PROPOSED RULEMAKING
DEPARTMENT OF
HUMAN SERVICES
[55 PA. CODE CH. 5230]
Psychiatric Rehabilitation Services
[52 Pa.B. 3828]
[Saturday, July 9, 2022]Statutory Authority
Notice is hereby given that the Department of Human Services (Department), under the authority of sections 911 and 1021 and Articles IX and X of the Human Services Code (62 P.S. §§ 911, 1021, 901—922 and 1001—1088), proposes to amend Chapter 5230 (relating to psychiatric rehabilitation services) as set forth in Annex A.
Purpose of Rulemaking
The purpose of this proposed rulemaking is to amend Chapter 5230 to allow individuals who are 14 years of age or older but under 18 years of age who meet the admission requirements to access psychiatric rehabilitation services (PRS) and to amend the diagnoses that allow an individual to access PRS without use of the exception process. Through the exception process, individuals without one of the specified diagnoses for admission to PRS can still receive PRS if they have a serious mental illness or serious emotional disturbance with a diagnosis of a mental, behavioral or emotional disorder that results in a moderate to severe functional impairment. In addition, the amendment clarifies the documentation that will be reviewed through the exception process to determine if an individual is eligible for PRS. It also revises outdated language and adds definitions of ''serious mental illness'' and ''serious emotional disturbance'' that align with the definitions currently used by the Federal Substance Abuse and Mental Health Services Administration. This proposed rulemaking supports the principles of recovery, resiliency and self-determination by permitting additional individuals who are experiencing a serious mental illness or a serious emotional disturbance to receive PRS.
Background
In 2013, the Department promulgated a regulation that provided for the minimum standards for the issuance of licenses for PRS facilities. PRS is an evidence-based service that uses an integrated therapeutic approach to assist individuals with serious mental illness or serious emotional disturbance to develop the skills needed to live, learn, socialize, and work in their community and improve or maintain their physical and mental health. PRS promotes recovery and resiliency, full community integration and improved quality of life for individuals who have been diagnosed with a serious mental illness or serious emotional disturbance that results in a moderate to severe functional impairment that interferes with or limits the individual's performance in one or more of the following domains: living, learning, working, socializing or wellness. Additionally, PRS may decrease the need for or shorten the length of stay in inpatient, partial hospitalization or outpatient treatment. PRS helps individuals reach age-appropriate functioning that has either been lost or never achieved because development was interrupted by a serious mental illness or serious emotional disturbance. This proposed rulemaking will result in more individuals being eligible for PRS because it allows youth 14 years of age or older to receive PRS. It will also allow individuals to access PRS through telehealth by removing barriers to providing PRS through telehealth. In addition, it identifies additional diagnoses that will enable individuals to receive PRS without requiring use of the exception process for receiving PRS.
The regulation as promulgated in 2013 limited PRS to individuals 18 years of age or older. Stakeholders have expressed that there is a need for additional supports for individuals 14 years of age or older that will engage them and will help them transition to the adult service system. Research has shown that the transition from adolescence to adulthood is especially challenging for youth diagnosed with a serious mental illness or a serious emotional disturbance. Many traditional adult mental health services do not focus on skill development to improve the individual's ability to be successful in the community, but rather focus on alleviating symptoms and psychological distress. Access to PRS, which focuses on helping individuals develop skills needed to be successful in the living, learning, working, social and wellness environments, will assist youth in transitioning to adulthood and maintaining independence in the community.
Requirements
The following is a summary of the specific provisions in this proposed rulemaking.
General Provisions
Definitions (§ 5230.3)
This proposed rulemaking adds definitions of the following terms: ''Associate's degree'' and ''Bachelor's degree'' to ensure that staff providing PRS have obtained degrees from properly accredited educational institutions; ''Child and family resiliency practitioner (CFRP)'' to identify the certification required for staff who provide PRS to individuals 14 years of age or older but under 18 years of age; and ''Serious emotional disturbance'' and ''Serious mental illness'' to define the conditions required for use of the exception process for admission to PRS and to align the definitions used in Chapter 5230 with the definitions currently used by the Federal Substance Abuse and Mental Health Services Administration.
In addition, this proposed rulemaking deletes the definition of ''Axis I'' to be consistent with the current version of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM). Prior versions of the DSM used a multiaxial documentation process for diagnosis. The current version of the DSM uses monoaxial documentation for diagnosis by combining the first three axes into one axis that includes all mental or other medical diagnoses to remove artificial distinctions among conditions. The definitions of ''DSM-IV-TR'' and ''ICD-9'' are also being deleted and replaced with definitions of ''DSM'' and ''ICD'' respectively to delete the reference to outdated versions of the DSM and the International Classification of Diseases (ICD) and to allow for the use of successor versions of the DSM and ICD.
This proposed rulemaking also deletes the definition of ''Face-to-face'' because the term is no longer used in the regulation and deletes outdated names of organizations. ''International Center for Clubhouse Development (ICCD)'' and ''The United States Psychiatric Rehabilitation Association (USPRA)'' are replaced with ''Clubhouse International'' and ''The Psychiatric Rehabilitation Association'' respectively. It also clarifies the definition of ''Full-time equivalent'' by deleting references to ''calendar.'' This proposed rulemaking amends the term ''Coordination of care'' to ''Coordination of services'' at the request of stakeholders to reduce the perceived stigma associated with individuals receiving PRS. It amends the definition of ''Functional impairment'' to be more specific to the admission requirements for PRS. It also adds a definition of ''Wellness'' to the regulation due to adding wellness as a domain at the request of the members of the workgroup that reviewed and provided input on this proposed rulemaking.
Finally, this proposed rulemaking amends the definition of ''Individual'' to clarify that individuals 14 years of age or older may receive PRS. In addition, it deletes the term ''individual'' from the definition of ''Licensed practitioner of the healing arts (LPHA)'' to clarify the definition. It revises the definition of LPHA to include licensed clinical social workers, licensed professional counselors and licensed marriage and family therapists because the Social Workers, Marriage and Family Therapists and Professional Counselors Act (63 P.S. §§ 1901—1922) has been amended to allow licensed clinical social workers, licensed professional counselors and licensed marriage and family therapists to diagnose and treat mental and emotional disorders as part of the scope of their practice.
Psychiatric rehabilitation processes and practices (§ 5230.4)
This proposed rulemaking adds wellness to the list of domains in which PRS agencies must assist an individual to develop or maintain skills. This domain addition will make PRS more comprehensive and consistent with current recovery-oriented practices.
This proposed rulemaking also adds the individual's home as a location where PRS can be delivered to clarify that PRS can be delivered in an individual's place of residence.
General Requirements
Agency records (§ 5230.13)
This proposed rulemaking adds the requirement that a PRS agency maintain records that contain copies of the criminal history background checks from both the Pennsylvania State Police and the Federal Bureau of Investigation (FBI) and child abuse certifications required under 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) for staff working in PRS programs serving individuals 14 years of age or older but under 18 years of age and a requirement that human resources policies and procedures be consistent with a PRS agency's service description and address child abuse certification requirements.
Agency service description (§ 5230.15)
This proposed rulemaking adds a requirement that PRS agencies include in their service descriptions outreach and engagement strategies and how they will engage and involve family members when the individual consents to the involvement because family involvement is an important component of services for individuals 14 years of age or older but under 18 years of age. It also adds the following requirements: a requirement that PRS agencies deliver PRS consistent with the approved service description, a requirement that PRS agencies include in the service description the age groupings and age range of the individuals the agency serves and an explanation of how the agency will maintain the separation of age groups. The Department is adding these requirements to ensure the health, safety and welfare of individuals receiving PRS. The Department also updated the name of the organization that is responsible for accreditation if the PRS facility is identified as a clubhouse and clarified that PRS agencies that are identified as a clubhouse must maintain clubhouse accreditation. Finally, an individual's home was added as a location that could be designated in the PRS agency's service description to clarify that PRS may be provided in an individual's home as well as in the PRS facility or the community.
Coordination of services (§ 5230.16)
This proposed rulemaking amends the term ''Coordination of care'' to ''Coordination of services'' to reduce the perceived stigma associated with receiving PRS. Additionally, this proposed rulemaking amends the outdated language of ''drug and alcohol programs'' to ''substance use disorder programs.''
This proposed rulemaking adds peer support services agencies to the list of providers with which PRS agencies must have an agreement to coordinate services because individuals who receive PRS may also receive peer support services. This proposed rulemaking also adds agencies and systems that serve individuals 14 years of age or older to the list of providers with which PRS agencies may have agreements to coordinate services to ensure all appropriate services that affect the youth population are included.
Individual Record
Content of individual record (§ 5230.21)
This proposed rulemaking provides for parental or caregiver consent to receive PRS if the individual is under 18 years of age and allows for the release of records with the individual's consent or parent's or caregiver's consent if the individual is under 18 years of age to family members and other supports, as appropriate, because their input is important when individuals under 18 years of age receive PRS. It also adds a requirement that staff documentation of coordination with other services and supports includes a description of outreach and engagement efforts with natural supports, which are individuals or organizations chosen by the individual to provide assistance and resources, and a description of ongoing contacts and involvement with formal supports.
Documentation standards and record security, retention and disposal (§ 5230.22)
This proposed rulemaking amends the word ''is'' to ''shall be'' to require that individual records are kept in a permanent, secure location.
Admission, Continued Stay and Discharge Requirements
Admission requirements (§ 5230.31)
This proposed rulemaking revises the admission requirements for PRS. Individuals 14 years of age or older but under 18 years of age with serious emotional disturbance or serious mental illness will now be eligible for admission to PRS. This proposed rulemaking also updates the names of diagnoses that have been changed as a result of revisions to the DSM and expands the diagnoses for which an individual may receive PRS without going through the exception process for receiving PRS. The new diagnoses an individual may have that do not require review through the exception process include posttraumatic stress disorder, attention deficit hyperactivity disorder, major depressive disorder, bipolar disorder and anxiety disorders.
Additionally, this proposed rulemaking clarifies that for an individual to be eligible for PRS without having to go through the exception process, the LPHA's written recommendation for PRS must include documentation of one of the specified diagnoses that is required to be eligible for PRS and documentation of a moderate to severe functional impairment that interferes with or limits the individual's performance in one or more of the following domains: living, learning, working, socializing or wellness.
This proposed rulemaking also revises the exception process. If an individual does not have one of the specified diagnoses, the individual can still receive PRS if the LPHA's written recommendation for PRS includes documentation of serious mental illness or serious emotional disturbance with a diagnosis of a mental, behavioral or emotional disorder that is listed in the current DSM or ICD and a description of the resulting moderate to severe functional impairment in at least one of the following domains: living, learning, working, socializing or wellness. The LPHA's written recommendation for PRS must also include documentation of the anticipated benefit that PRS will provide for the individual. Serious emotional disturbance has been added to the admission requirements because individuals under 18 years of age will be eligible for PRS.
This proposed rulemaking also clarifies that the PRS agency must complete an initial functional impairment screening to confirm the individual's moderate to severe functional impairment in at least one domain identified in the LPHA's written recommendation. Finally, this proposed rulemaking adds wellness as one of the domains in which an individual can have a moderate to severe functional impairment resulting from serious mental illness or serious emotional disturbance and receive PRS.
Continued stay requirements (§ 5230.32)
Because individuals who are under 18 years of age will now be eligible to receive PRS, the Department proposes to amend the continued stay requirements for PRS to add that an individual with a serious emotional disturbance that results in a functional impairment that is addressed in the individual rehabilitation plan can continue to receive PRS.
Rights
Nondiscrimination (§ 5230.42)
To conform with other regulations recently promulgated by the Department, this proposed rulemaking amends the prohibition against discrimination by a PRS agency by deleting the terms ''sex,'' ''religion,'' ''ethnic origin,'' ''economic status'' and ''sexual orientation or gender identity or expression'' and adding the terms ''color,'' ''creed,'' ''religious affiliation,'' ''ancestry,'' ''gender,'' ''gender identity or expression,'' ''sexual orientation'' and ''National origin.'' This proposed rulemaking also requires PRS agencies to comply with applicable Federal and State statutes and regulations.
Staffing
Staff qualifications (§ 5230.51)
This proposed rulemaking amends ''associate of arts'' degree to ''associate's'' degree, which is the defined term. Additionally, to ensure that staff are properly qualified, this proposed rulemaking adds requirements for PRS agencies that serve individuals under 18 years of age. A PRS director of an agency that serves individuals under 18 years of age must meet both the requirements to be a PRS director of an agency that serves individuals 18 years of age or older and have or attain CFRP certification within the later of 2 years of the date of hire as a PRS director or within 2 years of the date the agency received approval of its service description that includes that it will be serving individuals 14 years of age or older. This proposed rulemaking also requires a psychiatric rehabilitation specialist that is employed by a PRS agency that serves individuals under 18 years of age to be certified as a CFRP or have a bachelor's degree and 2 years of work experience in mental health direct service, 1 year of which must be work experience in PRS. If the psychiatric rehabilitation specialist is not certified as a CFRP, he or she must obtain CFRP certification within the later of 2 years of the date of hire as a psychiatric rehabilitation specialist or within 2 years of the date the agency received approval of its service description that includes that it will be serving individuals 14 years of age or older.
General staffing requirements (§ 5230.52)
This proposed rulemaking adds a requirement that in addition to developing a schedule that includes a plan to maintain staffing requirements during deployment of staff for PRS delivered in the community, the schedule must also include a plan to maintain staffing requirements during deployment of staff for PRS delivered in individuals' homes to ensure that sufficient staff is available at the PRS facility when staff is working with individuals in their homes or in the community. This proposed rulemaking also increases the time by which a minimum of 25% of the PRS agency's full-time equivalent staff must meet the qualifications of a psychiatric rehabilitation specialist that are included in § 5230.51(b) and (f) (relating to staff qualifications) from 1 year to 2 years of initial licensing. It also adds the requirement that if a PRS agency serves individuals under 18 years of age, a minimum of 25% of the PRS agency's full-time equivalent staff complement must have CFRP certification within the later of 2 years of initial licensing or within 2 years of the date the agency received approval of its service description that includes that the PRS agency will be serving individuals 14 years of age or older but under 18 years of age. This requirement was added to ensure that staff providing PRS have the right type of training and qualifications to provide services to individuals under 18 years of age.
Individual services (§ 5230.53)
This proposed rulemaking clarifies that in addition to being provided in a PRS facility or in the community, individual services can be provided in an individual's home.
Group services (§ 5230.54)
This proposed rulemaking clarifies that group services can be provided in a PRS facility, in the community or in the home, but limits the provision of group services in the home to services provided only through telehealth. This proposed rulemaking also specifies that group services delivered in the community may include only individuals who receive PRS from the agency. This requirement ensures that only the individuals receiving group services from the PRS agency receive the group services and protects confidentiality. In addition, the Department proposes to amend the requirement to design group services to protect confidentiality to require that confidentiality be protected wherever group services are provided and not just if they are provided in the community.
Supervision (§ 5230.55)
The requirement that the meetings between staff and a PRS director or psychiatric rehabilitation specialist designated as a supervisor be face-to-face is proposed to be deleted from the regulation because the meeting is no longer required to be face-to-face.
Staff training requirements (§ 5230.56)
This proposed rulemaking adds resiliency as an optional training topic for staff serving individuals under 18 years of age because resiliency training is important for helping professionals deal with common challenges relating to skill development or retention that may impact individuals under 18 years of age. In addition, this proposed rulemaking requires a minimum of 6 hours of training be specifically focused on youth services. This proposed rulemaking also requires that staff who serve individuals under 18 years of age receive training in the child abuse mandated reporter requirements found in 23 Pa.C.S. §§ 6301—6388. Finally, this proposed rulemaking clarifies that the 6 hours of mentoring new staff must receive prior to delivering services must be completed in person.
Criminal history checks and child abuse certification (§ 5230.57)
This proposed rulemaking adds a requirement that a PRS agency that serves individuals under 18 years of age complete criminal history checks and child abuse certifications for staff as required under 23 Pa.C.S. §§ 6301—6388 and Chapter 3490 (relating to protective services). This proposed rulemaking requires PRS agencies that serve individuals under 18 years of age to develop and implement written policies and procedures regarding personnel decisions that comply with 23 Pa.C.S. §§ 6301—6388 and Chapter 3490.
Service Planning and Delivery
Assessment (§ 5230.61)
This proposed rulemaking requires that an assessment be completed in collaboration with the individual and the individual's natural and formal supports, including family members, as directed by the individual, to identify any other services or resources that may be needed to assist the individual. It proposes to add the requirement that in addition to addressing the multiple dimensions of the individual's living, learning, working and socializing domains, the assessment must also address the wellness domain if identified as a goal by the individual. In addition, the proposed amendment requires that the assessment identify any human services programs or facilities that could support the individual so that the individual is made aware of other programs or benefits that could help meet the individual's health or other needs. Information and referral to additional supports may be necessary for individuals transitioning to adulthood. This proposed rulemaking also adds the requirement that an assessment be updated when the individual's diagnosis and identified needs change and allows for documentation that the assessment was reviewed with the individual to allow for the provision of PRS through telehealth.
Individual rehabilitation plan (§ 5230.62)
This proposed rulemaking allows individuals the option of verbally consenting to their individual rehabilitation plan and any updates to the plan. This change will allow the PRS agency to document the individual's consent to the individual rehabilitation plan when the individual is not available to sign the plan in person. This proposed rulemaking also deletes the requirement that an individual rehabilitation plan update include documentation of the reason the individual did not sign the individual rehabilitation plan because the individual is no longer required to sign the individual rehabilitation plan.
Daily entry (§ 5230.63)
This proposed rulemaking deletes the requirement for the individual to sign the daily entry. This change is being made to remove an unnecessary burden on staff and the individual. Section 5230.23 (relating to access to individual record) allows an individual to review, provide written comments and sign daily entries in their individual record. As a result, individuals still have access to their files, but do not have the burden of signing the daily entry every day.
Quality Improvement
Quality improvement requirements (§ 5230.81)
This proposed rulemaking amends the information to be included in the annual quality improvement plan to align with changes to the admission requirements for PRS. The annual quality improvement plan must include the number of individuals admitted to PRS that do not have one of the diagnoses specified in § 5230.31(a)(2) (relating to admission requirements) and their average length of stay in PRS.
Affected individuals and organizations
This proposed rulemaking affects agencies that provide PRS and individuals who will be eligible for PRS as a result of the proposed amendments.
The Department convened a workgroup to review and provide input on this proposed rulemaking. The workgroup included family members, Office of Mental Health and Substance Abuse Services staff and representatives from the following entities: Pennsylvania Healthy Transitions Partnership; Pennsylvania Council of Children, Youth and Family Services; Drexel University/Behavioral Healthcare Education; Dickinson Center, Inc.; Holcomb Behavioral Health Systems Berks County; Community Services Group; Commerce Park Clubhouse; Philadelphia Department of Behavioral Health; Threshold Rehabilitation Services, Inc.; Family Services of Western Pennsylvania; Child and Family Focus, Inc.; Allied Services; Aurora Social Rehabilitation Services; Office of Vocational Rehabilitation; Transition Age Advisory Group; Rehabilitation and Community Providers Association; Pennsylvania Association of Psychiatric Rehabilitation Services; Mental Health Association in Pennsylvania; and the mental health service system in Allegheny, Beaver, Berks, Bucks and Montgomery Counties.
Accomplishments and benefits
PRS promotes resiliency and recovery, full community integration and improved quality of life for individuals who have been diagnosed with serious mental illness or serious emotional disturbance. The proposed amendments to the PRS rulemaking benefit individuals 14 years of age or older but under 18 years of age with a serious emotional disturbance by allowing these individuals to access evidence-based PRS as they transition into adulthood, which fosters engagement in PRS into adulthood and may reduce the need for or shorten the length of stay in inpatient, partial hospitalization and outpatient treatment. This proposed rulemaking adds requirements that ensure the health and safety of individuals 14 years of age or older but under 18 years of age who receive PRS by requiring that services are provided by qualified and adequately trained staff and that the PRS agency has completed criminal history checks and child abuse certifications for staff. It also proposes to add requirements that promote the engagement of youth and families in the recovery process, which will result in better outcomes for individuals receiving services.
This proposed rulemaking will also benefit individuals diagnosed with posttraumatic stress disorder, attention deficit hyperactivity disorder, bipolar disorder, major depressive disorder or anxiety disorders because individuals with these disorders will no longer need to use the exception process to be eligible for PRS. This will assist individuals diagnosed with these disorders to develop skills needed to live, learn, socialize and work in their community and improve or maintain their physical and mental health.
This proposed rulemaking also adds wellness as a domain in which PRS agencies may assist individuals receiving PRS to develop skills. This addition will allow an individual to learn how to manage his or her physical and mental health needs to promote or support his or her recovery and resiliency.
Finally, this proposed rulemaking will benefit all individuals who receive PRS by clarifying that PRS can be provided in the home and by removing barriers to the provision of PRS through telehealth.
Fiscal Impact
It is anticipated that the implementation of this proposed rulemaking may result in a small initial increase in costs for PRS agencies that serve individuals 14 years of age or older but under 18 years of age because the director, psychiatric rehabilitation specialist and 25% of the full-time equivalent staff complement will need to obtain CFRP certification, and the PRS agencies will need to obtain child abuse certifications for staff. The cost to obtain the CFRP certification is approximately $395 (registration and examination fee) per person. The costs to obtain child abuse certifications include a child abuse clearance for $13 per person and an FBI background check for $22.60 per person.
The Department is unable to determine the fiscal impact of a PRS agency's decision to provide PRS through telehealth because of the individualized nature of the cost to provide PRS through telehealth. Each agency will need to determine whether it wants to provide PRS through telehealth. If an agency chooses to provide PRS through telehealth, the cost to provide PRS through telehealth will depend on the PRS agency's current technical capabilities, including access to telehealth equipment, and the cost of the telehealth equipment the PRS agency chooses to use. In addition, the cost to provide PRS through telehealth will fluctuate based on the number of individuals served through telehealth.
The Department does not expect that there will be costs to the Department as a result of this proposed rulemaking. While more individuals will be eligible for PRS and more individuals may be able to access PRS through telehealth in addition to in person, the Department expects to realize savings from the implementation of this proposed rulemaking. Allowing individuals 14 years of age or older but under 18 years of age to receive PRS will allow more individuals access to an evidence-based practice. National research indicates that evidence-based practices and programs result in shorter periods of treatment, reduced need for more expensive higher levels of care, decreased juvenile justice system involvement, improved school attendance and performance and better overall outcomes for children and their families.
The Department also does not anticipate any costs to local governments or individuals who receive PRS as a result of the proposed rulemaking.
Paperwork Requirements
This proposed rulemaking will result in a minimal increase in paperwork for PRS agencies because they will need to submit an updated agency service description.
Effective Date
This proposed rulemaking will be effective upon publication of the final-form rulemaking in the Pennsylvania Bulletin.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding this proposed rulemaking to the Department of Human Services, Office of Mental Health and Substance Abuse Services, Attention: Laurie Madera, Bureau of Policy, Planning and Program Development, Commonwealth Towers, 11th Floor, 303 Walnut Street, Harrisburg, PA 17105, RA-PWPsychRehab@pa.gov within 30 calendar days after the date of the publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference Regulation No. 14-548 when submitting comments. Persons with a disability who require an auxiliary aid or service may submit comments by using the Pennsylvania Hamilton Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P.S. § 745.5(a)), on June 23, 2022, the Department submitted a copy of this proposed rulemaking to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Human Services Committee and the Senate Health and Human Services Committee. In addition to submitting the proposed rulemaking, the Department has provided the Committees and IRRC with a copy of a Regulatory Analysis Form prepared by the Department. A copy of this form is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria in section 5.2 of the Regulatory Review Act (71 P.S. § 745.5b) which have not been met. The Regulatory Review Act specifies detailed procedures for review prior to final publication of the rulemaking by the Department, the General Assembly and the Governor.
MEG SNEAD,
Acting SecretaryFiscal Note: 14-548. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 55. HUMAN SERVICES
PART VII. MENTAL HEALTH MANUAL
Subpart D. NONRESIDENTIAL AGENCIES/FACILITIES/SERVICES
CHAPTER 5230. PSYCHIATRIC REHABILITATION SERVICES
GENERAL PROVISIONS § 5230.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
[Axis I—
(i) One of five dimensions relating to different aspects of the diagnosis of a psychiatric disorder or disability as organized in the DSM-IV-TR or subsequent revisions.
(ii) Axis I specifies clinical disorders, including major mental disorders.]
BH-MCO—Behavioral health managed care organization—An entity that manages the purchase and provision of mental health and substance abuse services.
Best practice—Service delivery practice based directly on principles and standards that are generally recognized by a profession and are documented in the professional literature.
CFRP—Child and Family Resiliency Practitioner—A person who has satisfied the required education, experience and testing, and who is certified as a Child and Family Resiliency Practitioner by the Psychiatric Rehabilitation Association or its successor.
CPRP—Certified Psychiatric Rehabilitation Practitioner—A person who has [completed] satisfied the required education, experience and testing, and who is [currently] certified as a Certified Psychiatric Rehabilitation Practitioner by the [USPRA] Psychiatric Rehabilitation Association or its successor.
CPS certificate—Certified peer specialist certificate—A certificate awarded to a person who has successfully completed the Department-approved training in peer support services.
Clubhouse—A PRS facility that is accredited by [the ICCD] Clubhouse International or its successor.
Coordination of [care] services—Direct contact by a PRS agency with other mental health, physical health or human services formal and natural supports, to ensure continuity in service planning [between service agencies].
* * * * * [DSM-IV-TR—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.] DSM—The current version of the Diagnostic and Statistical Manual of Mental Disorders.
* * * * * FTE—Full-time equivalent—37.5 hours per [calendar] week of staff time.
[Face-to-face—Contact between two or more people that occurs at the same location, in person.]
Formal support—An agency, organization or person who provides assistance or resources to others within the context of an official role.
Functional impairment—[The loss or abnormality of the ability to complete necessary tasks.] Difficulties that interfere with or limit skill development or functioning in a domain.
* * * * * Human services—Programs or facilities designed to meet basic health, welfare and other needs of a society or group.
[ICCD—International Center for Clubhouse Development.
ICD-9—International Classification of Diseases, Ninth Edition.] ICD—The current version of the International Classification of Diseases.
IRP—Individual rehabilitation plan—A document that describes the current service needs based on the assessment of the individual and identifies the individual's goals, interventions to be provided, the location, frequency and duration of services and staff who will provide the service.
Individual—A person[, 18] 14 years of age or older [who has a functional impairment resulting from mental illness, who uses] who receives PRS.
LPHA—Licensed practitioner of the healing arts—
[(i) An individual] A person who is licensed by the Commonwealth to practice the healing arts.
[(ii) The] This term is limited to a physician, physician's assistant, certified registered nurse practitioner [and], licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor or psychologist.
* * * * * PRS—Psychiatric rehabilitation service—A recovery-oriented service offered individually or in groups which is predicated upon the principles, values and practice standards of [the ICCD, USPRA] Clubhouse International, the Psychiatric Rehabilitation Association or other Nationally-recognized professional PRS association.
* * * * * Psychiatric rehabilitation principles—A list of core values inherent in psychiatric rehabilitation as defined by Nationally-recognized professional associations, including the [USPRA, the ICCD] Psychiatric Rehabilitation Association, Clubhouse International and the Coalition for Community Living.
* * * * * QI plan—Quality improvement plan—A document outlining the ongoing formal process to ensure optimal care and maximize service benefit as part of the licensing process.
Serious emotional disturbance—A condition experienced by an individual under 18 years of age who currently has, or at any time during the past year has had, a diagnosable mental, behavioral or emotional disorder of sufficient duration to meet the diagnostic criteria for the mental, behavioral or emotional disorder specified in the current DSM.
Serious mental illness—A condition experienced by an individual 18 years of age or older who currently has, or at any time during the past year has had, a diagnosable mental, behavioral or emotional disorder of sufficient duration to meet diagnostic criteria for the mental, behavioral or emotional disorder specified in the current DSM.
[USPRA—The United States Psychiatric Rehabilitation Association.]
Wellness—A domain that helps an individual to develop skills needed to improve or maintain physical and mental health.
§ 5230.4. Psychiatric rehabilitation processes and practices.
(a) A PRS agency shall assist an individual to develop, enhance and retain skills and competencies in living, learning, working [and], socializing and wellness so that an individual can live in the environment of choice and participate in the community.
* * * * * (f) A PRS agency may offer PRS in a PRS facility [or], in the community[, or both] or in the individual's home, or all three, as is consistent with an approved agency service description.
GENERAL REQUIREMENTS § 5230.13. Agency records.
A PRS agency shall maintain records that contain copies of the following:
* * * * * (6) Human resources policies and procedures that are consistent with the PRS agency's service description and address the following:
(i) Job descriptions for staff positions.
(ii) Criminal history background [check] checks and child abuse certification requirements and protocol in accordance with § 5230.57 (relating to criminal history checks and child abuse certification).
* * * * * (10) Quality improvement documents, including the following:
(i) QI plan.
(ii) Data gathering tools.
(iii) Annual review reports.
(11) Child abuse certifications as required under 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law).
§ 5230.15. Agency service description.
(a) Prior to the initial licensing visit, and when changes occur to the agency service description, a PRS agency shall submit to the Department for prior approval an agency service description that includes the following:
(1) The governing body, advisory board and an agency table of organization.
(2) The philosophy of the PRS agency, incorporating psychiatric rehabilitation principles.
(2.1) Strategies for outreach to and engagement of individuals referred for PRS.
(3) The population to be served, including the following:
(i) Anticipated daily attendance.
(ii) Age range and age groupings, including information on how different age groups will be separated while services are provided through the scheduling of services, providing services in different locations in the PRS facility's physical space and other procedures.
(iii) Diagnostic groups.
(iv) Plans to identify and accommodate special populations.
(v) Plans to identify and accommodate culturally diverse populations.
(4) The approach of PRS offered including EBPs and best practices utilized.
(5) A PRS facility identified as a clubhouse must be accredited by [the ICCD] Clubhouse International within 3 years of licensing and maintain accreditation.
(6) The location of service, whether in a PRS facility, [or] in the community, or in the individual's home, or a combination of [both] the three locations.
(7) Expected service outcomes for individuals.
(8) Staffing, including the following:
(i) Staffing patterns.
(ii) Staff to individual ratios.
(iii) Staff qualifications.
(iv) Staff supervision plans.
(v) Staff training protocols.
(9) Service delivery patterns, including frequency, duration and method (group or individual) of service delivery.
(10) The days and hours of PRS operation.
(11) The geographic limits of PRS operation.
(12) A description of the physical site, including copies of applicable or licenses and certificates.
(13) A process for development of an IRP with an individual.
(14) Admission and discharge policies and procedures.
(15) The methods by which PRS staff and an individual will collaborate to identify and use the individual's preferred community resources.
(16) A process for developing and implementing a QI plan.
(17) A procedure for filing and resolving complaints.
(18) A procedure for engaging and involving the individual's family members and natural supports when the individual consents to the involvement.
(b) The Department may deny agency service descriptions and approaches that do not meet EBP or best practices standards.
(c) PRS agencies shall deliver services consistent with the approved service description.
§ 5230.16. Coordination of [care] services.
(a) A PRS agency shall have written agreements to coordinate [care] services with other [service] providers, including the following:
* * * * * (5) Case management programs.
(6) Peer support services agencies.
(b) A PRS agency may have written agreements to coordinate [care] services with other [service] providers as needed, including the following:
(1) Housing and residential programs.
(2) [Drug and alcohol programs] Substance use disorder programs.
(3) Vocational, educational and social programs.
(4) Other agencies and systems that serve individuals 14 years of age or older.
INDIVIDUAL RECORD § 5230.21. Content of individual record.
A PRS agency shall develop and maintain a record for an individual served containing the following:
* * * * * (4) A signed set of documents providing the following:
(i) [Individual consent to receive services] Documentation of an individual's consent to receive PRS or, if the individual is 14 years of age or older but under 18 years of age, documentation of an individual's consent to receive PRS or documentation of consent by the individual's parent or legal guardian for the individual to receive PRS.
(ii) [Individual] Documentation of an individual's consent to release information to other providers and natural supports, including family members, or, if the individual is 14 years of age or older but under 18 years of age, documentation of the individual's consent to release information to other providers and natural supports, including family members, or, if the parent or legal guardian has provided the consent to receive PRS, documentation of consent by the individual's parent or legal guardian to release information to other providers and natural supports, including family members.
(iii) Verification that the individual received and had an opportunity to discuss the oral and written versions of the PRS statement of rights under § 5230.41 (relating to PRS statement of rights).
* * * * * (8) Staff documentation of coordination with other services and supports[.], including:
(i) A description of outreach and engagement efforts with natural supports, including family members, as directed by the individual.
(ii) A description of ongoing contacts and involvement with formal supports.
(9) Discharge summary.
§ 5230.22. Documentation standards and record security, retention and disposal.
A PRS agency shall ensure that an individual record meets the following standards:
* * * * * (6) The record [is] shall be kept in a permanent, secure location.
* * * * *
ADMISSION, CONTINUED STAY AND
DISCHARGE REQUIREMENTS§ 5230.31. Admission requirements.
(a) [General rule.] To be eligible for PRS, an individual [shall meet] must be 14 years of age or older and have a written recommendation from an LPHA acting within the scope of professional practice that includes the following information:
(1) [Have a written recommendation for PRS by an LPHA acting within the scope of professional practice] (Reserved).
(2) [Have the presence or history of a serious mental illness, based upon medical records, which includes] Documentation of one of the following diagnoses [by an LPHA]:
(i) Schizophrenia.
(ii) [Major mood disorder] Schizoaffective disorder.
(iii) [Psychotic disorder (not otherwise specified)] Other specified schizophrenia spectrum and other psychotic disorder.
(iv) [Schizoaffective disorder] Major depressive disorder.
(v) [Borderline personality disorder] Bipolar disorder.
(vi) Anxiety disorders.
(vii) Posttraumatic stress disorder.
(viii) Attention deficit hyperactivity disorder.
(ix) Borderline personality disorder.
(3) [As a result of the mental illness, have] Documentation that as a result of the individual's diagnosis, the individual has a moderate to severe functional impairment that interferes with or limits the individual's performance in at least one of the following domains:
(i) Living.
(ii) Learning.
(iii) Working.
(iv) Socializing.
(v) Wellness.
(4) [Choose to receive PRS] (Reserved).
(b) [Assessment. A PRS agency shall identify and document the functional impairment of the individual in an assessment as required under § 5230.61(b)(1) (relating to assessment)] (Reserved).
(c) [Individuals who do not meet the serious mental illness diagnosis requirement under subsection (a) may receive services when the following conditions are met] An individual who does not have a diagnosis listed in subsection (a)(2) is eligible for PRS if the individual has a written recommendation from an LPHA acting within the scope of professional practice that includes the following information:
(1) [The written recommendation by the LPHA includes a diagnosis of mental illness] Documentation of a serious mental illness or serious emotional disturbance with a diagnosis of a mental, behavioral or emotional disorder that is listed [on Axis I in the DSM-IV-TR or ICD-9 or subsequent revisions] in the current DSM or ICD.
(2) [The written recommendation by the LPHA includes a description of the functional impairment resulting from the mental illness as required under subsection (a)(3).] Documentation that includes a description of a moderate to severe functional impairment in at least one of the following domains that is a result of the individual's serious mental illness or serious emotional disturbance:
(i) Living.
(ii) Learning.
(iii) Working.
(iv) Socializing.
(v) Wellness.
(3) Documentation of the anticipated benefit that PRS will provide for the individual.
(d) Upon an individual's admission to PRS, the PRS agency shall complete an initial functional impairment screening with the individual to confirm the individual's moderate to severe functional impairment that interferes with or limits performance in at least one domain identified in the LPHA's written recommendation.
§ 5230.32. Continued stay requirements.
(a) A PRS agency shall determine an individual's eligibility for continued stay during an IRP update required under § 5230.62(c) (relating to individual rehabilitation plan).
(b) An individual's eligibility for continued stay shall be determined by documentation of the following:
(1) An individual chooses continued participation in the PRS.
(2) A continued need for service based upon one or both of the following:
(i) As a result of a serious mental illness or serious emotional disturbance, there is a functional impairment [or skill deficit] that is addressed in the IRP.
(ii) The withdrawal of service could result in loss of rehabilitation gain or goal attained by an individual.
RIGHTS § 5230.42. Nondiscrimination.
A PRS agency may not discriminate against an individual or staff on the basis of [age, race, sex, religion, ethnic origin, economic status, sexual orientation or gender identity or expression, or disability] race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, National origin or age and shall comply with applicable Federal and State statutes and regulations.
STAFFING § 5230.51. Staff qualifications.
(a) A [PRS] director of a PRS agency that serves individuals 18 years of age or older shall have one of the following:
(1) A bachelor's degree and CPRP certification.
(2) A bachelor's degree and at least 3 years work experience in mental health direct service, 2 years of which must be work experience in PRS. CPRP certification shall be attained within 2 years of hire as a PRS director.
(3) An [associate of arts] associate's degree and CPRP certification, if employed as the PRS director of a licensed PRS facility for at least 6 months immediately prior to May 11, 2013.
(b) A psychiatric rehabilitation specialist who works with individuals 18 years of age or older shall have one of the following:
(1) A bachelor's degree and 2 years work experience in mental health direct service, 1 year of which must be work experience in PRS. CPRP certification shall be attained within 2 years from the date of hire as a psychiatric rehabilitation specialist.
(2) CPRP certification.
* * * * * (d) A psychiatric rehabilitation assistant shall have a high school diploma or GED and 6 months experience in human services.
(e) A director of a PRS agency that serves individuals 14 years of age or older but under 18 years of age shall meet the qualifications for a PRS director in subsection (a) and have or attain CFRP certification within either 2 years of the date of hire as a PRS director or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later.
(f) A psychiatric rehabilitation specialist who works with individuals 14 years of age or older but under 18 years of age shall have one of the following:
(1) A bachelor's degree and 2 years work experience in mental health direct service, 1 year of which must be work experience in PRS. CFRP certification shall be attained either within 2 years from the date of hire as a psychiatric rehabilitation specialist or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later.
(2) CFRP certification.
(g) An associate's degree or bachelor's degree must be awarded by a college or university accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation, or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
§ 5230.52. General staffing requirements.
* * * * * (e) A PRS agency shall develop a schedule that includes a plan to maintain staffing requirements during:
(1) Staff absence.
(2) Deployment of staff for PRS delivered in the home or community.
(f) A PRS agency shall document staffing by maintaining work schedules, time records and utilization data.
(g) When a PRS agency operates more than one PRS facility, the PRS director shall be present at each licensed PRS facility an average of 7.5 hours per week in a calendar month.
(h) A minimum of 25% of the [FTE staff complement] staff based on the number of FTE positions shall meet the qualifications of a psychiatric rehabilitation specialist provided under § 5230.51(b) or (f) (relating to staff qualifications) within [1 year] 2 years of initial licensing.
(i) [A] When a PRS agency serves individuals 18 years of age or older, a minimum of 25% of the [FTE staff complement] staff based on the number of FTE positions shall have CPRP certification within 2 years of initial licensing.
(i.1) When a PRS agency serves individuals 14 years of age or older but under 18 years of age, a minimum of 25% of the staff based on the number of FTE positions shall have CFRP certification within either 2 years of initial licensing or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later.
(j) Trained staff shall be available, or other accommodations made, to address the language needs of an individual, including American Sign Language and Braille.
§ 5230.53. Individual services.
A PRS agency shall provide individual services in a PRS facility [or], in the community or in the home on a one staff to one individual (1:1) ratio.
§ 5230.54. Group services.
(a) A PRS agency shall provide group services in a PRS facility [or], in the community or in the home.
(1) When a group service is provided in a PRS facility, group size may vary as long as the requirement under § 5230.52(c) (relating to general staffing requirements) is met.
(2) When a group service is delivered in the community, one staff shall serve a group of no more than five individuals. Group size in the community may not exceed five individuals.
(3) When an individual receives a group service in a home, all other individuals receiving the group service must be in another location.
(b) Group services delivered in the community shall be limited to individuals who have IRP goals that specify the need for services in the community.
* * * * * (f) A PRS agency shall design group services [delivered in the community] to protect confidentiality [in a public location].
(f.1) Only individuals who receive PRS from the PRS agency may be included in group services delivered in the community.
(g) A PRS agency shall arrange for group discussion of the experience before and after service is conducted in the community. The group discussion shall occur in a setting which assures confidentiality.
§ 5230.55. Supervision.
* * * * * (c) A PRS director or psychiatric rehabilitation specialist designated as a supervisor shall meet with staff individually[, face-to-face,] no less than two times per calendar month.
* * * * * § 5230.56. Staff training requirements.
A PRS agency shall implement a staff training plan that ensures initial and ongoing training in PRS practices as specified under § 5230.4 (relating to psychiatric rehabilitation processes and practices).
(1) Staff providing services in a PRS agency shall complete a Department-approved 12-hour psychiatric rehabilitation orientation course no later than 1 year after hire. This course shall be credited to the annual training requirement listed under paragraph (2) for the calendar year in which it is completed.
(2) Staff providing services in a PRS agency shall complete 18 hours of training per calendar year [with 12 hours specifically focused on psychiatric rehabilitation or recovery practices, or both.] as follows:
(i) If the PRS agency serves individuals 18 years of age or older, 12 hours of the required training shall be specifically focused on psychiatric rehabilitation or recovery practices, or both.
(ii) If the PRS agency serves individuals 14 years of age or older but under 18 years of age, 12 hours of the required training shall be specifically focused on psychiatric rehabilitation or resiliency, or both, with a minimum of 6 hours specifically focused on youth services.
(2.1) If the PRS agency serves individuals 14 years of age or older but under 18 years of age, training in the child abuse mandated reporter requirements of 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services) shall be completed.
(3) A PRS agency shall assure competency of new staff by providing an additional PRS service-specific orientation that includes the following:
(i) Six hours of training in the specific PRS model or approach outlined in the agency service description prior to new staff working independently. This training is required within the first year of employment.
(ii) Six hours of [face-to-face] mentoring for new staff prior to new staff delivering services independently. Mentoring shall be provided by a PRS director or psychiatric rehabilitation specialist designated as a supervisor and [is required] must be completed in person within the first year of employment.
(4) A PRS agency shall assure that training has learning objectives.
(5) A PRS agency shall maintain documentation of training hours in the PRS agency records under § 5230.13(6)(v) (relating to agency records).
§ 5230.57. Criminal history [background check] checks and child abuse certification.
(a) A PRS agency that serves individuals 18 years of age or older shall complete a criminal history background check for staff that will have direct contact with [an individual] individuals receiving PRS.
(b) A PRS agency that serves only individuals 18 years of age or older shall develop and consistently implement written policies and procedures regarding personnel decisions based on the criminal history background check.
(c) A PRS agency that serves individuals 14 years of age or older but under 18 years of age shall complete criminal history background checks and child abuse certifications for staff as required under 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services).
(d) A PRS agency that serves individuals 14 years of age or older but under 18 years of age shall develop and consistently implement written policies and procedures regarding personnel decisions in accordance with 23 Pa.C.S. §§ 6301—6388 and Chapter 3490.
SERVICE PLANNING AND DELIVERY § 5230.61. Assessment.
(a) A PRS agency shall complete an assessment of an individual prior to developing the IRP.
(b) The assessment shall be completed in collaboration with the individual and as directed by the individual, with formal and natural supports, including family members, and must:
(1) Identify the functioning of the individual in the living, learning, working [and], socializing and wellness domains.
(2) Identify the strengths and needs of the individual.
(3) Identify existing and needed natural and formal supports, including other [health care facilities and social service agencies] human services programs or facilities.
(4) Identify the specific skills, supports and resources the individual needs and prefers to accomplish stated goals.
(5) Identify cultural needs and preferences of the individual.
(6) Be signed by the individual and staff or include documentation that the assessment was reviewed with the individual and the date of review.
(7) Be updated annually and when one of the following occurs:
(i) The individual requests an update.
(i.1) The individual's diagnosis and identified needs change.
(ii) The individual completes a goal.
(iii) The individual is not progressing on stated goals.
§ 5230.62. Individual rehabilitation plan.
(a) A PRS staff and an individual shall jointly develop an IRP that is consistent with the assessment and includes the following:
* * * * * (7) Dated signatures of the individual, the staff working with the individual and the PRS director or documentation of consent to the IRP by the individual and the date consent was provided and the dated signatures of the staff working with the individual and the PRS director.
* * * * * (d) An IRP update must include a comprehensive summary of the individual's progress that includes the following:
* * * * * (5) The dated signature of the individual or documentation of consent by the individual and date consent was provided.
(6) [Documentation of the reason if the individual does not sign] (Reserved).
(7) The dated signature of the PRS staff working with the individual and the dated signature of the PRS director.
§ 5230.63. Daily entry.
A PRS agency shall include an entry for the day service was provided in the record of an individual as follows:
(1) Indicates the date, time, duration, location and type of interaction.
(2) Documents service provided in the context of the goal.
(3) Documents the individual response to service.
(4) [Includes the signature of the individual, or if the individual does not sign, documents the reason] (Reserved).
(5) Is signed and dated by staff providing the service.
QUALITY IMPROVEMENT § 5230.81. Quality improvement requirements.
(a) A PRS agency shall establish and implement a written QI plan that meets the following requirements:
(1) Provides for an annual review of the quality, timeliness and appropriateness of services, including the following:
(i) Outcomes for PRS.
(ii) Individual record reviews.
(iii) Individual satisfaction.
(iv) [Use of exceptions to admission and continued stay requirements] Number of individuals admitted to PRS that did not have a diagnosis listed in § 5230.31(a)(2) (relating to admission requirements).
(iv.1) Average length of stay in PRS for individuals who did not have a diagnosis listed in § 5230.31(a)(2).
(v) Evaluation of compliance with the approved agency service description.
* * * * *
[Pa.B. Doc. No. 22-1008. Filed for public inspection July 8, 2022, 9:00 a.m.]
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