Pa. Code 5221.33

Intensive case management records-statement of policy

This section specifies the minimum content requirements for intensive case management (ICM) records in Pennsylvania, serving as a statement of policy to satisfy recordkeeping obligations under the broader ICM chapter. Providers must maintain records covering intake information, assessments and evaluations, written service plans, documentation of services, and discharge information. The requirements apply to both adult and child consumers enrolled in intensive case management services under the Office of Mental Health and Substance Abuse Services.

55 Pa. Code § 5221.33 - Intensive case management records-statement of policy 

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To satisfy the recordkeeping requirements in §§
 
5221.31
(4)
 and
 
5221.41
 (relating to
 responsibilities of providers; and recordkeeping), intensive case management
 records should contain, at a minimum, the following:

(1)

Intake information
. The
 following shall be included: 
(i)
 Identifying
 information to include the consumer's name, address, date of birth, social
 security number and third-party resources.

(ii)
 Referral Form, to include date, source
 and reason for referral to intensive case management and DSM III-R, or
 subsequent revision, diagnosis.

(iii)
 Verification of eligibility to receive
 intensive case management, such as past treatment records, psychiatric or
 psychological evaluation, letter summarizing treatment history, Individual
 Education Plan (IEP), and the like.

(2)

Assessments and
 evaluations.

(i)
 The following
 assessments and evaluations should be made: 
 
(A)
 Medical history, taken within the past 12
 months, or documentation of the intensive case manager's efforts to assist the
 consumer in obtaining a physical examination.

(B)
 Assessment of the consumer's strengths,
 needs and interests.

(C)
 Summaries
 of hospitalizations, incarcerations or other out-of-home placements while
 enrolled in intensive case management, including the place and date of
 admission, the reason for admission, length of stay and discharge
 plan.

(D)
 Children only: IEP,
 school testing-for example, psychological evaluations-guidance counselor
 reports, and the like, or documentation of the intensive case manager's efforts
 to obtain the information if not in the record.

(E)
 Outcome information required for annual
 Consolidated Community Reporting System reporting-that is, consumer level of
 functioning, independence of living and vocational/educational
 status.

(ii)
 The
 following applies to clauses (A), (C) and (D): 
 
(A)
 If the intensive case management provider
 is part of a multiple service agency which maintains the assessments and
 evaluations in clauses (A), (C) and (D) in another file, the information other
 than that required to establish eligibility for intensive case management does
 not need to be duplicated for the intensive case management record.

(B)
 These reports are considered to be part
 of the intensive case management record, and shall be made available if the
 intensive case management record is requested.

(3)

Written service plan
.
 The initial plan shall:
(i)
 Be developed
 within 1 month of registration and reviewed at least every 6 months.

(ii)
 Reflect documented assessment of the
 consumer's strengths and needs.

(iii)
 Identify specific goals, objectives,
 responsible persons, time frames for completion and the intensive case
 manager's role in relating to the consumer and involved others.

(iv)
 Be signed by the consumer, the family if
 the consumer is a child, the intensive case manager, the intensive case
 management supervisor and others as determined appropriate by the consumer and
 the intensive case manager. If the signatures cannot be obtained, attempts to
 obtain them should be documented.

(4)

Documentation of
 services
. The following shall be included: 
 
(i)
 Case notes. The case notes shall: 
 
(A)
 Be legible.

(B)
 Verify the necessity for the contact and
 reflect the goals and objectives of the intensive case management service
 plan.

(C)
 Include the date, time
 and circumstance of contacts, regardless of whether or not a billable service
 was provided.

(D)
 Identify the
 consumer by name or case number on both sides of each page on which there is
 writing on both sides. The consumer's name and case number should appear
 together earlier in the file.

(E)

 Be dated and signed by the individual providing the service.

(ii)
 Documentation of referral for
 other services.

(iii)
 Encounter
 forms.

(5)

Discharge information
. The following shall be included: 
 
(i)
 A termination summary, including a reason
 for admission to intensive case management, the services provided, the goals
 attained, the goals not completed and why and a reason for closure. The summary
 shall:
(A)
 Contain the signature of the
 consumer, the family if the consumer is a child, and involved others, if
 obtainable, to verify agreement of the termination.

(B)
 Contain the signature of the county
 administrator or designee if the consumer (or family, if the consumer is a
 child) does not consent to the termination.

(iii)
 A recommended after-care
 plan.

Notes

55

 Pa. Code §
 
5221.33

The
 provisions of this § 5221.33 adopted September 10, 1993, effective upon
 publication and apply retroactively to August 31, 1993, 23 Pa.B.
 4312.

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