	Residential Treatment Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-RTX 3: Assessment

An individualized, strengths-based assessment, completed in a timely manner with family and resident participation, is the basis for service, discharge, and aftercare planning and delivery.

Interpretation: Legislation requires that children and youth who receive child welfare services have a permanency plan consistent with federal guidelines.

Note: Refer to the Assessment Matrix for additional assessment criteria. The elements of the matrix can be tailored according to the needs of specific individuals or service design.

PA-RTX 3.01

Individuals entering a crisis stabilization center are accepted on a 24-hour basis, and a qualified professional provides:

an assessment at admission to determine an appropriate level of care; and
a mental health evaluation within 24 hours of admission.

NA The agency does not operate or refer individuals to a crisis stabilization unit.

PA-RTX 3.02

Assessments consider factors related to successful group living including:

possible reciprocal individual and group effects;
the individual’s ability to adjust to a group; and
previous placements.

Interpretation: Safety issues may arise when placing individuals, with little or no notice, into a residential living environment prior to completion of a full assessment. The agency must ensure the smoothest transition possible for both new and current residents.

PA-RTX 3.03

Clinical personnel conduct a bio-psychosocial evaluation with the participation of a licensed psychiatrist, psychologist, or other qualified mental health professional, or review a recent evaluation that includes:

a psychiatric history;
a mental status examination;
a trauma assessment;
intelligence and projective tests, as necessary; and
a behavioral appraisal.

Interpretation: Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms.

Note: The agency should have mechanisms in place for sharing information among service providers, that respects confidentiality and encourages continuity of care and treatment.

PA-RTX 3.04

Residents receive an individualized interdisciplinary assessment of:

family, environmental, cultural, and religious or spiritual preferences;
educational and vocational goals and needs; and
strengths, skills, and special interests.

Interpretation: Culturally responsive assessments can include attention to geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, and developmental level.

PA-RTX 3.05

When a resident’s initial assessment or screening indicates a substance use condition, the agency:

records a thorough alcohol and drug use history, including an evaluation of the effects of alcohol and other drug use on the resident’s family;
arranges for an appropriate level of care and detoxification, as necessary; and
provides referral when the program does not serve individuals with substance use conditions.

Research Note: The connection between child welfare and justice system use of residential resources for youth prompts consideration of mental health screening practice that is appropriate for both populations. “Reception” or “emergent risk” screening information is of current interest to practitioners seeking consensus on best practices for screening and assessment of youth in the justice system. Depending on service history and current situation, and when mental health concerns are noted, it is recommended that screening include emergency medical conditions, use of medications, substance use, and risk of suicidal, self-injurious and assaultive behavior.

Research Note: A reliable, valid screening tool reduces biases that can influence staff recommendations. Agencies with this knowledge can promote use of the most reliable and well-validated screening tools available.

PA-RTX 3.06

The agency assesses and treats or refers identified victims and perpetrators of abuse and neglect.

Interpretation: The agency complies with mandatory reporting laws and only releases information with the written, informed consent of the person or legal guardian.

QUICK JUMP TO


	PURPOSE: Residential Treatment Services are delivered according to an articulated philosophy that ties individual needs to specific interventions and education, and to achievement of stated goals, such as gains in measurable skills, increased productivity and pro-social behavior, improved functioning, and a stable living arrangement in the community.

RELATED FILES


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	CRITERIA Systematically developed, objective, and quantifiable statements used to assess the appropriateness of specific decisions, services, and outcomes.


	QUALIFIED PROFESSIONAL An individual licensed by the state in which the organization operates to perform duties outlined in the regulation requirements. Similar terms include: qualified health practitioner, qualified clinician, and qualified medical practitioner.


	EVALUATION The review and assessment of organizational operations, programs and services.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	DISCHARGE See CASE CLOSING


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	SCREEN A preliminary test administered to a client to determine whether he/she meets eligibility criteria for the services offered by an organization.


	CONFIDENTIALITY An ethical and practice principle that requires the protection of information shared within a professional-client relationship. An organization that upholds confidentiality prohibits personnel from disclosing information about persons served without their written consent.


	DETOXIFICATION The process by which drugs or other harmful substances are removed from a person's body for a time period sufficient to restore adequate physiological and psychosocial functioning.


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	MENTAL HEALTH SCREENING A general assessment used to detect the possible presence of, or risk for, a mental health problem. If the screening is positive, a further assessment by a trained professional is necessary to definitively establish the presence or absence of a mental health problem and to establish a diagnosis.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	MEDICATION A prescribed or over-the-counter drug that is injected, taken orally, applied topically, or otherwise administered.


	MANDATORY REPORTING The legal obligation to report specific forms of child abuse to a government authority when a person suspects that abuse has occurred. State laws outline specific reporting requirements for professionals if they have information related to public or private safety issues. For example, certain professionals are required to report to state authorities if they see evidence of child abuse or neglect, or have knowledge that someone is likely to be dangerous to themselves or others.


	INFORMED CONSENT The explicit granting of permission by a consumer or his/her legal guardian to the service provider and organization to use a specific intervention or participate in research. The consent is predicated on full disclosure of the facts to enable the consumer to make a decision based on knowledge of the risks and alternatives.


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.