59A-36.020 Limited Mental Health – Records | FL

RECORDS.

(a) A facility with a limited mental health license must maintain an up-to-date admission and discharge log containing the names and dates of admission and discharge for all mental health residents. The admission and discharge log required in rule 59A-36.015, F.A.C., satisfies this condition provided that all mental health residents are clearly identified.

(b) Staff records must contain documentation that designated staff have completed limited mental health training as required by rule 59A-36.011, F.A.C.

(c) Resident records must include:

1. Documentation, provided by a mental health care provider within 30 days of the resident’s admission to the facility, that the resident is a mental health resident as defined in section 394.4574, F.S., and that the resident is receiving social security disability or supplemental security income and optional state supplementation as follows:
2. An affirmative statement on the Alternate Care Certification for Optional State Supplementation (OSS) form, CF-ES 1006, October 2005, which is hereby incorporated by reference and available for review at: http://www.flrules.org/Gateway/reference.asp?No=Ref-03988, that the resident is receiving SSI or SSDI due to a mental disorder,
3. Written verification provided by the Social Security Administration that the resident is receiving SSI or SSDI for a mental disorder. Such verification may be acquired from the Social Security Administration upon obtaining a release from the resident permitting the Social Security Administration to provide such information, or
4. A written statement from the resident’s case manager or other mental health care provider that the resident is an adult with severe and persistent mental disorder. The case manager or other mental health care provider must consider the following minimum criteria in making that determination:

(I) The resident is eligible for, is receiving, or has received mental health services within the last 5 years, or

(II) The resident has been diagnosed as having a severe or persistent mental disorder.

2. An appropriate placement assessment provided by the resident’s mental health care provider within 30 days of admission to the facility that the resident has been assessed and found appropriate for residence in an assisted living facility. Such assessment must be conducted by a psychiatrist, clinical psychologist, clinical social worker, psychiatric nurse, or an individual supervised by one of these professionals.
3. Any of the following documentation that contains the name of the resident and the name, signature, date, and license number, if applicable, of the person making the assessment, meets this requirement:

(I) Completed Alternate Care Certification for Optional State Supplementation (OSS) form, CF-ES Form 1006,

(II) Discharge Statement from a state mental hospital completed no more than 90 days before admission to the assisted living facility provided it contains a statement that the individual is appropriate to live in an assisted living facility, or

(III) Other signed statement that the resident has been assessed and found appropriate for residency in an assisted living facility.

1. A mental health resident returning to a facility from treatment in a hopsital or crisis stabilization unit will not be considered a new admission and will not require a new assessment. However, a break in a resident’s residency that requires the facility to execute a new resident contract or admission agreement will be considered a new admission and the resident’s mental health care provider must provide a new assessment.
2. A Community Living Support Plan. Each mental health resident and the resident’s mental health case manager must, in consultation with the facility administrator, prepare a plan within 30 days of the resident’s admission to the facility or within 30 days after receiving the appropriate placement assessment in paragraph (2)(c), whichever is later, that:
3. Includes the specific needs of the resident that must be met in order to enable the resident to live in the assisted living facility and the community,
4. Includes the clinical mental health services to be provided by the mental health care provider to help meet the resident’s needs, and the frequency and duration of such services,
5. Includes any other services and activities to be provided by or arranged for by the mental health care provider or mental health case manager to meet the resident’s needs, and the frequency and duration of such services and activities,
6. Includes the obligations of the facility to facilitate and assist the resident in attending appointments and arranging transportation to appointments for the services and activities identified in the plan that have been provided or arranged for by the resident’s mental health care provider or case manager,
7. Includes a description of other services to be provided or arranged by the facility,
8. Includes a list of factors pertinent to the care, safety, and welfare of the mental health resident and a description of the signs and symptoms particular to the resident that indicate the immediate need for professional mental health services,
9. Is in writing and signed by the mental health resident, the resident’s mental health case manager, and the assisted living facility administrator or manager and a copy placed in the resident’s file. If the resident refuses to sign the plan, the resident’s mental health case manager must add a statement that the resident was asked but refused to sign the plan,
10. Is updated at least annually or if there is a significant change in the resident’s behavioral health,
11. May include the Cooperative Agreement described in subparagraph (2)(c)4. If included, the mental health care provider must also sign the plan; and,
12. Must be available for inspection to those who have legal authority to review the document.
13. Cooperative Agreement. The mental health care provider for each mental health resident and the facility administrator or designee must prepare a written statement, within 30 days of the resident’s admission to the facility or receipt of the resident’s appropriate placement assessment, whichever is later. The statement:
14. Provides procedures and directions for accessing emergency and after-hours care for the mental health resident. The provider must furnish the resident and the facility with the provider’s 24-hour emergency crisis telephone number;
15. Must be signed by the administrator or designee and the mental health care provider, or by a designated representative of a Medicaid prepaid health plan if the resident is on a plan and the plan provides behavioral health services in section 409.912, F.S.;
16. May cover all mental health residents of the facility who are clients of the same provider; and,
17. May be included in the Community Living Support Plan described in subparagraph (2)(c)3.
18. Missing documentation will not be the basis for administrative action against a facility if the facility can demonstrate that it has made a good faith effort to obtain the required documentation from the appropriate party. A documented request for such missing documentation made by the facility administrator within 72 hours of the resident’s admission will be considered a good faith effort. The documented request must include the name, title, and phone number of the person to whom the request was made and must be kept in the resident’s file.