Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0077 - Mental Health and Substance Use Disorder Services › Chapter 2 - BEHAVIORAL HEALTH SERVICE PROVIDER CERTIFICATION › Section 2-11 - Client Case Records

Current through July 13, 2024
(a) A provider shall maintain a client case
				record for each client admitted for services.
(b) A provider shall maintain all client case
				records in accordance with professional standards of practice, including
				storage of records in a secure and designated area.
(c) Client case records must include the
				following documentation and reflect the following applicable services utilizing
				ASAM criteria, according to the unique needs of each individual client:
(i) Consent to receive treatment signed by
				the client or legal guardian;
(ii)
				A statement signed by the client or legal guardian affirming that
				confidentiality was explained to them and that they understand what information
				is protected and under what circumstances information can or cannot be
				released;
(iii) A form signed by
				the client or legal guardian acknowledging receipt and affirming that they
				understand the procedures for filing a complaint;
(iv) A form signed within the last year by
				the client or legal guardian acknowledging receipt and affirming that they
				understand client rights;
(v) A
				form signed by the client or legal guardian acknowledging receipt,
				understanding, and acceptance of provider policies and procedures governing the
				treatment process;
(vi) Clinical
				assessments, based on the following criteria:
(A) A provider serving adults shall utilize
				an evidence-based assessment tool which includes comprehensive information
				regarding the client's biopsychosocial and spiritual needs;
(B) A provider serving adolescents shall
				utilize a bio-psychosocial assessment tool which, at a minimum, includes the
				following domains: medical, criminal, substance use, family, psychiatric,
				developmental and academic history; intellectual capacity; physical and sexual
				abuse history; spiritual needs; peer, environmental, and cultural history; and,
				assessment of suicidal and homicidal ideation;
(C) A provider shall utilize the ASAM
				criteria including the dimensional criteria for each domain in the assessment
				process;
(D) A provider shall
				adequately assess the client's need for case management services according to
				subsection (ix) of this section; and
(E) When a client is transferred from another
				provider which completed the assessment, a receiving provider shall complete a
				transfer note showing that the assessment information was reviewed. Further, a
				provider shall determine if the client's needs are congruent with this
				assessment, make needed adjustments to treatment recommendations, and note the
				adjustment in the client file;
(vii) Diagnosis and diagnostic summary
				utilizing diagnostic tools which are standard for the field and which are
				acknowledged by the Department and payer sources;
(viii) Treatment plans, which must:
(A) Be completed when treatment is initiated
				and updated at a minimum of every ninety (90) calendar days;
(B) Be developed utilizing the assessment
				information, including the diagnosis and ASAM criteria;
(C) Integrate mental health needs if included
				as part of the assessment and diagnosis, if identified as part of the
				assessment process, or at any point during the course of treatment;
				and
(D) Include:
(I) Evidence the client or guardian
				participated in the development of the treatment plan, signed the treatment
				plan, and received a copy of the treatment plan;
(II) Outcome driven goals and measurable
				objectives;
(III) Changes in the
				client's symptoms and behaviors that are expected during the course of
				treatment in the current level of service, expressed in measurable and
				understandable terms;
(IV) The
				desired improved functioning level of the client utilizing the assessment;
				and
(V) Documentation of
				appropriate actions taken following specific program infractions, which do not
				require immediate termination, with appropriate timeframes for clients to
				address infractions prior to terminating the client;
(ix) A case management plan, based
				on the following criteria;
(A) A provider
				shall provide case management services directly or through written formal
				agreement among multiple agencies or providers;
(B) Upon determination from the client's
				primary qualified clinical staff that the case management services would
				benefit the client, case management services must include collaboration with
				other available agencies, providers, and services to meet individual client
				needs based on ongoing assessments when applicable; and
(C) Special emphasis must be placed on
				coordinating with other entities including, but not limited to, education
				institutions, vocational rehabilitation, recovery supports, and workforce
				development services to enhance the client's skill base, chances for gainful
				employment, housing, community resource supports, and other options for
				independent functioning;
(x) Progress notes, which must:
(A) Document the symptoms and condition of
				the client, response to treatment, and progress or lack of progress toward
				specific treatment goals;
(B) Be
				detailed enough to allow a qualified clinical staff to follow the course of
				treatment;
(C) Be completed as they
				occur for individual, IOP, and group therapy sessions. The dates of services
				shall be documented as part of each individual or group therapy session
				progress note; and
(D) Be signed by
				the staff providing services to the client. If the staff is not a qualified
				clinical staff the progress notes shall also be signed by a qualified clinical
				supervisor;
(xi)
				Releases of client confidential information completed in full and signed by the
				client or legal guardian and the provider;
(xii) Referrals;
(xiii) Quality of care reviews by the
				client's treatment team of clinical documentation for the purpose of reviewing
				the client's progress in treatment and the services provided to ensure the most
				appropriate level of care is provided, to coordinate needed services outside
				the provider, and for internal quality assurance;
(xiv) Correspondence relevant to the client's
				treatment, including all letters and dated notations of telephone conversations
				conducted by provider staff;
(xv)
				Documentation of any prescribed medication, to include:
(A) The client was fully apprised about the
				medication;
(B) The assessment for
				the medication;
(C) Each prescribed
				medication;
(D) Medication
				monitoring; and
(E) If the client
				is receiving Medication Assisted Treatment (MAT) through a different MAT
				practitioner, documentation of collaboration and attempts to collaborate with
				the MAT practitioner;
(xvi) Evidence the client was given
				information regarding communicable diseases, referred for screening, and
				provided linkages to appropriate counseling; and
(xvii) Documentation of continued stay,
				transition, and discharge planning, including the ASAM level of care
				recommendation. Discharge summaries must contain a summary of pertinent case
				record information and any plan for continuing care, referral, or admission to
				another level of care.