Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 83 - THERAPEUTIC FOSTER CARE › Section 317:30-5-742.2 - Individual plan of care (IPC)

Current through Vol. 41, No. 20, July 1, 2024
All behavioral health services in a TFC 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-psycho-social 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 TFC agencies must assess each individual to determine
				  whether he or she could be an appropriate candidate for TFC services.
(B)
Qualified
				  professional.
This service is performed by a licensed behavioral health
				  professional (LBHP) or licensure candidate.
(C)
Limitations.
Assessments are
				  compensable on behalf of a member who is seeking services for the first time
				  from the TFC 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 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, to include 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
				  parents(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)
				  Alcohol, drug, and/or other addictions history;
(VI) Trauma, abuse, neglect, violence, and/or
				  sexual assault history of self and/or others, including OKDHS involvement;
(VII) Family and social history,
				  including psychiatric, substance use, drug and alcohol addiction, other
				  addictions, and trauma/abuse/neglect;
(VIII) Educational attainment, difficulties,
				  and history;
(IX) Cultural and
				  religious orientation;
(X)
				  Vocational, occupational, and military history;
(XI) Sexual history, including human
				  immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), other
				  sexually transmitted diseases (STDs), and at-risk behaviors;
(XII) Marital or significant other
				  relationship history;
(XIII)
				  Recreation and leisure history;
(XIV) Legal or criminal record, including the
				  identification of key contacts (e.g. attorneys, probation officers);
(XV) Present living arrangements;
(XVI) Economic resources; and
(XVII) 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 qualified practitioner who performed the
				  face-to-face behavioral assessment. If performed by a licensure candidate, it
				  must be countersigned by the LBHP who is responsible for the member's care.