Pa. Code 5240.21

Assessment

This section establishes assessment requirements for behavior consultation and mobile therapy services under Pennsylvania's Chapter 5240 framework. Within 15 days of service initiation, a qualified clinician must complete a face-to-face, individualized assessment covering developmental, behavioral, clinical, cultural, and family domains for the child, youth, or young adult served. The assessment must be reviewed and updated at least annually or upon specified triggering events, and must be signed and dated by the completing staff person. ABA services and EBT/group services are explicitly excluded from certain provisions.

55 Pa. Code § 5240.21 - Assessment 

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(a)
 Within 15 days
 of the initiation of services and prior to completing an ITP, a face-to-face
 assessment shall be completed for the child, youth or young adult by an
 individual qualified to provide behavior consultation services or mobile
 therapy services.

(b)
 The assessment
 shall be completed in collaboration with the child, youth, young adult or
 parent, legal guardian or caregiver of the child or youth, as
 appropriate.

(c)
 The assessment
 shall be individualized and include the following: 
 
(1)
 The strengths and needs across
 developmental and behavioral domains of the child, youth or young
 adult.

(2)
 The strengths and needs
 of the family system in relation to the child, youth or young adult.

(3)
 Existing and needed natural and formal
 supports.

(4)
 The specific
 services, skills, supports and resources the child, youth or young adult
 requires to address the child's, youth's or young adult's identified
 therapeutic needs.

(5)
 The specific
 supports and resources, if any, the parent, legal guardian or caregiver of the
 child, youth or young adult requires to assist in addressing the child's,
 youth's or young adult's identified therapeutic needs.

(6)
 Clinical information that includes the
 following: 
(i)
 Treatment history.

(ii)
 Medical history.

(iii)
 Developmental history.

(iv)
 Family structure and history.

(v)
 Educational history.

(vi)
 Social history.

(vii)
 Trauma history.

(viii)
 Other relevant clinical
 information.

(7)
 The
 child's, youth's or young adult's level of developmental, cognitive,
 communicative, social and behavioral functioning across the home, school and
 other community settings.

(8)
 The
 cultural, language or communication needs and preferences of the child, youth
 or young adult and the parent, legal guardian or caregiver.

(d)
 The assessment shall include a
 summary of the treatment recommendations received from health care providers,
 school or other service providers involved with the child, youth or young
 adult.

(e)
 The assessment shall be
 reviewed and updated at least every 12 months or if one of the following
 occurs:
(1)
 A parent, legal guardian or
 caregiver of the child or youth requests an update.

(2)
 The youth or young adult requests an
 update.

(3)
 The child, youth or
 young adult experiences a change in living situation that results in a change
 of the child's, youth's or young adult's primary caregivers.

(4)
 The child, youth or young adult has made
 sufficient progress to require an update.

(5)
 The child, youth or young adult has not
 made significant progress towards the goals identified in the ITP within 90
 days from the initiation of the services.

(6)
 The child, youth or young adult
 experiences a crisis event.

(7)
 A
 staff person, primary care physician, other treating clinician, case manager or
 other professional involved in the child's, youth's or young adult's services
 provides a reason an update is needed.

(f)
 The assessment and all updates shall be
 signed and dated by the staff person who completed the assessment.

(g)
 This section does not apply to ABA
 services.

(h)
 Subsection (a) does
 not apply to EBT or group services.

Notes

55

 Pa. Code §
 
5240.21

This section cited in 55 Pa. Code §
 
1155.32
 (relating to payment
 conditions for individual services); 55 Pa. Code §
 
5240.22
 (relating to individual
 treatment plan); 55 Pa. Code §
 
5240.41
 (relating to individual
 records); 55 Pa. Code §
 
5240.95
 (relating to assessment);
 and 55 Pa. Code §
 
5240.102
 (relating to assessment
 and individual treatment plan).

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