Minnesota Administrative Rules

9520.0640 RESIDENT RECORDS.

Subpart 1.

Individual program plan development.

The mental health residential program staff shall, within ten days after admission, write short-term goals with each resident in order to address the resident's immediate needs. The program staff shall, within 30 days of admission, write an individual program plan which contains the components specified in subpart 2. Medical, social, psychological, and psychiatric histories of the resident shall be used in the development of the plan. The plan shall be developed by an interdisciplinary team including the resident, the program staff, a representative of the referring agency and other appropriate resources, such as family, concerned others, and health care providers requested by the resident. Each resident shall be actively involved in developing his or her plan, unless contraindicated. The persons involved in the development of the individual program plan shall be noted on the plan. The extent of the resident's participation in developing the program plan shall also be noted on the plan. The plan and documentation related to it shall be kept in the facility where the mental health program is located.

Subp. 2.

Plan contents.

An individual program plan shall contain at least the following components:

A.

an assessment, including a strength and need list, of the resident in at least the following areas of life: social, medical, legal, family, leisure and recreation, spiritual or religious, psychological, financial, vocational, and educational;

B.

the specific problems to be resolved;

C.

a list of goals in order of priority;

D.

specific, measurable, and time-limited objectives which relate directly to the goals;

E.

specific methods, strategies, and resources, including medications, to be used by the staff in assisting the resident to accomplish the goals and objectives;

F.

the names of community resource personnel, program staff, or other persons designated to assist the resident in implementing the various components of the plan; and

G.

notes indicating progress in achieving the goals and objectives.

Subp. 3.

Progress report.

A quarterly review of the resident's response to the individual treatment plan and his or her involvement in the facility's overall program shall be written. Copies of this report shall be given to the resident and shall be sent to the representative of the referring agency and other persons deemed appropriate by the program director and resident. The resident's level of participation in the development and the review of the report shall be documented. The report shall be kept at the facility.

Subp. 4.

Discharge or transfer summary.

A discharge or transfer summary shall be written for each person transferred or discharged. The summary shall include at least the following information:

A.

a brief review of the resident's problems, strengths, and needs while a resident of the program;

B.

the response of the resident to his or her individual treatment plan and to the facility's overall program;

C.

an aftercare plan which identifies the persons, including at least the resident, a program staff member, and a representative of the referring agency, who participated in the development of the aftercare plan; goals and objectives for the first three months after discharge or transfer; and individuals or agencies who will be working with the resident after discharge or transfer; and

D.

a forwarding address and telephone number for follow-up contacts.

Subp. 5.

Accidents and missing persons.

A copy of any report regarding accidents and missing persons must be documented in the individual's resident record if the resident is involved in the report.

Subp. 6.

Release of information.

Private data regarding a resident shall not be used or released by the facility to any person or agency, except pursuant to the Minnesota Government Data Practices Act. The facility shall use written consent forms for any release of resident information or data.

Statutory Authority:

MS s 245A.09

Published Electronically:

October 16, 2013