441—85.24(249A) Responsibilities of facilities.
	85.24(1) Medical record requirements. The medical records maintained by psychiatric medical institutions for children shall permit determination of the degree and intensity of the treatment provided to persons who are furnished services in the facility.
	a. 	Development of assessment and diagnostic data. Medical records shall stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is admitted.
	(1)	The identification data shall include the patient’s legal status.
	(2)	A provisional or admitting diagnosis shall be made on every patient at the time of admission, and shall include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses.
	(3)	The reasons for admission shall be clearly documented as stated by the patient or others significantly involved.
	(4)	The social service records, including reports of interviews with patients, family members, and others, shall provide an assessment of home plans and family attitudes and community resource contacts, as well as a social history.
	(5)	When indicated, a complete neurological examination shall be recorded at the time of the admission physical examination.
	b. 	Psychiatric evaluation. Each patient shall receive a psychiatric evaluation that shall:
	(1)	Be completed within seven days of admission.
	(2)	Include a medical history.
	(3)	Contain a record of mental status.
	(4)	Note the onset of illness and the circumstances leading to admission.
	(5)	Describe attitudes and behavior.
	(6)	Estimate intellectual functioning, memory functioning, and orientation.
	(7)	Include an inventory of the patient’s assets in descriptive, not interpretive, fashion.
	c. 	Treatment plan.
	(1)	Each patient shall have an individual comprehensive treatment plan that shall be based on an inventory of the patient’s strengths and disabilities. The written plan shall include a substantiated diagnosis, short-term and long-range goals, the specific treatment modalities utilized, the responsibilities of each member of the treatment team, and adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.
	(2)	The treatment received by the patient shall be documented in a way to ensure that all active therapeutic efforts are included.
	d. 	Recording progress. Progress notes shall be recorded by the doctor of medicine or osteopathy responsible for the care of the patient, nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but shall be recorded at least weekly for the first two months and at least once a month thereafter and shall contain recommendations for revisions in the treatment plan as indicated, as well as precise assessment of the patient’s progress in accordance with the original or revised treatment plan.
	e. 	Discharge planning and discharge summary. The record of each patient who has been discharged shall have a discharge summary that includes a recapitulation of the patient’s stay at the facility and recommendations from appropriate services concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge.
	f. 	The facility shall obtain a professional review organization (PRO) determination that the person requires psychiatric medical institution level of care when a person applying or eligible for Medicaid enters the facility, returns from an acute care hospital stay longer than 10 days, or enters the facility after 30 consecutive days of visitation. Periodic PRO determinations of the need for continuing care are also required.
	85.24(2) Fiscal records.
	a. 	Form 470-0042 shall be submitted to the department whenever a Medicaid applicant or recipient enters the facility, changes level of care, is hospitalized, leaves for visitation, or is discharged from the facility.
	b. 	The facility shall bill after each calendar month for the previous month’s services.
	85.24(3) Additional requirements. Additional requirements are mandated for persons under the age of 21.
	a. 	Active treatment. Inpatient psychiatric services shall involve active treatment. Active treatment means implementation of a professionally developed and supervised individual plan of care that is developed and implemented by an interdisciplinary team no later than 14 days after admission and is designed to achieve the recipient’s discharge from inpatient status at the earliest possible time.
	b. 	Individual plan of care. An individual plan of care is a written plan developed for each recipient to improve the recipient’s condition to the extent that inpatient care is no longer necessary. The plan shall be reviewed every 30 days by the team to determine that services being provided are or were required on an inpatient basis and to recommend changes in the plan as indicated by the recipient’s overall adjustment as an inpatient. The plan of care shall:
	(1)	Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the recipient’s situation and reflects the need for inpatient psychiatric care.
	(2)	Be developed by a team of professionals, as specified in paragraph “c” below, in consultation, if possible, with the recipient and the recipient’s parents, legal guardians or others in whose care the recipient will be released after discharge.
	(3)	State the treatment objectives.
	(4)	Prescribe an integrated program of therapies, activities and experiences designed to meet the objectives.
	(5)	Include, at an appropriate time, postdischarge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient’s family, school and community upon discharge.
	c. 	Interdisciplinary team. The individual plan of care shall be developed by an interdisciplinary team of physicians and other personnel who are employed by the facility or who provide services to patients in the facility. Membership in the interdisciplinary plan of care team includes those physicians and other professionals who are involved in the direct provision of treatment services, involved in the organization of the plan of care, or involved in consulting with or supervising those professionals involved in the direct provision of care.
	(1)	Based on education and experience, preferably including competence in child psychiatry, the team shall be capable of assessing the recipient’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; assessing the potential resources of the recipient’s family; setting treatment objectives; and prescribing therapeutic modalities to achieve the plan’s objectives.
	(2)	The team shall include, as a minimum, either a board-eligible or board-certified psychiatrist, a clinical psychologist who has a doctoral degree and a physician licensed to practice in medicine or osteopathy, or a physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases and a psychologist who has a master’s degree in clinical psychology and has been licensed by the state.
	(3)	The team shall also include one of the following: a social worker with a master’s degree in social work with specialized training or one year’s experience in treating persons with mental illness, a registered nurse with specialized training or one year’s experience in treating persons with mental illness, an occupational therapist who is licensed and who has specialized training or one year of experience in treating persons with mental illness, or a psychologist who has a master’s degree in clinical psychology or who has been licensed by the state.
[ARC 6714C, IAB 11/30/22, effective 2/1/23]