Florida Administrative Code › 65 - DEPARTMENT OF CHILDREN AND FAMILIES › 65E - Mental Health Program › Chapter 65E-4 - COMMUNITY MENTAL HEALTH REGULATION › Section 65E-4.014 - Standards for Client Records, Treatment and Quality Assurance

Current through Reg. 50, No. 138; July 16, 2024
(1) Introduction - This chapter establishes
				client record, treatment and quality assurance standards for mental health
				clients receiving state supported services from community mental health
				providers, exclusive of alcohol and drug abuse services, throughout
				Florida.
(2) Definitions - The
				definitions provided in this section are limited to this Rule
				 65E-4.014, F.A.C.
(a) CCMS - The Department of Children and
				Family Services Continuity of Care Management System as described in Section
				 394.4573, F.S.
(b) Screening - The preliminary determination
				of the type, extent and immediacy of the service needs of the individual
				seeking help.
(c) Intake - The
				determination of a client's service and treatment needs.
(d) Evaluation - A specific study of a
				client's pertinent functional areas such as socioeconomic, cultural, medical,
				psychological, psychiatric, educational, vocational, and environmental. This
				information is necessary to determine a client's problems and the services
				needed.
(e) Assessment - The
				determination of a client's current and potential strengths, problems and
				needs, by utilizing current intake, diagnosis and evaluation information in
				order to identify service needs.
(f) Planning - The development of a client's
				service plan or treatment plan which includes an assessment, the setting of
				client goals, and the identification of necessary services and resources, based
				upon identified needs.
(g) Quality
				Assurance Program - A systematic approach designed to evaluate the quality of
				care of an agency on an ongoing basis and to promote and maintain efficient,
				effective mental health services.
(h) Utilization Review - A case-by-case
				assessment of the utilization of an agency's services as recorded in client
				records.
(i) Peer Review - Review
				of staff members' professional work by a comparably trained and qualified
				individual performing similar tasks, taking into account client
				characteristics, accuracy of assessment, appropriateness of treatment, duration
				of treatment, adequacy of planning, and relevant follow-up
				procedures.
(j) Case Management -
				Activities aimed at assessing client needs, planning services, linking the
				service system to a client, coordinating the various system components,
				monitoring service delivery and evaluating the effects of service
				delivery.
(k) Primary Therapist or
				Treatment Coordinator - The provider's treatment staff member responsible for
				the coordination of treatment and services to the client who is not assigned a
				CCMS case manager due to not meeting CCMS priority criteria.
(l) Rehabilitation - An education-based
				process which provides the opportunities for mentally ill persons to attain the
				physical, emotional and intellectual skills needed to function successfully in
				living, learning, work and social environments. The process includes developing
				the resources needed to support or strengthen clients' ability to function in
				these environments.
(m) Service
				Provider or Provider or Agency - Any agency under contract with the Department
				of Children and Family Services, in which all or any portion of the program or
				services set forth in Section
				 394.675, F.S., are carried
				out.
(n) Service Plan - The
				document developed with the CCMS client by the case manager which depicts goals
				or objectives for the attainment of services and resources. For non-CCMS
				clients, service or resource goals or objectives may be established on the
				treatment plan or on a separate service plan.
(o) Treatment - Services, provided to persons
				individually or in groups, which include rehabilitation, counseling, supportive
				therapy, chemotherapy, psychotherapy or any other accepted therapeutic,
				educational or supportive process.
(p) Treatment Plan - An individual document
				or identifiable section of the service plan developed by treatment staff and
				the client which depicts goals or objectives for the provision of services
				within specific treatment environments. Examples of treatment environments
				include but are not limited to day treatment, vocational, residential,
				outpatient and activities of daily living programs.