Chapter 10: Assessment and Planning

10.1 Overview

The provider must ensure that appropriate assessment and planning policies and procedures are in place, so that each participant receives the maximum benefit from the CRS program.

The services for CRS are individualized to ensure that a participant gets the maximum benefit identified in the service arrays and the variety of processes described in this manual.

10.2 Assessment

Each staff member of the interdisciplinary team (IDT), as appropriate, assesses a participant's abilities and limitations in relation to that staff member's area of expertise. The case manager writes a report of the assessments within two weeks of a participant's admission into the program. Each member of the IDT receives a copy of the report. Discharge planning utilizing the wraparound approach should be completed during the assessment and ongoing during IDT meetings.

The assessment of the participant must address each of the following areas:

  • Specific developmental strengths and participant preferences
  • Specific functional and adaptive social skills that the participant acquires from treatment
  • Presenting disabilities and, when possible, their causes
  • Need for services (without regard to their availability)
  • Preauthorization of benefits
  • Medical or physical history, or both
  • Nutritional status including determining the appropriate diet, the adequacy of the participant’s total food intake, the participant’s eating skills, including disorders related to chewing, sucking, and swallowing disorders, the food service practices, and the participant’s ability to monitor and supervise their own nutritional status
  • Social history
  • Mental health needs
  • Substance misuse needs
  • Ability to self-administer medication
  • Cognitive status
  • Activities of daily living, as follows:
    • Bathing and showering
    • Dressing
    • Self-feeding
    • Functional mobility
    • Personal hygiene and grooming
    • Toilet hygiene
    • Managing money
    • Shopping for groceries or clothing
    • Using the phone or other form of communication
    • Using technology
    • Transportation within the community
  • Mobility
  • Behavior
  • Communication
  • Required level of supervision
  • Avocational skills
  • Ongoing support needs
  • Access to public benefits, including the Supplemental Nutritional Assistance Program
  • Initial discharge plan
  • Recommended course of treatment, duration and frequency of therapy and how progress will be tracked and monitored.

10.3 Development of Individualized Program Plan

The Individualized Program Plan (IPP) is based on the findings of the assessment and must address all deficit areas noted therein. All planned and needed services for the participant must be documented in the IPP. All interdisciplinary team (IDT) members must participate in developing the IPP, and must document their participation as shown by their attendance on sign-in sheets with signatures. The IDT meets to develop the IPP after the assessment is completed, but no later than 30 days after a participant's admission to the program. After the initial IPP is developed it must be reviewed every 30 days unless otherwise specified for a specific service array. The CRS counselor and the participant's representative, if applicable, are notified at least one week in advance about the date, time, and location of the IPP review meeting.

The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the participant's needs. The IDT reaches decisions as a team, rather than individually, about how best to address the participant’s needs. Everyone involved in the participant's care must work together to provide a uniform and consistent approach to implementation of the IPP.

Note: The word participate means to provide input through whatever means is necessary to ensure that the participant's IPP meets the participant's needs.

The IPP must identify means to prevent or slow regression and prevent the loss of current optimal functional status.

The IPP must include opportunities for participant choice and self-management and identifies the following:

  • Assessments performed by licensed professionals in the areas of service, including but not limited to occupational therapy, physical therapy, speech therapy, cognitive rehabilitation therapy, neuropsychological, or other assessments used to develop and provide therapy services.
  • The frequency and duration of therapy services (as noted in the recommendations section of the assessments), if the assessments indicated that services are warranted.
  • The goals and objectives to be met, including long-and short-term goals that are stated in measurable terms and that relate to increasing a participant's ability to live more independently.
  • The team member who will implement the plan and the specific strategies that will be used.

The provider must provide a copy of the assessment report and the IPP to the CRS program staff member within 10 working days of the IPP meeting. A copy is made available to the participant and to the participant's representative. The results of the assessment and the IPP may be combined into a single report, signed by all pertinent IDT members (as applicable).

Each participant must receive a continuous program of needed interventions and services in sufficient intensity and frequency to support the achievement of the IPP objectives. Except for those facets of the IPP that must be implemented only by licensed personnel, each participant’s IPP must be implemented by all staff members who have been trained to work with the participant, including professional and paraprofessional staff members.

10.4 Interdisciplinary Team Meetings

The interdisciplinary team (IDT), at a minimum, must include the:

  • CRS counselor;
  • participant;
  • participant’s representative or advocate (if applicable);
  • professional staff appropriate to the participant’s needs;
  • professional staff currently providing services or planned to provide services, provider case manager; and
  • any community resources such as family members, friends, or people invited by the participant, and community resource providers.

The Interdisciplinary team meeting is also known as a medical team conference and can occur with or without the participant or family member. The expectation is to always include the participant, family member or both, unless extenuating circumstances prevents them from attending. Attendance and participation in the IDT meetings by such IDT members must be documented. Professionals must add their credentials to the signatures.

For example, if a participant is experiencing health problems, their nurse would attend the IDT meeting, or the participant may ask their best friend to participate in the IDT meeting.

The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the participant’s needs. The IDT reaches decisions as a team, rather than individually, about how best to address the participant’s needs. Everyone involved in the participant’s care must work together to provide a uniform and consistent approach to implementation of the IPP.

  • Meetings formally occur every 30 days to develop and review measurable goals and objectives;
  • review a participant’s progress or lack of progress in attaining the goals and objectives;
  • review the efficacy of the services being provided;
  • determine whether to change the participant’s goals, objectives, and timelines and the persons designated as responsible; and
  • review and assess on-going discharge plan and identify needs.

The CRS counselor, the participant, and the participant’s representative or advocate must be notified in writing of the date, time, and location of all IDT meetings at least one week in advance.

The results of the IDT meeting must be documented in a written report. A copy of the report is provided to the CRS counselor within 10 working days after the meeting. A copy must be made available to the participant or the participant’s representative.

In addition to holding the required meeting every 30 days, the IDT must meet as frequently as prudent and necessary, based on need, to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary. Meetings must provide enough time for the participant to ask questions to ensure the participant or family members understanding of the treatment plan.

10.5 Behavior Management Plans

Behavior management plans are developed and monitored by licensed professionals or board certified professionals to address behaviors, to ensure the participant can obtain maximum gains from services being delivered. Plans may include therapeutic medication, interventions that include positive reinforcement, verbal cues and rewards.

If restrictive procedures, such as the use of routine, sedative, or psychotropic medications to control behavior, the removing or restricting of access to personal property, and the use of restraint are used as a behavior modification technique, the provider's policies and procedures must clearly state when and how the procedures are implemented.

In the case of participants who are minors or persons who are incapacitated, as determined by a court, informed consent for use of restrictive programs, practices, or procedures must be obtained from the participant’s legal guardian or representative (see 9.3 Participant Information), in accordance with state law, to act on behalf of the participant.

Informed consent, signed by the participant or the participant’s representative, for restrictive procedures must be indicated on a separate document from the general programmatic consents obtained when a participant enters the program. The consent lists the risks and benefits of the restrictive interventions and states how the restrictive interventions are monitored and faded.

Standing or as-needed programs to control inappropriate behavior are not permitted. All interventions addressing the control of inappropriate behaviors must be justified by the assessment and the participant’s current level of behavior.

A behavior management plan:

  • must be developed and signed by a licensed professional (see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications for provider qualifications);
  • must identify the triggers and prevention strategies that are incorporated into the plan;
  • must be reviewed and approved by the interdisciplinary team (IDT) member and CRS counselor, as indicated by an attendance sheet with the IDT members’ signatures and a short summary of the team’s discussion before the plan is implemented by the IDT;
  • must be written in a manner that can be understood by the participant and staff;
  • must provide evidence that staff members were trained before implementing the behavior management plan;
  • must indicate that a licensed professional must oversee the staff members who implement the plan; and
  • must be incorporated into the participant’s Individualized Program Plan.

10.6 Emergency Restrictive Procedures

Emergency restrictive procedures are the least-restrictive procedures possibly used for the briefest time necessary to control severely aggressive or destructive behaviors that place the participant or others in imminent danger and when those behaviors could not have been reasonably anticipated. Emergency restrictive procedures are used only as necessary within the context of positive behavioral programming.

Each time a participant is restrained, a written report must document the details of the incident. This written report must be filed in the participant’s file maintained by the provider. The participant’s interdisciplinary team (IDT) must review each report by the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.

The provider may use restraint as an emergency measure only if necessary to protect the participant or others from injury.

The provider's policy must include providing training on the appropriate procedures and techniques for physical restraint to staff members who have direct contact with participants. The procedures must clearly indicate the training required for all staff members at hire and at least annually thereafter.

The use of restraints to control inappropriate behavior:

  • must be approved by the IDT, noted in the participants’ s Individualized Program Plan (IPP), and agreed to by the CRS counselor, as indicated by an attendance sheet with the CRS counselor’s and IDT members’ signatures and a short summary reflecting team discussions;
  • must be used only as an integral part of the participant's IPP and specifically to reduce and eventually eliminate the behaviors for which the restraint, drugs or both are employed;
  • must be monitored by the IDT closely in conjunction with the physician to ensure appropriateness, desired responses and adverse consequences;
  • must be justified in that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the restraint; and
  • must be part of a developed plan that includes less-restrictive interventions to address behaviors that require more than two physical or chemical restraints in 30 days.

If chemical or physical restraints are used more than twice in 30 days, or more than once in 30 days for minors, the IDT must meet to discuss changing the participant’s treatment to address behaviors that place the participant or others at risk. Changes must be made to treatment approaches, treatment goals and strategies, and behavior management strategies must be developed.

If restraints are required to participate in the program, the IDT must determine whether the program is in the participant’s best interest or whether the participant should be discharged from the program.

The CRS counselor must be notified within 48 hours after restraint is used.
Documentation of the IDT meeting must indicate the modifications made to the treatment plans or treatment approaches. Efficacy of this intervention should be reflected in data and decreasing trends in the use of emergency restrictive procedures.

10.7 Substance Abuse

If the CRS participant has a substance abuse disability and there are observations or other evidence of the use of alcohol or drugs, the provider must report the observations and evidence immediately to the CRS counselor. The provider must document that the counselor was informed and document all observations and other evidence of the participant's use of alcohol or drugs. Chemical dependency services must be delivered to the participant.  

Chemical dependency services must:

  • be provided based on assessed needs;
  • be developed and approved by the interdisciplinary team; and
  • become part of the participant’s Individualized Program Plan.