Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 84 - INTENSIVE TREATMENT FAMILY CARE › Section 317:30-5-753 - Individual plan of care (IPC) requirements

Current through Vol. 41, No. 20, July 1, 2024
All behavioral health services in an ITFC setting are
					 provided as a result of an individual assessment of the member's needs and
					 documented in the IPC.
(1)
Assessment.
(A)
Definition.
Gathering and assessment of historical and current
				  bio-psychosocial information which includes face-to-face contact with the
				  member and the member's foster parent(s) or legal guardian or other person,
				  including biological parent(s) when applicable, who have pertinent information
				  about the member resulting in a written summary report, diagnosis, and
				  recommendations. All ITFC agencies must assess each individual to determine
				  whether they could be an appropriate candidate for ITFC services.
(B)
Qualified professional.
This
				  service is performed by a licensed behavioral health professional (LBHP).
(C)
Limitations.
Assessments are compensable on behalf of a member who is seeking services for
				  the first time from the ITFC agency. This service is not compensable if the
				  member has previously received or is currently receiving services from the
				  agency, unless there has been a gap in service of more than six (6) months and
				  it has been more than one (1) year since the previous assessment.
(D)
Documentation requirements.
The assessment must include all elements and tools required by the Oklahoma
				  Health Care Authority (OHCA). In the case of members under the age of eighteen
				  (18), it is performed with the direct, active, face-to-face participation of
				  the member and foster parent(s) or legal guardian or other persons, including
				  biological parent(s) when applicable. The member's level of participation is
				  based on age, developmental, and clinical appropriateness. The assessment must
				  include all related diagnoses from the Diagnostic and Statistical Manual of
				  Mental Disorders (DSM-V). The assessment must contain, but is not limited to,
				  the following:
(i) Date, including month,
				  day, and year of the assessment session(s);
(ii) Source of information;
(iii) Member's first name, middle initial,
				  and last name;
(iv) Gender;
(v) Birth date;
(vi) Home address;
(vii) Telephone number;
(viii) Referral source;
(ix) Reason for referral;
(x) Person to be notified in case of
				  emergency;
(xi) Presenting reason
				  for seeking services;
(xii) Start
				  and stop time for each unit billed;
(xiii) Dated signature of foster parent(s) or
				  legal guardian [Oklahoma Department of Human Services (OKDHS) or Oklahoma
				  Office of Juvenile Affairs (OJA)] or other persons, including biological
				  parent(s) (when applicable) participating in the face-to-face assessment.
				  Signatures are required for members fourteen (14) years of age and over;
(xiv) Bio-psychosocial
				  information, which must include:
(I)
				  Identification of the member's strengths, needs, abilities, and preferences;
(II) History of the presenting
				  problem;
(III) Previous
				  psychiatric treatment history, including treatment of psychiatric issues,
				  substance use, drug and alcohol addiction, and other addictions;
(IV) Health history and current biomedical
				  conditions and complications;
(V)
				  Trauma, abuse, neglect, violence, and/or sexual assault history of self and/or
				  others, including OKDHS involvement;
(VI) Family and social history, including
				  psychiatric, substance use, drug and alcohol addiction, other addictions, and
				  trauma/abuse/neglect;
(VII)
				  Educational attainment, difficulties, and history;
(VIII) Cultural and religious orientation;
(IX) Vocational, occupational, and
				  military history;
(X) Sexual
				  history, including human immunodeficiency virus (HIV), acquired immune
				  deficiency syndrome (AIDS), other sexually transmitted diseases (STDs), and
				  at-risk behaviors;
(XI) Marital or
				  significant other relationship history;
(XII) Recreation and leisure history;
(XIII) Legal or criminal record,
				  including the identification of key contacts (e.g. attorneys, probation
				  officers);
(XIV) Present living
				  arrangements;
(XV) Economic
				  resources; and
(XVI) Current
				  support system, including peer and other recovery supports.
(xv) Mental status and level of
				  functioning information, including, but not limited to, questions regarding the
				  following:
(I) Physical presentation, such as
				  general appearance, motor activity, attention, and alertness;
(II) Affective process, such as mood, affect,
				  manner, and attitude;
(III)
				  Cognitive process, such as intellectual ability, social-adaptive behavior,
				  thought processes, thought content, and memory; and
(IV) All related diagnoses from the DSM-V.
(xvi) Pharmaceutical
				  information for both current and past medications, to include the following;
(I) Name of medication;
(II) Strength and dosage of medication;
(III) Length of time on the
				  medication; and
(IV) Benefit(s)
				  and side effects of medication.
(xvii) LBHP's interpretation of findings and
				  diagnosis; and
(xviii) Dated
				  signature and credentials of the LBHP who performed the face-to-face behavioral
				  assessment.