Cal. Code Regs. tit. 9 § 786.15

Current through Register 2024 Notice Reg. No. 25, June 21, 2024

Section 786.15 - Rehabilitation Program-Individual Service Plan and Documentation Requirements

(a) The written individual service plan shall be prepared within 30 days following admission by the program director or a staff member that is a licensed mental health professional, and shall include, but not be limited to, the following:

(1) Specific goals and measurable objectives, the staff and client's responsibilities for their achievement.

(A) Statement of specific treatment/rehabilitation needs and goals.

(B) The individual service plan shall indicate the services to be provided, the objectives to be accomplished, and the staff responsible for the provision of each service.

(C) The objectives shall be measurable, with time frames, and shall be reviewed and updated at least monthly.

(b) There shall be weekly progress notes in the record for each client which shall include notes written by members of the program staff or interdisciplinary professional staff providing rehabilitation services to the client. The notes shall be a general review of weekly progress.

(c) Documentation of reviews by staff and clients of the individual service plan on at least a monthly basis.

(1) Clients shall be involved in an on-going review of progress towards goal attainment and in the planning and evaluation of their treatment/rehabilitation goals.

(2) Anticipated length of stay for the client in the mental health rehabilitation center needed to accomplish identified goals, and methods to evaluate the achievement of these goals.

(d) There shall be a review and updating of the individual service plan as necessary but at least quarterly, and more often if there is a change in the client's condition.

(1) The quarterly review shall include a reevaluation which shall be a summary of the progress of the client in the rehabilitation program, the appropriateness of identified needs, client goals and objectives and the success of the plan.

(2) The client should be present at the quarterly review and if agreed to by the client, family members may be notified and attend the quarterly review.

(e) The service plan shall be approved by the program director or a licensed mental health professional, and signed by the client.

(f) Prior to discharge, there shall be a written discharge summary prepared by the staff which shall include an outline of services provided, goals accomplished, reason and plan for discharge, and referral follow-up plans.

(g) At least every four (4) months, the mental health rehabilitation center in conjunction with the local mental health director or designee, shall reassess each client to determine the need for continued placement of the client in the mental health rehabilitation center.

Cal. Code Regs. Tit. 9, § 786.15

1. New section filed 8-21-95 as an emergency; operative 8-21-95 (Register 95, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-17-95 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-9-96 as an emergency; operative 2-9-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-8-96 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-10-96 as an emergency; operative 6-10-96 (Register 96, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-8-96 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 10-8-96 as an emergency; operative 10-8-96 (Register 96, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-5-97 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-8-96 order transmitted to OAL 2-5-97; disapproved by OAL and order of repeal as to 10-8-96 order filed on 3-21-97 (Register 97, No. 12).
6. New section filed 3-21-97 as an emergency; operative 3-21-97 (Register 97, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-21-97 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-21-97 order, including renumbering of former section 786.15 to new section 786.14, and renumbering and amendment of former section 786.16 to new section 786.15, transmitted to OAL 7-21-97 and filed 8-21-97 (Register 97, No. 34).

Note: Authority cited: Sections 5675 and 5768, Welfare and Institutions Code; Section 3 of Chapter 678 of the Statutes of 1994. Reference: Sections 5675 and 5768, Welfare and Institutions Code.