Pa. Code 5310.33

Residential service plan

This section requires Community Residential Rehabilitation Service (CRRS) staff to develop an individualized written residential service plan with each client upon enrollment, based on a psychosocial evaluation assessing functional strengths and needs across areas such as self-care, health care, money management, and community participation. The plan must include short- and long-term goals, skills to be developed, and service methods, and must be reviewed and updated every 60 days. Staff must assign each client a responsible staff person to coordinate in-residence services, referrals, and case recording. Annual reassessments are required, or more frequently if the client's functioning changes significantly.

55 Pa. Code § 5310.33 - Residential service plan 

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(a)
 The
 community residential rehabilitation service (CRRS) staff shall develop with
 each client an individualized written client residential service plan upon the
 client's enrollment in the CRRS.

(b)

 The individual residential service plan must be based on the client's
 psychosocial evaluation which is a functional assessment of the client's
 strengths and needs in the major areas related to independence in residential
 and community functioning and addresses the client's: 
 
(1)
 Self-care skills.

(2)
 Health care, including medication
 management.

(3)
 Housekeeping
 skills.

(4)
 Ability to meet
 nutritional needs.

(5)

 Mobility.

(6)
 Money management
 skills.

(7)
 Interpersonal
 skills.

(8)
 Vocational/educational
 pursuits.

(9)
 Use of leisure
 time.

(10)
 Time
 structuring.

(11)
 Community
 participation such as social networking and utilization of services and
 resources.

(c)
 The
 residential service plan must include the following items: 
 
(1)
 Short and long-term goals for service
 formulated jointly by the staff and client.

(2)
 Behaviors to be modified and skills to be
 developed.

(3)
 Type and frequency
 of rehabilitation services to be provided.

(4)
 Techniques and methods of service to be
 used.

(5)
 A list of persons
 involved in the implementation of the plan.

(d)
 The CRRS staff shall evaluate the
 client's adjustment to the program within 30 days of enrollment and modify the
 service plan as needed. The residential service plan must be reviewed and
 updated every 60 days thereafter.

(e)
 Each client in a CRRS must spend a major
 portion of his time out of the residence. The goal of such involvement outside
 the residence is to increase the client's use of community resources and
 participation in community activities which the client can continue to use upon
 program termination. The method for achieving this goal must be reflected in
 each client's residential services plan.

(f)
 The client shall participate in the
 goal-setting, service planning, decision-making and progress assessment
 associated with the service plan.

(g)
 The original residential service plan,
 subsequent plan revisions, written plan reviews and documentation of client
 participation must be included in the client record.

(h)
 At the time of enrollment into CRRS and
 throughout the service period, each client shall be assigned to a CRRS staff
 person who is responsible for assuring:
(1)

 In-residence services are provided according to the client's residential
 service plan.

(2)
 Referrals to and
 arrangements for service provision by other agencies specified in the client's
 residential service plan occur and are coordinated with the agency or agencies
 responsible for treatment/case management of the client, such as the Mental
 Health/Mental Retardation Base Service Unit, Veterans' Administration,
 Domiciliary Care, and therapist.

(3)
 Case recording of intake information,
 service plan, progress notes, service plan reviews, annual reassessment,
 referrals, and termination summary.

(i)
 A complete reassessment of the client's
 strengths and needs as determined by the psychosocial evaluation and a review
 of the services provided to the client must be performed annually, or more
 frequently if a significant change in the client's level of functioning occurs.
 The reassessment must take place at a conference which includes the persons
 involved in the individual service plan development and implementation. The
 results of this meeting must be documented in the case record and submitted in
 writing to the agency or agencies responsible for treatment and/or case
 management of the client.

Notes

55

 Pa. Code §
 
5310.33

This section cited in 55 Pa. Code §
 
5310.32
 (relating to intake); 55
 Pa. Code §
 
5310.91
 (relating to special
 requirements for community residential rehabilitation services (CRRS) serving
 children); and 55 Pa. Code §
 
5310.123
 (relating to residential
 service plan).

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