Pa. Code 5320.52

Review and periodic reexamination

This regulation requires the interdisciplinary treatment team at residential mental health facilities licensed under 55 Pa. Code Chapter 5320 to review each resident's treatment plan at least every 30 days, or more frequently if the resident's condition changes. The team must document reexamination reports, treatment provided, plan revisions, and discharge criteria in the resident's record. Annual reassessments of each resident's mental, physical, and social needs (including mobility) are also required, with additional reassessments triggered by material changes in condition or at the request of the county administrator or Department.

55 Pa. Code § 5320.52 - Review and periodic reexamination 

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The interdisciplinary treatment team shall review
 treatment plans at least every 30 days or more frequently as the resident's
 condition changes. A report of the review and findings and the resident's
 progress toward meeting program goals and objectives shall be documented by the
 interdisciplinary team in the resident's record.

(1)
 The interdisciplinary treatment team
 shall maintain a record of each reexamination and review to include: 
 
(i)
 A report of the reexamination.

(ii)
 A brief description of the treatment
 provided to the person during the period preceding the reexamination and the
 results of that treatment.

(iii)

 Continuation or revision of the individual treatment plan for the next
 period.

(iv)
 Criteria for discharge
 and recommendation for discharge if these criteria have been met.

(2)
 Changes to the treatment plan
 and the reasons for the changes shall be made by the interdisciplinary
 treatment team and recorded in the resident's record as a progress note or on
 another form specifically designed for that purpose.

(3)
 The record shall include information
 required by §
 
5100.16
 (relating to review and
 periodic reexamination).

(4)

 Reassessment of each resident's mental, physical and social needs, including a
 mobility assessment as follows:
(i)

 Annually.

(ii)
 If the condition of
 the resident materially changes prior to the annual assessment.

(iii)
 At the request of the county
 administrator or the Department if there is cause to believe that an additional
 assessment is required.

Notes

55

 Pa. Code §
 
5320.52

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