N.Y. Comp. Codes R. & Regs. tit. 14 § 27.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 27.3 - Individual service plans

(a)General requirements.

Directors of facilities and their staff shall develop services which are commensurate with each patient's needs and well-being, the well-being of others, and are least restrictive to a patient's rights.

(b)Formulation of the plan.

Directors of facilities and their staff shall assure each patient the opportunity to participate to the fullest extent possible in the establishment and revision of his or her individual service plan, except in the case of those programs which comply with the requirements of section 27.2(g) of this Part. Integrated residential communities are required to comply with subdivision (f) of this section. An appropriate staff member of the facility shall note the nature of the participation in the patient's clinical record.

(c)Contents of plan.

Appropriate members of each facility's staff shall establish for each patient a written individual service plan. For outpatients, this plan shall include those elements below which are appropriate to the goals of service. For inpatients, the plan shall include:

(1) a comprehensive statement of the physical, psychological, social, economic, educational and vocational assets and disabilities stated in terms of performance and functional capabilities of the patient;

(2) a statement of the goals of the services to be provided, derived from and based on the statement of assets and disabilities and related to plans for return to the larger community; and

(3) a statement of the methods, procedures, techniques and activities to be provided towards the attainment of these goals; the statement shall identify the specific staff who will be involved in carrying out the several aspects of the plan.

(d)Periodic reviews.

Directors of facilities shall designate appropriate staff members to make periodic review of the functional assets and disabilities of the patient, and of the goals, methods and effects of services provided. In facilities for the mentally ill, the timing of the reviews shall be as stipulated in the utilization review plans of the facility. In facilities for the mentally retarded and developmentally disabled, the review shall be no less often than every six months, except in the case of those programs which comply with the requirements of section 27.2(g) of this Part. Integrated residential communities are required to comply with subdivision (f) of this section.

(e)Filing in patient's record.

The designated staff members of facilities shall include a copy of the service plan and a written report on the content and results of each review in the patient's clinical record. The written report should include the dates of resolution (or nonresolution) of specific problems.

(f)Program narrative.

Integrated residential communities are required to develop a narrative description for each client served in the program setting. The narrative shall include:

(1) a description of the individual's strengths and needs;

(2) an annual summary encompassing the client's activities and interests in all aspects of life, including work, home social/leisure, community involvement and family involvement wherein the resident's contribution to the program setting is described. The client's activities and role in the community will depend on his or her interests, skill development and community needs;

(3) a description of the approaches that will be used to address each identified need within the integrated 24-hour setting. Staff responsible for implementing components specified in the program narrative shall be identified;

(4) a means of identifying how the client's overall degree of independence, capacity for responsibility and involvement in the community has been facilitated or enhanced; and

(5) for clients who are receiving psychotropic medications, a full description of the reasons justifying the use of such medications and a specific program plan designed to eliminate the need for the use of said psychotropic medications.

(g)Program narrative review and update.

An integrated residential community creates a setting in which consistent, continuous and routine interaction occurs between program staff, who live and work with clients and the clients themselves. Review of the progress of individuals is therefore an ongoing, integral part of the program structure. A specific review or update of each individual's program narrative shall be required on an annual basis. All staff who are responsible for implementation of components of the program narrative shall participate in the annual review. More frequent reassessments of the individual's strengths and needs as part of the program narrative will formally occur only when necessary, as indicated by dramatic changes in client behavior or interest, or by staff concerns that warrant such reassessment.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 27.3

Amended, New York State Register, Volume XXXVI, Issue 22, effective 6/4/2014