N.J. Admin. Code § 10:37G-2.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:37G-2.2 - Assessment and service planning

(a) The STCF's written procedures shall require that STCF staff shall inquire as to the existence of a Wellness and Recovery Action Plan for each patient and shall provide services consistent with that plan.

(b) The STCF's written procedures shall require that STCF staff shall complete written diagnostic evaluations of each patient. These evaluations shall provide clear descriptions of each patient's psychiatric, psychosocial, medical and social service needs, trauma history, and other life domains that shall be addressed during their stay in the STCF.

(c) The STCF's written procedures shall require that, within 24 hours of admission, the following evaluations, at a minimum, shall be completed:

1. A psychiatric assessment and mental status examination, which includes the patient's psychiatric and trauma history and family's psychiatric history and concludes with a diagnosis, and treatment recommendations;

2. A physical examination, including a medical, alcohol and substance abuse history and resulting in a summary with conclusions; and

3. A nursing assessment by a registered nurse, concluding with individualized clinical treatment recommendations and reflecting nursing staff interventions.

(d) The STCF's written procedures shall require the completion, within 24 hours of admission, of an initial treatment plan. This plan shall be completed by a board certified or board eligible psychiatrist or a licensed psychiatric resident under the supervision of a board certified or board eligible psychiatrist to minimally address the patient's presenting problem(s) and any emergent medical or physical needs.

(e) The STCF's written procedures shall require that prior to the development of the comprehensive treatment plan, the following evaluations shall be completed:

1. A social assessment, including information regarding family, educational, and employment history, current mental health and social services used by the patient, financial status, and current living arrangements, and concluding with clinical treatment recommendations and discharge planning; and

2. A rehabilitation/creative arts assessment that evaluates functional performance and interests related, but not limited to, psychosocial, lifestyle, and environmental factors, and concluding with treatment recommendations.

3. A psychological evaluation, as appropriate;

4. A comprehensive assessment of any known co-occurring disorder, including history and pattern of use or incidence, completed by a person qualified by education and experience to conduct an assessment of mental disorders with co-occurring features; and

5. A nutritional assessment, if clinically indicated.

(f) A written comprehensive treatment plan for each patient shall be completed within 72 hours of admission. This written comprehensive treatment plan shall be updated every five days or more frequently as the patient's needs change, and shall:

1. Identify and build upon patient strengths and areas of health, identify needs, and enhance existing skills and supports and shall consider the development of a patient-driven personal safety plan;

2. Be patient-driven and reflect the input of the patient, the patient's family, the psychiatrist, the registered nurse, the social worker, the rehabilitation/creative arts therapist, any other significant hospital staff involved in treatment, and, as appropriate, the findings and recommendations of the ICMS or PACT worker or current treatment provider. Where applicable, STCF staff shall document an invitation to a family member, other relative, a close personal friend of the patient or any other person identified by the patient, as permitted with patient's consent, to participate in treatment planning activities;

3. Include stabilization goals to be achieved by the patient which are discharge-oriented and which address mental, medical, and social goals, as appropriate; and

4. Be based upon the assessment of the life domains necessary for the patient's recovery and return to the community and shall include specific measurable objectives that relate to those goals, indicate frequency of interventions, identify responsible staff and include anticipated time frames for achievement.

(g) Clinical privileges shall be provided to ICMS and PACT staff so that they shall have access to the clinical records of the patients they serve and so that they may participate in both the assessment process and the discharge planning process.

(h) STCF staff shall document in the patient's record in chronological order the following information:

1. Treatment provided and the patient's response;

2. Implementation of the treatment plan and changes made in the treatment plan;

3. Significant incidents or events occurring during the patient's treatment;

4. Attendance at and level of participation in unit activities and therapies; and

5. Discharge planning.

(i) The psychiatrist or licensed independent practitioner shall document all patient contacts and describe the patient's clinical status.

1. Every patient shall receive a face-to-face visit by a psychiatrist or licensed independent practitioner every day unless there is a clinical basis to justify the patient not receiving such a visit, which is documented in the medical record by the psychiatrist or licensed independent practitioner. In all cases, a patient shall receive a visit by a psychiatrist or licensed independent practitioner at least once every two days.

(j) The social worker shall document in the patient's record discharge-oriented progress notes twice per week indicating progress toward treatment goals as identified in the assessment and treatment plans.

(k) The rehabilitation/creative arts therapist shall document in the patient's record individual discharge-oriented progress notes twice per week indicating progress toward treatment goals as identified in the assessment and treatment plans.

(l) Nursing staff shall document in the patient's record individual discharge-oriented progress notes twice per week indicating progress toward treatment goals as identified in the assessment and treatment plans.

N.J. Admin. Code § 10:37G-2.2

Amended by47 N.J.R. 1323(a), Effective 6/15/2015