West Virginia Code of State Rules › Agency 78 - Human Services › Title 78 - LEGISLATIVE RULE DEPARTMENT OF HUMAN SERVICES BUREAU FOR SOCIAL SERVICES › Series 78-03 - Minimum Licensing Requirements for Residential Child Care and Treatment Facilities for Children and Transitioning Adults and Vulnerable and Transitioning Youth Group Homes and Programs in West Virginia › Section 78-3-13 - Initial Assessment and Plan of Care

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1.
				Multidisciplinary Team.
In all instances in which there is a legally designated
				  Multidisciplinary Team (MDT), the organization's assessments and care plans
				  shall be provided to the DHHR representative of the MDT for the purpose of
				  maintaining consistency in assessment, treatment and placement planning. The
				  MDT is responsible by statute for overseeing the assessment and case planning
				  process for all children who are in the custody of the Department. The
				  organization shall supply a representative to the MDT who is familiar with the
				  child, his or her current status and his or her progress in treatment. The
				  Department of Health and Human Resources designee assigned as the child's
				  representative to the MDT is responsible for approving plans of care designed
				  by the organization. This approval shall include permissions for
				  treatment.
13.2. Initial
				Assessment.
Each child or transitioning adult that enters residential
				  treatment shall have a thorough assessment and a subsequent plan of care, if
				  considered appropriate by a health care professional.
13.2.1. For children and transitioning adults
				who have comprehensive assessments completed within six months prior to
				admission, further assessments are not required, unless circumstances have
				significantly changed, or the assessments are incomplete.
13.2.2. The organization shall have a
				comprehensive assessment procedure for children entering the organization's
				care. Clinical assessments shall be completed by an appropriately licensed or
				certified clinical professional or an individual under supervision for the
				licensure. Other assessments may be completed by employees meeting the
				requirements of their scope of practice. All assessments comprising the
				comprehensive assessment shall be completed prior to the development of the
				plan of care and shall include as appropriate and available:
13.2.2.a. Demographic information including
				custody status;
13.2.2.b.
				Presenting problems and reason for referral;
13.2.2.c. A history of treatment;
13.2.2.d. A medical history;
13.2.2.e. A social history;
13.2.2.f. The potential need for use of
				restrictive behavior management interventions;
13.2.2.g. A developmental history;
13.2.2.h. An educational or vocational
				history;
13.2.2.i. A legal
				history;
13.2.2.j. A substance
				abuse history;
13.2.2.k. A mental
				status examination;
13.2.2.l. An
				assessment of independent living and adaptive living skills;
13.2.2.m. A summary of the child's
				strengths;
13.2.2.n. A summary of
				family strengths and weaknesses; and
13.2.2.o. A summary of presenting problems or
				potential focus for treatment as identified through the assessment.
13.2.3. When appropriate to the
				needs of the person served, the assessment shall include:
13.2.3.a. A review of adaptive behavior or a
				functional assessment, or both.
13.2.3.b. A review of the need for assistive
				technology, auxiliary aids and services and other special
				accommodations;
13.2.3.c.
				Nutritional and dietary needs;
13.2.3.d. Special or unique behavioral
				issues; and
13.2.3.e. A review of
				academic, cognitive, and vocational testing or assessments, if
				available.
13.2.4. Each
				assessment shall consider any unique aspects of the person's racial, ethnic,
				and cultural background, and the need for any special service approaches
				resulting from that assessment.
13.2.5. The assessment shall result in a
				written integrated summary of findings and recommendations that shall guide the
				organization's treatment efforts. The integrated summary of findings shall
				include:
13.2.5.a. Recommendations for dental,
				visual, and other health screenings or treatment;
13.2.5.b. A diagnosis, stated in terms as
				provided is the most recent version of the Diagnostic and Statistical Manual of
				Mental Disorders, if applicable;
13.2.5.c. Recommendations for further
				assessment as appropriate;
13.2.5.d. Recommendations for clinical
				behavioral health treatment, if applicable;
13.2.5.e. Recommendations for interventions
				to be made in the home environment, as necessary and appropriate;
13.2.5.f. Preliminary recommendations for
				placement and aftercare upon discharge;
13.2.5.g. Recommendations for family
				visitation unless contraindicated clinically or legally; and
13.2.5.h. Any recommendations for rights
				restrictions.
13.2.6.
				The organization shall have a policy establishing timelines for completion of a
				full assessment that shall take into account urgency of child need, expected
				duration of treatment, and timelines for plan of care. The timelines shall
				facilitate provision of an appropriate range of services at the earliest
				opportunity depending on the unique needs of the individual and the expected
				duration of services. Exceptions to those timelines shall be fully documented
				and justified in the clinical record.
13.2.7. When the organization is required to
				accept assessments from another organization or subcontracting entity, it shall
				review each assessment for sufficiency and conduct additional assessments if
				the product does not meet the standard.
13.2.8. The organization shall have a written
				practice to incorporate families into the assessment and service-planning
				process unless clinically or legally contra-indicated.