Authority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4

Affected: IC 12-25

Sec. 9. (a) The facility shall have policies and procedures that govern the intake and assessment process to determine eligibility for services.

(b) Treatment required by a consumer shall be appropriate to the facility and the professional expertise of the staff.

(c) A consumer may be admitted if alternatives for less intensive and restrictive treatment are not available in the community.

(d) A physical examination shall be completed by:

1. (1) a licensed physician;
2. (2) an advanced practice nurse; or
3. (3) a physician's assistant;

within twenty-four (24) hours after admission.

(e) An initial:

1. (1) emotional;
2. (2) behavioral;
3. (3) social; and
4. (4) legal;

assessment of each consumer shall be completed upon admission.

(f) If the consumer being admitted is less than eighteen (18) years of age, then the initial assessment shall also include the following:

1. (1) An evaluation of school progress.
2. (2) A report of involvement with other social or legal services agencies.
3. (3) An assessment of family functioning and relationships.

Family input and advice shall be considered in the diagnosis, treatment planning, and discharge planning process.

(g) A child who is fourteen (14) years of age or younger may be admitted to a nonsegregated unit, that is, an adult unit, only in an emergency. The facility shall:

1. (1) specify in advance the criteria for such an emergency admission; and
2. (2) require an evaluation of the child by a child psychiatrist within sixty (60) hours of admission.

(h) A facility shall do the following:

1. (1) Verbally report to the division an admission under subsection (g) within twenty-four (24) hours of the admission as required under 440 IAC 1.5-2-2(e)(5).
2. (2) Submit a written report to the division within ten (10) working days as required under 440 IAC 1.5-2-2(f) in the form specified in 440 IAC 1.5-2-2(h).

(i) A preliminary treatment plan for each consumer shall be formulated within sixty (60) hours of admission on the basis of the intake assessment at the time of admission.

(j) Each consumer shall be encouraged and allowed to participate in the development and review of the consumer's own treatment plan. If the consumer:

1. (1) agrees to family participation; and
2. (2) signs a release of information;

the facility shall consider input from and participate with the family in the diagnosis and treatment process.

(k) A consumer's choice not to participate in the consumer's treatment planning process shall be documented in the clinical record.

(l) The treatment plan shall:

1. (1) specify the services necessary to meet the consumer's needs; and
2. (2) contain discharge or release criteria and the discharge plan.

(m) Progress notes shall be entered daily in the consumer's record by staff having knowledge of the consumer and responsibility for implementing the treatment plan. The notes from all sources shall be:

1. (1) entered in an integrated chronological order in the record;
2. (2) signed; and
3. (3) dated.

(n) Each consumer's treatment plan shall be:

1. (1) reviewed at least every seven (7) days; and
2. (2) revised as necessary.

(Division of Mental Health and Addiction; 440 IAC 1.5-3-9; filed Oct 11, 2002, 11:26 a.m.: 26 IR 743; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119-IR-440080742RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA; readopted filed Nov 9, 2020, 3:09 p.m.: 20201209-IR- 440200502RFA)