N.J. Admin. Code § 10:37J-2.6

Current through Register Vol. 56, No. 8, April 15, 2024

Section 10:37J-2.6 - Assessment; recovery planning; progress notes

(a) Each clinical record shall document the initial and comprehensive assessment.

1. The initial assessment shall be conducted at the time of the consumer's admission (also the date of the first face-to-face contact documented on the USTF) to the PACT program. The initial assessment shall include:

i. The referral source;

ii. The reason for referral to PACT; and

iii. The rationale for admission to PACT.

2. A comprehensive assessment shall be completed prior to the development of the comprehensive recovery plan. The results of the comprehensive assessment shall be documented and include:

i. The clinical necessity for entry into or continued provision of PACT services;

ii. An identification of the strengths, abilities, needs and preferences of the consumer;

iii. Evidence of the consumer's involvement in the assessment process through direct and current input of the consumer's expectations and desired outcomes. Where the consumer has been referred by an inpatient facility, for example, a State or county psychiatric hospital or a short-term care facility, the PACT team shall attempt to solicit this input prior to the consumer being discharged into the community. Where possible, the comprehensive assessment shall include direct quotes of desired outcomes from the consumer and (where appropriate) family members or significant others;

iv. The outcomes anticipated by the assessors;

v. Evidence that the comprehensive assessment was completed after consultation with the consumer, family members and significant others, as appropriate and upon consent of the consumer;

vi. Current psychiatric symptoms and mental status;

vii. Psychiatric history, including pattern of hospitalization and compliance with and response to prescribed medical/psychiatric treatment;

viii. Medical history, including information regarding a complete and current physical examination (if the consumer consents), which may be provided directly by the PACT team, for example, the psychiatrist, or through referral to a medical professional in the community.

(1) Where a complete medical history cannot be ascertained at the time of the consumer's admission to the PACT program, only such medical history as is known is sufficient.

(2) During the first 30 days of a consumer's enrollment in the PACT program, a complete RN assessment shall be completed and, upon the consumer's consent, referral made to a medical doctor for a physical examination, which shall be performed by the time of the first treatment plan revision (within three months);

ix. Medical, dental, and other health needs, for example, nutritional;

x. Extent and effect of substance use;

xi. Housing situation and conditions of daily living;

xii. Vocational and educational functioning including job-related interests and abilities, as well as on-the-job assessments; and assessment of the effect of the consumer's mental illness on employment. Specific behaviors that interfere with the consumer's work performance shall be identified and interventions to reduce or eliminate these behaviors shall be developed;

xiii. Extent and effect of criminal justice involvement;

xiv. Current social functioning;

xv. Recent life events;

xvi. Self-care and independent living capacity;

xvii. Relationship with consumer's family; significant others; family needs and supports;

xviii. Other specified problems and needs; and

xix. Treatment recommendations.

3. The ongoing assessment process shall be conducted with active participation of the consumer, the consumer's family and significant others, when appropriate and in accordance with the legal requirements for consumer consent to such involvement. Such participation shall be clearly documented in the clinical record.

4. The comprehensive assessment shall include consideration of all available information including self-reports, input of family members and other significant parties and written summaries from other agencies including police, courts, and inpatient facilities, where applicable.

(b) Each clinical record shall contain an initial and comprehensive recovery plan and recovery plan revision.

1. An initial written recovery plan shall be developed on the date of the client's admission to the PACT program. The initial recovery plan shall include:

i. The interventions which address the consumer's immediate needs for food, clothing, shelter and medication;

ii. Reason for referral/rationale for admission; and

iii. Time framed, measurable objectives relating to the goals.

2. A comprehensive recovery plan shall be completed within 30 days of the consumer's admission to the program. The comprehensive recovery plan shall be based on the comprehensive assessment and shall include:

i. Goals and specific objectives that are written in behavioral, measurable terms and include target dates;

ii. Specific treatment, rehabilitation and support interventions (including staff responsible) that demonstrate consumer involvement and choice, and their frequency and duration;

iii. Key areas including symptom stability, symptom education and management, medication monitoring, substance abuse, medical and dental needs, housing, employment, and family and social relationships; and

iv. The signatures of all participants involved in the development of the plan including the psychiatrist, and the consumer, family members and significant others.

3. The comprehensive recovery plan shall document collaboration of the PACT team, representatives from other agencies and facilities, for example, RHCFs, BHs, and other medical service providers, the consumer, members of the consumer's social network, and when indicated, the consumer's family.

4. The comprehensive recovery plan shall be reviewed and revised via treatment planning meetings every three months during the consumer's first year of PACT enrollment, or sooner if there is a significant change in the consumer's condition or course of treatment. After the consumer's first year in the program, recovery plan revisions may be done every six months, so long as the consumer's mental status is stable and the level of functioning shows continuing improvement. If not, recovery plans shall be revised no less than every three months until stability and improvement of functioning are documented.

5. Recovery plan revisions shall be based on:

i. Assessment of current functioning;

ii. Consideration of the consumer's progress or lack of progress since the last plan development or review; and

iii. The consumer's goals for treatment and/or changes the consumer would like to make in the recovery plan.

6. To assure family participation in developing the comprehensive recovery plan and revisions, the PACT team shall seek the input of family members or close personal friends at the development and revision of the comprehensive recovery plan; however, the PA may not disclose protected health information to family members or close personal friends except, in accordance with the Health Information Portability and Accessibility Act, 45 CFR 160.103 and 30:4-24.3 and as follows:

i. Protected health information may be disclosed to the extent permitted by a valid written authorization;

ii. If the consumer is present at the service planning milestone, or otherwise available prior to, protected health information may be disclosed at that meeting if it is directly relevant to the family member's or close personal friend's involvement with the consumer's care and one of the following conditions is present:

(1) The consumer agrees to disclosure of the information at the time of service planning milestone;

(2) The consumer is provided with an opportunity to object to the disclosure at the service planning milestone and does not express an objection; or

(3) Based on the exercise of professional judgment, the PA reasonably infers from the circumstances at the service planning milestone that the consumer does not object to the disclosure. Absent countervailing circumstances, the consumer's agreement to participate in the service planning milestone with the family member or close personal friend present indicates that the consumer does not object to disclosure of protected health information that is directly relevant to the family member's or close personal friend's involvement with his or her care; or

iii. If the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the individual's incapacity or an emergency circumstance, the PA may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the individual and, if so, disclose only the protected health information that is directly relevant to the person's involvement with the individual's health care.

(c) Where protected health information is disclosed pursuant to (b)6ii or iii above, the PA shall document the basis for the disclosure. Disclosure in accordance with (b)6ii or iii above shall not authorize or otherwise provide a basis for future disclosures not in compliance with this section.

(d) Information resulting from the ongoing assessment process may be documented in any of the following: daily progress notes, annual discipline-specific assessments, recovery plans, annual psychiatric assessments, or any other component of the clinical file.

(e) Each clinical record shall contain progress notes.

1. Progress notes shall be completed for each individual face-to-face contact and shall be included in the clinical record within 72-hours. Documentation of face-to-face contacts that occur after the team's regular working hours may be recorded the next working day. On weekends and holidays, there should be a documented exchange of information between on-call staff.

2. Progress notes shall, at a minimum, address the following:

i. The date, time, and location where the service was provided, the duration of the contact, and the names of staff who rendered the services;

ii. The type of visit and the services provided;

iii. The consumer's condition at the time of contact including appearance, mood and affect, and mental illness symptoms;

iv. Interventions and their relationship to the treatment plan goals and objectives;

v. A description of the consumer's response to treatment interventions;

vi. In the absence of observed side effects, documentation is not required for the ongoing monitoring of administration of medications and the detection of adverse drug reactions; and

vii. Ongoing communication with other service providers, including health care providers, as appropriate.

N.J. Admin. Code § 10:37J-2.6

Amended by 48 N.J.R. 420(b), effective 3/7/2016