# Title 75 — Department of Human Services

## Article 75-05 — Human Service Center Licensure Standards

## Chapter 75-05-04 — Client Management

### § 75-05-04-01. Admission process.

1. The regional director shall designate admission personnel who are responsible for the initial
contact with the individual and, as determined appropriate, the individual's family to define and
evaluate the presenting problems and make disposition for necessary services.
2. If, in the judgment of the admission personnel, the contact which has been made is of an
emergency nature, the admission personnel shall comply with emergency service procedures.
3. If, in the judgment of the admission personnel, the contact which has been made is not of an
emergency nature, the admission personnel shall determine if the human service center can
provide the treatment or services that the individual and the individual's family require. Upon
determination that required services are available, the admission personnel shall assure that
an appointment is scheduled.
4. A signed application for services must be completed at the time of admission.
5. The initial admission process must involve a face-to-face interview with the consumer and
include the following:
a. A statement of the presenting problems;
b. An assessment of the consumer's current emotional, cognitive, and behavioral
functioning;
c. The consumer's history, including family background, social history, psychiatric history,
medical history (including a list of the consumer's current medications, both prescribed
and over the counter, and allergies), developmental history, educational history, and
employment history; and
d. A signed release of information form from the consumer and the consumer's parent or
guardian, when deemed necessary.
6. If the consumer is being referred for community residential services, the consumer, if possible,
should visit the residential facility.
7. The human service center must have a mechanism to review service needs and formulate
recommendations for consumers when the initial unit to which the consumer was referred
cannot provide services. If the human service center or the unit to which the consumer has
been referred cannot provide services, the professional staff member shall document, in the
consumer record, the reasons the consumer is not provided services. The consumer, or
parent or guardian, must be informed of the results of the review and the results must be
documented in the consumer record.

History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
January 1, 2009.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
### § 75-05-04-02. Admission.

Repealed effective December 1, 1991.
### § 75-05-04-03. Individual plans.

1. Each consumer who has been admitted for service to the human service center shall have an
individual plan based on the admission data and needs of the consumer.
2. Overall development and implementation of the individual plan are the responsibility of the
professional staff member assigned the consumer.
3. The individual plan must contain the consumer's name, problems, service strategies to resolve
problems, goals, measurable objectives, names of staff members responsible for service
strategies, and the signature of the case manager.
4. The professional staff member assigned to the consumer shall develop and review the
individual plan with the consumer, shall document in the consumer's record the consumer's
input in the development and review indicating the extent of the involvement in developing the
individual plan, and shall have the consumer sign the treatment plan. If the consumer refuses
or is unable to sign the treatment plan, this must be documented in the consumer's record.
5. Except in the case of emergency services, within twenty working days from the date of
admission, which is the time when the consumer and the staff member first meet to begin the
admission process, the multidisciplinary team shall hold a case staffing to confirm or to revise
the diagnosis and treatment plan, or to reassign the consumer to an appropriate member of
the professional staff.
History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
January 1, 2009; July 1, 2020.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
### § 75-05-04-04. Progress notes.

1. Progress notes related to the consumer's treatment plan goals and objectives must describe
the consumer's progress in treatment chronologically and must document the consumer's
response to services related to the treatment.
2. Progress notes must address the following:
a. Activities and services provided as they relate to the goals and objective of the treatment
plan, including ongoing reference to the treatment plan;
b. Documentation of the progress or lack of progress made in treatment as it relates to the
treatment plan;
c. Documentation of the implementation of the individualized treatment plan, including
consumer activities and services and all treatment rendered;
d. Documentation of the consumer's response to treatment services, changes in behavior
and mood, and outcome of treatment or services; and

e. Plans for continuing therapy, for transfer, or for discharge, whichever is appropriate.
3. Progress notes must be documented according to the following time frames:
a. Individual and family therapy must be documented after each visit or transaction,
including missed appointments; and
b. Group therapy must be documented at least weekly.
4. Progress notes must include service date, signature of staff member and any professional
credentials of the staff member, and the signature date.
History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
January 1, 2009.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
### § 75-05-04-05. Individual plan review.

For clinical services, the consumer, case manager, and case manager's supervisor shall review
individual plans at least every six months, except when consumer circumstances necessitate a change
to the treatment plan.
History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
March 1, 1997; January 1, 2009; July 1, 2020.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
### § 75-05-04-06. Completion of treatment or service.

1. The case manager shall enter a treatment or service completion summary in the consumer's
record when consumers have not received treatment within six months after documented
attempts to contact the consumer have been made, when termination is mutually agreed upon
by the consumer and the case manager, or when it has been determined by a multidisciplinary
team that a consumer no longer needs treatment or that treatment is inappropriate.
2. The treatment or service completion summary must include at a minimum:
a. Presenting problem at intake;
b. Medication summary when applicable;
c. Treatment provided and treatment outcome and results;
d. Discharge plan; and
e. Signature of staff member, professional credentials, if any, and date of summary.
3. When the service completion summary has been finalized, the closure must be entered on the
data collection system.
History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
January 1, 2009.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2

### § 75-05-04-07. Consumer referrals.

1. When a consumer needs treatment or service which the human service center does not
provide, staff shall assist the consumer in obtaining the services, if available.
2. The staff shall provide pertinent information to the referral agency. Before any referral is made,
a release of information must be signed by the consumer, or the consumer's parent or
guardian, or a determination must be made that the signed release of information form is not
necessary for the referral.
History: Effective November 1, 1987; amended effective January 1, 2009.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
### § 75-05-04-08. Records maintenance.

1. The regional director shall designate a staff member who is responsible for the safekeeping of
each consumer's record.
2. All data and information in the consumer's record is confidential.
a. Records must be maintained in accordance with federal and state confidentiality
requirements.
b. Upon written request, the consumer's record is available to the consumer, or to any
individual designated by the consumer, for review unless a legally sufficient basis for
denying the consumer access to the record has been established. In those cases, the
request and the reason for the denial must be documented in the consumer's record. The
human service center shall establish policies which encourage consumers to seek
professional assistance while undertaking a review of records, and which prevent the
alteration of any record during a review.
3. The human service center shall comply with department policies and procedures concerning
records management.
History: Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996;
January 1, 2009.
General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2
