SERVICE PLANNING AND DELIVERY
§ 5240.21. Assessment.
(a) Within 15 days of the initiation of services and prior to completing an ITP, a face-to-face assessment shall be completed for the child, youth or young adult by an individual qualified to provide behavior consultation services or mobile therapy services.
(b) The assessment shall be completed in collaboration with the child, youth, young adult or parent, legal guardian or caregiver of the child or youth, as appropriate.
(c) The assessment shall be individualized and include the following:
(1) The strengths and needs across developmental and behavioral domains of the child, youth or young adult.
(2) The strengths and needs of the family system in relation to the child, youth or young adult.
(3) Existing and needed natural and formal supports.
(4) The specific services, skills, supports and resources the child, youth or young adult requires to address the child’s, youth’s or young adult’s identified therapeutic needs.
(5) The specific supports and resources, if any, the parent, legal guardian or caregiver of the child, youth or young adult requires to assist in addressing the child’s, youth’s or young adult’s identified therapeutic needs.
(6) Clinical information that includes the following:
(i) Treatment history.
(ii) Medical history.
(iii) Developmental history.
(iv) Family structure and history.
(v) Educational history.
(vi) Social history.
(vii) Trauma history.
(viii) Other relevant clinical information.
(7) The child’s, youth’s or young adult’s level of developmental, cognitive, communicative, social and behavioral functioning across the home, school and other community settings.
(8) The cultural, language or communication needs and preferences of the child, youth or young adult and the parent, legal guardian or caregiver.
(d) The assessment shall include a summary of the treatment recommendations received from health care providers, school or other service providers involved with the child, youth or young adult.
(e) The assessment shall be reviewed and updated at least every 12 months or if one of the following occurs:
(1) A parent, legal guardian or caregiver of the child or youth requests an update.
(2) The youth or young adult requests an update.
(3) The child, youth or young adult experiences a change in living situation that results in a change of the child’s, youth’s or young adult’s primary caregivers.
(4) The child, youth or young adult has made sufficient progress to require an update.
(5) The child, youth or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.
(6) The child, youth or young adult experiences a crisis event.
(7) A staff person, primary care physician, other treating clinician, case manager or other professional involved in the child’s, youth’s or young adult’s services provides a reason an update is needed.
(f) The assessment and all updates shall be signed and dated by the staff person who completed the assessment.
(g) This section does not apply to ABA services.
(h) Subsection (a) does not apply to EBT or group services.
Cross References This section cited in 55 Pa. Code § 1155.32 (relating to payment conditions for individual services); 55 Pa. Code § 5240.22 (relating to individual treatment plan); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.95 (relating to assessment); and 55 Pa. Code § 5240.102 (relating to assessment and individual treatment plan).
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