Section 132.148   Evaluation and Planning

 

a)         Mental health assessment is a formal process of gathering information regarding a client's mental and physical status and presenting problems through face-to-face, video conference or telephone contact with the client and collaterals, resulting in the identification of the client's mental health service needs and recommendations for service delivery.  A diagnosis of mental illness is not required prior to beginning a mental health assessment.

 

1)         A mental health assessment is required prior to the development and implementation of an ITP.  A mental health assessment is not required prior to the initiation of crisis services described in Section 132.150(b) and case management services described in Section 132.165(a)(1).

 

2)         The provider shall complete a mental health assessment report within 30 days after the first face-to-face contact.  When a client is hospitalized for crisis services, the first face-to-face contact shall be the initial contact following discharge from the hospital.

 

3)         A written mental health assessment report shall be a compilation of the following:

 

A)        Identifying information: name, gender, date of birth, primary method of communication;

 

B)        Extent, nature, and severity of presenting problems;

 

C)        DSM-IV or ICD-9-CM diagnosis;

 

D)        Family history, including the history of mental illness in the family;

 

E)         Mental status evaluation, including, at a minimum, attention, memory, information, attitudes, perceptual disturbances, thought content, speech, affect, suicidal or homicidal ideation, and an estimation of the ability and willingness to participate in treatment;

 

F)         Client preferences relating to services and desired treatment outcomes;

 

G)        Personal history, including mental illness and mental health treatment;

 

H)        History of abuse/trauma (childhood sexual or physical abuse, intimate partner violence, sexual assault or other forms of interpersonal violence);

 

I)          Present level of functioning, including social adjustment and daily living skills;

 

J)         Legal history and status, including guardianship and current court involvement;

 

K)        Assessment of risk, including the identification of factors that may endanger either the client or the client's family and other immediate threats to the client's personal safety (e.g., gang involvement, domestic violence, elder abuse);

 

L)         Education, specialized training, and vocational skills;

 

M)       Employment history;

 

N)        Interests, activities and hobbies;

 

O)        History of current alcohol or other substance use, abuse or dependence;

 

P)         Name and contact information of the client's primary care physician;

 

Q)        Previous and current psychotropic medications, including date of most recent psychiatric evaluation;

 

R)        General physical health, including date of last physical examination, any known symptoms or complaints, and current medications not noted in subsection (a)(2)(Q), including over-the-counter medications;

 

S)         Resources such as family, community, living arrangements, religion, and personal client strengths; and

 

T)         Summary analysis, conclusions and recommendations for specific Part 132 services.

 

4)         An admission note may be used to initiate services prior to the completion of a mental health assessment for a client who is admitted to a specialized substitute care living arrangement; a residential facility designated by the public payer for the purpose of stabilizing a crisis; or ACT prior to the completion of a comprehensive assessment as required in Section 132.150(i)(2)(A).  An Admission Note must be completed within 24 hours after a client's admission and is effective for a maximum of 30 days.

 

A)        The Admission Note is a written report of an initial assessment and treatment plan and shall include the following:

 

i)          Identifying information: name, gender, date of birth, primary language or method of communication, date of initiating assessment;

 

ii)         Client's current mental health functioning level;

 

iii)         Provisional diagnosis;

 

iv)        Pertinent history;

 

v)         Precautions (e.g., suicidal risk, homicidal risk, flight risk) and special programming to meet the client's needs;

 

vi)        Initial treatment plan, including a list of Part 132 services that will be provided and the staff responsible for those services; and

 

vii)        Other relevant information.

 

B)        An Admission Note shall be completed by at least an MHP following a face-to-face or video conference meeting with the client.

 

C)        A QMHP shall be responsible for approving the completed Admission Note as documented by the QMHP's dated signature on the Admission Note.

 

            5)         A QMHP who has had, at a minimum, one face-to-face or video conference contact with the client shall be responsible for the completed mental health assessment report as documented by his/her dated signature on the mental health assessment.  MHPs may participate in the mental health assessment.

 

6)         The client's family or guardian may participate in the mental health assessment during which the family will be given the opportunity to provide pertinent information or support.  Participation by the family and other interested persons must be in accordance with the Confidentiality Act and HIPAA.

 

7)         The mental health assessment report shall be reviewed and approved by the LPHA as documented by the LPHA's dated signature on the mental health assessment.  The LPHA shall determine in writing if any additional evaluations are required to assess the client's functioning or service needs.

 

8)         The mental health assessment shall be updated annually by the QMHP who has, at a minimum, one face-to-face contact with the client prior to the completion of the updated mental health assessment.  The annual update must occur within 12 months after the LPHA's signature on the mental health assessment report or the previous update.  The QMHP shall be responsible for the completed update as documented by his or her dated signature on the updated mental health assessment.  The LPHA shall review and approve the assessment as documented by the LPHA's dated signature on the updated mental health assessment.  MHPs may participate in the mental health assessment update.

 

9)         For services initiated by an Admission Note, the provider shall complete a mental health assessment report or a comprehensive assessment for an ACT client within 30 days after the client's admission.

 

10)         The annual update of the mental health assessment shall minimally include all requirements specified under subsection (a)(3) with the exception of requirements listed under subsections (a)(3)(A), (D), (G) and (H).  Providers may include requirements under subsections (a)(3)(A), (D), (G) and (H) as medically necessary and clinically indicated as part of the mental health assessment update.  Providers may also indicate "no change" where applicable on the mental health assessment update if there has been no change in status.

 

b)         A psychological evaluation, if recommended, shall:

 

1)         Be conducted within 90 days after completion of the ITP and documented by the provider consistent with the Clinical Psychologist Licensing Act [225 ILCS 15] using nationally standardized psychological assessment instruments; a master's level professional may assist;

 

2)         Be conducted face-to-face or video conference with the client; and

 

3)         Result in a written report that includes a formulation of problems, tentative diagnosis and recommendations for treatment or services.

 

c)         Treatment plan development, review and modification is a process that results in a written ITP, developed with the participation of the client and the client's parent/guardian, as applicable, and is based on the mental health assessment report and any additional evaluations.  The ITP is also known as a rehabilitation treatment plan or a recovery treatment plan.  Active participation by the client and/or persons of the client's choosing, which may include a parent/guardian, is required for all ITP development, whether it is the initial ITP or subsequent reviews and modifications.  Participation by the client or parent/guardian shall be documented by the client's or parent's/guardian's signature on the ITP.  In the event that a client or a client's parent/guardian refuses to sign the ITP, the LPHA, QMHP or MHP shall document the reason for refusal and indicate by his or her dated signature on a progress note that the ITP was reviewed with the client and that the client or his or her parent/guardian refused to sign the ITP.

 

1)         The initial ITP shall be completed within 45 days after the completion of the mental health assessment as documented by the LPHA's dated signature on the ITP.  When an Admission Note was completed to initiate services, the ITP shall be developed, following the completion of a mental health assessment, within 30 days after the client's date of admission.

 

2)         A written ITP is a compilation of the following:

 

A)        The goals/anticipated outcomes of services;

 

B)        Intermediate objectives to achieve the goals;

 

C)        The specific Part 132 mental health services to be provided;

 

D)        The amount, frequency and duration of Part 132 services to be provided; and

 

E)         Staff responsible for delivering services.

 

3)         The ITP shall include a definitive diagnosis that has been determined for all five axes in the DSM-IV or the ICD-9-CM.  If the diagnosis cannot be determined by the time the ITP is completed or a rule out diagnosis is given, the client's clinical record must contain documentation as to what evaluations will occur in order to provide a definitive diagnosis in the ITP.  A diagnosis shall be determined within 90 days and the ITP shall be modified to reflect the diagnosis, as necessary.

 

4)         Responsibility for development, review and modification of the ITP shall be assumed by a QMHP as documented by his/her dated signature on the ITP.  MHPs may participate in the development of the ITP.  An LPHA shall provide the clinical direction of mental health services identified in the ITP as documented by his/her dated signature on the ITP.

 

5)         The LPHA and the QMHP shall review the ITP no less than once every 6 months to determine if the goals set forth in the ITP are being met and whether each of the services described in the plan has contributed to meeting the stated goals.  The ITP shall be modified if it is determined that there has been no measurable reduction of disability or restoration of functional level.

 

6)         The ITP review shall include continuity of care planning with the client or the client's parent/guardian.  The ITP review shall also include an estimated transition or discharge date and identify goals for continuing care.

 

7)         The results of crisis assessments, reassessments or additional evaluations after the client's ITP is completed shall be incorporated into a modified ITP, if appropriate, within 30 days.

 

8)         The provider shall explain to the client and/or persons of the client's choosing, which may include a parent/guardian, as applicable and as evidenced by a signed and dated statement by the provider and the client or parent/guardian, the process for the development, review and modification of the contents of the ITP. 

9)         The ITP and all its revisions shall be signed by the parent or guardian if the client is under 12 years of age.  If the client is 12 through 17 years of age, the ITP shall be signed by the client and by the parent/guardian, as applicable, unless the client is an emancipated minor.  A client 18 years of age or older or an emancipated minor shall sign the ITP.  If the client is 18 years of age or older and has been adjudicated as legally incapable, the ITP shall be signed by the legally appointed guardian. 

 

10)         A copy of the signed ITP shall be given to the client, if not clinically contraindicated, and the client's parent/guardian, as applicable.  The ITP and documentation that the signed ITP has been provided to the client or parent/guardian, or proof of clinical contraindication, shall be incorporated into the client's clinical record.

 

11)         Commencement of Services

 

A)        Mental health services may be provided concurrently with ITP development if:

 

i)          The mental health assessment report is completed, signed and dated by the LPHA or the Admission Note is signed and dated by the QMHP;

 

ii)         The service is recommended as medically necessary on the completed mental health assessment; and

 

iii)         The services provided are included in the completed ITP, signed by an LPHA within the designated time frame.

 

B)        If services are provided prior to completion of the ITP, and the client terminates services before the ITP is completed and signed, the provider must complete the ITP and document that the client terminated services and was unavailable to sign the ITP.

 

(Source:  Amended at 32 Ill. Reg. 9981, effective July 1, 2008)