65E-4.014. Standards for Client Records, Treatment and Quality Assurance

(1) Introduction – This chapter establishes client record, treatment and quality assurance standards for mental health clients receiving state supported services from community mental health providers, exclusive of alcohol and drug abuse services, throughout Florida.

(2) Definitions – The definitions provided in this section are limited to this Rule 65E-4.014, F.A.C.

(a) CCMS – The Department of Children and Family Services Continuity of Care Management System as described in Section 394.4573, F.S.

(b) Screening – The preliminary determination of the type, extent and immediacy of the service needs of the individual seeking help.

(c) Intake – The determination of a client’s service and treatment needs.

(d) Evaluation – A specific study of a client’s pertinent functional areas such as socioeconomic, cultural, medical, psychological, psychiatric, educational, vocational, and environmental. This information is necessary to determine a client’s problems and the services needed.

(e) Assessment – The determination of a client’s current and potential strengths, problems and needs, by utilizing current intake, diagnosis and evaluation information in order to identify service needs.

(f) Planning – The development of a client’s service plan or treatment plan which includes an assessment, the setting of client goals, and the identification of necessary services and resources, based upon identified needs.

(g) Quality Assurance Program – A systematic approach designed to evaluate the quality of care of an agency on an ongoing basis and to promote and maintain efficient, effective mental health services.

(h) Utilization Review – A case-by-case assessment of the utilization of an agency’s services as recorded in client records.

(i) Peer Review – Review of staff members’ professional work by a comparably trained and qualified individual performing similar tasks, taking into account client characteristics, accuracy of assessment, appropriateness of treatment, duration of treatment, adequacy of planning, and relevant follow-up procedures.

(j) Case Management – Activities aimed at assessing client needs, planning services, linking the service system to a client, coordinating the various system components, monitoring service delivery and evaluating the effects of service delivery.

(k) Primary Therapist or Treatment Coordinator – The provider’s treatment staff member responsible for the coordination of treatment and services to the client who is not assigned a CCMS case manager due to not meeting CCMS priority criteria.

(l) Rehabilitation – An education-based process which provides the opportunities for mentally ill persons to attain the physical, emotional and intellectual skills needed to function successfully in living, learning, work and social environments. The process includes developing the resources needed to support or strengthen clients’ ability to function in these environments.

(m) Service Provider or Provider or Agency – Any agency under contract with the Department of Children and Family Services, in which all or any portion of the program or services set forth in Section 394.675, F.S., are carried out.

(n) Service Plan – The document developed with the CCMS client by the case manager which depicts goals or objectives for the attainment of services and resources. For non-CCMS clients, service or resource goals or objectives may be established on the treatment plan or on a separate service plan.

(o) Treatment – Services, provided to persons individually or in groups, which include rehabilitation, counseling, supportive therapy, chemotherapy, psychotherapy or any other accepted therapeutic, educational or supportive process.

(p) Treatment Plan – An individual document or identifiable section of the service plan developed by treatment staff and the client which depicts goals or objectives for the provision of services within specific treatment environments. Examples of treatment environments include but are not limited to day treatment, vocational, residential, outpatient and activities of daily living programs.

(3) Client Record System.

(a) A service provider must develop an individualized record for each client it serves except for those clients seen on a brief emergency basis, and for whom no further services are indicated. The detail and comprehensiveness of each record will depend upon the amount of contact the agency has with the client. The information in subparagraphs 65E-4.014(3)(b)1. and 9., F.A.C., must be obtained for every client. The necessity for all other information will vary depending upon the service needs of the client.

(b) Record Information – The provider must obtain from or develop for each client it serves the following information:

1. Name, address, telephone number, marital status, sex, race, date of birth, names and addresses of client’s next of kin or guardian, referral source, presenting problem and financial eligibility information as specified by the department,

2. The name of the individual having primary responsibility for the client’s treatment,

3. Assessment information,

4. Information on results from diagnosis and evaluation,

5. Service plan,

6. Progress notes,

7. Medication profile,

8. As necessary, a time-specific statement authorizing release of confidential information, signed and dated by the client or guardian, which designates the agency to receive the information,

9. Termination reports,

10. Treatment plan and treatment plan updates; and,

11. Legal status.

(c) Progress notes, activity notes or status reports shall be prepared at least monthly for clients having a service plan or treatment plan unless the plan indicates less frequent need. Content shall include:

1. Dates of contact with client, and as needed, client’s family, friends, and involved service or resource agencies,

2. Description of client progress, or lack thereof, relative to the service plan or treatment plan; and,

3. Description of any modification to the service plan or treatment plan resulting from such factors as changes in client’s needs, changes in resources and new assessment findings.

(d) Termination Reports – A termination report must be filed in the record within 4 weeks after official termination of services. For clients not requiring additional services and for whom services are being terminated, the report shall contain the following:

1. Reason for termination – Non-CCMS cases with no contact over a 90-day period must be closed or terminated except in those cases where the service plan or treatment plan does not indicate the need for such frequent contact. Examples of reasons to close a case are refusal of services, no longer in need of services, referred to another agency, left the area and deceased,

2. Evaluation of impact of agency’s services on each client’s service plan or treatment plan goals or objectives,

3. Signature of individual preparing report and date of preparation; and,

4. For a client whose case is being closed and who is being referred to another agency for further services that are not provided by the referring agency, the report must also include the reason for referral.

(e) Policies and Procedures for Client Records – Service providers shall have written policies and procedures regarding client records which insure the following:

1. Client records are current and accurate,

2. Client records are stored in a locked room or container,

3. The information in client records is safeguarded against loss, defacement, tampering or use by unauthorized persons,

4. Confidentiality of the information contained in a client’s record and communication between staff members and clients is protected as stated in subsection 394.4615, F.S., and Rule 65E-5.038, F.A.C.,

5. Records shall be removed from the jurisdiction and safekeeping of the provider only in accordance with written policies and procedures as required by law,

6. Training in verbal and written confidentiality requirements is provided to all staff as part of new staff orientation and ongoing staff development,

7. There is a master filing system which includes a comprehensive record of each client’s involvement in every aspect of the program,

8. Client records are maintained minimally for 7 years after the date of the last entry,

9. The client record system is directed, staffed and equipped to facilitate processing, checking, indexing, filing, retrieval and review of all client records; and,

10. There is adequate space, equipment and supplies, compatible with the needs of the client record services to enable the personnel to function effectively and to maintain client records readily accessible.

(4) Screening and Intake Procedures – Providers must have written screening and intake procedures which minimally assure that:

(a) A single telephone number is established that is manned 24 hours daily, 7 days per week through which a client may secure information and referral for initial intake with an appropriate provider;

(b) Upon initial request for service, a screening is done to determine the immediacy of the client’s needs;

(c) Screening services are conducted by staff members specifically trained to perform this function, in order to ascertain the appropriateness of the agency’s services to meet the needs of the client;

(d) For cases determined to be non-emergency, initial intake services are offered as immediately as appropriate to meet the needs of the client;

(e) When the services offered by the agency are found to be inappropriate for the needs of a potential client, the agency shall secure a timely referral for the person to a more appropriate agency or service and make all reasonable efforts to confirm that the client has been accepted for service. If no referral is established, the agency shall, with the consent of the client, notify Children and Family Services district CCMS staff to assist them in identifying service gaps in the community;

(f) During the intake process, all potential clients have explained to them the nature of the services offered, the procedures, fees, and hours involved, and their choices, rights, and responsibilities while receiving services; and,

(g) A smooth and effective transition occurs from intake to initiation of services. For clients who are not eligible for assignment to a CCMS case manager, a primary therapist or treatment coordinator must be assigned.

(5) Evaluation Procedures – Each agency will have a written procedure describing the process whereby evaluation services will be initiated and completed for clients.

(6) Assessment and Treatment Plan Development – The assessment and treatment plan must be completed, and the actions specified in the plan must be initiated for each active client within 30 days after completion of intake.

(a) The assessment must, with input from the client, include:

1. Description and evaluation of presenting problem,

2. Information from the intake and evaluation; and,

3. Description of the client’s current and potential strengths and problems, the client’s family and friends, pertinent service agencies with whom the client has been involved, and other social support systems that may contribute to the course of treatment.

(b) Treatment plan goals or objectives must be derived from the initial assessment of the client’s needs and strengths.

1. Each goal or objective must be developed with the client, be achievable, have a reasonable time frame for achievement and be stated in terms of observable and measurable outcomes.

2. For each goal or objective, the actions needed to attain that goal and the responsible individual or individuals must be listed.

3. A minimum of one goal or objective shall be developed with the client for each treatment environment serving the client. Social programs, networks and clubs are exempt from this requirement.

4. For clients who are assessed to be in need of services or resources external to the provider and who do not meet CCMS criteria for the assignment of a case manager, externally related service or resource goals or objectives shall be developed by the primary therapist or treatment coordinator on either the treatment plan or service plan.

a. If the agency does not offer the services needed, the primary therapist for the non-CCMS client must refer and link the client to appropriate agencies which provide the needed services. A copy of the relevant parts of the service plan or treatment plan and other relevant client information shall be submitted to referral agencies when authorized by the client or guardian.

b. If the service needed is not available in the community, this information shall be reported to district CCMS staff.

5. Dates and results of follow-up contacts by the primary therapist must be entered into the client record.

(7) Quality Assurance Program, including Utilization and Peer Review Systems.

(a) Service providers are required to have an established, ongoing quality assurance program.

(b) Each service provider must describe in writing its quality assurance program to include:

1. Composition of review committees,

2. Procedures to be followed in reviewing cases,

3. Criteria and standards used in the review process and procedures for their development; and,

4. Procedures to be followed to assure dissemination of the results.

Rulemaking Authority 394.78 FS. Law Implemented 394.4573, 394.75, 394.78 FS. History–New 11-3-82, Formerly 10E-4.14, Amended 4-20-89, 5-23-96, Formerly 10E-4.014, Amended 12-20-98.