(a) Each program shall have an admission agreement, signed on entry by the client or an authorized representative and program representative, describing the services to be provided and the expectations and rights of the client regarding house rules, client involvement in the program, and fees. The client shall receive a copy of the signed admission agreement.
(b) There shall be a written assessment of each client on admission which includes at least:
(1) Health and psychiatric histories;
(2) Psychosocial skills;
(3) Social support skills;
(4) Current psychological, educational, vocational and other functional limitations;
(5) Medical needs, as reported; and,
(6) Meal planning, shopping and budgeting skills.
(c) The program and client shall together develop a written treatment/rehabilitation plan specifying goals and objectives and the staff and client's responsibilities for their achievement. Clients shall be involved in an on-going review of progress towards reaching established goals and be involved in the planning and evaluation of their treatment goals. The plan shall contain at least the following elements:
(1) Statement of specific treatment needs and goals.
(2) Description of specific services to address identified treatment needs.
(3) Documentation of reviews by staff and client of the treatment/rehabilitation plan adhering to the following schedule:
(A) Short-term Crisis Residential Treatment Program: at least weekly.
(B) Transitional Residential Treatment Program: at least once every 30 days.
(C) Long Term Residential Treatment Program: at least once every 60 days.
(4) Anticipated length of stay needed to accomplish identified goals, and methods to evaluate the achievement of these goals.
(d) If an individual treatment/rehabilitation plan requires services to be provided by another program or agency, there shall be documented evidence in the client's case record of communication between all persons responsible for carrying out specific aspects of the treatment/rehabilitation plan.
(e) The agency or program shall arrange for clients to attend community programs when needs are identified in the treatment/rehabilitation plan which cannot be met by the facility, but can be met in the community.
(f) There shall be a written discharge summary prepared by staff and client, which includes an outline of services provided, goals accomplished, reason and plan for discharge, and referral follow-up plans.
(g) The admission assessment, treatment/rehabilitation plan, and discharge summary shall be prepared by staff who have received training in the development and preparation of these documents.
(1) Training required to be provided by the facility shall include:
(A) A minimum of one hour of instruction on the development and preparation of the admission assessment.
(B) A minimum of one hour of instruction on the development and preparation of the treatment/rehabilitation plan.
(C) A minimum of one hour of instruction on the development and preparation of the discharge summary.
(D) Subject matter for all training provided for in this subsection shall include the expected content of documentation, methods used to prepare the document, timeframes for completion of documentation, and consultative sources to be utilized in preparing the document.
(2) Training provided for in this subsection shall consist of one or more of the following presentation methods:
(A) Formal classroom instruction;
(B) Oral presentation;
(C) Videotape, film, or audiovisual presentation;
(D) Audiotape presentation; or
(E) Performing the duties, on the job, under the direct supervision of the instructor.
Credits
Note: Authority cited: Sections 4090 and 14700, Welfare and Institutions Code. Reference: Sections 4090, 4091, 5670, 5670.5 and 5671, Welfare and Institutions Code.
2. Change without regulatory effect amending Note filed 8-12-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 33).
This database is current through 5/3/24 Register 2024, No. 18.
