N.J. Admin. Code § 10:37I-5.8

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

Section 10:37I-5.8 - Assessment, service preferences, and record documentation

(a) The PA shall maintain individualized and complete records for all families for whom an assessment is completed and service preferences are documented and cosigned by the family.

(b) The assessment process shall continue throughout the entire length of service and the documents related to the assessment process shall be revised whenever there is a significant change.

(c) The records shall be maintained in an up-to-date, organized manner in a secure location at the PA.

(d) The records shall contain all relevant information and shall be maintained to preserve confidentiality. At a minimum, the records shall contain the following:

1. The original IFSS family intake information, which identifies, at a minimum:

i. The names of involved family members;

ii. Referral date and source;

iii. Presenting needs; and

iv. Whether or not the family is dealing with an emergent crisis.

2. IFSS assessments, which shall document in the record the following information as it occurs:

i. A family concerns survey approved by the Division, after submission of documentation. The records shall include all family concern surveys administered by IFSS staff at admission into the program at six months, one year from the six-month date and annually thereafter. Level of concern information shall also be collected regarding families with closed case files. If the level of concern survey is not completed despite reasonable and diligent staff attempts to do so, the record shall note these attempts;

ii. Family strengths and vulnerabilities: for example, their understanding of their loved one's illness and treatment options, aging and health issues, social support network;

iii. Expressed needs;

iv. Functioning, diagnosis and medications of family members with a serious mental illness, if known; and

v. Service preferences, including location of services;

3. IFSS service preferences, as follows:

i. The record shall contain documentation of a family's service preferences which shall be cosigned by the family support specialist and the family members participating in the Intensive Family Support Program;

ii. The record shall contain documentation that the range of family support services available in the county has been explained to the family;

iii. The PA shall request family members to indicate in writing on the service preference form that they have received information regarding self-help and other support resources in the community.

iv. Documentation of service preferences shall be completed as part of the assessment process;

v. Service preferences shall be related to documented family need and request for services; and

vi. Service preferences shall be reviewed with the family and revised whenever there is a significant change in the family's situation but minimally in conjunction with the administration of the family concerns survey, as delineated at (d)2i above;

4. Progress notes, as follows:

i. A summary of services shall be documented for each face-to-face contact;

ii. The initial face-to-face contact with the family shall be documented specifying the outcome of the contact and other significant information available at the time;

iii. Progress notes shall make reference to the family's preferences and reflect the family's status, interventions provided, family response to interventions and change in service provision;

iv. Progress notes shall reflect collateral contacts and communication with persons other than the family on behalf of the family which impact on the family's status or service provision;

v. Progress notes shall reflect attempts to complete the family level of concern survey and the family preference form in compliance with the timeframes specified in (d)2i above if the documents referenced in this section are not completed, despite reasonable and diligent staff attempts;

vi. Progress notes shall reflect status of the family's natural support system;

vii. Progress notes shall specify location of face-to-face contact; and

viii. Notes shall be properly authenticated with a signature, date and title for each entry;

5. Activity logs which identify the type, date and frequency of all support services a family is receiving including those provided by IFSS PAs and other agencies, and self-help organizations, when known;

6. Documentation that summarizes the family's well-being when placed on inactive status and at the six-month follow-up contact required by N.J.A.C. 10:37I-5.4(d);

7. Relevant release of information forms;

8. Documentation that the family has received a referral to their local NAMI-NJ affiliate and other self-help organizations; and

9. PA's summary report regarding family's termination from IFSS program.

i. The summary shall include:

(1) The reasons for termination;

(2) Family's status at termination in relation to most recent family concerns survey;

(3) Family response to services including, when possible, a family's self-assessment of progress and further needs, and a final family concerns survey; and

(4) Recommendations, plans or linkages for further service, if needed.

N.J. Admin. Code § 10:37I-5.8

Amended by 48 N.J.R. 2439(b), effective 11/21/2016