N.Y. Comp. Codes R. & Regs. tit. 14 § 584.16

Current through Register Vol. 46, No. 45, November 2, 2024

Section 584.16 - Case record

(a) There shall be a complete case record maintained at one location for each resident admitted to the residential treatment facility. For those children or youth that have been determined to be classified with an educational disability and in need of special educational services and programs, there may also be an individualized education program, but such individualized education program shall be separate and distinct from the case record.

(b) The case record shall be confidential and access shall be governed by the requirements of section 33.13 of the Mental Hygiene Law and 45 C.F.R. Parts 160 and 164 as incorporated by reference in Part 800 of this Title.

(c) The case record shall be available to all clinical staff involved in the care and treatment of the resident, consistent with the provisions of 45 C.F.R. Parts 160 and 164.

(d) Each case record shall include:

(1) identifying information about the resident served and the resident's family;

(2) a note upon admission, indicating source of referral, date of admission, rationale for admission, the date service commenced, presenting problem and immediate treatment needs of the resident;

(3) the application for admission to a residential treatment facility and any other information obtained from the Office of Mental Health or commissioner's designee's evaluation of eligibility for access to residential treatment facility services, including an assessment from the committee on special education, when available;

(4) assessments of psychiatric, medical, educational, emotional, social and recreational needs. Where appropriate, assessments of vocational and nutritional needs shall be included. Special consideration shall be given to the role of the resident's family in each area of assessment;

(5) reports of all mental and physical diagnostic examinations and assessments, including findings and conclusions;

(6) reports of all special studies performed, including, but not limited to, X-rays, clinical laboratory tests, psychological tests, or electroencephalograms;

(7) initial and comprehensive treatment plans;

(8) Progress notes which relate to the goals and objectives of the initial or comprehensive treatment plans, which shall be signed by the staff member who provided the service or by one participating staff member when several staff members have had significant interaction with the resident.

(i) Progress notes shall be written at least weekly and additionally whenever a significant event occurs that affects, or potentially affects, the resident's condition or course of treatment.

(ii) Progress notes shall be written regarding the educational program as determined in the resident's individualized education program.

(iii) Progress notes shall be written regarding involvement of the family or legal guardian in treatment as determined in the resident's treatment plan;

(9) summaries of treatment plan reviews and special consultations regarding all aspects of the resident's complete daily program;

(10) dated and signed orders which indicate commencement and termination dates for all medications;

(11) a discharge summary, prepared within 15 days of discharge or transfer, which includes a summary of the clinical treatment, or reasons for discharge or transfer and, if appropriate, the provision for alternative treatment services which the resident may require; and

(12) information as may be required for the effective implementation of the utilization review plan provided for in section 584.18 of this Part.

(e) initial treatment plan shall include:

(1) admission diagnosis or diagnostic impression;

(2) a brief description of the resident's and the resident's family problems, strengths, conditions, disabilities or needs;

(3) objectives relating to the resident's problems, conditions, disabilities and needs, and the treatments, therapies and staff actions which will be implemented to accomplish these objectives; and

(4) initial discharge goals and criteria for determining the specific resident's discharge readiness, the anticipated discharge date and any other requirements established in standards and procedures established by the Office of Mental Health or commissioner's designee.

(f) The comprehensive treatment plan shall include:

(1) diagnosis;

(2) a brief description of the resident's and the resident's family problems, strengths, conditions, disabilities, functional deficits or needs;

(3) a brief description of the treatment and treatment planning which demonstrates that the program is addressing the functional deficits of the resident which substantiated the resident's eligibility for admission to the residential treatment facility;

(4) goals to address the resident's problems, conditions, disabilities and needs which indicate the expected duration of the resident's need for services in the residential treatment facility;

(5) objectives relating to the resident's goals. Objectives must be written to reflect the expected progress of the resident. Projections for accomplishing these objectives should be specific;

(6) the specific treatments, therapies and staff actions which will be implemented to accomplish each of the objectives and goals. These must be stated clearly to enable all staff members participating in the treatment program to implement the goals and objectives;

(7) discharge goals and the criteria for determining the specific resident's discharge readiness, the anticipated discharge date and any other requirements established in standards and procedures established by the Office of Mental Health or commissioner's designee;

(8) the name of the clinical staff member, designated as case coordinator, exercising primary responsibility for the resident;

(9) identification of the staff members who will provide the specified services, experiences and therapies;

(10) documentation of participation by the patient in the development of the treatment plan whenever possible and by representatives of the resident's school district, parent or legal guardian and referring agent, where appropriate;

(11) date for the next scheduled review of the treatment plan; and

(12) a copy of the individualized education program as defined in accordance with requirements of the Commissioner of Education.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 584.16

Amended New York State Register August 17, 2016/Volume XXXVIII, Issue 33, eff. 8/17/2016

Amended New York State Register July 3, 2024/Volume XLVI, Issue 27, eff. 7/3/2024