharmacist that specifies the disposition of discontinued, unused, outdated or deteriorated medication.

   (4)  A written procedure for accessing pharmaceutical services on an emergency basis.

Cross References

   This section cited in 55 Pa. Code §  5320.22 (relating to governing body); and 55 Pa. Code §  5320.53a (relating to clarification of the term ‘‘written’’—statement of policy).

§ 5320.53a. Clarification of the term ‘‘written’’—statement of policy.

 (a)  The term ‘‘written’’ in §  5320.53 (relating to medication) includes orders that are handwritten or recorded and transmitted by electronic means.

 (b)  Written orders transmitted by electronic means must be electronically encrypted or transmitted by other technological means designed to protect and prevent access, alteration, manipulation or use by an unauthorized person.

 (c)  The term ‘‘countersigned’’ in §  5320.53(a)(7)(ii) includes a handwritten or electronic signature that is made in accordance with the Electronic Transactions Act (73 P. S. § §  2260.101—2260.5101).


   The provisions of this §  5320.53a adopted August 2, 2013, effective August 3, 2013, 43 Pa.B. 4355.

§ 5320.54. Seclusion and restraints.

 (a)  The use of seclusion is prohibited in LTSRs.

 (b)  The use of restraints for behavior management is prohibited in LTSRs.

 (c)  The use of restraints to promote body alignment, positioning and physical functioning is allowable in an LTSR only when the following conditions are met:

   (1)  The requirements of §  13.4 (relating to use of restraints to control involuntary movement due to organic causes or conditions).

   (2)  State or local standards for hospital, nursing home and residential care occupancy governing these facilities when a resident’s mobility is compromised by the use of this type of restraint. See, for example, 28 Pa. Code Part IV (relating to health facilities); 34 Pa. Code Chapters 49—59, National Fire Protection Agency related to institutional occupancy (current applicable standards of Life Safety Code) and equivalent standards of cities with 1st class status; and Chapter 5300 (relating to private psychiatric hospitals).

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