C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-28, subsec. 144-101-II-28.05

Current through 2024-44, October 30, 2024

Subsection 144-101-II-28.05 - MEMBER RECORDS, COMPREHENSIVE ASSESSMENT, INDIVIDUAL TREATMENT PLANS, AND PROGRESS NOTES

28.05-1Written Record

The provider must keep a specific written record for each member, which must include:

A. Member's name, address, birth date, and MaineCare ID number;

B. A written copy of the member's comprehensive assessment;

C. Individual Treatment plan (ITP), including the strengths and needs identified in the planning process;

D. Written, signed, credentialed with licensure or certification, if applicable, and dated progress notes, kept in the member's records;

E. DHHS, or its authorized agent, must approve changes regarding intensity and duration of treatment services provided. The Provider must document the approval of the changes in the ITP and in the member's record.

28.05-2Comprehensive Assessment

A. A supervisor must complete a comprehensive assessment within thirty (30) days of initiation of services and must be included in the members record. The comprehensive assessment process must include a direct encounter with the member, if appropriate, and parents or guardians.

The comprehensive assessment must be updated as needed, annually at a minimum.

B. The comprehensive assessment must contain documentation of the following:

1. the member's identifying information, including the reason for referral,

2. family history relevant to family functioning including, but not limited to, concerns regarding mental health, developmental disabilities, substance abuse, domestic violence and trauma,

3. the member's developmental history, if known, educational history and current status, and transition planning if age appropriate, and

4. identification of the member's strengths and needs regarding functioning in the areas of behavior, social skills, activities of daily living , communication, cultural issues and need for accommodation and for members fourteen (14) years of age or older, independent living skills.

C. The assessment must be summarized, signed, credentialed with licensure or certification, if applicable, and dated by the staff conducting the assessment, the parent or guardian and the member, if appropriate, and include the source and date of the diagnosis.

D. The assessment must contain documentation if information is missing and the reason the information cannot be obtained.

28.05-3Individual Treatment Plan (ITP)

A. Within thirty (30) days of initiation of services, the treatment team must develop an ITP. The ITP is based on the comprehensive assessment and is appropriate to the developmental level of the member.

B. The ITP must contain the following:

1. The member's diagnosis and reason for receiving the service.

2. Specific medically necessary treatment services to be provided with methods, frequency and duration of services and designation of who will provide the service.

3. Objectives with target dates that allow for measurement of progress toward meeting identified developmentally appropriate goals.

4. Special accommodations needed to address barriers to provide the service.

5. The parent or guardian and the member, if applicable, must sign and date the ITP.

6. Be reviewed every ninety (90) days by the treatment team.

7.If indicated, the member's needs may be reassessed and the ITP revised.

8. The provider will provide the member with a copy of the initial and reviewed ITP within ten (10) days of signing.

9. Discharge plan must:

a. identify discharge criteria that are related to the goals and objectives described in the ITP; and

b. identify the individuals responsible for implementing the plan; and

c. identify natural and other supports necessary for the member and family to maintain the safety and well-being of the member, as well as sustain progress made during the course of treatment; and d. Be reviewed by the treatment team every ninety (90) days.

10. Crisis/Safety Plan, as applicable

The plan must:

a. Identify the potential triggers which may result in a crisis;

b. Identify the strategies and techniques that may be utilized to assist the member who is experiencing a crisis and stabilize the situation;

c. Identify the individuals responsible for the implementation of the plan including any individuals identified by the member (or parents or guardian, as appropriate) as significant to the member's stability and well-being.

28.05-4Progress Notes

1. Providers must maintain written progress notes for all treatment services, in chronological order.

2. All entries must include the treatment service provided, the provider's signature, the date on which the service was provided, the duration of the service, and the progress the member is making toward attaining the goals or outcomes identified in the ITP.

3. For in-home services, the provider must ask the member, or an adult responsible for the member, to sign off on the progress note documenting the date, time of arrival, and time of departure of the provider.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-28, subsec. 144-101-II-28.05