Section 388-877C-0120. Problem and pathological gambling services—Clinical record content and documentation requirements.

In addition to the general clinical record content requirements in WAC 388-877-0640, an agency providing problem and pathological gambling treatment services must maintain an individual's clinical record that contains:

(1) Evidence the individual was notified of the assessment results and documentation of the treatment options provided and the individual's choice. If the individual was not notified of the results and advised of referral options, the reason must be documented.

(2) Documentation that each individual received a copy of the rules and responsibilities for treatment participants, including the potential use of interventions or sanctions.

(3) Documentation that the individual service plan was completed before the individual received treatment services.

(4) Documentation that the individual service plan was reviewed monthly.

(5) Documentation of progress notes that occurs in a timely manner and before any subsequent scheduled appointments of the same type of service session or group type occur, or documentation as to why this did not occur. Progress notes must include the date, time, duration, participant names, a brief summary of the session, including the individual's response to treatment, and the name of the staff member who provided the treatment.

(6) Documentation of referrals made for specialized care or services.

(7) Documentation that staff members met with each individual at the time of discharge, unless the individual left without notice, to:

(a) Determine the appropriate recommendation for care and finalize a continuing care plan.

(b) Assist the individual in making contact with necessary agencies or services.

(c) Provide and document the individual was provided with a copy of the plan.

(8) Documentation that a discharge summary, including the date of discharge and a summary of the individual's progress towards each individual service plan goal, was completed within seven days of the individual's discharge.

[Statutory Authority: Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877C-0120, filed 5/31/13, effective 7/1/13.]

Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877C-0120, filed 5/31/13, effective 7/1/13.

Rules

388-877-0640,