(a) Mental health targeted case management documentation. Mental health targeted case management services must be documented in the individual's medical record. Case managers are required to maintain a record of every individual receiving mental health targeted case management, including:
  (1) the name of the individual;
  (2) the name of the comprehensive provider agency and the name of the assigned case manager;
  (3) the date, nature, content, and units of each service received and whether goals specified in the recovery/treatment plan have been achieved;
  (4) whether the individual has declined services in the recovery/treatment plan;
  (5) the need for, and occurrences of, coordination with other staff members;
  (6) a timeline for obtaining needed services; and
  (7) a timeline for reevaluation of the recovery/treatment plan.
(b) Service documentation. The case manager must document the following for each service provided:
  (1) the event or behavior that occurs while providing the service or the reason for the specific encounter;
  (2) the person, persons, or entity, including other staff members, with whom the encounter or contact occurred;
  (3) a collateral contact that is directly related to identifying the needs and supports for helping the individual access services and managing the individual's care, including coordination with other staff members;
  (4) the recovery/treatment plan goal(s) that was the focus of the service, including the progress or lack of progress in achieving recovery plan goal(s);
  (5) the specific intervention provided;
  (6) the date the service was provided;
  (7) the start and end time of the service;
  (8) the mode of delivery used to provide the service and if provided in person, the location where the service was provided; and
  (9) the signature of the case manager providing the service, including credentials.
(c) Crisis service documentation. In addition to the general documentation requirements described in subsection (b) of this section, a staff member must document the following for crisis intervention services:
  (1) behavioral description of the presenting problem;
  (2) lethality (e.g., suicide, violence);
  (3) the individual's relevant substance use;
  (4) the individual's relevant trauma, abuse, or neglect;
  (5) all actions, including rehabilitative interventions and referrals to other agencies, used by the provider of crisis intervention services to address the problems presented;
  (6) the response of the individual, and if appropriate, the response of the LAR or primary caregiver and family members;
  (7) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA or a QMHP-CS;
  (8) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service;
  (9) follow up activities, which may include referral to another provider; and
  (10) the outcome of the individual's crisis.
(d) Refusing mental health targeted case management services. If the individual refuses mental health targeted case management services, the assigned case manager must:
  (1) document the individual's stated reason for the refusal in the individual's medical record; and
  (2) request that the individual sign a waiver of case management services that is filed in the individual's medical record.

Source Note: The provisions of this §354.2657 adopted to be effective October 17, 2018, 43 TexReg 6819; amended to be effective January 23, 2023, 48 TexReg 209