(A)
The purpose of
this rule is to establish department policy and guidelines governing the
development and implementaton of assessments, treatment plans and discharge
plans.
(B)
The following definitions shall apply to this rule in
addition to or in place of those appearing in rule
5122-1-01 of the
Administrative Code.
(1)
"Basic neurological exam" means an examination of
cranial nerves, sensory and motor functions, coordination, and deep tendon
reflexes.
(2)
"CPST" means community psychiatric supportive
treatment service which provides an array of services delivered by community
based, mobile individuals or multidisciplinary teams of professionals and
trained others. Services address the individualized mental health needs of the
client. They are directed toward adults, children, adolescents and families and
will vary with respect to hours, type and intensity of services, depending on
the changing needs of each individual. The purpose/intent of CPST service is to
provide specific, measurable, and individualized services to each person
served. CPST services should be focused on the individual's ability to succeed
in the community; to identify and access needed services; and to show
improvement in school, work and family and integration and contributions within
the community.
(3)
"Day" means a calendar day, unless otherwise
indicated.
(4)
"Direct care nursing staff" means, but is not limited
to, registered nurses, licensed practical nurses, mental health technicians,
and therapeutic program workers.
(5)
"Goal" means an
expected result or condition that takes time to achieve, that is specified in a
statement that provides guidance in establishing intermediate objectives
directed towards its attainment.
(6)
"Long-term view"
means the life situation the patient would like to attain in the next three to
five years. Usually described in the patient's own words, the long-term view
includes all elements that are important to the patient. This may include
living arrangements, vocational/educational activities, relationships, and
other factors that are important to the quality of life desired by the
patient.
(7)
"Objective" means an expected result or condition that
takes less time to achieve than a goal, is stated in measurable terms, has a
specified time for achievement, and is related to the attainment of a
goal.
(8)
"Physical disabilities" means conditions such as
deaf/hard-of-hearing, visual impairment, and/or other physical limitations in
what would be considered normal physical functioning that may affect an
individual's access to treatment, and that needs to be considered in the
overall assessment process, and in the development of an individual's treatment
plan.
(9)
"Physical examination" means an examination of a
patient by a physician including, but not limited to, all the items indicated
on "History of Physical Illness" and "Physical Examination" forms designated by
the department.
(10)
"Physician" means a person licensed under the laws of
this state to practice medicine.
(11)
"Psychiatric
examination" means an examination of a patient by a psychiatrist, or a
physician privileged by the facility to conduct such examinations, including,
but not limited to, all the items indicated on the "Psychiatric Examination"
form designated by the department.
(12)
"Psychiatrist"
means a licensed physician who has satisfactorily completed a residency
training program in psychiatry, as approved by the residency review vommittee
of the American council on graduate medical education, the committee on
graduate education of the American osteopathic association, or the American
osteopathic board of neurology and psychiatry, or who, as of July 1, 1989, has
been recognized as a psychiatrist by the Ohio state medical association or the
Ohio osteopathic association on the basis of formal training and five or more
years of medical practice limited to psychiatry.
(13)
"Psychologist"
means an individual who holds a current license under Chapter 4732. of the
Revised Code which authorizes the practice of psychology.
(14)
"Recovery"
means a personal process of overcoming the negative impact of a psychiatric
disability despite its continued presence.
(15)
"Registered
nurse" means an individual who holds a current license issued under Chapter
4723. of the Revised Code which authorizes the practice of nursing as a
registered nurse.
(16)
"Social worker" means a person who uses the
application of specialized knowledge of human development and behavior, and
social, economic and cultural systems in directly assisting individuals,
families, and groups to improve or restore their capacity of social
functioning, including assessment, counseling, and the use of social work
interventions and social psychotherapy.
(17)
"Treatment
plan" (also known as "plan of care") means a written statement of specific,
reasonable and measurable goals and objectives for an individual established by
the treatment team, in conjunction with the patient, with specific criteria to
evaluate progress towards achieving those objectives.
(18)
"Treatment
team" means a team comprised of the patient, patient's family as defined and
authorized by the patient, psychiatrist, or physician so privileged by the
facility, registered nurse, social worker, and other appropriate personnel
(such as activity therapist, CPST worker, interpreter, readers, dietitian,
occupational therapist, pharmacist, psychologist, and others as appropriate)
based on patient needs and standard-setting agency requirements.
(C)
Assessments
The RPH shall be responsible for
conducting a complete assessment of each patient, including a consideration of
the patient's abilities, strengths, stage in the recovery process, problems,
and needs, and the types of services required to meet those needs in the least
restrictive setting. Assessments shall contain a statement of individual
strengths, and anticipated treatment interventions and recommendations. The
assessment process shall pay careful attention to the uniqueness of individual
patients, such as the presence of any physical disabilities, cultural
differences, and/or religious preferences. To the fullest extent possible, each
assessment shall be conducted in the patient's preferred method of
communication; for deaf/hard of hearing patients, an interpreter shall be used
to communicate unless the patient has expressed a preference for an alternative
form of communication. See ODMH policy MD-10 "Providing Services to Deaf and
Hard-of-Hearing (Deaf/HOH) Patients in ODMH Hospitals." The assessments shall
include, but not be limited to, the following areas: physical, mental,
behavioral, social, recreational, financial, housing, vocational, recovery
stage, and when appropriate, educational, legal, risk, nutritional, cultural,
and spirituality. Information from relevant community agencies with whom the
patient has been involved in treatment should be used as appropriate in the
assessment process. It is understood that, due to a patient's condition, and/or
unwillingness to cooperate with an assessment or with certain portions of it,
the time frames indicated for assessments may not be met in every
instance.
(1)
A complete history and physical examination shall be
completed on all patients within twenty-four hours of admission. This history
and physical examination shall include a medical, alcohol and drug history, and
a vision and hearing screening. It shall also include appropriate information
about past and current physical disorders, and a basic neurological
examination. Phrases like, "gross neurological examination within normal
limits", "intact", and "no abnormalities", without any indication of tests
performed and their result, are not acceptable.
(2)
A psychiatric
examination shall be completed and in the patient's medical record within sixty
hours of admission.
(3)
A nursing assessment by a registered nurse shall be
completed, and in the patient's medical record within twenty-four hours of
admission.
(4)
A social work assessment, including a social history,
shall be completed, and in the patient's medical record prior to the
development of the comprehensive individual treatment plan.
(5)
A psychological
assessment shall be provided as appropriate to patient need.
(6)
Other patient
assessments shall be completed as appropriate, depending on the patient's
needs, and standard-setting agency requirements.
(7)
The physical and
psychiatric examinations and the nursing and social service assessments shall
be updated as often as indicated by the patient's changing condition, but in no
case less frequently than annually. Other assessments shall be reviewed and
updated as appropriate, based on patient need.
(8)
Comprehensive
physical examinations performed within thirty days prior to admission by a
privileged member of the medical staff may be accepted, provided they are
reviewed by the physician and are authenticated as still current, or are
updated as needed; and provided a legible copy of the examination as
authenticated or updated is placed in the patient's medical record within
twenty-four hours of admission.
(9)
Each RPH shall
have a policy relating to needed assessments, or portions thereof, that are
refused by the patient or that are deferred for some reason. The policy shall
state the manner in which these deferrals or refusals are to be dealt with, and
time frames for doing so.
(D)
Treatment plan
Each patient shall have developed with
the treatment team a treatment plan which is responsive to the treatment needs
and recovery process of the patient, based on information provided by the
patient, the patient's family/significant others, and assessments by the
treatment team. The plan shall include services to be provided to the patient
during the inpatient stay and needed services after discharge. Services to be
planned for all patients after discharge shall include medication, housing,
financial, and when appropriate, vocational and peer support services. This
plan shall be developed with the involvement of the patient, and, when
appropriate, the patient's family/significant others, and the CPST worker. The
active involvement of the patient, any significant others, and the CPST worker,
shall be documented. Each treatment plan shall pay careful attention to the
uniqueness of individual patients, such as the presence of any physical
disabilities, cultural differences, and/or religious preferences. In treatment
plan development and implementation, the patient's preferred method of
communication shall, to the fullest extent possible, be utilized. The treatment
plan shall be developed and implemented as follows:
(1)
An
admitting/initial treatment plan, based on the intake assessments, shall be
developed at the time of admission. This plan may be documented in the
physician's admission note, and/or admitting orders. It shall give adequate
direction to all relevant staff regarding the treatment regimen to be followed
pending the development of the comprehensive treatment plan. This plan shall be
reviewed and updated as indicated.
(2)
Each patient
shall have a comprehensive treatment plan developed by the treatment team. This
plan shall be developed no later than five calendar days from admission,
counting the day of admission as day one. This plan shall be based on the
assessments referred to in paragraphs (C)(1) to (C)(7) of this rule, and upon
identified patient abilities, strengths, stage in recovery process, problems,
and needs. In most instances this plan will be a further evolution of the plan
begun at the time of admission, but based now on more comprehensive assessment
information.
(3)
Each patient's comprehensive treatment plan shall be
reviewed and updated by the treatment team as often as is indicated by the
patient's condition, and his/her progress, or lack thereof, in achieving the
goals of treatment. It is to be emphasized that the patient's changing
condition, and his/her progress, or lack thereof, in moving towards recovery
and the achievement of established treatment goals, is the primary determinant
of the need for a review and update of the individual treatment plan. However,
in no case shall the interval between reviews and updates exceed the
following:
(a)
Thirty days from the date of the comprehensive treatment plan;
(b)
Every thirty
days for the next two months of receiving RPH services;
(c)
Every sixty days
thereafter during the first year of receiving RPH services;
and
(d)
For patients who
are in the RPH beyond one year, at least every ninety days for the duration of
receiving RPH services.
(4)
Each review and
update of the treatment plan shall include a reassessment of the individual's
diagnosis, and principal behaviors necessitating inpatient care. Changes shall
be made in the treatment regimen, as appropriate, based on the patient's
changing condition. The active participation in this entire process of the
patient, any significant others, and the CPST worker, shall be encouraged and
documented.
(E)
Treatment plan contents
Each individual treatment plan and
reviews or updates shall contain:
(1)
A substantiated
diagnosis;
(2)
Clearly identified patient abilities, strengths,
problems, needs, and stage of recovery drawn from the assessments, and any
updates, thereof, that will be addressed in treatment;
(3)
Clearly stated
and measurable goals and objectives relative to the identified abilities,
strengths, problems and needs, including recovery-related issues;
(4)
Estimated time frames for the achievement of each goal and objective;
(5)
Specific treatment methodologies, with their frequencies, focus, and duration,
that will be used in an effort to achieve each stated objective;
(6)
Individual names of staff responsible for carrying out, or assuring the
carrying out, of each treatment method referenced in paragraph (E)(5) of this
rule. The professional discipline shall be clearly indicated;
(7)
Criteria for
transition to the community, that is, clearly stated patient mental and
behavioral status sufficient to allow continued treatment as needed in a
community setting;
(8)
Specific plans, or recommendations, for post-discharge
services;
(9)
The patient's involvement in and expressed concerns
about the treatment plan;
and
(10)
The patient's
long-term view.
(F)
Discharge
planning Discharge planning should start the day of admission. Upon admission,
or linkage to a provider organization, the CPST worker, if applicable, and the
community provider organization shall be notified, and invited to participate
in, and kept fully apprised of plans, including the discharge date.
Appropriate levels of supervision,
housing, and peer support services, if appropriate, shall be identified by the
treatment team and communicated to the provider staff. If the patient is not
able to be discharged within one week after he/she is ready for discharge due
to placement problems, the RPH social worker shall inform the RPH social work
director/designee. The RPH social work director/designee shall contact the
community provider organization to facilitate the discharge. These cases are
reviewed by the RPH utilization review committee. Regular meetings between the
RPH chief clinical officer and the mental health center chief clinical officers
and their staffs need to be held to address cases that cannot be resolved by
the social work directors.
(G)
Patient access
to medical records
(1)
Pursuant to division (A)(5) of section
5122.31 of the Revised Code, a
patient shall, upon request, be granted access to his/her medical record unless
clear treatment reasons, i.e., likely to endanger the life or physical safety
of the patient or others, are documented in the individual treatment plan and
physician progress notes restrict such access. Examples of clear treatment
reasons include:
(a)
The information is about another person and the RPH
determines that patient review would cause sufficient harm to another
individual to warrant withholding; or
(b)
Review by the
patient could be reasonably likely to endanger the life or physical safety of
the patient or anyone else.
(2)
If restricted,
the areas in the record from which the patient is restricted to view shall be
noted; the non-restricted areas are still accessible to the patient. The
patient's written treatment plan shall specify the treatment designed to
eliminate the restriction.
(H)
Authorization of
individual treatment plans
The names of all team members actually
participating in the development and/or review and update of the treatment plan
shall appear on the treatment plan. The individual treatment plan and each
review and update thereof shall be signed by a psychiatrist, or a physician so
privileged by the RPH. A psychiatrist, or a physician so privileged by the RPH,
shall assume primary responsibility for supervision and evaluation of each
patient's ongoing care and treatment. The patient shall participate in the
development of his/her treatment plan and shall be asked to sign it.
(I)
Implementation of treatment plans
Treatment plan progress notes shall be
completed for patients. The frequency of the notes is determined by the
condition of the patient. Progress notes are written at least weekly or more
frequently if clinically indicated. Such notes shall indicate the treatment
interventions carried out in relation to a specific problem or goal on the
treatment plan, and shall contain a careful assessment of the patient's
progress in accordance with the stated goals and objectives on the treatment
plan, and subsequent updates thereof. They shall also contain any
recommendations for the continuation of or modifications in the patient's
treatment regimen. All such entries shall be signed and dated by the staff
member and the professional discipline shall be clearly indicated. In addition,
direct care nursing staff shall complete regular notes. These notes shall be
daily for the first week of admission. After the first week, while no required
frequency is given, the notes shall be frequent enough to give a clear picture
of the patient's clinical status and his/her response to the active treatment
interventions.
(J)
Treatment plan monitoring
Individual treatment plans governed by
this policy shall be monitored by the RPH quality assurance/ improvement
program. Results of the monitoring activity shall be distributed as appropriate
both to inform staff persons with a need to know, and in order to assure prompt
and effective corrective action on all identified deficiencies.
Replaces: 5122-2-12
Notes
Ohio Admin. Code
5122-2-12
Effective:
9/18/2010
Promulgated Under:
111.15
Statutory
Authority: 4731., 5119.01,
5122.28,
5122.29
Rule
Amplifies: 5119.01,
5122.28,
5122.29
Prior
Effective Dates: 12-15-1975, 7-1-1980, 6-7-1993, 2-1-2000, 9-30-2002