6 Colo. Code Regs. § 1011-1-2.6

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-2.6 - Client Assessment, Admission, Service Plan, and Discharge

2.6.1 The BHE shall develop and implement admission and discharge policies. Such policies may be for the BHE, a particular endorsement, and/or a specific physical location, as appropriate, and shall include, at a minimum:

(A) Criteria ensuring the BHE, endorsement, and/or location only treats clients for whom it can provide immediate treatment and an appropriate assessment based on the individual's needs.

(B) Admission criteria ensuring treatment in the least restrictive appropriate setting based on the client's level of care needs.

(C) Procedures for transferring a client from a service or endorsement to a different service or endorsement within the BHE.

(D) Procedures for referral to other service providers for individuals who cannot be admitted to the BHE.

(E) Criteria and procedures for a client's discharge from treatment, including, but not limited to:

(1) Procedures for when a client is being transferred from the BHE to another provider.

(2) Timely discharge of a client receiving services on a voluntary basis upon the client's request, once appropriate screening and assessment is complete.

(3) Discharge and transfer procedures for a client receiving services on an involuntary basis, if applicable.

(4) Information and documentation to be provided to the client upon discharge, unless clinically contraindicated, including, but not limited to:

(a) Medication information, including medication name, dosage, and instructions for follow-up.

(i) The BHE may provide clients with unused, prescribed medications as part of the discharge process, consistent with policies developed in accordance with Part 2.9.1(C).

(b) Detailed information on transitioning care to other providers, including referral information as appropriate.

(c) Documentation that the discharge is being made against the advice of the provider, as applicable.

(d) Documentation required when the above information is not provided to the client at discharge.

(F) Requirements for a discharge summary to facilitate continuity of client care, including, but not limited to:

(1) The timeframe for discharge summary completion, which shall be no more than thirty (30) calendar days after discharge.

(2) Information to be included in the discharge summary to inform future providers of treatment history, including, but not limited to:

(a) Information on the client's legal status, including any type of behavioral health certification or hold;

(b) A summary of medications prescribed during treatment, including the individual's responses to medications;

(c) Medications recommended and prescribed at discharge; and

(d) Documentation of referrals and recommendations for follow up care.

2.6.2 The BHE shall develop and implement assessment policies. Such policies may be for the BHE, an endorsement, a service, or a physical location, as appropriate, and shall include, at a minimum:

(A) A comprehensive assessment shall be completed for each client as soon as is reasonable upon admission, but no later than the endorsement- or service-specific time requirements found elsewhere in this Chapter, as applicable.

(B) The assessment shall be reviewed and updated when there is a change in the client's level of care or functioning.

(C) Methods and procedures used for client assessment shall be developmentally and age appropriate, culturally responsive, and conducted in the client's preferred language and/or mode of communication.

2.6.3 The BHE shall ensure the development and review of a written service plan for each client as follows:

(A) The service plan shall be developed as soon as reasonable after admission, but no later than the endorsement-specific timeframes included in this Chapter.

(B) The service plan shall be reviewed and revised in writing when there is a change in the client's level of functioning or service needs, and no later than the endorsement-specific timeframes. Such revision shall include documentation of progress made in relation to planned treatment outcomes, changes in treatment focus, and length of stay adjustments, as applicable.

(C) The service plan shall:

(1) Be developmentally, culturally, and age appropriate.

(2) Identify the type, frequency, and duration of services.

(3) May include tasks or labor to be performed by the client, such as a client doing their own laundry or preparing their own meals/snacks, only when such tasks or labor is therapeutic. Tasks or labor shall not be included in the service plan solely for the convenience of the BHE.

(D) The service plan shall be signed by all parties involved in the development of the plan, including the client, or the client's parent or legal guardian in cases where the client is a minor or under the control of a legal guardian.

(1) A copy of the service plan shall be offered to the client, or to the client's parent or legal guardian, as appropriate. If the client is a minor the client's parent or legal guardian shall be offered a copy of the plan.

(2) The BHE shall include documentation in the client record in cases where the plan is not signed by the client or other party involved in the development of the plan, and in cases where offering the service plan for a child or adolescent to the parent or legal guardian is contraindicated.

6 CCR 1011-1-2.6