WSR 10-09-061

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed April 19, 2010, 6:58 a.m. , effective May 20, 2010 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The health and recovery services administration is amending the intake evaluation, individual service plan, and clinical record WACs to allow mental health providers more flexibility in meeting the needs of individuals while still meeting the statutory requirements for collecting client history data.

Citation of Existing Rules Affected by this Order: Amending WAC 388-865-0420, 388-865-0425, and 388-865-0430.

Statutory Authority for Adoption: RCW 71.05.560, 71.24.035 (5)(c), and 71.34.380.

Adopted under notice filed as WSR 10-02-098 on January 6, 2010.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-865-0420 (2)(d)(i):

Presenting problem(s) as described by the individual, including a review of any documentation of a mental health condition provided by the individual. It must be inclusive of people who provide active support to the individual, if the individual so requests, or if the individual is under thirteen years of age;

WAC 388-865-0420 (2)(d)(iv):

Sufficient clinical information to justify the provisional diagnosis using diagnostic and statistical manual (DSM IV TR) criteria, or its successor;

WAC 388-865-0420 (2)(d)(v):

An identification of risk of harm to self and others, including suicide/homicide. Note: A referral for provision of emergency/crisis services, consistent with WAC 388-865-0452, must be made if indicated in the risk assessment;

WAC 388-865-0425:

In collaboration with the individual, or their parent or other legal representative if applicable, the clinician The community mental health agency must develop a consumer-driven, strength-based individual service plan that meets the individual's unique mental health needs. The individual service plan must be developed in collaboration with the individual, or the individual's parent or other legal representative if applicable. The service plan must:

WAC 388-865-0425(1):

Be initiated with at least one goal identified by the individual, or their parent or other legal representative if applicable, at the intake evaluation or the first session following the intake evaluation.

WAC 388-865-0425(7):

Demonstrate the individual's participation in the development of the individual service plan. Participation may be demonstrated by the individual's signature, and/or individual's quotes and/or individual's comments documented in the plan. Participation must include family or significant others as requested by the individual. If the provider developing the plan is not a mental health professional, the plan must also document review approval by a mental health professional.

WAC 388-865-0425(9):

With the individual's consent, or their parent or other legal representative if applicable, coordinate with any systems or organizations the individual identifies as being relevant to the individual's treatment. This includes coordination with any individualized family service plan (IFSP) when serving children under three years of age.

WAC 388-865-0430:

The licensed community support service provider mental health agency must maintain a clinical record for individual served in a manner consistent with WAC 388-865-0435, 388-865-0436, or any successors.

WAC 388-865-0430 (3)(f):

Discharge summaries and/or evaluations stemming from outpatient or inpatient psychiatric mental health services received within the last five years, when available.

WAC 388-865-0430(13):

Documentation of confidential information that has been released without the consent of the consumer including, but not limited to individual under the provisions in RCW 70.02.050, 71.05.390, and 71.05.630, and the Health Insurance Portability and Accountability Act (HIPAA);

WAC 388-865-0430(15):

Demonstration of collaboration with the individual must include family or significant others as requested by the individual; (16) A description of the individual's strengths and resources;

A final cost-benefit analysis is available by contacting Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1344, fax (360) 586-9727, e-mail kevin.sullivan@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.

Date Adopted: April 19, 2010.

Susan N. Dreyfus

Secretary

4158.6
AMENDATORY SECTION(Amending WSR 07-06-050, filed 3/2/07, effective 4/2/07)

WAC 388-865-0420   Intake evaluation.   (1) ((The intake evaluation or brief intake evaluation must be provided by a mental health professional and:

(a) Be initiated prior to the provision of any noncrisis mental health services;

(b) Be initiated within ten working days of the request for services;

(c) Be developed in collaboration with the consumer;

(d) Be inclusive of input of people who provide active support to the consumer, if the consumer requests or if the consumer is under age thirteen;

(e) Be completed within thirty working days of the initiation of the intake evaluation; and

(f) Include a consent for treatment or a copy of detention or involuntary treatment order.

(2) Except as when a brief intake evaluation as described in WAC 388-865-0420(4) is provided, a full intake evaluation must include:

(a) A description of the presenting problem, presented needs;

(b) A description of the consumer's and family's strengths;

(c) Consumer's needs and desired outcomes in the consumer's own words;

(d) Consumer's culture/cultural history (including, but not limited to, ethnicity or race, and religion);

(e) History of other disorders, substance/alcohol abuse, developmental disability, any other relevant disability, and treatment, if any;

(f) Medical history, hospitalizations, treatment, past and current medications;

(g) Mental health services history, past and current medication;

(h) Assessment of suicide/homicide and self harm risk. A referral for provision of emergency/crisis services, consistent with WAC 388-865-0452, must be made if indicated in the risk assessment;

(i) Sufficient information to justify the provisional diagnosis;

(j) Documentation showing the consumer has been asked if they are under the supervision of the department of corrections or juvenile court;

(k) If the consumer is a child:

(i) Developmental history;

(ii) Parental goals and desired outcomes (if consent is obtained or not required due to age or state custody); and

(iii) Family and/or placement issues, including, if appropriate, family dynamics, placement disruptions, and current placement needs.

(3) If seeking any of the information required in subsection (2) of this section presents a barrier to the provision of services for the consumer, any portion of the intake may be left incomplete providing the reason for the omission is clearly documented in the clinical record.

(4) A brief intake evaluation may be used when it is reasonably believed services to the consumer will be completed within a six-month period. A brief intake evaluation may also be substituted for a full intake evaluation if a consumer is resuming services after being out of services for a period of less than twelve months and had received a full intake evaluation as part of the previous service provision. A brief intake evaluation must include:

(a) A description of presenting problem, presented needs, desired outcomes, and consumer strengths identified by both the consumer and the clinician;

(b) Sufficient information to justify the provisional diagnosis;

(c) The consumer's current physician and prescribed medications;

(d) Current and historical substance use/abuse or other co-occurring disorders including developmental disabilities;

(e) Mental health services history including past and current medications;

(f) Assessment of suicide/homicide and self-harm risk. A referral for provision of emergency/crisis services, consistent with WAC 388-865-0452, must be made if indicated in the risk assessment;

(g) Documentation that the consumer has been asked if they are under the supervision by the department of corrections or juvenile court; and

(h) Identification of mutually agreed upon outcomes that are expected to be accomplished within the six-month period that will be the treatment plan. This treatment plan will be used in place of the treatment plan required in WAC 388-865-0425.

(5) In cases where a consumer initially receives services based on a brief intake evaluation, the community support service provider must complete the additional elements required in a full intake evaluation if the consumer is expected to continue to receive services after six months. In these cases a treatment plan must be developed that meets all the requirements of WAC 388-865-0425.

(6) If seeking any of the information required in subsection (4) of this section presents a barrier to the provision of services for the consumer, any portion of the intake may be left incomplete providing the reason for the omission is clearly documented in the clinical record)) All individuals receiving community mental health outpatient services, with the exception of crisis, stabilization, and rehabilitation case management services, must have an intake evaluation. The purpose of an intake evaluation is to gather information to determine if a mental illness exists which is a covered diagnosis under Washington state's section 1915(b) capitated waiver program, and if there are medically necessary state plan services to address the individual's needs. (For a listing of the covered diagnoses and state plan services go to: http://www.dshs.wa.gov/pdf/hrsa/mh/Waiver_2008_2010_PIHP_NEW_%200408_with_final_revisions.pdf)

(2) The intake evaluation must:

(a) Be provided by a mental health professional.

(b) Be initiated within ten working days from the date on which the individual or their parent or other legal representative requests services and completed within thirty working days of the initiation of the intake.

(c) Be culturally and age relevant.

(d) Document sufficient information to demonstrate medical necessity as defined in the state plan, and must include:

(i) Presenting problem(s) as described by the individual, including a review of any documentation of a mental health condition provided by the individual. It must be inclusive of people who provide active support to the individual, if the individual so requests, or if the individual is under thirteen years of age;

(ii) Current physical health status, including any medications the individual is taking;

(iii) Current substance use and abuse and treatment status (GAIN-SS);

(iv) Sufficient clinical information to justify the provisional diagnosis using diagnostic and statistical manual (DSM IV TR) criteria, or its successor;

(v) An identification of risk of harm to self and others, including suicide/homicide. Note: A referral for provision of emergency/crisis services, consistent with WAC 388-865-0452, must be made if indicated in the risk assessment;

(vi) Whether they are under the supervision of the department of corrections; and

(vii) A recommendation of a course of treatment.

[Statutory Authority: RCW 71.24.035. 07-06-050, 388-865-0420, filed 3/2/07, effective 4/2/07. Statutory Authority: RCW 71.05.445 and 71.05.390 as amended by 2004 c 166. 05-14-082, 388-865-0420, filed 6/30/05, effective 7/31/05. Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800, 9.41.047, 43.20B.020, and 43.20B.335. 01-12-047, 388-865-0420, filed 5/31/01, effective 7/1/01.]


AMENDATORY SECTION(Amending WSR 01-12-047, filed 5/31/01, effective 7/1/01)

WAC 388-865-0425   Individual service plan.   ((Community support service providers must provide consumers with an individual service plan that meets his or her unique needs. Individualized and tailored care is a planning process that may be used to develop a consumer-driven, strength-based, individual service plan. The individual service plan must:

(1) Be developed collaboratively with the consumer and other people identified by the consumer within thirty days of starting community support services. The service plan should be in language and terminology that is understandable to consumers and their family, and include goals that are measurable;

(2) Address age, cultural, or disability issues of the consumer;

(3) Include measurable goals for progress toward rehabilitation, recovery and reintegration into the mainstream of social, employment and educational choices, involving other systems when appropriate;

(4) Demonstrate that the provider has worked with the consumer and others at the consumer's request to determine his/her needs in the following life domains:

(a) Housing;

(b) Food;

(c) Income;

(d) Health and dental care;

(e) Transportation;

(f) Work, school or other daily activities;

(g) Social life; and

(h) Referral services and assistance in obtaining supportive services appropriate to treatment, such as substance abuse treatment.

(5) Document review by the person developing the plan and the consumer. If the person developing the plan is not a mental health professional, the plan must also document review by a mental health professional. If the person developing the plan is not a mental health specialist required per WAC 388-865-405(5) there must also be documented consultation with the appropriate mental health specialist(s);

(6) Document review and update at least every one hundred eighty days or more often at the request of the consumer;

(7) In the case of children:

(a) Be integrated with the individual education plan from the education system whenever possible;

(b) If the child is under three, the plan must be integrated with the individualized family service plan (IFSP) if this exists, consistent with Title 20, Section 1436)) The community mental health agency must develop a consumer-driven, strength-based individual service plan that meets the individual's unique mental health needs. The individual service plan must be developed in collaboration with the individual, or the individual's parent or other legal representative if applicable. The service plan must:

(1) Be initiated with at least one goal identified by the individual, or their parent or other legal representative if applicable, at the intake evaluation or the first session following the intake evaluation.

(2) Be developed within thirty days from the first session following the intake evaluation.

(3) Address age, cultural, or disability issues identified by the individual, or their parent or other legal representative if applicable, as relevant to treatment.

(4) Include treatment goals or objectives that are measurable and that allow the provider and individual to evaluate progress toward the individual's identified recovery goals.

(5) Be in language and terminology that is understandable to individuals and their family.

(6) Identify medically necessary service modalities, mutually agreed upon by the individual and provider, for this treatment episode.

(7) Demonstrate the individual's participation in the development of the individual service plan. Participation may be demonstrated by the individual's signature and/or quotes documented in the plan. Participation must include family or significant others as requested by the individual. If the provider developing the plan is not a mental health professional, the plan must also document approval by a mental health professional.

(8) Include documentation that the individual service plan was reviewed at least every one hundred eighty days. It should also be updated to reflect any changes in the individual's treatment needs or as requested by the individual, or their parent or other legal representative if applicable.

(9) With the individual's consent, or their parent or other legal representative if applicable, coordinate with any systems or organizations the individual identifies as being relevant to the individual's treatment. This includes coordination with any individualized family service plan (IFSP) when serving children under three years of age.

(10) If an individual disagrees with specific treatment recommendations or is denied a requested treatment service, they may pursue their rights under WAC 388-865-0255.

[Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800, 9.41.047, 43.20B.020, and 43.20B.335. 01-12-047, 388-865-0425, filed 5/31/01, effective 7/1/01.]


AMENDATORY SECTION(Amending WSR 06-17-114, filed 8/18/06, effective 9/18/06)

WAC 388-865-0430   Clinical record.   The licensed community ((support service provider)) mental health agency must maintain a clinical record for each ((consumer and safeguard the record against loss, defacement, tampering, or use by unauthorized persons)) individual served in a manner consistent with WAC 388-865-0435, 388-865-0436, or any successors. The clinical record must contain:

(1) An intake evaluation;

(2) Evidence that the consumer rights statement was provided to the ((consumer)) individual, or their parent or other legal representative if applicable;

(3) ((A copy of any advance directives, powers of attorney or letters of guardianship provided by the consumer;)) Documentation that the provider requested a copy of and inserted into the clinical record if provided, any of the following:

(a) Mental health advance directives;

(b) Medical advance directives;

(c) Powers of attorney;

(d) Letters of guardianship, parenting plans and/or court order for custody;

(e) Least restrictive alternative order(s);

(f) Discharge summaries and/or evaluations stemming from outpatient or inpatient mental health services received within the last five years, when available.

(4) ((The)) Any crisis ((treatment)) plan ((when appropriate)) that has been developed;

(5) The ((individualized)) individual service plan and all ((changes in)) revisions to the plan;

(6) Documentation that services are provided by or under the clinical supervision of a mental health professional;

(7) Documentation ((that services are provided by, or under the clinical supervision, or the clinical)) of any clinical consultation ((of)) or oversight provided by a mental health specialist((. Consultation must occur within thirty days of admission and periodically thereafter as specified by the mental health specialist));

(8) ((Periodic)) Documentation of ((the course of treatment and)):

(a) All service encounters;

(b) Objective progress toward established goals ((for rehabilitation, recovery and reintegration into the mainstream of social, employment and educational choices)) as outlined in the treatment plan; and

(c) How any major changes in the individual's circumstances were addressed.

(9) ((A notation of extraordinary events affecting the consumer;

(10))) Documentation ((of)) that any mandatory reporting of abuse, neglect, or exploitation ((of consumers)) consistent with chapters 26.44 and 74.34 RCW has occurred;

(((11))) (10) Documentation that the department of corrections was notified by the provider when ((a consumer)) an individual on ((an)) a less restrictive alternative or department of corrections order for mental health treatment informs ((them)) the provider that ((they are)) the individual is under supervision by the department of corrections. Notification can be either written or oral. If oral notification, it must be confirmed by a written notice, including e-mail and fax. The disclosure to department of corrections does not require the person's consent((;)).

(a) If the individual has been given relief from disclosure by the committing court, the individual must provide a copy of the court order to the treating community mental health agency (CMHA).

(b) There must be documentation that an evaluation by a designated mental health professional (DMHP) was requested in the following circumstance:

(i) The mental health provider becomes aware of a violation of the court-ordered treatment of an individual when the violation concerns public safety; and

(ii) The individual's treatment is a less restrictive alternative and the individual is being supervised by the department of corrections.

(((12))) (11) ((If the consumer has been given relief by the committing court it must be confirmed in writing;

(13) When the mental health provider becomes aware of a violation that relates to public safety of court ordered treatment of a consumer who is both in a less restrictive alternative and is being supervised by the department of corrections, documentation that an evaluation by a designated mental health professional was requested;

(14))) Either documentation of informed consent to treatment ((and medications)) by the ((consumer)) individual or ((legally responsible other)) parent or other legal representative or if treatment is court ordered, a copy of the detention or involuntary treatment order;

(12) Documentation that the individual, or their parent or other legal representative if applicable, are informed about the benefits and possible side effects of any medications prescribed for the individual in language that is understandable;

(((15))) (13) Documentation of confidential information that has been released without the consent of the ((consumer including, but not limited to)) individual under the provisions in RCW 70.02.050, 71.05.390 ((and)), 71.05.630, and the Health Insurance Portability and Accountability Act (HIPAA);

(14) For individuals receiving community support services, the following information must be requested from the individual and the responses documented:

(a) The name of any current primary medical care provider;

(b) Any current physical health concerns;

(c) Current medications and any related concerns;

(d) History of any substance use/abuse and treatment;

(e) Any disabilities or special needs;

(f) Any previously accessed inpatient or outpatient services and/or medications to treat a mental health condition; and

(g) Information about past or current trauma and abuse.

(15) A description of the individual's strengths and resources; and

(16) A description of the individual's self-identified culture.

[Statutory Authority: RCW 71.24.035, 71.05.560, and chapters 71.24 and 71.05 RCW. 06-17-114, 388-865-0430, filed 8/18/06, effective 9/18/06. Statutory Authority: RCW 71.05.445 and 71.05.390 as amended by 2004 c 166. 05-14-082, 388-865-0430, filed 6/30/05, effective 7/31/05. Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800, 9.41.047, 43.20B.020, and 43.20B.335. 01-12-047, 388-865-0430, filed 5/31/01, effective 7/1/01.]

Washington State Code Reviser's Office