New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 584 - Operation Of Residential Treatment Facilities For Children And Youth › Section 584.16 - Case record

Current through Register Vol. 46, No. 28, July 10, 2024
(a) There shall be a complete
				case record maintained at one location for each resident admitted to the residential
				treatment facility. For those children or youth that have been determined to be
				classified with an educational disability and in need of special educational
				services and programs, there may also be an individualized education program, but
				such individualized education program shall be separate and distinct from the case
				record.
(b) The case record shall be
				confidential and access shall be governed by the requirements of section 33.13 of
				the Mental Hygiene Law and 45 C.F.R. Parts 160 and 164 as incorporated by reference
				in Part 800 of this Title.
(c) The case
				record shall be available to all clinical staff involved in the care and treatment
				of the resident, consistent with the provisions of 45 C.F.R. Parts 160 and
				164.
(d) Each case record shall include:
(1) identifying information about the resident
				served and the resident's family;
(2) a
				note upon admission, indicating source of referral, date of admission, rationale for
				admission, the date service commenced, presenting problem and immediate treatment
				needs of the resident;
(3) the
				application for admission to a residential treatment facility and any other
				information obtained from the Office of Mental Health or commissioner's designee's
				evaluation of eligibility for access to residential treatment facility services,
				including an assessment from the committee on special education, when
				available;
(4) assessments of
				psychiatric, medical, educational, emotional, social and recreational needs. Where
				appropriate, assessments of vocational and nutritional needs shall be included.
				Special consideration shall be given to the role of the resident's family in each
				area of assessment;
(5) reports of all
				mental and physical diagnostic examinations and assessments, including findings and
				conclusions;
(6) reports of all special
				studies performed, including, but not limited to, X-rays, clinical laboratory tests,
				psychological tests, or electroencephalograms;
(7) initial and comprehensive treatment
				plans;
(8) Progress notes which relate
				to the goals and objectives of the initial or comprehensive treatment plans, which
				shall be signed by the staff member who provided the service or by one participating
				staff member when several staff members have had significant interaction with the
				resident.
(i) Progress notes shall be written at
				least weekly and additionally whenever a significant event occurs that affects, or
				potentially affects, the resident's condition or course of treatment.
(ii) Progress notes shall be written regarding the
				educational program as determined in the resident's individualized education
				program.
(iii) Progress notes shall be
				written regarding involvement of the family or legal guardian in treatment as
				determined in the resident's treatment plan;
(9) summaries of treatment plan reviews and
				special consultations regarding all aspects of the resident's complete daily
				program;
(10) dated and signed orders
				which indicate commencement and termination dates for all medications;
(11) a discharge summary, prepared within 15 days
				of discharge or transfer, which includes a summary of the clinical treatment, or
				reasons for discharge or transfer and, if appropriate, the provision for alternative
				treatment services which the resident may require; and
(12) information as may be required for the
				effective implementation of the utilization review plan provided for in section
				584.18  of this Part.