POLICY/PROCEDURE. Issued By: Clinical Services. Date Reviewed/Revised: 5/99, 10/00, 4/01, 3/02, 3/03

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1 Title: Plan for the Provision of Care POLICY/PROCEDURE Issued By: Clinical Services Policy No.: CC.000 Date Issued: 10/98 Date Reviewed/Revised: 5/99, 10/00, 4/01, 3/02, 3/03 Approved: Leadership - 5/18/99, 4/9/01 Clinical Services Function 8/05/02, 5/15/03 Medical Executive Committee 10/98, 2/99, 6/17/99, 7/15/99, 5/17/01, 8/23/02, 5/15/03 Board of Trustees 10/98, 2/99, 6/24/99, 8/23/99, 5/24/01, 8/23/02, 5/15/03 I.0 INTRODUCTION Prairie St. John s is a private, freestanding health care facility that specializes in psychiatric and chemical dependency treatment. Inpatient care is provided on a 24-hour basis, seven days a week, in a 53 bed acute care psychiatric setting. Outpatient and partial hospitalization services are provided on a 5-day per week basis, days and evenings. 2.0 PHILOSOPHY AND PURPOSE We believe that mind, body and spirit exist as an inseparable unit and that our responsibility is to treat the total person in the knowledge that pathology in one affects the level of functioning in the other. We believe that the human being is a delicate balance of emotional, intellectual, physical, and spiritual dimensions. Psychiatric disorders result in disturbances in thought, behavior and affective processes. These disturbances impair the patient's ability to perform basic life roles and severely disrupt family, social, and educational relationships, which can be ameliorated by prompt psychiatric care. Page 1 of 37

2 Prairie St. John s is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility's mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family and staff goals in the most effective and efficient manner possible. The best principles and most current information available about human behavior are incorporated into the plan of care for each program. Prairie St. John s provides a comprehensive therapeutic environment through an individualized treatment program for each patient. This is achieved through group, family, marital, educational, and activity therapies, and the focus is on the patient as a unique individual. Care is provided according to an established code of ethical conduct and strict adherence to patient rights. Involvement of the family, whenever possible, is encouraged to promote support for the patient's recovery. We offer patient centered care, and support our holistic philosophy with a full continuum of care. Resources are organized around each patient through the development of an individualized, comprehensive treatment plan. The patient's strengths provide the cornerstone of the treatment plan and are mobilized from admission, throughout hospitalization and into discharge. Responsibility for the well being of the patient is recognized as being in the patient's hands as soon as possible. 3.0 ORGANIZATION Prairie St. John s is a freestanding psychiatric facility with its own Board of Trustees, CEO, Clinical/Nursing Services Director, and Clinical and Business Services Functions. The Board of Trustees, as the governing body of Prairie, has ultimate responsibility and authority for all patient care services provided as described fully in its Bylaws. The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout the facility. The Medical Executive Committee, as the executive body of the medical staff, is accountable to the Governing Body for clinical and administrative aspects of patient care, as well as performance improvement activities. The committee is chaired by the Chief the Medical Staff and provides a forum for discussion and review of clinical activities. Medical staff accountability to the Medical Executive Committee is defined fully in the Medical Staff Bylaws. The Clinical Services Function consists of the CEO, Clinical/Nursing Services Director, Medical Director/Physician Executive, Chief of Staff/Physician Executive, and Quality Management Director. The Business Services Function consists of the CEO, Chief Financial Officer, Human Resources and Quality Management Directors. The functions work with the Executive Committee of the Board of Trustees and the Page 2 of 37

3 Medical Executive Committee as the organizational planning bodies for budget, staffing and programmatic direction and patient care.. For a summary of various forms of interdisciplinary deliberation or review, see the Master Meeting Schedule (attached). Prairie utilizes the "medical model" for patient treatment with a strong emphasis on interdisciplinary input in terms of screening, evaluation, diagnosis and treatment of patients. Staff providing treatment as part of the interdisciplinary team include the psychiatrist, nurse(s), social worker, activities therapist, group therapist(s) and individual and/or family therapist. Substance abuse counselors, chaplains and teachers participate as members of the treatment team as appropriate. All disciplines complete assessments within the first 72 hours, summarize, present their findings and develop a comprehensive treatment plan. The plan contains the following: Specific interventions that relate to goals, written in behavioral and measurable terms and include expected achievement dates as well as the person responsible for implementation. Specific discharge criteria necessary for the individual patient to achieve and maintain, emotional, physical, social and vocational/recreational stability as deemed appropriate for the patient s capabilities. Referral for needed services for the individual patient not provided directly by the hospital and A plan for involving family and/or significant others when appropriate. All team members are responsible to the team leader, who is the attending physician. General functions of team members are described for employees by their respective job descriptions. Physicians and therapists who are independent practitioners provide treatment consistent with clinical privileges defined through the medical staff credentialing process. Treatment teams are organized in accordance with the services provided. All treatment modalities are designed according to the type and level of care. The attending psychiatrist supervises the clinical work of his or her team members. The Clinical/Nursing Services Director supervises the clinical group functions and clinical staff of nursing, chemical dependency, occupational therapy/activity therapy services, and social services. Service and Clinical Department Supervisors meet on twice monthly as a team with the Nursing/Clinical Services Director. The focus on these meetings includes treatment issues, overall programming, and quality management activities. Each department has a director or supervisor who is responsible to the CEO and Physician Executives. Department directors and Supervisors are accountable for Page 3 of 37

4 the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, and performance improvement activities. (Reference Leadership Plan LD.002) The organizational relationship of the programs, channels of staff communication, responsibility, authority and supervisory relationships are depicted in the organizational chart attached and made a part hereof. Each department has a description of its organizational structure, channels of communication and interdisciplinary collaboration relative to the overall philosophy and goals of Prairie. Patient support is provided by a variety of individual departments, which may not have direct contact with the patients, but who support the care provided by the hands-on care providers. All services, whether patient care or patient support services are available to ensure care and services are maintained in an uninterrupted and continuous manner. 4.0 PROGRAMS The staff of Prairie believes in and strives to maintain a total therapeutic environment through an individualized treatment approach for each patient and family. Each program is designed to provide services appropriate to the scope and level of care required by the patient population served. A multi-disciplinary staff provides comprehensive treatment-oriented activities. Clinical staff provide individual therapy, group therapy, family therapy, occupational therapy, activity therapy, and educational services. All clinical services are delivered by qualified professional staff including, but not limited to, psychiatrists, registered nurses, licensed practical nurses, behavioral health technicians, clinical social workers, psychologists, chaplains, teachers, a dietician, pharmacist, licensed addiction counselors and activity or occupational therapists. Clinical services that are not available within the facility may be provided through referral, consultation or contractual agreements with area professionals and other health care facilities. (e.g. Education staff, physical therapy,, dietician, laboratory, pharmacy) The goal of treatment is to promote the highest level of functioning for each patient with emphasis on individual, group and family therapy provided at the least restrictive level of care. The patient's symptoms, strengths, family support and discharge needs provide the basis for care from admission to discharge. The programs provide for a continuum of care from more intensive to less intensive treatment options. Page 4 of 37

5 4.1 Adult Programs Adult Inpatient Mental Illness Program The adult inpatient mental illness program is designed for the treatment of adult patients, ages 18 and over, with primary psychiatric diagnoses. Some patients may have a secondary substance abuse diagnosis who meet the criteria for medically supervised in-patient treatment. The following patients are excluded: Disorders caused by chronic organic brain dysfunction without treatable psychiatric symptoms Behavioral, cognitive and/or physical impairment which would render the patient unable to function at a minimally acceptable level within the treatment program, such as a medically unstable patient whose safety requires treatment in a medical-surgical hospital Those who meet criteria for less restrictive treatment. The programs are based in an acute-care setting, in a 24 (twenty-four) bed unit, and is in operation 24 hours per day, seven days per week and include. AREAS OF CARE SERVICE PROVIDERS Psychiatric Evaluation Psychiatrists Psychosocial Assessment Social Services Staff Nursing Assessment Registered Nurses History and Physical Exam PA or Physician Medical/Surgical Consults Physicians Dietary Consults Registered Dietitian Psychological Screening Psychologists and/or Testing Neuropsychological Psychologists Evaluation Diagnostic Testing: Lab, EKG Physicians Activity Therapy Therapeutic Recreation Specialist Occupational Therapist Page 5 of 37

6 Individual/Family/Group Therapy Continuing Care Planning Spiritual Assessments and Pastoral Counseling Counselors and Social Services Staff Social Services Staff and Treatment Team Chaplain Adult Inpatient Chemical Dependency (CD) Program The Adult Inpatient Chemical Dependency Program is designed for the treatment of patients, ages 18 or over with a primary diagnosis of chemical dependency who meet the criteria for medically supervised inpatient treatment. Patients who are so medically fragile that their safety demands treatment in a medical/surgical setting, or who are so mentally impaired that they cannot reasonably benefit from less restrictive treatment. The program operates 24 hours per day, seven days per week in an acute care setting, and operates on the Adult Unit. Areas of care provided by identified service providers are the same as for the Adult Mental Illness Program with the following additions: AREAS OF CARE SERVICE PROVIDERS Chemical Dependency Licensed Addiction Counselors Assessment Adult Inpatient Dual Diagnosis Program The Adult Inpatient Dual Diagnosis Program is designed for the treatment of patients, ages 18 and over who meet criteria for inpatient psychiatric treatment and for chemical dependency treatment. Areas of care provided by identified service providers are the same as for the Adult Mental Illness Program with the following additions: AREAS OF CARE SERVICE PROVIDERS Chemical Dependency Licensed Addiction Counselors Assessment Adult Partial Hospitalization Program This program is designed to meet the increasing need for variations in psychiatric care. The program provides care for patients 18 years of Page 6 of 37

7 age or older if developmentally appropriate. Individuals with less intensive treatment needs than those addressed through the in-patient setting benefit from this program. Patients participate in either the: a. Mental Health Track b. Dual Diagnosis Track c. Chemical Dependency Track The program is in operation 5 days per week, 6 hours per day. Areas of care by identified service providers are the same as those provided through the Adult Mental Illness Program. Level of care will be determined by the admitting/attending psychiatrist. For those patients who meet the criteria for the Adult Partial Program and do not have a stable home where they would be geographically too far to commute for treatment, transitional housing (see policy TX.001.4) is available Adult Mental Illness Day Treatment This program is designed for the treatment of patients ages 18 and over, with a primary psychiatric diagnosis. The program is in operation 3 days per week, 4 hours per day. Areas of care are provided by the following service providers. AREAS OF CARE SERVICE PROVIDERS Case Management Social Work Psychiatry Supervision MD Psychiatry Symptom Management/Medication Ed. RN OT Coping Skills OTR/L OT Healthy Life Skills OTR/L Cognitive Behavioral Skills Psychology Health Care Screening RN Other services as provided by the Adult Mental Illness and/or Addicitve Disease Programs are available and will be utilized based upon individual need. Page 7 of 37

8 4.1.6 Adult Chemical Dependency Day Treatment Outpatient Program This program is designed for the treatment of patients, ages 18 or over, with a primary diagnosis of alcohol and/or drug dependency who meet the criteria for medically supervised day treatment outpatient services. Those patients who are individually unstable or who are so impaired that they cannot benefit form outpatient treatment may be excluded. The program is in operation varying between 4.5 hours and 8.5 hours per day for a total of 21 hours per week. AREAS OF CARE Psychosocial Data base Health Care Screening Individual/Group Therapy Continuing Care Planning Lectures SERVICE PROVIDERS Social Services Staff / Needs Assessment Staff Physicians, RN, Qualified Medical Staff Licensed Counselors, LAC. and other staff as needed Psychiatrist, Social Service and Nursing Staff, LAC Treatment Team and other staff as needed LAC, and other Qualified Staff Adult Chemical Dependency Intensive Outpatient Program This program is designed for the treatment of patients, ages 18 or over, with a primary diagnosis of alcohol and/or drug dependency who meet the criteria for medically-supervised, intensive outpatient treatment. Those patients who are medically unstable or who are so impaired that they cannot benefit from outpatient treatment may be excluded. The Intensive Outpatient Program is in operation for three (3)hours per day, Monday, through Friday of each week. The Areas of Care and Service Providers match that of the Adult Day Page 8 of 37

9 Treatment Program listed above. Other services as provided for the Adult Psychiatric and/or Adult Addictive Disease Programs are available and will be utilized based upon individual need. Page 9 of 37

10 4.1.8 Adult Chemical Dependency Low Intensive Outpatient Program This program is designed for the treatment of patients 18 years of age and older with a primary diagnosis of alcohol and/or drug dependency who have successfully benefited from Intensive Outpatient Services. Patients receive three (3) hours of programming per day for 1-3 times per week. AREAS OF CARE lecture group therapy psychoeducation SERVICE PROVIDERS LAC LAC LSW 4.2 Pediatric Programs Adolescent Inpatient Treatment Program The Adolescent Inpatient Treatment Program is designed for the treatment of adolescents, ages 12 through 18 or older is developmentally appropriate, with primary psychiatric diagnoses who meet the criteria for medically-supervised, inpatient acute treatment. Patients participate in either the: a. Mental Health Track b. Dual Diagnosis Track c. Chemical Dependency Track The program operates 24 hours per day, seven days per week, on a twenty-nine (29) bed unit, in an acute care setting. Sharing resources with the children s inpatient treatment program. Areas of care provided by identified service providers are the same as for Adult Inpatient Psychiatric Treatment with the following additions: AREAS OF CARE Education Assessment Speech, Language and Hearing Testing Developmental History SERVICE PROVIDERS Certified Teachers Speech Language Therapist Social Services and Nursing Staff Page 10 of 37

11 4.2.2 Children's Treatment Program The Children's Inpatient Program shares space with the Adolescent Inpatient Treatment program on a twenty-nine (29) bed unit in an acute care setting. The program is generally designed for the treatment of children less than 12, with primary psychiatric diagnoses who meet the criteria for medically supervised, in-patient treatment. Excluded are those patients who are so medically unstable that their safety requires treatment in a medical-surgical hospital; those who are so behaviorally or cognitively impaired that they cannot benefit from treatment in a less restrictive setting; those who meet criteria for less restrictive treatment; or those with chronic organic brain dysfunction without treatable psychiatric symptoms. Patients participate in either the: a. Mental Health Track b. Dual Diagnosis Track c. Chemical Dependency Track The program is in operation 24 hours per day, seven days per week. Areas of care provided by identified service providers are the same as for the Adolescent Psychiatric Program Pediatric Partial Hospitalization Program This program is designed to meet the increasing need for variations in psychiatric care. The program provides care for patients up to 18 years of age, or older if developmentally appropriate. Individuals with less intensive treatment needs than those addressed through the in-patient setting benefit from this program. Patients participate in either the: a. Mental Health Track b. Dual Diagnosis Track c. Chemical Dependency Track The program is in operation 5 days per week, 6 hours per day. Areas of care by identified service providers are the same as those provided through the Pediatric Psychiatric Program. Level of Care will be determined by the admitting/attending psychiatrist. Page 11 of 37

12 4.2.4 Adolescent Chemical Dependency Day Treatment Program This program is designed for the treatment of patients up to 18 years of age with A primary diagnosis of alcohol and/or drug dependency who meet the criteria for a day treatment program. Those patients who are medically unstable or who are so impaired that they cannot benefit from day to day treatment may be excluded. This program operates for 5 (Five) hours per day, Monday through Friday of each week. The Areas of Care and Service Providers match the Adult CDIOP Adolescent Chemical Dependency Intensive Outpatient Program This program is designed for the treatment of patients up to the age of 18 with a primary diagnosis of alcohol and/or drug dependency who meet the criteria for a medically-supervised intensive outpatient treatment. Those patients who are medically unstable or who are so impaired that they cannot benefit from outpatient treatment may be excluded. The Intensive Outpatient Program is in operation for three (3) hours per day, Monday through Friday of each week. The Areas of Care and Service Providers match the Adult CDIOP Adolescent Chemical Dependency Low Intensity Outpatient Program This program is designed for the treatment of patients up to 18 years of age with a primary diagnosis of alcohol and/or drug dependency who have successfully benefited from Intensive Outpatient Services. Patients may receive three (3) to six (6) hours of programming per week. Areas of Care lecture group therapy psychoeducation Service Providers LAC LAC LSW Page 12 of 37

13 5.0 SERVICES 5.1 Needs Assessment Screening and Intake Prairie accepts referrals from the professional community (physicians, courts, community agencies, education systems, psychologists and counselors), as well as by patients, or their supports. Intake screening and evaluations are performed by qualified Needs Assessment counselors or by a member of the clinical supervisory staff, Social Services staff, registered nurse or active member of the Medical Staff, 24 hours per day, seven days per week. The individual is advised of the program structure at the time of the evaluation, together with a recommendation for the appropriate level of treatment according to admission criteria and physician recommendation. Financial information is provided. If admission criteria is not met, or if PRAIRIE does not offer a program to meet the patient's needs, recommendations are made for assistance available elsewhere in the community. As needed, provision for a safe transfer to an accepting facility and physician will be arranged. Admission to an inpatient program may be voluntary or court-ordered. Patients are admitted to inpatient and partial hospitalization under the care of a psychiatrist. Day treatment and Intensive outpatient programs are under the supervision of a psychiatrist. 5.2 Admission Process Inpatient and Partial Hospitalization Programs: Upon receipt of physician's orders and signed consent for treatment, the patient meeting admission criteria will be admitted to the appropriate unit/program. Partial hospitalization patients will be instructed upon when to arrive at next program day, if not in progress. An initial assessment will be completed by a registered nurse. The physician's admission orders and the nursing assessment then guide the initial treatment plan. The patient's family or support persons, if available, will be interviewed by a member of the staff to obtain collateral family history. The unit program will be explained to the patient and Page 13 of 37

14 family and a copy of the program handbook will be provided. The patient and belongings will be searched for unsafe items. All dangerous items will be secured, labeled and placed for safekeeping on the unit if not taken home by the family. The patient will be oriented to the unit to which he is admitted, including introductions to staff and peers, and the patient's rights explained. The patient will be introduced into the unit/program activity in progress at the time of admission, as appropriate MI Day Treatment For direct admission to the MI Day Treatment program, patients are assessed by a Needs Assessment counselor. If the individual meets the criteria for the program and requires this level of care, the Needs Assessment counselor facilitates obtaining of the physician's admission order, schedules start date for programming, and schedules a psychiatric evaluation (by psychiatrist or psychiatric nurse practitioner) to be completed on or before the first day of treatment. If the patient is stepping down from a higher level of care, the discharging physician order for the referral to MI Day Treatment. The psychiatric evaluation from the higher level of care will be copied and placed in the patient's MI Day Treatment chart. On the first treatment day, the program BHT will meet with the new patient and review the schedule and orientation materials. The BHT will also schedule the nursing assessment for the first day of treatment. OT and SW assessments are completed within the first 4 days of treatment. RN will complete health screening within 3 treatment days Chemical Dependency Day Treatment For a direct admission to the CD Day Treatment program, patients are assessed by a Needs Assessment counselor and a Licensed Addiction Counselor(LAC). If the individual meets the criteria for the program and requires this level of care, the Needs Assessment counselor coordinates the admission process by the pre-certification of benefits in coordination with Utilization Review, schedules a Nursing Assessment, and sets a start date. If the individual is stepping down from a higher level of care, the discharging physician will order for referral to CD Day Treatment. The psychiatric evaluation and other consults from the higher level of care will be copied by Page 14 of 37

15 Medical Records and placed in the patient's CD Day Treatment chart. On the start date the LAC or CDBHT will meet with the individual and they are given all required program material. The LAC develops the initial treatment plan and with input from the Social Worker prepares the treatment plan for a weekly review with the treatment team Chemical Dependency Intensive Outpatient For a direct admission to CDIOP, individuals are assessed by a Needs Assessment counselor and a Licensed Addiction Counselor (LAC). If the individual meets the criteria for the program and requires this level of care, the Needs Assessment counselor coordinates the admission process by the pre-certification of benefits in coordination with Utilization Review, scheduling a Nursing Assessment, and sets a start date. If the individual is stepping down from a higher level of care this is coordinated between the treatment team, and the discharging physician will order the referral to CDIOP. The psychiatric evaluation and other consults from the higher level of care will be copied by Medical Records and placed in the patient's CDIOP chart. On the start date the LAC or CDBHT will meet with the individual and they are given all required program material. The LAC develops the initial treatment plan and with input from the Social Worker prepares the treatment plan for review with the treatment team every two weeks Chemical Dependency Low Intensive Outpatient For a direct admission to CDLIOP, individuals are assessed by a Needs Assessment counselor and a Licensed Addiction Counselor (LAC). If the individual meets the criteria for the program and requires this level of care, the Needs Assessment counselor coordinates the admission process by the pre-certification of benefits in coordination with Utilization Review, scheduling a Nursing Assessment, and sets a start date. If the individual is stepping down from a higher level of care this is coordinated between the treatment team, and the discharging physician will write the order for admission to CDLIOP. The psychiatric evaluation and other consults from the higher level of care will be copied by Medical Records and placed in the patient's CDLIOP chart. On the start date the LAC or CDBHT will meet with the individual and they are Page 15 of 37

16 given all required program material. The LAC develops the initial treatment plan and with input from the Social Worker prepares the treatment plan for review with the treatment team once a month Intensive Outpatient Services: Upon receipt of signed consent for treatment, the patient meeting admission criteria will be admitted to the program and scheduled for attendance at the next treatment day or provided appointment information. The therapist will complete a health screening and collect key medical information. This information, along with the initial needs assessment will be the basis for the treatment plan. If indicated, the patient's family will be interviewed by the therapist to obtain collateral family information. The patient will receive an orientation to the therapy expectations and physical layout and patient rights explained. A copy of the patient handbook or information sheet will be provided. 5.3 Assessment and Evaluation Procedures Assessment of all patients begins on admission and is integral to the treatment process. Treatment planning is individualized according to individual needs identified through assessments. Primary assessments include the following: Inpatient Psychiatric Evaluation: Performed by the attending psychiatrist within 24 hours of admission. Includes a history of the present disorder, brief psychiatric history, including history of substance abuse, brief family history, brief medical history, mental status exam, diagnostic impression, strengths and weaknesses, and initial plan of care. Medical History and Physical: Performed by the consulting physician or Physician s Assistant within 24 hours of admission. Includes history of previous medical problems, present illness, family medical history and review of systems and physical examination. Page 16 of 37

17 Nursing Assessment: Performed by a registered nurse within 8 hours of admission and includes the patient's physical/mental health, a nutritional screening, assessment for pain, potential for safety concerns, mental status exam and immunization status for children/adolescents. Additional age-specific assessments will be conducted on all geriatric, children, and adolescents. The nurse initiates the preliminary treatment plan based upon findings of the assessment. Psychosocial History: Performed with the patient and, when possible, family members/ significant others by Social Services staff within 72 hours of admission and includes a complete family history, interpersonal relationships, medical/psychiatric history, ethnic/cultural and religious issues affecting treatment, abuse history, discharge planning and an integrated summary. Spiritual Assessment: Administered by an RN or LPN within 24 hours of admission and includes the patient s spiritual history, and if requested, the need for a chaplain s visit and/or contacting the patient s own clergy/spiritual leaders. Occupational/Activity Therapy Assessment: Performed by a licensed/certified occupational therapist within 72 hours of admission. Patient/Family Educational Learning Assessment: Performed by the Registered Nurse at the time of the nursing assessment, documented and includes information on any limitations or disabilities that may impact learning ability Partial Hospitalization Program: Psychiatric Evaluation: Performed by the attending psychiatrist within or 3 treatment days of admission. Includes a history of the present disorder, brief psychiatric history, including history of substance abuse, brief family history, brief medical history, mental status exam, diagnostic impression, strengths and weaknesses, and initial plan of care. Medical History and Physical: Following review of the Nursing Assessment, the physician may order a Medical History and Physical. The H&P shall be completed the first day of treatment for patients admitted directly from an inpatient service, the current physical examination may suffice(if conducted within Page 17 of 37

18 the previous 30 days). The physical examination is reviewed, updated, approved, and recorded as acceptable by the responsible physician for PHP. Nursing Assessment: Performed by a registered nurse within 8 hours of admission and includes the patient's physical/mental health, a nutritional screening, and immunization status for children/adolescents. Additional age-specific assessments will be conducted on all geriatric, children, and adolescents. The nurse initiates the preliminary treatment plan based upon findings of the assessment. Psychosocial History: Performed with the patient and, when possible, family members/ significant others by Social Services staff within 5 days of admission and includes a complete family history, interpersonal relationships, medical/psychiatric history, ethnic/cultural and religious issues affecting treatment, abuse history, discharge planning and an integrated summary. Spiritual Assessment: Administered by an RN or LPN within 24 hours of admission and includes the patient s spiritual history, and if requested, the need for a chaplain s visit and/or contacting the patient s own clergy/spiritual leaders. Occupational/Activity Therapy Assessment: Performed by a licensed/certified activities therapist within 5 days of admission. Patient/Family Educational Learning Assessment: Performed by the Registered Nurse at the time of the nursing assessment, documented and includes information on any limitations or disabilities that may impact learning ability. Outpatient Summary List: Completed by the Registered Nurse on admission and includes known significant medical diagnoses and conditions, known adverse and allergic drug reactions, medications known to be prescribed for or used by the patient, and any known significant operative or invasive procedures Intensive Outpatient Comprehensive Needs Assessment: Completed in Needs Assessment and Referral Center or by therapist and provides information on presenting symptomatology, and key social and Page 18 of 37

19 risk factors to provide a baseline of information for treatment planning. Health Screening Form: Completed by the therapist and reviewed by the physician overseeing the program. Includes information on current health status and medical issues. Outpatient Summary List: Completed by the therapist/designee no later that the third visit and includes known significant medical diagnoses and conditions, known adverse and allergic drug reactions, medications known to be prescribed for or used by the patient, and any known significant operative or invasive procedures Additional Assessments: As indicated by patient need, physician and treatment team assessment, the following assessments may be provided: Educational Assessment: As indicated by length of stay, or special need an education assessment may be performed on children and adolescent patients by a certified teacher with input from the home school. Includes grade level, history, test results, strengths, weaknesses and interventions. Completed within 3 days of admission/physician's order or within 3 Treatment Days. Psychological Assessment: Performed by a psychologist as ordered by the physician to assist the treatment team in understanding the nature of the illness. May includes personality, intellectual and neuropsychological testing as ordered by the physician. Nutrition Assessment: Performed by the Registered Dietitian within 48 hours or within 2 Treatment Days of a written order by the physician or notification by nursing that nutritional screening criteria established by the medical staff has been met. Includes dietary needs, assessment of lab results, preferences, habits, and recommendations. Page 19 of 37

20 Drug and Alcohol Assessment: Performed when indicated by the Chemical Dependency Counselor within 72 hours or within 2 Treatment days of order or admission to program. Includes history of alcohol/drug use, history of physical problems associated with dependence, use of alcohol and other drugs by family members, spiritual orientation, types of previous treatment and responses to that treatment, history of physical or sexual abuse as the abuser or the abused, and sexual orientation.. Other Assessments: Laboratory, radiology, MRI, EKG/EEG, CT Scan, vocational, rehabilitation, spiritual and other specialized consultations such as speech, language and hearing are ordered on an individualized basis to assure optimal utilization of resources. 5.4 Service Delivery Methods Individualized treatment is based on the findings of the completed assessments and is provided by a multi- disciplinary team of professional staff. This team includes, but is not limited to, the psychiatrist, psychologist, nursing staff, social services staff, chaplains, dietitian, occupational and activity therapist(s) and educational staff. The primary objective of the treatment team is the assessment, treatment and rehabilitation of the patient in an environment that promotes positive behavioral change. This may include, but is not limited to, the following therapeutic modalities: Individual Therapy: The purpose of individual therapy is to assist the patient to gain a dynamic cognitive or supportive understanding of emotional and/or behavioral problems that have led to his present life situation. The goal of individual therapy is to help the patient attain a more appropriate and rewarding psychosocial adjustment to facilitate psychological comfort, goals and aspirations. Individual therapy is conducted by a qualified counselor, psychiatrist, therapist or social worker, who may or may not also act as the patient's case manager Group Therapy: The group process is utilized to help alleviate interpersonal and social dysfunction, to develop communication and relationship skills, to develop identity with allegiance to a group of peers, to increase understanding of illness and coping options, and to foster pro-treatment attitudes Page 20 of 37

21 and behaviors. Other goals of the group include development of group cohesion, reality testing within age- appropriate limits, inter-personal learning, role communication, a beginning ability to identify internal and external behaviors and developing insight into the interrelationships between internalized feelings and externalized behavior Family Therapy: Implicit in the treatment philosophy is the importance of parental and family involvement in the total treatment program. A dysfunctional family system is usually a significant aspect of the total pathology of the identified patient. The family is involved in treatment to address the pertinent issues within the family system. The goal is to restore or maintain as functional and healthy a family system as possible to provide for the continued emotional growth and development and well- being of the identified patient and other family members Activity Therapy: Assists the patient in working on psychological and physical development through involvement in structured and unstructured activities. The patient is assessed for level of functioning and therapeutic needs are identified Educational Therapy: Provided by certified teachers, employed by the Fargo School District, or other qualified staff who assess each patient's educational needs. Learning opportunities, when clinically appropriate, are provided to enable each study to stay current with missed schoolwork and to remediate specific academic deficiencies. Department staff work closely with the patient's home school at admission and strive to continue the course work of the student through on-going communication with the home school Milieu Therapy: Provides a predictable, structured and safe treatment setting. Uniform and consistent limits, set by the clinical staff, assist in the management of behaviorally expressed feelings. Special emphasis is placed on the learning of appropriate behavior. Clinical staff act as role models and help patients through daily routines such as mealtimes and bedtime. Interpersonal skills in building and maintaining appropriate relationships with peers and authority figures are stressed. Patients and treatment staff meet in community sessions in all treatment programs. Page 21 of 37

22 The adolescent and child programs utilize a level system in order to promote a clear reflection of the patient's progress and provide specific feedback to the patient about how effectively he is handling personal responsibility Spirituality: Provided by professional chaplains. Examples of programming include individual meetings, daily Thought for the Day announcements, adult morning reflection, adolescent and child evening reflection groups, optional worship services, group therapy with topics on the nature of spirituality, forgiveness, guilt/shame, grief, serenity, empowerment/communication, and intimacy. In these sessions, the chaplains explore with patient's their spiritual histories and the areas of spiritual injury, as well as assist in developing healthy attitudes and practices with the patients Therapy Groups: Patients are involved in specific therapy groups according to their individual needs and level of care. These may include: Child and Adolescent Programs Process Group - facilitated by Master's level or PhD level therapists focuses primarily on the process of the interaction between group members and therapist rather than the content. This focus on process helps the therapist to identify recurrent aspects of the patients relationship with others and lead the participants toward interpersonal learning, insight and support. Didactic or Psychoeducation Group - may include drug awareness and education, assertive skills, coping skills, sex education, suicide education and prevention, drug and alcohol awareness, problem solving, family issues and sexual abuse; facilitated by the primary therapist, case manager or certified substance abuse counselor. Activity Therapy - is provided by a licensed recreation therapist to provide opportunities for leisure counseling and develop effective life skills. Family Therapy - facilitated as indicated by the case manager, social worker, therapist, psychologist or attending psychiatrist to foster communication skills, cohesion and adaptability between the youth and his caretakers. Page 22 of 37

23 Daily Community - facilitated daily by unit staff to enhance the patient's ability to function in social settings with both adults and peers. Morning and/or afternoon community meetings are utilized to establish and evaluate goals set by each patient in the acute programs. Community is held each session for the PHP and IOP programs. Spirituality: Provided by professional chaplains. Examples of programming include individual meetings, daily Thought for the Day announcements, adult morning reflection, adolescent and child evening reflection groups, optional worship services, group therapy with topics on the nature of spirituality, forgiveness, guilt/shame, grief, serenity, empowerment/communication, and intimacy. In these sessions, the chaplains explore with patient's their spiritual histories and the areas of spiritual injury, as well as assist in developing healthy attitudes and practices with the patients. Adult Chemical Dependency Programs Daily Community- facilitated daily by unit staff to enhance the patient's ability to function in social settings with both adults and peers. Morning and/or afternoon community meetings are utilized to establish and evaluate goals set by each patient in the acute program. Community is held each session for the PHP and IOP programs. 12-Step - in-depth reading and discussion of the "Big Book" of Alcoholics Anonymous. Individual reading and written work may take place during this period depending on the needs of the group. Lecture -Facilitated by a nurse, social worker, physician, chaplain or counselor, lecture topics include medication education, spiritual issues, grief, humor, self-talk and self-help. Self-help Support Group - AA, NA, AL- ANON, ACOA, etc., are support groups for the patient and family dealing with various addictive disease issues. These meetings are usually open to the general public and are led by a volunteer from the recovering community in various community locations. Page 23 of 37

24 Process Group - These groups provide an opportunity for patients to give input into their treatment plan, receive feedback from the clinical team and participate in structured activities related to various didactic groups. Peer review may also provide feedback about patient progress in the various programs. Spirituality Provided by professional chaplains. Examples of programming include individual meetings, daily Thought for the Day announcements, adult morning reflection groups, optional worship services, and group therapy with topics on the nature of spirituality, forgiveness, guilt/shame, grief, serenity, empowerment/communication, intimacy, and groups dealing with Steps One through Five of the 12 Step program. In these sessions, the chaplains explore with patient s their spiritual histories and the areas of spiritual injury, as well as assist in developing healthy attitudes and practices with the patients as they further develop a relationship with their Higher Power. At the patient s requests, the chaplains will assist in connecting patients with local clergy/spiritual leaders in hearing their fifth steps. Adult Treatment Program Daily Community- facilitated daily by unit staff; community is designed to enhance the patient's ability to function in social settings with both staff and peers. Morning and /or afternoon community meetings are utilized to establish and evaluate goals set by each patient in the acute programs. Community is held each session for PHP and IOP programs. Lecture - Facilitated by a nurse, social worker, physician, chaplain or counselor, lecture topics include medication education, spiritual issues, grief, humor, self-talk and self-help. Process Group - facilitated by Master's level or PhD level therapists focuses primarily on the process of the interaction between group members and therapist rather than the content. This focus on process helps the therapist to identify recurrent aspects of the patients relationship with others and lead the participants toward interpersonal learning, insight and support.. Relaxation Group - Different types of relaxation training, such as guided imagery, progressive muscle relaxation and breathing Page 24 of 37

25 exercises are taught in a group setting. Lifestyle changes needed to alleviate stress will be identified. Activity Therapy Group - Facilitated by a licensed Recreation Therapist to provide opportunities for leisure counseling and develop effective life skills. Psychoeducational Groups - facilitated by Social Workers, therapists or nursing staff, these groups provide specific information about health, wellness, diagnosis, coping skills or discharge planning. Spirituality: Provided by professional chaplains. Examples of programming include individual meetings, daily Thought for the Day announcements, adult morning reflection groups, optional worship services, and group therapy with topics on the nature of spirituality, forgiveness, guilt/shame, grief, serenity, empowerment/communication and intimacy. In these sessions, the chaplains explore with patients their spiritual histories and the areas of spiritual injury, as well as assist in developing healthy attitudes and practices with patients Pharmacotherapy Treatment Planning Can be initiated for the treatment of severe emotional disturbance or chemical abuse/addiction upon written order of the attending physician. The use of medication is judiciously individualized for each patient. The Pharmacy and Therapeutics Function of the medical staff monitors utilization through ongoing monitoring and evaluation activities, which may include peer review. Medications may be administered only by physicians, registered nurses, licensed practical nurses in the inpatient, residential, partial hospitalization. Licensed nurses may accept verbal or telephone orders from a qualified physician. Any such orders must be countersigned by the physician within the time frame specified in the Medical Staff Rules and Regulations. Each program has a multidisciplinary approach to treatment planning. Those involved in the treatment planning process, based on the program, may include the patient's physician, Page 25 of 37

26 nursing staff, social workers, psychologists, counselors,, licensed addiction counselors, behavioral health technicians, chaplains, teachers and activity therapists. The team is responsible for development of the individualized treatment plan and the review and evaluation of ongoing treatment. Preliminary Treatment Plan - The preliminary treatment plan is initiated upon admission by the registered nurse, physician or designee. It is based on the intake assessment, nursing assessment and physician's orders. It includes the following: Identification of initial problems, symptomatic behavior of the problem and assessment of the cause of the problem. Goals of treatment. Measurable short-term objectives based on the goals of treatment. Therapeutic approaches (interventions) to be used with the patient. Accountable individual or department. Initial Patient Assignments Master Treatment Plan - The master treatment plan is formalized no later than 3 days after admission for acute care, within 5 days for the PHP and by the fifth session in IOP. The treatment plan is a reflection of our philosophy of treatment and reflects the interdisciplinary input and collaboration of all team members. It includes the following: Identification of physical, psychological and social problems the patient is experiencing. The process of identifying and agreeing upon the three major problem areas (target behaviors) to be addressed in treatment occur as a result of the social worker meeting with the patient and family. The target behaviors are then rated by the patient and/or parents, in terms of severity, at the time of identification and again at discharge. Coping mechanisms for each of the target behaviors are also agreed upon during this initial assessment phase. Once Page 26 of 37

27 treatment is implemented, the team evaluates changes in the target behaviors on a weekly basis as part of the treatment review process. The treatment team, the patient and the family also complete a variety of assessments of functioning tools. The psychiatrist completes the Global Assessment of Functioning (GAF). The RN facilitates the patient completion of the Admission Patient Depression Inventory. Social Work completes the Global Assessment of Relationship Functioning (GARF), Social Support Scale and assist parents with the Parent Rated Global Assessment Scale (PGAS).These tools allow the patient, family and treatment team to regularly assess areas of improvement and serve to keep the treatment team focused on those areas where improvement is still essential for successful discharge. At the time of discharge patient, parent, if applicable, and staff again complete the various assessment of functioning tools as a way of evaluating the overall success of treatment. Achievable long-term goals of treatment stated in behavioral terms. Measurable short-term goals stated in behavioral terms that will reflect progress toward the goal achievement. Therapeutic approaches (interventions) used by each discipline to assist the patient in meeting the target area treatment goals. The individual or discipline accountable for assisting the patient with therapeutic approaches. Page 27 of 37