Section 22-A3907. REHABILITATION RECORDS AND DOCUMENTATION REQUIREMENTS

3907.1Each Clubhouse shall establish and adhere to policies and procedures for clinical and rehabilitative record documentation, security, and confidentiality of consumer and family information, clinical records retention, maintenance, purging and destruction, and for disclosure of consumer and family information, and informed consent that comply with applicable federal and District laws and regulations (Rehabilitation Records Policy). The Rehabilitation Records Policy shall:

 

(a)Require the Clubhouse to maintain all clinical and rehabilitative records in a secured and locked storage area; 

 

(b)Require the Clubhouse to maintain and secure a current, clear, organized, and comprehensive clinical and rehabilitative record for every individual assessed, treated, or served which includes information deemed necessary to provide treatment, protect the Clubhouse, or comply with applicable federal and District laws and regulations; and 

(c)Set forth requirements for documentation maintained in the clinical and rehabilitative record.

 

3907.2The following documents shall be included in the member’s clinical and rehabilitative record:

 

(a)current psychiatric evaluation;

 

(b) referral from a psychiatrist, psychologist, psychiatric APRN, LICSW, certified addictions professional or licensed practitioner of the healing arts recommending Clubhouse services;

 

(c) current annual treatment plan prepared by a CSA in accordance with the MHRS certification standards (Title 22A Chapter 34 Sections 3407 - 3408) (IRP) which includes a recommendation for Clubhouse services;

 

(d) a current annual rehabilitation plan completed by the Clubhouse, signed by the Clubhouse director or other qualified practitioner and reviewed quarterly;

 

(e)  identifying information about the consumer, including enrollment information;

 

(f) identification of a person to be contacted in the event of emergency;

 

(g) basic screening and intake information;

 

(h) advance instructions and advance directives; 

 

(i) methods for addressing consumers’ and families’ special needs, especially those which relate to communication, cultural, and social factors;

 

(j) detailed description of services provided;

 

(k) progress notes (as further described in subsections 3907.3 and 3907.4 below);

 

(l) discharge planning information;

 

(m) appropriate consents for service;

 

(n) appropriate release of information forms; and

 

(o)signed Consumer Rights Statement.

 

3907.3The Clubhouse staff shall write a daily progress note.  The daily progress note shall:

 

(a)describe the activities performed to enhance and/or support the member’s rehabilitation in social, educational, pre-vocational and transitional employment;

 

(b)describe what supportive interventions were used to improve a member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements;

 

(a) document the member’s response to the activities and interventions described in the progress note, including the choices and perceptions of the consumer regarding the service(s) provided; and

 

(d)be signed and dated by the staff member making the entry. 

 

3907.4Clubhouse staff shall write a monthly progress note that meets the requirements of Title 22A chapter 34 Subsection 3410.7.  A staff member with a CPRP shall countersign monthly progress notes made by credentialed staff.  If the monthly note is written by credentialed staff and the CPRP is not a Qualified Practitioner, the note must also be countersigned by a Qualified Practitioner. 

 

3907.5The Clubhouse shall provide the member’s referring CSA with a copy of the     member’s rehabilitation plan and the monthly progress notes. 

 

3907.6 The Clubhouse shall ensure that that all clinical and rehabilitative records of members are completed promptly, filed, and retained in accordance with the MHRS provider’s Rehabilitation Records Policy. 

 

3907.7The member’s referring CSA shall:

 

(a) Prepare a monthly progress note at the end of each month that:

 

(1) reflects how the services provided by the Clubhouse are linked to the goals and objectives of the member’s IRP and rehabilitation plan;

 

(2) describes the member’s progress relative to the IRP and the rehabilitation plan;

 

(3) describes the activities performed to enhance and support the member’s rehabilitation in social, educational, pre-vocational and transitional employment and what supportive interventions were used to improve the member’s potential for establishing and maintaining social relationships and obtaining occupational or educational achievements;

 

(4) is signed by a qualified practitioner employed by the CSA, who is responsible for coordinating services for the member and ensuring that all MHRS services, including Clubhouse services are delivered in accordance with the IRP; and

 

(5) is forwarded to the Clubhouse within ten (10) days of completion. 

 

(b) Provide the Clubhouse the member’s current IRP and any updates to the IRP.

 

authority

The Director of the Department of Mental Health (Department), pursuant to the authority set forth in sections 104, and 105 of the Department of Mental Health Establishment Amendment Act of 2001, effective December 18, 2001, (D.C. Law 14-56; D.C. Official Code §§ 7-1131.04 and 7-1131.05).

source

Emergency and Proposed Rulemaking published at 57 DCR 4010 (May 7, 2010)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 57 DCR 7734 (August 20, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 8698, 8704 (September 24, 2010).