TARRY HOUSE, INC.
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Subject:
Records Entry Time Frames |
Procedure Number:
C.P. 07 |
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Site: Tarry House Recovery Home |
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Issued By: Executive Director |
Effective: |
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Approved By: The Board of Trustees |
Revised: 10/03/88; 10/30/90; 12/2/91; 8/11/98; 10/05/99;
10/30/99; 10/18/01; 4/21/03; 5/18/05; 2/23/06, 11/6/08 |
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Reference
Policy: C.P. 02 |
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Standards Reference: CARF: 2G ODMH: 5122-27-05(B) & (C) |
Reviewed: 12/95; |
POLICY:
It is the policy of Tarry
House, Inc. to maintain complete and accurate files for all persons served.
PROCEDURE:
The following form is started
when a referral is received from Community Support Services or the Community
Support Network:
¨
Tarry
House, Inc. Assessment, Intake, and Orientation Checklist.
THE FOLLOWING ARE COMPLETED OR OBTAINED BEFORE OR AT
THE TIME OF ADMISSION:
¨
Documentation
from the referring agency that the person being considered for admission is at
least 18 years of age and is a resident of
¨
Documentation
from the referring agency that the person being considered for admission is in
need of residential treatment.
¨
Informed consent
for treatment.
¨
Written
documentation that the person being considered for admission had a negative tb test within the past six months.
¨
Emergency contact
& medical information and authorization for treatment in an emergency.
¨
Orientation to
fire safety.
¨
Authorization for
the release of information to and from the referring agency.
¨
Physicians’
orders for any medication, either prescribed or over-the-counter, that the
person is taking.
ON THE DAY OF ADMISSION:
¨
The
staff member responsible for coordinating services at Tarry House (usually the
Recovery Specialist) begins progress notes for the newly admitted person.
¨
A Medication
Administration/Treatment Record is prepared and made available to staff who
will be monitoring the self-administration of medications.
¨
The name of the
newly admitted person is added to the “Medication Checklist” so that
information about medication and medication monitoring can be communicated
between staff members.
¨
The name of the
newly admitted person is added to the “Meal Chart.”
¨
Direct
care staff (Recovery Aides) begin documentation of the
progress of the newly admitted
person. At least one note per shift is
completed.
¨
A written
introduction of the newly admitted person is prepared and made available to
direct care staff. It may describe the
types of problems or concerns the newly admitted person might experience and
suggest how to help or support the new resident.
¨
A file is
prepared for the new person. His/her
name is indicated on the spine, along with any allergies.
¨
The belongings of
the newly admitted person are inventoried.
WITHIN TWENTY-FOUR HOURS OF ADMISSION:
¨ Orientation is completed, including the following: Ohio Department of Mental Health and
¨
The newly
admitted person is asked for his/her preferences regarding the involvement of
family and friends in his her treatment.
WITHIN THREE BUSINESS DAYS OF ADMISSION:
¨
The person served
completes a self-assessment and indicates his/her goals for treatment.
WITHIN FIVE BUSINESS DAYS OF ADMISSION:
¨
The Initial
Assessment is completed.
WITHIN SEVEN BUSINESS DAYS OF ADMISSION:
¨
Documentation of
the need for residential treatment is completed; the
WITHIN TWELVE BUSINESS DAYS OF ADMISSION:
¨ An Assessment Summary is
written which includes the strengths and limitations of the person served, the
problems, issues, and/or concerns that will be addressed by Tarry House, the tentative
goals for treatment, the services and interventions to be offered, any
immediate needs, the projected length of treatment, factors that will affect
the course or outcome of treatment, and any problems to be referred.
WITHIN FIFTEEN BUSINESS DAYS OF ADMISSION:
¨
The person
served, his/her case manager, and the Recovery Specialist formalize a treatment
plan (IRSP) and plan for transition.
¨
With the written
permission of the person served, his/her family members are contacted. They are oriented to the Tarry House program
and are acquainted with other services (e.g.,
DAILY:
¨
Direct care staff
on each shift write at least one note documenting the progress of the person
served toward the goals and objectives in his/her treatment plan (IRSP).
WEEKLY:
¨
The
staff member responsible for coordinating services at Tarry House (usually the
Recovery Specialist) documents contact
with the person served and indicates his/her progress toward the goals and
objectives in his/her treatment plan (IRSP).
NINETY DAYS FOLLOWING ADMISSION & QUARTERLY
THEREAFTER:
¨
The Recovery
Specialist documents meeting with the person served to discuss and rate his/her
progress toward the goals and objectives in his/her treatment plan. The meeting may take place up to two weeks
before or as late as two weeks after the quarter. For example, if a person is admitted on
January 1, his first review is due between March 18 and April 15. His second review is due between June 17 and
July 15, etc.
¨
A functional
assessment is completed.
¨
A “Level of Care
Utilization System” form (LOCUS) is completed.
ANNUALLY:
¨
After the fourth
quarter review of the treatment plan (IRSP), the person served, his/her case
manager, and the Recovery Specialist develop a new
annual treatment plan (IRSP) and transition plan.
¨
Ohio Department
of Mental Health and
BEFORE TRANSITION:
¨
Transition from
Tarry House may be initiated by the person served, the referring agency, or
Tarry House. In some cases, the person
leaves Tarry House suddenly for medical, psychiatric, or legal reasons. In all cases, planning for a smooth
transition should be initiated at the time of admission and documented in the
file of the person served on an ongoing basis.
WITHIN
FIFTEEN DAYS OF TRANSITION FROM TARRY HOUSE, INC.:
¨
A summary of
treatment is completed and placed in the file of the person served.
60-90 DAYS
FOLLOWING TRANSITION FROM TARRY HOUSE, INC.:
¨
The
Post-Discharge Follow-Up Interview is completed.
RETAINING RECORDS
¨ Clinical Records will be retained for no less than
seven years in a securely locked area and shredded when disposed.
___________________________ _______________________
Executive Director Date