International property

Residential Services agency

(a) The community residential rehabilitation service (CRRS) staff shall develop with each client an individualized written client residential service plan upon the client’s enrollment in the CRRS.

(b) The individual residential service plan must be based on the client’s psychosocial evaluation which is a functional assessment of the client’s strengths and needs in the major areas related to independence in residential and community functioning and addresses the client’s:

(1) Self-care skills.

(2) Health care, including medication management.

(3) Housekeeping skills.

(4) Ability to meet nutritional needs.

(5) Mobility.

(6) Money management skills.

(7) Interpersonal skills.

(8) Vocational/educational pursuits.

(9) Use of leisure time.

(10) Time structuring.

(11) Community participation such as social networking and utilization of services and resources.

(c) The residential service plan must include the following items:

(1) Short and long-term goals for service formulated jointly by the staff and client.

(2) Behaviors to be modified and skills to be developed.

(3) Type and frequency of rehabilitation services to be provided.

(4) Techniques and methods of service to be used.

(5) A list of persons involved in the implementation of the plan.

(d) The CRRS staff shall evaluate the client’s adjustment to the program within 30 days of enrollment and modify the service plan as needed. The residential service plan must be reviewed and updated every 60 days thereafter.

(e) Each client in a CRRS must spend a major portion of his time out of the residence. The goal of such involvement outside the residence is to increase the client’s use of community resources and participation in community activities which the client can continue to use upon program termination. The method for achieving this goal must be reflected in each client’s residential services plan.

(f) The client shall participate in the goal-setting, service planning, decision-making and progress assessment associated with the service plan.

(g) The original residential service plan, subsequent plan revisions, written plan reviews and documentation of client participation must be included in the client record.

(h) At the time of enrollment into CRRS and throughout the service period, each client shall be assigned to a CRRS staff person who is responsible for assuring:

(1) In-residence services are provided according to the client’s residential service plan.

(2) Referrals to and arrangements for service provision by other agencies specified in the client’s residential service plan occur and are coordinated with the agency or agencies responsible for treatment/case management of the client, such as the Mental Health/Mental Retardation Base Service Unit, Veterans’ Administration, Domiciliary Care, and therapist.

(3) Case recording of intake information, service plan, progress notes, service plan reviews, annual reassessment, referrals, and termination summary.

(i) A complete reassessment of the client’s strengths and needs as determined by the psychosocial evaluation and a review of the services provided to the client must be performed annually, or more frequently if a significant change in the client’s level of functioning occurs. The reassessment must take place at a conference which includes the persons involved in the individual service plan development and implementation. The results of this meeting must be documented in the case record and submitted in writing to the agency or agencies responsible for treatment and/or case management of the client.

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