Cal. Code Regs. Tit. 9, § 1927 - Mental Health Program Components and Documentation Requirements

(a) The certificate holder of a CTF shall ensure that the required child facility records are kept on each child residing within the facility. Required child facility records include:

(1) A signed and dated copy of the interagency placement committee's placement authorization letter from the child's county of residence;

(2) Documentation of the child's, and his parents' or conservator's voluntary consent to treatment, when applicable;

(3) The intake report;

(4) The admission assessment;

(5) A psychiatric evaluation;

(6) A needs and services plan;

(7) Daily progress notes;

(8) Monthly clinical review reports;

(9) Written informed consent by the child for prescribed psychotropic medication, and, when applicable, by the parents, conservator or judge pursuant to Section 851 of Chapter 4;

(10) A copy of the court order for conservatorship if the child is conserved;

(11) A copy of the administrative hearing ruling if the child contested placement and a pre-admission administrative hearing was held or a copy of the form waiving this right signed by the child;

(12) A discharge summary;

(13) A discharge report.

(14) A Welfare and Institutions Code, Section 6552 order if the child is a ward or dependent of the court.

(b) The intake report shall be a typed document completed prior to admission which shall be signed by a member of the facility's licensed mental health professional staff and placed into the child's facility record upon intake that includes:

(1) Demographic information as defined in Section 84168.2(c)(1) of Title 22, California Code of Regulations;

(2) Presenting problems;

(3) Current DSM diagnosis;

(4) An assessment of danger to self and others;

(5) Medications;

(6) Immediate educational, service and treatment needs;

(c) The admission assessment shall be a typed document which shall be completed and signed by a member of the facility's licensed mental health professional staff within five (5) calendar days of admission. A typed copy of the admission assessment shall be provided to the child's parents, conservator, or the person designated by the court to manage the placement within ten (10) working days of assessment completion and it shall be included in the child's facility record. The admission assessment shall contain a prognosis and estimated length of stay based upon and including:

(1) The reasons for referral;

(2) A statement of presenting problems;

(3) Precipitating events;

(4) Factors relating to presenting problems;

(5) Psychiatric history including onset of symptoms and progressions;

(6) Medical history;

(7) Psychological history including a review and summary of existing psychological evaluation material;

(8) Academic and school history;

(9) Social history;

(10) Family history;

(11) Work history if applicable;

(12) Developmental status;

(13) DSM Diagnosis;

(14) A summary of the child's strengths and weaknesses as related to his family, school and social relationships.

(d) A psychiatric evaluation shall be completed by a psychiatrist within five (5) calendar days of admission but may be performed up to sixty (60) calendar days prior to admission unless CTF mental health professionals admitting the child feel it is no longer accurate. It shall be part of the admission assessment and shall include:

(1) A mental status examination;

(2) Indications and contraindications for medications; and

(3) Therapeutic response to medications, including an assessment of side effects, if available, and the child's compliance with medications when appropriate.

(e) Each child residing within a CTF shall have an NSP completed by a licensed mental health professional within fifteen (15) calendar days of admission which shall include:

(1) Identified specific behavioral goals and specific actions to be undertaken by facility staff to assist the child in accomplishing these goals within a defined period of time through appropriate behavioral interventions and treatment modalities which shall include but not be limited to a determination of the expected duration of each use of secure containment;

(2) Discharge goals that are general indicators of the child's readiness for transition to alternative treatment settings;

(3) Participation of the child, and, when appropriate, parent, conservator or person identified by the court to manage the child's placement in the development or modification of the NSP;

(4) A review at least every thirty (30) calendar days;

(5) Appropriate clinical oversight for a child involved with the maintenance of his residential unit. This participation shall be for the purpose of skill development in cooperative living to the extent the activities are age appropriate, and within the functioning level and physical capacity of the child. Clinically indicated restrictions to protect the safety and welfare of the child and the other children and facility staff shall be documented in the child's NSP.

(A) A child shall not be used as a substitute for employed staff and shall be supervised by treatment team staff while participating in any of the above cited activities contained within his NSP.

(f) When scheduled reviews of a child's participation within the facility's program activities indicate that the child requires transition to or from a secure portion of the facility for continued treatment at the facility, the mental health program director, or a designee, shall provide the child, and, when appropriate, parent, conservator, or the person identified by the court to manage the placement, with prior notification. This notification shall include an estimated treatment duration within the new portion of the facility. The method of notification, time, date, person doing the notification and the person notified shall be entered in the child's facility record.

(1) When a child is transferred from a non-secure portion to a secure portion of the facility based upon immediate need, the notification of the parent, conservator, or person identified by the court to manage the placement shall occur as soon as possible, but not more than twenty-four (24) hours after the transfer and shall include an estimated treatment duration within the secure portion of the facility.

(g) Progress notes shall be written daily to document a child's participation and responses to the prescribed mental health treatment services and additionally whenever a significant event occurs which affects or potentially affects the child's condition or course of treatment. The progress notes shall be maintained in the child's facility record. A licensed mental health professional shall review these progress notes on a regular basis, but not less than every thirty (30) calendar days, documented by a date and the initials of the reviewer.

(h) The monthly clinical review report is a typed document substantiating a child's status and progress in treatment, signed and dated by a licensed mental health professional, to be completed every thirty (30) days based on the date of the admission assessment. It shall include:

(1) The justification for decisions concerning admission or a continued stay for a child;

(2) The types and intensity of services provided to the child and family including the use of restraint and secure containment;

(3) The impact of these same services upon treatment goals, changes in or continuation of the treatment plan objectives;

(4) The facility's discharge planning activities and a summary of the progress of a child toward his discharge goals.

(i) A typed discharge summary for a child shall be completed and signed by a member of the facility's licensed mental health professional staff and provided to the child's parent, conservator, or the person identified by the court to manage the placement on the date of discharge which shall include:

(1) Demographic information as defined in Section 84168.2(c)(1) of Title 22, California Code of Regulations;

(2) Date of admission;

(3) DSM diagnosis;

(4) Current emotional and/or behavioral problems;

(5) Continuing therapeutic and educational needs;

(6) Medications;

(7) Reason for discharge.

(j) A typed discharge report shall be completed and signed by a member of the facility's licensed mental health professional staff within fourteen (14) calendar days of the date of discharge for each child, and a copy provided to the parent, conservator or the person identified by the court to manage the placement. It shall include:

(1) The reason for admission;

(2) The reason for discharge, referencing the child's discharge planning goals, or the reason for removal;

(3) The course of treatment, including medications and the child's response;

(4) The child's discharge diagnosis according to the current edition of the DSM;

(5) Medical and dental services received while in the CTF;

(6) The child's prognosis and recommendations for further mental health treatment, educational programs or placement;

(7) A signed written approval of discharge or removal from the child's parent, conservator, or the person identified by the court to manage the placement, and the name, address and relationship to the child of the person to whom the child was released. If the written approval cannot be secured, the child's record shall include an explanation of why the written approval was not obtained.

Notes

Cal. Code Regs. Tit. 9, § 1927

1. New section filed 6-24-98; operative 7-1-98 pursuant to Government Code section 11343.4(d) (Register 98, No. 26).
2. Governor Newsom issued Executive Order N-55-20 (2019 CA EO 55-20), dated April 22, 2020, which suspended certain provisions related the operation of treatment and rehabilitation facilities that could restrict staffing flexibility, due to the COVID-19 pandemic.

Note: Authority cited: Section 4094, Welfare and Institutions Code. Reference: Sections 4094 et seq., Welfare and Institutions Code; and Section 1502, Health and Safety Code.

1. New section filed 6-24-98; operative 7-1-98 pursuant to Government Code section 11343.4(d) (Register 98, No. 26).