Statutory Authority – Max Association

Statutory Authority

The Department of Human Services (Department), by this order, adopts the regulation set for in Annex A under the authority of sections 911 and 1021 of the Human Services Code (62 P.S. §§ 911 and 1021). Notice of the proposed rulemaking was published at 52 Pa.B. 3828 (July 9, 2022).

Purpose of Regulation

The purpose of this final-form rulemaking is to amend Chapter 5230 (relating to psychiatric rehabilitation services) to allow individuals who are 14 years of age or older but under 18 years of age who meet the admission requirements to access psychiatric rehabilitation services (PRS) and to amend the diagnoses that allow an individual to access PRS without the use of the

exception process. Through the exception process, individuals without one of the specified diagnoses for admission to PRS may still receive PRS if they have a diagnosis of a mental, behavioral or emotional disorder that results in a moderate to severe functional impairment. In addition, the amendment clarifies the documentation that will be reviewed through the exception process to determine if an individual is eligible for PRS and also revises outdated language. This final-form rulemaking supports the principles of recovery, resiliency and self-determination by permitting additional individuals to receive PRS.

Background

In 2013, the Department promulgated this chapter, which provides for the minimum standards for the issuance of licenses for PRS facilities. PRS is an evidence-based service that uses an integrated approach to assist individuals who have a moderate to severe functional impairment as a result of a diagnosed mental, behavioral or emotional disorder to develop the skills needed to live, learn, socialize and work in their community and to improve or maintain

their physical and mental health. PRS is primarily used to meet the needs of individuals diagnosed with serious mental illness or serious emotional disturbance, specifically individuals with a diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder (I or II), anxiety disorder or posttraumatic stress disorder.

PRS promotes recovery and resiliency, full community integration and improved quality of life. Additionally, PRS may decrease the need for or shorten the length of stay in inpatient, partial hospitalization or outpatient treatment. PRS helps individuals reach age-appropriate functioning that has either been lost or never achieved because development was interrupted by a mental, behavioral or emotional disorder. This final-form rulemaking will result in more individuals being eligible for PRS because it allows youth 14 years of age or older to receive PRS. In addition, it identifies additional diagnoses that will enable individuals to receive PRS without requiring the use of the exception process for receiving PRS.

This chapter, as promulgated in 2013, limited PRS to individuals 18 years of age or older. Stakeholders have expressed that there is a need for additional supports for individuals 14 years of age or older that will engage them and help them transition to the adult service system. The majority of mental health disorders are identified during adolescence and early adulthood. Many traditional adult mental health services do not focus on skill development to improve the individual’s ability to be successful in the community, but rather focus on alleviating symptoms and psychological distress. Access to PRS, which focuses on helping individuals develop skills needed to be successful in the living, learning, working, social and wellness environments, will assist youth in transitioning to adulthood and maintaining independence in the community.

Affected Individuals and Organizations

This final-form rulemaking affects agencies that provide PRS and the individuals who will be eligible for PRS as a result of the regulatory amendments. Specifically, the final-form rulemaking allows 111 community-based licensed PRS agencies and their 33 satellite locations to provide PRS to individuals 14 years of age or older but under 18 years of age. The Department convened a workgroup to review and provide input on the proposed rulemaking. The workgroup included family members and representatives from the following entities: Pennsylvania Healthy Transitions Partnership; Pennsylvania Council of Children, Youth and Family Services; Drexel University/Behavioral Healthcare Education; Dickinson Center, Inc.; Holcomb Behavioral Health Systems Berks County; Community Services Group; Commerce Park Clubhouse; Philadelphia Department of Behavioral Health; Threshold Rehabilitation Services, Inc.; Family Services of Western Pennsylvania; Child and Family Focus, Inc.; Allied Services; Aurora Social Rehabilitation Services; Office of Vocational Rehabilitation; Transition Age Advisory Group; Rehabilitation and Community Providers Association; Pennsylvania Association of Psychiatric Rehabilitation Services; Mental Health Association in Pennsylvania; and the mental health service system in Allegheny, Beaver, Berks, Bucks and Montgomery Counties.

Accomplishments and Benefits

PRS promotes resiliency and recovery, full community integration and improved quality of life for individuals who have a diagnosed mental, behavioral or emotional disorder. This final form rulemaking will benefit individuals 14 years of age or older but under 18 years of age with a diagnosed mental, behavioral or emotional disorder by allowing these individuals to access evidence-based PRS as they transition into adulthood, which will foster engagement in PRS into

adulthood and may reduce the need for or shorten the length of stay in inpatient, partial hospitalization and outpatient treatment. This final-form rulemaking includes requirements that ensure the health and safety of individuals 14 years of age or older but under 18 years of age who receive PRS by requiring that services are provided by qualified and trained staff and that the PRS agency has completed criminal history checks and child abuse certifications for staff. It also adds requirements that promote the engagement of youth and families in the recovery process, which will result in better outcomes for individuals receiving services. This final-form rulemaking will also benefit individuals diagnosed with posttraumatic stress disorder, bipolar disorder, major depressive disorder or anxiety disorders because individuals with these disorders will no longer need to use the exception process to be eligible for PRS. This will assist individuals diagnosed with these disorders to develop skills needed to live, learn, socialize and work in their community and improve or maintain their physical and mental health. This final-form rulemaking also adds wellness as a domain in which PRS agencies may assist individuals receiving PRS to develop skills. This addition will allow individuals to learn how to manage their physical and mental health needs to promote or support their recovery and resiliency.

Fiscal Impact

It is anticipated that the implementation of this final-form rulemaking will result in an increase in costs for PRS agencies that choose to serve individuals 14 years of age or older but under 18 years of age. Staff will need to obtain child abuse certifications, in accordance with State law, if they serve children under 18 years of age. The PRS director, psychiatric rehabilitation specialists and 25% of the staff based on the number of full-time equivalent positions will also need to obtain Child and Family Resiliency Practitioner (CFRP) certification.

The current cost to obtain child abuse certifications is $13 for each child abuse clearance. The cost to obtain the CFRP certification is approximately $395 (registration and examination fee) per person.

A PRS director and psychiatric rehabilitation specialist who does not have CFRP certification is required to obtain CFRP certification within 2 years of hire or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later. The approximate cost for the CFRP certification using an approximate lowest cost of $12 for 45 training hours is $540; plus the addition of the cost of the exam and registration which is $395. If a PRS agency that serves individuals 14 years of age or older but under 18 years of age also serves adults, the PRS director and psychiatric rehabilitation specialists will also need to obtain Certified Psychiatric Rehabilitation Practitioner (CPRP) certification. The approximate cost to obtain CPRP certification is the same as the cost to obtain CFRP certification. The Department estimates that approximately 10%, or around 15 of the 144 PRS locations, would choose to serve youth populations. The total cost of the required child abuse clearance, CFRP certification and training required for CFRP certification is $42,660 for the first year, assuming 15 locations would choose to serve individuals 14 years of age or older but under 18 years of age. Each year after the initial certification, the total cost of the required child abuse clearance, CFRP recertification and training would be $10,845.

While more individuals will be eligible for PRS, the Department may potentially realize long term savings from the implementation of this final-form rulemaking. Allowing individuals 14 years of age or older but under 18 years of age to receive PRS will allow more individuals access to an evidence-based practice. In addition, access to PRS will provide a service option to keep

individuals within their community, and not be placed within an inpatient service or another costly service. As such, it is anticipated there will be a potential reduction in the need for future crisis and inpatient services. Many adults and youth who currently receive residential services can be successfully supported by community-based services.

The Department also does not anticipate any costs to local governments or individuals who receive PRS as a result of this rulemaking.

Paperwork Requirements

PRS agencies that wish to provide services to individuals 14 years of age or older but under 18 years of age will need to update their service descriptions to include information about the services they will provide and the staff who will provide PRS to this new population. The Department estimates that it may take a PRS agency staff person up to 2 hours to update a service description. PRS agencies that wish to provide services to individuals 14 years of age or older but under 18 years of age must ensure that staff comply with requirements in the Child Protective Services Law (CPSL) (23 Pa.C.S. §§ 6301—6386) for criminal history background checks and mandated reporter training. Additional paperwork will need to be completed by agency staff to comply with the requirements for criminal history background checks and mandated reporter training.

In addition, all PRS agencies will need to update their service descriptions to address new service description requirements, which will result in an increase in paperwork. Likewise, requiring the number of individuals who were admitted to PRS through the exception process and their average length of stay to be tracked as part of the agency’s quality improvement plan will result in an increase in paperwork. Additionally, PRS agencies that do not already have a

written agreement with a peer support services agency will have to obtain one, which will also result in an increase in paperwork.

While there is potential for an increase in paperwork, this increase will be offset by a reduction in paperwork because the requirement for a daily progress note is being replaced by a requirement for a weekly progress note. It is anticipated that the staff time and costs for completion of these paperwork requirements is nominal.

Public Comment

Written comments, suggestions and objections regarding the proposed rulemaking were requested within a 30-day period following publication in the Pennsylvania Bulletin. The Department received 30 written responses containing 372 comments. These comments represented feedback from a broad spectrum of advocates, including the Pennsylvania Association of Psychiatric Rehabilitation Services; providers, including UPMC, Community Services Group, Horizon House and Merakey; professionals; counties; and behavioral health managed care organizations and other organizations. Additionally, the Department received comments from the Independent Regulatory Review Commission (IRRC) and one comment from Representative Kathy Rapp.

Discussion of Comments and Major Changes

The following is a summary of the major comments received within the public comment period following the publication of the proposed rulemaking and the Department’s responses to these comments and a summary of additional changes to the final-form rulemaking.

General – Lowering the age of eligibility for PRS

Several commentators stated they were in agreement with allowing individuals as young as 14 years of age to be eligible for PRS. These commentators supported lowering the age of eligibility for PRS because an underserved population will be able to receive PRS and younger individuals will benefit from PRS’s promotion of recovery, resiliency and self-determination. One commentator is opposed to allowing individuals 14 years of age or older but under 18 years of age to receive PRS because they currently have sex offenders participating in their program. Another commentator stated that teenagers should not be made to attend site-based services alongside adults. Representative Kathy Rapp supports the initiative to expand services, but expressed concerns about parental rights to determine what is in the best interest of a child. She requested the “Department to clarify whether there are specific statutory provisions, whether state or federal, that provides the Department with authority to promulgate regulations regarding minors receiving PRS without needing parental consent.”

Response:

The Department appreciates the support for lowering the minimum age for eligibility for PRS. As required under section 5230.15(a) of the final-form rulemaking, if a PRS agency serves individuals 14 years of age or older but under 18 years of age, the agency is required to include in their service descriptions information on how different age groups will be separated while services are provided through the scheduling of services and through the provision of services in different locations in the PRS facility’s physical space. In response to comments, the Department also clarified section 5230.15(a)(3)(ii) to require information on how different age groups will be separated while services are provided. Under the final-form rulemaking the information shall demonstrate the separation of individuals through the scheduling of services,

providing the services in different locations in the PRS facility’s physical space, and other procedures the agency plans to use in order to separate individuals under 18 years of age from individuals 18 years of age and older, or any needed age groupings. Lastly, the statutory authority regarding parental consent, additional comments and the accompanying revisions are discussed in further detail under the response to comments received on section 5230.21(4) (relating to content of individual record).

General – Therapeutic approach

Four commentators do not agree with the use of the word “therapeutic” in the background section of the Preamble. The commentators explained that PRS is an evidence-based approach that utilizes strength-based interventions that focus on functioning in life roles and environments. The commentators were concerned that the term “therapeutic” implied that PRS is treatment via therapy.

Response:

The Department agrees that PRS is not therapy. The use of the word “therapeutic” was intended to describe the effect of PRS on the individual receiving PRS. The background section of the final-form rulemaking does not contain the word “therapeutic” to clarify that PRS is not therapy.

General – Use of telehealth

Although commentators were supportive of the use of telehealth to provide PRS, IRRC and numerous commentators sought clarification on the use of telehealth to deliver PRS. IRRC and the commentators commented that the Preamble included a discussion of telehealth, but the regulatory amendments in the annex did not include reference to telehealth. They recommended that a definition of “telehealth” be added to the regulation. Commentators also suggested that the

Department reference the Office of Mental Health and Substance Abuse Services’ telehealth guidance in the final-form rulemaking.

In addition, several commentators requested that the Department allow the limited delivery of PRS by telephone consistent with the Department’s requirements for the delivery of peer support services, which allows 25% of peer support services to be delivered by telephone. Commentators are in favor of allowing audio-only services because many individuals do not have access to technologies that support two-way video conferencing. IRRC and commentators stated that PRS agencies that deliver PRS through telehealth should have policies that ensure that telehealth is utilized only when it is clinically appropriate to do so and that licensed practitioners that deliver PRS through telehealth comply with the standard of practice established by their licensing board. IRRC requested the Department explain how PRS agencies will implement access to services through telehealth.

Response:

The Department appreciates and thanks the commentators and IRRC for their various comments surrounding the use and delivery of telehealth within PRS. Since the provision of services through telehealth is constantly evolving, the Department has removed references to “telehealth” from the preamble and has decided to not include telehealth requirements in this final-form regulation. Instead, the Department will continue to examine the use, frequency and technology of providing PRS via telehealth and will consider these parameters for future rulemakings. As such, the Department did not revise the annex.

As noted in the proposed rulemaking, the Department is removing the definition of “face to-face” and the requirements for face-to-face supervision under the final-form rulemaking in section 5230.55(c). As such, an agency may choose the medium for supervision, which may

include in-person supervision or supervision by two-way simultaneous audio-visual communication. However, under the final-form rulemaking, the Department further clarified that audio-only supervision is not permitted under section 5230.55(c).

General – Location of services

A few commentators were concerned about the implications of distinguishing “home” from the “community” as a location where PRS can be provided. Commentators noted that they support the delivery of services in an individual’s home, but home has always been considered a community location where services could be provided and that there is no need to distinguish between home and community to allow for services to be provided. Commentators explained that licensing documents currently state whether services are approved to be provided at a facility/clubhouse, in the community, or at both a facility/clubhouse and the community and that the home was previously considered a community location. Commentators were concerned that PRS agencies would be cited if their licensing documents are not amended.

In addition, commentators noted that separating the home location from the community location will have an impact on billing for services. One commentator explained that most managed care organizations require PRS to be billed by location and PRS agencies would need to bill separately for services that start in the home and move to the community and then conclude in the home, which will cause confusion and may necessitate multiple bills for services.

Commentators also objected to distinguishing between home and community because it would require that they revise their service descriptions. IRRC and commentators recommended that a definition of “community” be added to the regulations, or the regulations be revised to clarify that community includes an individual’s home. IRRC also requested that the Department

explain why it is necessary to add home as a service location. One commentator also requested clarification as to whether a school constitutes services in the community. Response:

The Department thanks the commentators for this clarification. The Department has carefully considered these comments and agrees with the objections about distinguishing between home and community. Therefore, the Department has deleted the proposed term “home” from section 5230.4(f), 5230.15(a)(6), 5230.52(e)(2), 5230.53 and 5230.54(a) of the final-form rulemaking. As such, the Department declines to define “community.” Instead, the Department will maintain the status quo and not distinguish between “community,” “school,” and “home.” General – Updating names of organizations

One commentator supported changing the names of organizations to their current names. Response:

The Department appreciates the commentator’s support of this change. In addition, in the final-form rulemaking, the Department is also referring to other similar nationally-recognized entities in section 5230.3 (relating to definitions) and 5230.15(a)(5) (relating to agency service description).

§ 5230.3 Definitions – Associate’s degree and bachelor’s degree

IRRC pointed out that the Department had stated in the Preamble of the proposed rulemaking that definitions for “associate’s degree” and “bachelor’s degree” were added to section 5230.3 (relating to definitions), but these definitions were not included in section 5230.3 and degree standards are stated in section 5230.51(g) (relating to staff qualifications). IRRC requested that the Department revise the Preamble to the final-form rulemaking to reflect the sections where degree standards are explained.

Response:

The Department incorrectly stated in the Preamble of the proposed rulemaking that the Department was adding these definitions. Since the Department has not defined “associate’s degree” and “bachelor’s degree” in the final-form rulemaking, the Department is also not referencing its addition in this Preamble.

§ 5230.3 Definitions – DSM and ICD

Four commentators supported the revisions of the definition of “DSM-IV-TR” and “ICD-9” to delete the reference to outdated versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). IRRC suggested that

the Department clarify the definitions of DSM and ICD by adding the publishers of the DSM and ICD.

Response:

The Department agrees with IRRC’s suggestion. As such, the Department has added the publishers of the DSM and ICD to the definitions of “DSM” and “ICD.”

§ 5230.3 Definitions – Functional impairment

IRRC and two commentators asked the Department to revise the proposed definition of “functional impairment” because it is vague and a licensed practitioner of the healing arts (LPHA) may be unfamiliar with assessing functioning and performance in life domains, which is needed to complete a recommendation for PRS.

Response:

The Department agrees. After careful consideration, the Department has removed the proposed revisions and will maintain the current definition of “functional impairment.”

§ 5230.3 – Definitions – LPHA – Licensed practitioner of the healing arts Several commentators support the inclusion of licensed clinical social worker, licensed marriage and family therapist and licensed professional counselor in the definition of “licensed practitioner of the healing arts” because it is consistent with State law and will improve an individual’s access to PRS by reducing obstacles for the individual to receive the required recommendation for PRS. Two commentators support the deletion of “an individual” from the definition of licensed practitioners of the healing arts to clarify the definition. Response:

The Department appreciates the commentators support of the changes it has made to the definition of “licensed practitioner of the healing arts.”

§ 5230.3 Definitions – serious emotional disturbance and serious mental illness

While four commentators agreed with the inclusion of definitions for “serious emotional disturbance” and “serious mental illness” that aligned with the Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) definitions, the Department has determined that the terms “serious emotional disturbance” and “serious mental illness” should be deleted from the final-form rulemaking because as explained in further detail below the Department is no longer requiring that an individual have a serious emotional disturbance or serious mental illness to be eligible for PRS.

§ 5230.3 Definitions – wellness

While commentators support the addition of wellness as one of the domains in which a PRS agency can assist an individual to develop or maintain skills, IRRC and numerous commentators stated that the definition of “wellness” is vague and does not reflect that wellness is a holistic integration of activities and lifestyle intended to enhance all the life domains listed in the

regulation. Commentators stated that their PRS programs utilize SAMHSA’s wellness initiative, which supports eight dimensions of wellness that are mutually interdependent dimensions that connect all aspects of behavioral health. The dimensions are physical, intellectual, emotional, social, spiritual, vocational, financial and environmental. In addition, a few commentators do not agree that SAMHSA’s definition of “wellness” should be added to the regulation. These commentators suggest changing the domain name from “wellness” to “physical and mental health/wellness” or “health self-maintenance.”

Response:

The Department agrees that the “wellness” definition should be clarified to include the use of SAMHSA’s eight dimensions of wellness because SAMHSA’s definition incorporates many different dimensions of health, which can have different meanings for each individual. As such, the Department has revised the definition of “wellness” to reflect these dimensions, which include the emotional, financial, social, spiritual, occupational, physical, intellectual and environmental dimensions. The Department, however, declines to use a different term other than “wellness” because “wellness” is a universal term that is currently used and understood by providers. Further, the term follows the definition established by SAMHSA.

§ 5230.13 – Agency records

A few commentators and IRRC recommended adding a requirement that the PRS agency maintain records that contain copies of criminal history background checks for all staff, including copies of the Pennsylvania State Police (PATCH) criminal background check and the FBI background check.

Response:

The Department agrees that a PRS agency should maintain records of staffs’ criminal history background checks. This language was clarified in the proposed rulemaking and maintained in the final-form rulemaking under section 5230.13 (relating to agency records). In addition, the department removed paragraph (11) in the final-form rulemaking since it is redundant of the revised paragraph (6)(ii).

§ 5230.15 – Agency service description

§ 5230.15(a)(2.1)

One commentator stated that the requirement that the PRS agency’s service description include strategies for outreach to and engagement of individuals referred to PRS is unclear because when an individual is referred to PRS, staff does outreach to explain the benefits of the service and set up a visit. The commentator explained that typically for PRS “outreach” describes the PRS agency’s process when an individual who is already enrolled to receive PRS is not attending the service regularly.

Response:

The Department appreciates this comment; however, the Department does not agree that this requirement is unclear. As such, the Department declines to make changes to this paragraph. The final-form rulemaking requires an agency’s service description to contain strategies for outreach to and engagement of individuals referred for PRS. PRS agencies should include in their service descriptions the strategies that the agency will use to reach out to and engage individuals who are referred for the service. For example, an agency may choose to use texting or other forms of technology to reach out to and engage young adults when initiating service. An

agency may also include strategies for outreach when an individual is not engaging in the service in its service description.

§ 5230.15(a)(3)(ii)

IRRC expressed that (a)(3)(ii) requires a PRS agency to submit to the Department a service description of the population served specifying the “[a]ge range and age groupings, including information on how different age groups will be separated while services are provided through the scheduling of services, providing services in different locations in the PRS facility’s physical space and other procedures.” One commentator requested that the Department clarify its expectations with regards to the requirement that the service description includes how different age ranges and age groupings will be separated while services are provided. IRRC asked the Department to explain the implementation procedures for the separation of age groups and the other procedures a PRS agency is expected to describe and requested that the Department consider revising this requirement to improve clarity.

Response:

It is up to PRS agencies to determine how to separate individuals by age according to the needs of the individuals served, the needs of the community being served, the age of the populations served and the agency’s needs. For example, PRS agencies can separate age groups while services are being provided by making sure that adults and teenagers are not scheduled for services at the same time or through serving different age groups in different areas of the facility’s physical space. Other procedures a PRS agency can use include using multiple entrances or restroom facilities so that different age groups remain separate while they are at the facility. As discussed previously under General – Lowering the age of eligibility for PRS, the Department also clarified this provision in the final-form rulemaking to require that the

information shall demonstrate the separation of individuals through the scheduling of services, providing the services in different locations in the PRS facility’s physical space, and other procedures the agency plans to use in order to separate individuals under 18 years of age from individuals 18 years of age and older, or any needed age groupings.

In addition, the Department’s field office licensing representatives will review the service description checklist the PRS agency completes to determine if the PRS agency is complying with the requirement to separate individuals by age. Field office staff and OMHSAS policy office staff work together to review and provide feedback on the service descriptions for programs that serve youth. Because it is up to each PRS agency to determine age groupings of the individuals served, the Department has not included additional requirements in section 5230.15(a)(3)(ii) for how to separate individuals by age range and age groupings.

§ 5230.21 – Content of individual record

§ 5230.21(4)

IRRC and several commentators had concerns about parental rights and youth consenting to PRS. Commentators are concerned that parents and guardians will be unable to determine what is in the youth’s best interest if a youth is allowed to consent to receive services. Commentators

questioned what will happen when parents or guardians and youth are not in agreement about treatment. Commentators also questioned if a parent or guardian can access the youth’s records without the youth’s consent if the youth has consented to receive PRS. As noted previously, one commentator requested that the Department clarify the specific statutory provisions, whether State or Federal, that provide the Department with the authority to promulgate regulations regarding youths receiving PRS without needing parental consent. IRRC also requested that the Department consider revising section 5230.21(4) (relating to the content of individual record) to

improve the clarity of the consent provisions so that they are more easily understood by the regulated community.

Response:

In the Commonwealth, minor consent to medical care is determined by state statute. Specifically, state statute governs who may provide consent for voluntary mental health treatment of youths who are 14 years of age or older. See Act 65 of 2020 (35 P.S. §§ 10101.1- 10101.2). Under Act 2020-65, a youth may consent to voluntary mental health treatment in both inpatient and outpatient settings. Therefore, pursuant to State statute, individuals 14 years of age and older may consent to receive PRS and parental consent is not required. Act 2020-65 also provides that if a youth consents to services, but the youth’s parent or guardian does not agree that services should be provided, the services may still be provided.

While pursuant to Act 2020-65, a parent or guardian may also consent to a youth receiving services even if the youth objects, because an individual’s consent to receive PRS is fundamental to PRS’s principles, PRS may not be provided if the youth objects to receiving PRS. For implementation purposes (and as discussed more fully below), to be eligible for PRS an individual receiving services must choose to receive PRS. For clarity, the Department has also added a requirement that documentation that an individual chooses to receive PRS be retained in an individual’s record.

Act 2020-65 also provides that a parent or guardian may only access a youth’s records if the parent or guardian provided the initial consent for PRS or if the youth who provided the initial consent revokes their consent and the parent or guardian subsequently provides consent for PRS. In response to IRRC’s request that the Department improve the clarity of the consent provisions, the Department revised section 5230.21(4) (relating to content of individual record)

to require documentation of consent and the release of records in accordance with Federal and State laws and regulations.

§ 5230.21(8)

While commentators were supportive of the addition of the requirement that an individual’s record include a description of outreach and engagement efforts with natural supports as directed by the individual and a description of ongoing contacts and involvement with formal supports, one commentator was concerned that the phrase “a description of” may be interpreted in different ways and suggested removing the language.

Response:

The Department agrees and has removed the language “a description of” from section 5230.21(8)(i) and (ii) (relating to content of individual record).

§ 5230.31 – Admission requirements

§ 5230.31(a)(2)

A few commentators support the broadening of the list of diagnoses that allow an individual to access PRS without the use of the exception process because this change will increase access to PRS and eliminate the need to use the exception process.

IRRC and several other commentators recommended that autism spectrum disorder (ASD) be added to the list of diagnoses that allow an individual to access PRS without review through the exception process because PRS has been shown to benefit individuals with ASD and will allow individuals with ASD access to a needed service, which will improve the quality of their lives. IRRC and one commentator also suggested clarifying the diagnoses listed in subsection (a)(2) by using select groupings from the DSM, including “Depressive Disorders” and “Trauma and

Stressor-Related Disorders,” to broaden the categories of diagnoses that allow an individual to access PRS without going through the exception process.

Response:

While the Department agrees that some individuals with ASD and functional impairment due to a diagnosed mental, behavioral or emotional disorder would benefit from PRS, the Department does not agree that ASD should be generally included in the list of diagnoses that allow an individual to access PRS without having to go through the exception process. Not every individual with ASD and a functional impairment is an appropriate candidate for PRS. Specifically, ASD is a neurological impairment that causes differences in the neuro-processing of information. As a disorder with a spectrum of severity and symptoms, individuals with ASD have a vast range of abilities and deficits. While PRS may be appropriate for some individuals living with ASD, they may also be completely inappropriate for other individuals with ASD. For example, PRS would not be appropriate for an individual who is non-verbal and unable to engage in group PRS activities. Because the intent of the final-form rulemaking is to define a client population that would benefit from PRS, and some individuals with ASD would benefit from PRS, the Department is removing the requirement that an individual have a serious mental illness or serious emotional disturbance to be eligible for PRS through the exception process. Therefore, individuals who have a diagnosis of ASD will be able to access PRS if a licensed practitioner of the healing arts determines that PRS will help the individual reach the individual’s desired goals.

The Department has also removed attention deficit hyperactivity disorder (ADHD) from the list of diagnoses that allow an individual to access PRS without having to go through the

exception process. The Department removed ADHD because the DSM categorizes ADHD as a neurodevelopmental disorder and the Department has determined that there should not be any diagnoses in the neurodevelopmental category included in the list of diagnoses that allow an individual to access PRS without having to go through the exception process. An individual diagnosed with ADHD, however, will be able to use the exception process under subsection (c) for an eligibility determination.

The Department determined the diagnoses listed in section 5230.31(a)(2) (relating to admission requirements) after careful consideration of the clinical characteristics of each disorder. The Department purposefully chose not to list entire diagnostic categories due to differences in characteristics among the diagnoses within a category.

§ 5230.31(a)(4)

IRRC and a few commentators oppose deleting the requirement that an individual has to choose to receive PRS to be eligible for services. Commentators explained that PRS is a voluntary service and individuals have a right to decide whether and how to participate in PRS and the individual’s consent is fundamental to PRS’s principles. In addition, an individual is required to choose continued participation in PRS to be eligible for continuation of PRS. Response:

The Department agrees that it is important for the individual to affirmatively choose to receive PRS. As such, the requirement that the individual chooses to receive PRS has been added under a new renumbered subsection (d).

§ 5230.31(c)

Several commentators and IRRC were concerned about the requirement that an LPHA document “the anticipated benefit that PRS will provide for the individual.” Commentators

oppose this requirement because an LPHA may not have experience using PRS interventions. They are also concerned that an LPHA’s identification of the anticipated benefit of PRS may take away from the individual’s ability to set rehabilitation goals with the PRS agency on their own. In addition, the recommendation for services already requires documentation of the functional impairment impacting a life domain, and therefore, it follows that the anticipated benefit of services is improved functioning in one of the life domains.

Response:

While the LPHA should expect that the provision of PRS will help the individual reach the individual’s goals, the Department agrees with the comments expressed by the commentators and IRRC regarding documentation of the anticipated benefit. As such, the Department clarified the requirement of documentation. Under the final-form rulemaking, the written recommendation from an LPHA shall include documentation that it is anticipated that PRS will help the individual reach the individual’s desired goal.

§ 5230.31(b) and (d)

IRRC and a few commentators oppose changing the requirement for admission from an assessment that documents the functional impairment of the individual to a screening to confirm the individual’s moderate to severe functional impairment in at least one domain identified in the LPHA’s written recommendation. Commentators explained that a screening is different from an assessment. An assessment is more thorough and lists skills and resources needed for the individual to meet a goal and reduce functional impairment. Commentators also noted that the initial assessment required by section 5230.61 (relating to assessment) at the start of services is a collaborative process with PRS staff and the individual and supports and this assessment ensures

that functional impairment and preliminary goals of PRS for the individual are identified so there is no need for a screening of the individual upon admission.

Response:

The Department agrees. After careful consideration, it is not necessary to include a requirement that a screening be completed as an admission requirement for PRS. Specifically, the Department is maintaining the assessment provision and is no longer deleting subsection (b). In addition, the Department is also removing proposed subsection (d), which provided: “Upon an individual’s admission to PRS, the PRS agency shall complete an initial functional impairment screening with the individual to confirm the individual’s moderate to severe functional impairment that interferes with or limits performance in at least one domain identified in the LPHA’s written recommendation.”

§ 5230.32 – Continued stay requirements

IRRC and a few commentators questioned why skill deficit is no longer required to be assessed as part of the determination of whether an individual is eligible for continued stay. They explained that assessing both functional impairment and skill deficit better describes the need for an individual’s continued stay. In addition, assessment of skill deficit is needed to determine if a goal has been met because functional impairment is not the only indicator of whether a goal has been met. IRRC asked the Department to explain why “skill deficit” was deleted and how the regulation continues to protect the public health, safety and welfare without this assessment. A few commentators requested that “skill deficit” not be deleted from the continued stay requirements. In addition, a few commentators suggested revising section

5230.32(b)(2)(i) (relating to continued stay requirements) to state that “there are domains of functioning that continue to be addressed in the [individual rehabilitation plans (IRP)],” because the language of “functional impairment” is negative.

Response:

After careful consideration, the Department agrees with commentators that “skill deficit” should not be deleted. As such, the term “skill deficit” is not deleted from the final-form rulemaking, and the language has been updated to include diagnosed mental, behavioral or emotional disorder to replace the removal of serious mental illness and serious emotional disturbance. The Department, however, does not agree that the focus on “functional impairment” is wrong, as an individual must have a functional impairment to be eligible for PRS. Therefore, the Department will not be making the suggested revision in the final-form rulemaking.

§ 5230.42 – Nondiscrimination.

Six commentators support the Department’s proposed revisions to the nondiscrimination requirements. The commentators agree that discrimination on the basis of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, National origin or age should be prohibited and PRS agencies should be required to comply with applicable Federal and State statutes and regulations.

Response:

The Department appreciates the comments in support of the proposed nondiscrimination language.

§ 5230.51 – Staff qualifications

One commentator asked how CPRP and CFRP credentials work together, specifically the training and exam.

One commentator recommended that the Department review the requirement that the PRS director and psychiatric rehabilitation specialist obtain CPRP certification because it has been difficult to hire staff who possess CPRP certification, and many staff are unable to pass the CPRP examination within 2 years of their hire. The commentator pointed out that the CPRP examination is a costly examination, which is an added expense for PRS agencies. The commentator proposes allowing a director or specialist who fails the CPRP examination twice within the first 2 years of their hire to have an additional 2 years to pass the test. The commentator also suggests lowering the passing score of the CPRP test and waiving the requirement for CPRP certification as long as COVID-related staffing shortages continue. Response

The Department understands that at times it is difficult to find qualified staff. However, it is important for staff to have proper qualifications to maintain the health, safety and welfare of individuals receiving PRS. In addition, in exceptional circumstances, waivers of specific requirements may be requested on a case-by-case basis in accordance with section 5230.91 (relating to request for waiver). Therefore, examination will still be required to be completed within two years of hire.

§§ 5230.51(a), (b), (e) and (f)

IRRC and several commentators requested that the Department clarify how subsections (a), (b), (e) and (f) will be implemented if a PRS agency serves both individuals over 18 years of age and individuals 14 years of age or older but under 18 years of age. They questioned whether a

staff member will be required to maintain dual certification as a CFRP and a CPRP. IRRC also suggested that the Department consider revising section 5230.51 (relating to staff qualifications) to improve clarity for the regulated community.

Response:

PRS agencies that serve both youth and adults must comply with both the requirements in section 5230.51 for PRS agencies that serve adults and the requirements for PRS agencies that serve youth. In addition, PRS agencies must comply with the general requirements in section 5230.51. As a result, the director and psychiatric rehabilitation specialist of a PRS agency that serves both youth and adults must maintain both CPRP certification and CFRP certification. The Department has revised section 5230.51 to clarify under subsection (h) that a PRS agency that serves both individuals over 18 years of age and individuals 14 years of age or older but under 18 years of age must have staff that meet the requirements to serve both age groups. §§ 5230.51(c) and (d)

IRRC and four commentators requested that the Department explain why the requirements to be a psychiatric rehabilitation worker, or a psychiatric rehabilitation assistant were not amended to address the requirements for staff members who work with individuals 14 years of age or older but under 18 years of age.

Response:

The Department thanks IRRC and the commentators for this comment. However, it is not necessary to change the requirements for a psychiatric rehabilitation worker or a psychiatric rehabilitation assistant who works with youth because the current regulatory requirements for these positions are sufficient to maintain the health, safety and welfare of individuals receiving PRS. In addition, the Department has added training requirements for all staff, including

psychiatric rehabilitation workers and assistants, who work with youth. Section 5230.56(2)(ii) requires individuals who work with youth to have 6 hours of annual training in youth services, which will help ensure the safety of individuals receiving PRS.

§ 5230.51(g)

One commentator asked who is responsible for producing documentation of a foreign college’s or university’s accreditation by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation and sought clarification as to whether the documentation must be part of the PRS agency’s records.

Response:

The PRS agency must ensure it has proper documentation for all staffing requirements. Any documents used to verify staff credentials should be kept in the PRS agency’s record as required by section 5230.13(6)(iv) (relating to agency records).

§ 5230.52 – General staffing requirements

§ 5230.52(h)

IRRC and two commentators asked the Department to clarify the requirement in section 5230.52(h) (relating to general staffing requirements) that a minimum of 25% of a PRS agency’s staff must meet the qualifications of a psychiatric rehabilitation specialist within 2 years of initial licensing because the requirements for a psychiatric rehabilitation specialist differ based on the population served. It is unclear to IRRC how a PRS program that serves both youth and adults will implement this staffing requirement.

Response:

If a PRS program serves both youth and adults, 25% of the PRS program’s psychiatric rehabilitation staff must have a CPRP and 25% must have a CFRP certification. In addition,

psychiatric rehabilitation specialists must meet the requirements under section 5230.51(b) and (f), as applicable. To clarify this provision, the Department changed the word “or” to “and” under the final-form rulemaking under subsection (h).

§ 5230.52(h) – (i.1)

One commentator asked if the requirements for a minimum of 25% of the staff meeting certain qualifications applies to all available positions, including vacancies, or to only currently staffed positions. IRRC asked the Department to explain the requirement to establish a clear standard for the regulated community.

One commentator opposes the requirement that a minimum of 25% of the staff have certain qualifications because the commentator believes the PRS agency will be immediately out of compliance when they experience staff turnover. This commentator requested that the regulations be amended to require that a minimum of 25% of the staff have certain qualifications 2 years post vacancy or 6 months post vacancy to allow the PRS agency time to submit a waiver if they cannot meet staffing requirements immediately.

Response:

As provided on proposed rulemaking, the regulation refers to the staff based on the number of full-time equivalent positions. As such, the requirement applies to all available positions, including vacancies.

The Department does not agree with the suggestion to amend the regulation to allow PRS agencies additional time to meet the requirements after a staff person leaves because it is important to have qualified staff provide PRS. Further, if needed, PRS agencies continue to have the option to submit and request regulatory waivers in exceptional situations. In addition, the Department added subsection (i.2) in the final-form rulemaking to clarify when both populations

are being served. Specifically, when a PRS agency serves both individuals 18 years of age or older and individuals 14 years of age or older, but under 18 years of age, the agency shall meet the certification staffing ratios under both subsections (i) and (i.1). The Department also added additional lead-in language to subsections (h), (i), (i.1) and (i.2) for clarity. § 5230.54 – Group services

§ 5230.54(a)(3)

In addition to comments from IRRC, the Department received seven comments regarding section 5230.54(a)(3) (relating to group services). Commentators questioned whether the requirement that other group members not be present in the home when an individual receives group services means that group services in the home can be delivered only through telehealth. Commentators also questioned why if two individuals are willing to work on skills together in one individual’s home they should not be allowed to do so, why individuals should not be allowed to host a group in their home and why individuals who live in the same residence and have a similar goal cannot both be present at the home during group services. Commentators believe that requiring individuals to be in separate locations to receive group services does not meet psychiatric rehabilitation goals, values and principles and fails to adequately accommodate individuals who live in the same residence.

Response:

After careful consideration, the Department has deleted the proposed provision that when an individual receives group services in a home all other individuals receiving group services must be in another location.

§ 5230.54(f.1)

IRRC and a few commentators disagreed with the addition of a requirement that only individuals who receive PRS from the PRS agency may be included in group services delivered in the community because it means that individuals could not participate in community activities that involve natural supports. Further, invited guests, such as alumni, could not participate in a group service. IRRC requested that the Department clarify this subsection to address the stated intent of protecting confidentiality and also consider allowing participation by natural supports and peers working on the same goals. One commentator asserted that regardless of the location where services are provided only people who receive PRS from the PRS agency should be present when services are provided.

Response:

The Department added these provisions to protect the integrity of group services delivered in the community. The group should only include individuals who are also enrolled in the psychiatric rehabilitation program. PRS is a separate and distinct service in which individuals are building skills; and as such should not be mixing with individuals receiving other levels of care. In the final-form rulemaking, the Department clarified that the only individuals who can be present during a group service are group attendees receiving a service, staff of the PRS agency and interns of the PRS agency. Individuals who are not receiving services through group PRS may not participate in the PRS group or receive services from PRS staff because PRS group services are for the benefit of individuals whose IRPs include group services. Further, alumni may not participate in group services as invited guests because only individuals currently enrolled in PRS may receive group PRS. Peers who want to work on skill building during PRS group service must also be enrolled in the psychiatric rehabilitation program.

§ 5230.55 – Supervision

Several commentators were supportive of the removal of the requirement that the meetings between staff and a PRS director or psychiatric rehabilitation specialist designated as a supervisor be face-to-face. Commentators believe that elimination of the face-to-face requirement will increase opportunities for supervision, which will improve the quality of services. One commentator requested that the regulation be amended to allow staff who have maintained successful employment with a PRS program for more than 1 year to have individual supervision one time per month.

Response:

The Department appreciates commentators support of the removal of the requirement that meetings between staff and a PRS director or psychiatric rehabilitation specialist designated as a supervisor be face-to-face.

The Department, however, does not agree that it should lower the supervision requirements for staff who have been employed with a PRS program for more than one year to one time per month because one individual supervision session per month is insufficient. Supervision is vital to performing services well and requiring two individual supervision sessions per month is comparable to other mental health services supervision requirements. Therefore, the Department has clarified in the final-form rulemaking that a PRS director or psychiatric rehabilitation specialist designated as a supervisor shall meet with staff individually, no less than two times per calendar month, for a period of no less than thirty minutes. As noted above, the Department also clarified in the final-form rulemaking, that audio-only supervision is not permitted.

§ 5230.56 – Staff training requirements

§ 5230.56(2)

Both IRRC and commentators expressed confusion regarding how the training hours for staff who serve youth are to be allocated among the required topics. Commentators questioned if the 6 hours of training focused on youth services count towards the requirement for 12 hours of training focused on psychiatric rehabilitation or resiliency or must the 6 hours of training focused on youth services be in addition to the 12 hours of training focused on psychiatric rehabilitation or resiliency. IRRC asked the Department to explain how the required training topics for each population protect the public health, safety and welfare, and how a PRS agency will be expected to implement the training requirements.

Response:

Based on the comments received, the Department has revised section 5230.56(2) (relating to staff training requirements) to clarify the required training topics. Section 5230.56(2) provides that staff must receive 18 hours of training each year. Twelve hours of the required annual training must be specifically focused on psychiatric rehabilitation, recovery practices, resiliency, or a combination of the three areas. In addition, if the PRS agency services individuals 14 years of age or older but under 18 years of age, 6 hours of the required annual training must be specifically focused on youth services.

To ensure the health, safety and welfare of the individuals served, all staff are required to complete 12-hours of psychiatric rehabilitation orientation training during their first year of employment so that staff understand the principles and approaches of PRS and deliver PRS in a manner that it is designed to be delivered. It is important that staff learn about resiliency and recovery, as PRS operates under a recovery and resiliency model rather than a medical model

meaning that individuals have a voice and choice in their PRS participation as described in the PRS statement of rights under section 5230.41 (relating to PRS statement of rights). Under section 5230.56(2.1) staff working with youth ages 14 years of age or older but under 18 years of age are also required to take child abuse mandated reporter training so that they can recognize child abuse and report it, which will help protect the health, safety and welfare of youth receiving PRS.

Additionally, section 5230.56(3) further ensures individual health, safety and welfare by requiring new staff to have training specific to the PRS approach the staff member will be using, as well as 6 hours of mentoring by experienced staff prior to delivering services independently.

§ 5230.56(2)

One commentator stated that within the 18 hours of required training there must be space for training on such topics as confidentiality, workplace safety and other topics, which are not recovery or resiliency oriented.

Response:

The Department is setting the minimum required training standards for staff providing PRS. Staff providing PRS must be competent in PRS and recovery, resiliency, or psychiatric rehabilitation. The Department agrees that workplace safety and confidentiality are important topics and PRS agencies may require additional training hours on topics the PRS agency believes are necessary for their staff to safely and effectively deliver PRS.

§§ 5230.56(2)(i) and (ii)

IRRC and three commentators were concerned about the inconsistency between the training requirements for PRS agencies that serve youth and PRS agencies that serve adults. Commentators believe that all staff members, regardless of the population served, should receive

training in resiliency and recovery practices. One commentator asked if the required orientation training will be revised to include topics on youth services.

Response:

As noted above, the final-form rulemaking is revised to require 12 hours of annual training on psychiatric rehabilitation, recovery practices, resiliency or a combination of the three areas. In addition, if a PRS agency serves individuals 14 years of age or older but under 18 years of age, 6 hours of the annual training shall be focused on youth services.

The Department is reviewing and considering adding topics concerning youth services to the orientation training, but at this time, is not requiring the orientation to cover specific topics concerning youth.

§ 5230.56(2.1)

One commentator asked if the training staff must receive in the child abuse mandated reporter requirements of 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services) count towards the 18 hours of training required each year.

Response:

The training in mandated reporter requirements may be counted towards the required annual training.

§ 5230.56(3)(ii)

Four commentators asked for clarification of the requirement that a PRS agency provide an additional PRS service-specific orientation that includes 6 hours of mentoring for new staff. Commentators are unsure how mentoring is different from training, supervision or on the job support.

Response:

Mentoring provides an opportunity for new staff to learn how to put the psychiatric rehabilitation model into practice. Mentoring allows a director or psychiatric rehabilitation specialist to provide PRS together with a new staff person, which enables the director or specialist to provide PRS while the new staff person shadows the director or specialist, or it allows the new staff person to deliver PRS while the director or specialist observes and provides support as necessary. Mentoring includes direction, modeling and feedback and can be used to determine if a new staff person is ready to provide PRS on their own. Mentoring is different from training because mentoring can only be provided by a director or specialist, and training may be provided by anyone with expertise in the training topic.

§ 5230.57 – Criminal history checks and child abuse certification

§§ 5230.57(b) and (c)

One commentator stated that section 5230.57(b) and (c) (relating to criminal history checks) implies that an agency can serve only youth or only adults in one program and suggested adding a new subsection stating that agencies that serve both age groups must meet the higher standard for youth.

Response:

PRS agencies that serve both youth and adults must comply with section 5230.57. The Department deleted “only” from section 5230.57(b) in the final-form rulemaking to clarify that a PRS agency can serve both youth and adults.

§ 5230.57(d)

IRRC suggests that in addition to requiring a PRS agency that serves individuals 14 years of age or older but under 18 years of age to develop and implement written policies and procedures

regarding personnel decisions in accordance with 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services), PRS agencies should also be required to develop and implement written policies and procedures regarding criminal background checks.

Response:

The Department agrees that if a PRS agency serves individuals 14 years of age or older but under 18 years, criminal background checks should be part of the PRS agency’s written policies and procedures on personnel decisions. The final-form rulemaking has been revised to include a requirement that PRS agencies that serve youth develop and implement written policies and procedures regarding personnel decisions based on the results of criminal history background checks and child abuse certifications.

§ 5230.61 – Assessment

§ 5230.61(b)

IRRC and one commentator expressed concern that including family members and other natural supports in an assessment could delay the assessment process for the individual, is demeaning to the individual because it suggests that the individual is unable to speak for themselves in terms of their needs and goals and violates confidentiality. Two commentators expressed support for including family members in the assessment process because it will help the individual identify other resources and services that may be helpful to the individual. Response:

Individuals should be allowed to choose to include formal and natural supports, including family members, in the assessment process. The Department does not agree that it is demeaning to the individual to include family members in the assessment process. Inclusion of an

individual’s family in the assessment process allows the family to be involved in the process to the extent desired by the individual. While the Department acknowledges that scheduling conflicts may occur during the assessment process and PRS agencies need to attempt to resolve these conflicts as expeditiously as possible, any impediment imposed by scheduling conflicts is outweighed by the benefits of having additional support during the assessment process, which may produce a more positive outcome for the individual.

§ 5230.61(b)(3)

IRRC and four commentators are concerned about the Department’s removal of the requirement that the assessment identify healthcare facilities as part of the identification of existing and needed natural and formal supports. They believe that the inclusion of healthcare facilities is important and beneficial to an individual’s physical wellness and recommend that the assessment continue to identify healthcare facilities.

Response:

The Department agrees that the support provided by individuals employed by health care facilities is an important support for an individual to have during treatment. For clarity, the Department revised paragraph (b)(3) in the final-form rulemaking to include healthcare facilities and human services programs.

§ 5230.61(b)(6)

A few commentators expressed concern that the proposed rulemaking added an option for individuals to have their assessments reviewed with them instead of being signed by the individual. The commentators were concerned that this option may result in individuals being less engaged in their recovery and take away from the collaborative approach of PRS. Two

commentators recommended that a provision be added allowing for the documentation of verbal confirmation of intent to sign the assessment.

Response:

The Department agrees that individuals should be involved in all aspects of their recovery, including their assessment, and has removed the proposed option for the assessment to only be reviewed with the individual.

§ 5230.61(b)(7)

IRRC and several commentators have expressed concern about the requirement that a PRS agency update the assessment when the individual’s diagnosis and identified needs change. Commentators oppose the inclusion of a change in diagnosis as a reason why the assessment must be updated because an LPHA may change a diagnosis and not report it to the PRS agency and the PRS agency will be unaware that it needs to update the assessment. They also assert that a diagnosis change may not have a direct impact on the functioning of the individual and a change in diagnosis is not relevant to the delivery of PRS as the focus is on changes in functioning. Commentators also stated that it is unclear if an update is needed when both the individual’s diagnosis and identified needs change or when an individual’s diagnosis or an individual’s identified needs change.

Response:

The Department agrees with IRRC and commentators that the assessment does not need to be updated if an individual’s diagnosis changes and, therefore, is removing this requirement from the final-form rulemaking. The Department agrees that a psychiatric rehabilitation program may not know when an individual’s diagnosis has been updated and that a change in diagnosis may not necessarily change the individual’s functioning in the domain areas.

§ 5230.62 – Individual rehabilitation plan

One commentator requested that the Department clarify the timing requirements for the dated signature by the PRS director and whether the IRP is active before the director’s signature is obtained. The commentator pointed out that it is a burden if the PRS program and the individual need to wait for the PRS director’s signature to make the IRP active.

Response:

The IRP is active once all of the required signatures are obtained because of the presence of the signature of the individual, the staff working with the individual and the PRS director completes the plan. As provided under the existing regulation, a PRS agency shall complete an IRP by day 20 of an individual’s attendance at the PRS program and no more than 60 calendar days after the PRS program’s initial contact with the individual, which includes obtaining dated signatures of the individual, the staff working with the individual and the PRS director. See section 5230.62(b).

§ 5230.62(a)(7)

A few commentators suggested that subsection (a)(7) not be amended to allow for documentation of consent to the IRP. Three commentators suggested removing the requirement to document why an individual does not sign the IRP and including a provision to document verbal confirmation of agreement with the IRP. Commentators believe the individual’s signature on the IRP is important to confirm collaboration between staff and the individual in developing the IRP and ensure an individual is actively involved in their own recovery planning process. Two commentators were confused by the revisions to subsections (a)(7) and (d)(5) because they did not specifically state that verbal consent is permissible. IRRC requested that the Department explain what is considered acceptable documentation of consent and to clarify the

provision by specifying that verbal consent is allowed. IRRC requested that the Department address the concerns regarding the active involvement of the individual and how the changes to section 5230.62 (relating to individual rehabilitation plan) protect the public health, safety and welfare.

Response:

The Department agrees that the individual should sign the IRP to ensure that the individual is engaged and actively involved in PRS. Therefore, the Department has removed the proposed language regarding documentation of consent to the IRP by the individual under (a)(7) and (d)(5).

§ 5230.62(d)

Three commentators are in favor of allowing an IRP update to include either documentation of consent by the individual or the signature of the individual. These commentators also agree that the requirement that the IRP update include documentation of the reason an individual does not sign their IRP update should be deleted from the rulemaking. One commentator believes that the rulemaking should continue to require documentation of the reason an individual does not sign the IRP update.

Response:

While the Department appreciates the comments in support of the revisions to section 5230.62(d), the Department will continue to require that the individual sign the IRP update unless the PRS agency documents the reason the individual did not sign the IRP update. As discussed above, it is important that the individual receiving PRS is engaged and involved in the development of their IRP, which includes updates of their IRP.

§ 5230.63(4) – Daily entry (retitled Documentation)

Several commentators support removing the requirement that the individual sign the daily entry, while three commentators are opposed to the Department changing the requirement that the individual sign the daily entry. Commentators support the removal of the signature requirement because it eliminates an obstacle to providing services through telehealth and reduces PRS agencies’ paperwork. In addition, individuals receiving PRS have access to their records so they can review the notes at any time. Other commentators oppose the removal of the signature requirement because it will decrease individuals’ involvement in the review of their records. The Department also received additional comments from a commentator who clarified its concern regarding daily progress notes. IRRC requested that the Department consider retaining the requirement that the individual sign the daily entry and also include the option for verbal consent to protect the public health, safety and welfare, or explain why it is not necessary to do so.

Response:

The Department appreciates the varying comments on this issue. Given that some models of PRS require attendance multiple times a week, daily progress notes create an unnecessary staff burden. It is important to verify the attendance of participants, but requiring staff to draft daily

progress notes is cumbersome, time consuming and of limited value. Further, the Department evaluated PRS regulations and provider manuals from other states, including Ohio, Virginia, Michigan, Mississippi and Missouri, and found daily attendance records and weekly progress notes to be a standard included in their state regulations and manuals. In response to the public comment and based on similar requirements in other states, changes were made to the final-form rulemaking to reflect changes to the daily entry requirement to now include weekly progress

notes signed and dated by staff and also daily attendance records. Specifically, under the final form rulemaking, a PRS agency is required to complete a progress note on a weekly basis for each service provided. In addition, a PRS agency is required to keep daily attendance records, including each individual’s actual attendance time, including start and end times, and activity or session attended.

§ 5230.81 – Quality improvement requirements

Two commentators stated they support the changes made to section 5230.81. One commentator objected to requiring PRS agencies to track the number of individuals admitted to PRS through the exception process and their average length of stay in PRS because that information would be more easily tracked by payers. One commentator stated that without an explanation as to why this information is being tracked, it appears to be unnecessary and excessive reporting.

Response:

The Department appreciates the comments received. After careful consideration, the Department is maintaining the requirement to track the average length of duration of PRS for individuals admitted through the exception process because it will help PRS agencies gain important information that they can use to improve the quality of services provided to individuals admitted through the exception process and because this data can be used to evaluate the efficacy of PRS in helping different populations reach their desired goals. Because of the use of this information, this requirement is neither unnecessary nor excessive. On final-form rulemaking, however, the Department further clarified this language from “length of stay” to “duration of PRS.”

In addition to the major changes discussed above, the Department made several changes in preparation of the final-form rulemaking, including correcting typographical errors, and revising language to improve clarity and to conform with the changes previously discussed.

Regulatory Review Act

Under § 5(a) of the Regulatory Review Act (71 P.S. § 745.5(a)), on July 25, 2024, the Department submitted a copy of this regulation to the IRRC and to the Chairpersons of the House Human Services Committee and the Senate Health and Human Services Committee. In compliance with the Regulatory Review Act, the Department also provided the Committees and the IRRC with a copy of all public comments received, as well as other documentation. In preparing the final-form rulemaking, the Department reviewed and considered comments from the Committees, the IRRC and the public.

In accordance with §§ 5.1 (j.1) and (j.2) of the Regulatory Review Act, this regulation was deemed approved by the Committees on _____________. The IRRC met on ___________ and approved the regulation.

In addition to submitting the final-form rulemaking, the Department has provided the IRRC and the Committees with a copy of the Regulatory Analysis Form prepared by the Department. A copy of this form is available to the public upon request.

Order

The Department finds:

(a) The public notice of intention to amend the administrative regulation by this Order has been given pursuant to §§ 201 and 202 of the Commonwealth Documents Law (45 P. S. §§ 1201 and 1202) and the regulations at 1 Pa. Code §§ 7.1 and 7.2.

(b) That the adoption of this regulation in the manner provided by this Order is necessary and appropriate for the administration and enforcement of the Human Services Code. The Department, acting pursuant to sections 911 and 1021 of the Human Services Code (62 P.S. §§ 911 and 1021) orders:

(a) The regulation of the Department is amended to read as set forth in Annex A of this Order. (b) The Secretary of the Department shall submit this Order and Annex A to the Offices of General Counsel and Attorney General for approval as to legality and form as required by law. (c) The Secretary of the Department shall certify and deposit this Order and Annex A with the Legislative Reference Bureau as required by law.

(d) This order shall take effect upon publication.

Annex A

TITLE 55. HUMAN SERVICES

PART VII. MENTAL HEALTH MANUAL

Subpart D. NONRESIDENTIAL AGENCIES/FACILITIES/SERVICES CHAPTER 5230. PSYCHIATRIC REHABILITATION SERVICES

GENERAL PROVISIONS

* * * * *

§ 5230.3. Definitions.

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

[Axis I—

(i) One of five dimensions relating to different aspects of the diagnosis of a psychiatric disorder or disability as organized in the DSM-IV-TR or subsequent revisions.

(ii) Axis I specifies clinical disorders, including major mental disorders.]

BH-MCO—Behavioral health managed care organization—An entity that manages the purchase and provision of mental health and substance abuse services.

Best practice—Service delivery practice based directly on principles and standards that are generally recognized by a profession and are documented in the professional literature.

CFRP—Child and Family Resiliency Practitioner—A person who has satisfied the required education, experience and testing and who is certified as a Child and Family Resiliency

Practitioner by the Psychiatric Rehabilitation Association, or its successor, OR OTHER SIMILAR NATIONALLY-RECOGNIZED CERTIFYING ENTITY.

CPRP—Certified Psychiatric Rehabilitation Practitioner—A person who has [completed] satisfied the required education, experience and testing, and who is [currently] certified as a Certified Psychiatric Rehabilitation Practitioner by the [USPRA] Psychiatric Rehabilitation Association, or its successor, OR OTHER SIMILAR NATIONALLY-RECOGNIZED CERTIFYING ENTITY.

CPS certificate—Certified peer specialist certificate—A certificate awarded to a person who has successfully completed the Department-approved training AND TESTING in peer support services.

Clubhouse—A PRS facility that is accredited by [the ICCD] Clubhouse International, or its successor, OR OTHER SIMILAR NATIONALLY-RECOGNIZED ENTITY THAT PROVIDES STANDARDS FOR THE CLUBHOUSE MODEL.

Coordination of [care] services—Direct contact by a PRS agency with other mental health, physical health or human services formal and natural supports to ensure continuity in service planning [between service agencies].

* * * * *

[DSM-IV-TR—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.] DSM—The current version of the Diagnostic and Statistical Manual of Mental Disorders PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCIATION.

* * * * *

FTE—Full-time equivalent—37.5 hours per [calendar] week of staff time. [Face-to-face—Contact between two or more people that occurs at the same location, in person.]

Formal support—An agency, organization or person who provides assistance or resources to others within the context of an official role.

Functional impairment—[The loss or abnormality of the ability to perform necessary tasks.] ~~Difficulties that interfere with or limit skill development or functioning in a domain.~~

* * * * *

Human services—Programs or facilities designed to meet basic health, welfare and other needs of a society or group.

[ICCD—International Center for Clubhouse Development.

ICD-9—International Classification of Diseases, Ninth Edition.] ICD—The current version of the International Classification of Diseases PUBLISHED BY THE WORLD HEALTH ORGANIZATION.

IRP—Individual rehabilitation plan—A document that describes the current service needs based on the assessment of the individual and identifies the individual’s goals, interventions to be provided, the location, frequency and duration of services and staff who will provide the service.

Individual—A person [, 18] 14 years of age or older [who has a functional impairment resulting from mental illness, who uses] who receives PRS.

LPHA—Licensed practitioner of the healing arts—

[(i) An individual] A person who is licensed by the Commonwealth to practice the healing arts.

[(ii) The] This term is limited to a physician, physician’s assistant, certified registered nurse practitioner [and], licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor or psychologist.

* * * * *

PRS—Psychiatric rehabilitation service—A recovery-oriented service offered individually or in groups which is predicated upon the principles, values and practice standards of [the ICCD, USPRA] Clubhouse International, the Psychiatric Rehabilitation Association or other SIMILAR Nationally-recognized professional PRS association.

* * * * *

Psychiatric rehabilitation principles—A list of core values inherent in psychiatric rehabilitation as defined by Nationally-recognized professional associations, including the [USPRA, the ICCD] Psychiatric Rehabilitation Association, Clubhouse International and the Coalition for Community Living, OR OTHER SIMILAR NATIONALLY-RECOGNIZED PROFESSIONAL ASSOCIATION.

* * * * *

QI plan—Quality improvement plan—A document outlining the ongoing formal process to ensure optimal care and maximize service benefit as part of the licensing process.

~~Serious emotional disturbance~~~~—A condition experienced by an individual under 18 years of~~ ~~age who currently has, or at any time during the past year has had, a diagnosable mental,~~ b~~ehavioral or emotional disorder of sufficient duration to meet the diagnostic criteria for the~~ ~~mental, behavioral or emotional disorder specified in the current DSM.~~

~~Serious mental illness~~~~—A condition experienced by an individual 18 years of age or older~~ ~~who currently has, or at any time during the past year has had, a diagnosable mental, behavioral~~ ~~or emotional disorder of sufficient duration to meet diagnostic criteria for the mental, behavioral~~ ~~or emotional disorder specified in the current DSM.~~

[USPRA—The United States Psychiatric Rehabilitation Association.]

Wellness—A domain that helps an individual to develop skills ~~needed to improve or maintain~~ p~~hysical and mental health~~ IN EMOTIONAL, FINANCIAL, SOCIAL, SPIRITUAL, OCCUPATIONAL, PHYSICAL, INTELLECTUAL AND ENVIRONMENTAL DIMENSIONS.

§ 5230.4. Psychiatric rehabilitation processes and practices.

(a) A PRS agency shall assist an individual to develop, enhance and retain skills and competencies in living, learning, working [and], socializing and wellness so that an individual can live in the environment of choice and participate in the community.

* * * * *

(f) A PRS agency may offer PRS in a PRS facility ~~[or]~~, ~~in the community[, or both]~~ ~~or in the~~ ~~individual’s home, or all three~~, OR IN THE COMMUNITY, OR BOTH, as is consistent with an approved agency service description.

GENERAL REQUIREMENTS

§ 5230.13. Agency records.

A PRS agency shall maintain records that contain copies of the following: * * * * *

(6) Human resources policies and procedures that are consistent with the PRS agency’s service description and address the following:

(i) Job descriptions for staff positions.

(ii) Criminal history background [check] checks and child abuse certification requirements and protocol in accordance with § 5230.57 (relating to criminal history checks and child abuse certification).

* * * * *

(10) Quality improvement documents, including the following:

(i) QI plan.

(ii) Data gathering tools.

(iii) Annual review reports.

~~(11) Child abuse certifications as required under 23 Pa.C.S. §§ 6301—6388 (relating to Child~~ ~~Protective Services Law).~~

§ 5230.15. Agency service description.

(a) Prior to the initial licensing visit, and when changes occur to the agency service description, a PRS agency shall submit to the Department for prior approval an agency service description that includes the following:

(1) The governing body, advisory board and an agency table of organization. (2) The philosophy of the PRS agency, incorporating psychiatric rehabilitation principles. (2.1) Strategies for outreach to and engagement of individuals referred for PRS. (3) The population to be served, including the following:

(i) Anticipated daily attendance.

(ii) Age range and age groupings, including information on how different age groups will be separated while services are provided. THIS INFORMATION SHALL DEMONSTRATE SEPARATION OF INDIVIDUALS through the scheduling of services, p~~roviding~~ THE PROVISION OF services in different locations in the PRS facility’s physical space, and other procedures THE PRS AGENCY USES TO SEPARATE INDIVIDUALS UNDER 18 YEARS OF AGE FROM INDIVIDUALS 18 YEARS OF AGE OR OLDER, OR ANY OTHER NEEDED AGE GROUPINGS. (iii) Diagnostic groups.

(iv) Plans to identify and accommodate special populations.

(v) Plans to identify and accommodate culturally diverse populations.

(4) The approach of PRS offered including EBPs and best practices utilized. (5) A PRS facility identified as a clubhouse must be accredited by [the ICCD] ~~Clubhouse~~ ~~International~~ A NATIONALLY-RECOGNIZED ENTITY THAT PROVIDES STANDARDS FOR THE CLUBHOUSE MODEL, within 3 years of licensing and maintain accreditation.

(6) The location of service, whether in a PRS facility~~, [or] in the community, or~~ ~~in the~~ ~~individual’s home,~~ ~~or a combination of [both] the~~ ~~three locations~~ OR IN THE COMMUNITY, OR A COMBINATION OF BOTH.

(7) Expected service outcomes for individuals.

(8) Staffing, including the following:

(i) Staffing patterns.

(ii) Staff to individual ratios.

(iii) Staff qualifications.

(iv) Staff supervision plans.

(v) Staff training protocols.

(9) Service delivery patterns, including frequency, duration and method (group or individual) of service delivery.

(10) The days and hours of PRS operation.

(11) The geographic limits of PRS operation.

(12) A description of the physical site, including copies of applicable licenses and certificates. (13) A process for the development of an IRP with an individual.

(14) Admission and discharge policies and procedures.

(15) The methods by which PRS staff and an individual will collaborate to identify and use the individual’s preferred community resources.

(16) A process for developing and implementing a QI plan.

(17) A procedure for filing and resolving complaints.

(18) A procedure for engaging and involving the individual’s family members and natural supports when the individual consents to the involvement.

(b) The Department may deny agency service descriptions and approaches that do not meet EBP or best practices standards.

§ 5230.16. Coordination of [care] services.

(a) A PRS agency shall have written agreements to coordinate [care] services with other [service] providers, including the following:

* * * * *

(5) Case management programs.

(6) Peer support services agencies.

* * * * *

(b) A PRS agency may have written agreements to coordinate [care] services with other [service] providers as needed, including the following:

(1) Housing and residential programs.

(2) [Drug and alcohol programs] Substance use disorder programs.

(3) Vocational, educational and social programs.

(4) Other agencies and systems that serve individuals 14 years of age or older.

* * * * *

INDIVIDUAL RECORD

§ 5230.21. Content of individual record.

A PRS agency shall develop and maintain a record for an individual served containing the following:

* * * * *

(4) A signed set of documents providing the following:

(i) [Individual consent to receive services] ~~Documentation of an individual’s consent to receive~~ ~~PRS or, if the individual is 14 years of age or older but under 18 years of age, documentation of~~ ~~an individual’s consent to receive PRS or documentation of consent by the individual’s parent or~~ ~~legal guardian for the individual to receive PRS~~. DOCUMENTATION OF CONSENT TO RECEIVE PRS THAT IS IN ACCORDANCE WITH FEDERAL AND STATE LAWS AND REGULATIONS ON OBTAINING CONSENT TO TREATMENT.

(ii) [Individual] ~~Documentation of an individual’s~~ ~~consent to release information to other~~ p~~roviders~~ ~~and natural supports, including family members, or, if the individual is 14 years of age~~ ~~or older but under 18 years of age, documentation of the individual’s consent to release~~ ~~information to other providers and natural supports, including family members, or, if the parent~~ ~~or legal guardian has provided the consent to receive PRS, documentation of consent by the~~ ~~individual’s parent or legal guardian to release information to other providers and natural~~ ~~supports, including family members.~~ DOCUMENTATION OF CONSENT TO RELEASE INFORMATION THAT IS IN ACCORDANCE WITH FEDERAL AND STATE LAWS AND REGULATIONS ON OBTAINING CONSENT TO RELEASE RECORDS.

(iii) Verification that the individual received and had an opportunity to discuss the oral and written versions of the PRS statement of rights under § 5230.41 (relating to PRS statement of rights).

(IV) DOCUMENTATION THAT THE INDIVIDUAL HAS CHOSEN TO RECEIVE PRS AS REQUIRED BY § 5230.31(d) (RELATING TO ADMISSION REQUIREMENTS).

* * * * *

(8) Staff documentation of coordination with other services and supports[.], including: (i) ~~A description of outreach~~ OUTREACH and engagement efforts with natural supports, including family members, as directed by the individual.

(ii) ~~A description of ongoing~~ ONGOING contacts and involvement with formal supports. (9) Discharge summary.

§ 5230.22. Documentation standards and record security, retention and disposal. A PRS agency shall ensure that an individual record meets the following standards:

* * * * *

(6) The record [is] shall be kept in a permanent, secure location.

* * * * *

ADMISSION, CONTINUED STAY AND DISCHARGE REQUIREMENTS

§ 5230.31. Admission requirements.

(a) [General rule.] To be eligible for PRS, an individual [shall meet] must be 14 years of age or older and have a written recommendation from an LPHA acting within the scope of professional practice that includes the following information:

(1) [Have a written recommendation for PRS by an LPHA acting within the scope of professional practice] (Reserved).

(2) [Have the presence or history of a serious mental illness, based upon medical records, which includes] Documentation of one of the following diagnoses [by an LPHA]: (i) Schizophrenia.

(ii) [Major mood disorder] Schizoaffective disorder.

(iii) [Psychotic disorder (not otherwise specified)] Other specified schizophrenia spectrum and other psychotic disorder.

(iv) [Schizoaffective disorder] Major depressive disorder.

(v) [Borderline personality disorder] Bipolar disorder.

(vi) Anxiety disorders.

(vii) Posttraumatic stress disorder.

(viii) ~~Attention deficit hyperactivity disorder.~~

~~(ix)~~ Borderline personality disorder.

(3) [As a result of the mental illness, have] Documentation that as a result of the individual’s diagnosis, the individual has a moderate to severe functional impairment that interferes with or limits the individual’s performance in at least one of the following domains: (i) Living.

(ii) Learning.

(iii) Working.

(iv) Socializing.

(v) Wellness.

(4) [Choose to receive PRS] (Reserved).

(b) [Assessment. A PRS agency shall identify and document the functional impairment of the individual in an assessment as required under § 5230.61(b)(1) (relating to assessment).] ~~(Reserved)~~.

~~(c)~~ ~~Exception~~~~. [Individuals who do not meet the serious mental illness diagnosis requirement~~ ~~under subsection (a) may receive services when the following conditions are met]~~ ~~An individual~~

~~who does not have a diagnosis listed in subsection (a)(2) is eligible for PRS if the individual has~~ ~~a written recommendation from an LPHA acting within the scope of professional practice that~~ ~~includes the following information~~:

~~(1) [The written recommendation by the LPHA includes a diagnosis of mental~~ ~~illness]~~ ~~Documentation of a serious mental illness or serious emotional disturbance with a~~ ~~diagnosis of a mental, behavioral or emotional disorder~~ ~~that is listed [on Axis I in the DSM-IV TR or ICD-9 or subsequent revisions]~~ ~~in the current DSM or ICD.~~

~~(2)~~ [~~The written recommendation by the LPHA includes a description of the functional~~ ~~impairment resulting from the mental illness as required under subsection~~ ~~(a)(3).]~~ ~~Documentation that includes a description of a moderate to severe functional impairment~~ ~~in at least one of the following domains that is a result of the individual’s serious mental illness~~ ~~or serious emotional disturbance:~~

~~(i) Living.~~

~~(ii) Learning.~~

~~(iii) Working.~~

~~(iv) Socializing.~~

~~(v) Wellness.~~

~~(3) Documentation of the anticipated benefit that PRS will provide the individual~~. ~~(d) Upon an individual’s admission to PRS, the PRS agency shall complete an initial~~ ~~functional impairment screening with the individual to confirm the individual’s moderate to~~ ~~severe functional impairment that interferes with or limits performance in at least one domain~~ ~~identified in the LPHA’s written recommendation.~~

(c) EXCEPTION. AN INDIVIDUAL WHO DOES NOT HAVE A DIAGNOSIS LISTED UNDER SUBSECTION (a)(2) IS ELIGIBLE FOR PRS IF THE INDIVIDUAL HAS A WRITTEN RECOMMENDATION FROM AN LPHA ACTING WITHIN THE SCOPE OF PROFESSIONAL PRACTICE THAT INCLUDES THE FOLLOWING INFORMATION:

(1) DOCUMENTATION OF A DIAGNOSIS OF A MENTAL, BEHAVIORAL OR EMOTIONAL DISORDER THAT IS LISTED IN THE CURRENT DSM OR ICD, WHICH RESULTS IN A MODERATE TO SEVERE FUNCTIONAL IMPAIRMENT IN AT LEAST ONE OF THE FOLLOWING DOMAINS:

(I) LIVING

(II) LEARNING.

(III) WORKING.

(IV) SOCIALIZING.

(V) WELLNESS.

(2) DOCUMENTATION THAT IT IS ANTICIPATED THAT PRS WILL HELP THE INDIVIDUAL REACH THE INDIVIDUAL’S DESIRED GOAL.

(d) ADMITTANCE. AN INDIVIDUAL MAY ONLY BE ADMITTED TO PRS IF THE INDIVIDUAL CHOOSES TO RECEIVE PRS.

§ 5230.32. Continued stay requirements.

(a) A PRS agency shall determine an individual’s eligibility for continued stay during an IRP update required under § 5230.62(c) (relating to individual rehabilitation plan). (b) An individual’s eligibility for continued stay shall be determined by documentation of the following:

(1) An individual chooses continued participation in the PRS.

(2) A continued need for service based upon one or both of the following: (i) As a result of a ~~serious~~ ~~mental illness~~ ~~or serious emotional disturbance~~ DIAGNOSED MENTAL, BEHAVIORAL OR EMOTIONAL DISORDER, there is a functional impairment [or skill deficit] that is addressed in the IRP.

(ii) The withdrawal of service could result in loss of rehabilitation gain or goal attained by an individual.

* * * * *

RIGHTS

* * * * *

§ 5230.42. Nondiscrimination.

A PRS agency may not discriminate against an individual or staff on the basis of [age, race, sex, religion, ethnic origin, economic status, sexual orientation or gender identity or expression, or disability] race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, National origin or age and shall comply with applicable Federal and State statutes and regulations.

STAFFING

§ 5230.51. Staff qualifications.

(a) A [PRS] director of a PRS agency that serves individuals 18 years of age or older shall have one of the following:

(1) A bachelor’s degree and CPRP certification.

(2) A bachelor’s degree and at least 3 years work experience in mental health direct service, 2 years of which must be work experience in PRS. CPRP certification shall be attained within 2 years of hire as a PRS director.

(3) An [associate of arts] associate’s degree and CPRP certification, if employed as the PRS director of a licensed PRS facility for at least 6 months immediately prior to May 11, 2013. (b) A psychiatric rehabilitation specialist who works with individuals 18 years of age or older shall have one of the following:

(1) A bachelor’s degree and 2 years work experience in mental health direct service, 1 year of which must be work experience in PRS. CPRP certification shall be attained within 2 years from the date of hire as a psychiatric rehabilitation specialist. (2) CPRP certification.

* * * * *

(d) A psychiatric rehabilitation assistant shall have a high school diploma or GED and 6 months experience in human services.

~~(e) A director of a PRS agency that serves individuals 14 years of age or older but under 18~~ ~~years of age shall meet the qualifications for a PRS director in subsection (a) and have or attain~~ ~~CFRP certification within either 2 years of the date of hire as a PRS director or within 2 years of~~ ~~the date the PRS agency received approval of its service description that identifies that it will be~~ ~~serving individuals 14 years of age or older but under 18 years of age, whichever is later.~~ (e) A DIRECTOR OF A PRS AGENCY THAT SERVES INDIVIDUALS 14 YEARS OF AGE OR OLDER BUT UNDER 18 YEARS OF AGE SHALL HAVE ONE OF THE FOLLOWING:

(1) A BACHELOR’S DEGREE AND CFRP CERTIFICATION.

(2) A BACHELOR’S DEGREE AND AT LEAST 3 YEARS WORK EXPERIENCE IN MENTAL HEALTH DIRECT SERVICE, 2 YEARS OF WHICH MUST BE WORK EXPERIENCE IN PRS. CFRP CERTIFICATION SHALL BE ATTAINED WITHIN 2 YEARS OF HIRE AS A PRS DIRECTOR OR WITHIN 2 YEARS OF THE DATE THE PRS AGENCY RECEIVED APPROVAL OF ITS SERVICE DESCRIPTION THAT IDENTIFIES THAT IT WILL BE SERVING INDIVIDUALS 14 YEARS OF AGE OR OLDER BUT UNDER 18 YEARS OF AGE, WHICHEVER IS LATER.

(f) A psychiatric rehabilitation specialist who works with individuals 14 years of age or older but under 18 years of age shall have one of the following:

(1) A bachelor’s degree and 2 years work experience in mental health direct service, 1 year of which must be work experience in PRS. CFRP certification shall be attained either within 2 years from the date of hire as a psychiatric rehabilitation specialist or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later.

(2) CFRP certification.

(g) An associate’s degree or bachelor’s degree must be awarded by a college or university accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation, or an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. or the National Association of Credential Evaluation Services. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.

(H) IF THE PRS AGENCY SERVES BOTH INDIVIDUALS 18 YEARS OF AGE OR OLDER AND INDIVIDUALS 14 YEARS OF AGE OR OLDER BUT UNDER 18 YEARS OF AGE, THE DIRECTOR AND THE PSYCHIATRIC REHABILITATION SPECIALISTS SHALL HAVE BOTH A CPRP CERTIFICATION AND A CFRP CERTIFICATION.

§ 5230.52. General staffing requirements.

* * * * *

(e) A PRS agency shall develop a schedule that includes a plan to maintain staffing requirements during:

(1) Staff absence.

(2) Deployment of staff for PRS delivered in the ~~home or~~ community.

(f) A PRS agency shall document staffing by maintaining work schedules, time records and utilization data.

(g) When a PRS agency operates more than one PRS facility, the PRS director shall be present at each licensed PRS facility an average of 7.5 hours per week in a calendar month. (h) PSYCHIATRIC REHABILITATION SPECIALIST STAFFING RATIO. A minimum of 25% of the [FTE staff complement] staff based on the number of FTE positions shall meet the qualifications of a psychiatric rehabilitation specialist provided under § 5230.51(b) [or] AND (f) (relating to staff qualifications), AS APPLICABLE, within [1 year] 2 years of initial licensing. (i) [A] CPRP CERTIFICATION STAFFING RATIO. When a PRS agency serves ONLY individuals 18 years of age or older, a minimum of 25% of the [FTE staff complement] staff based on the number of FTE positions shall have CPRP certification within 2 years of initial licensing.

(i.1) CFRP CERTIFICATION STAFFING RATIO. When a PRS agency serves ONLY individuals 14 years of age or older but under 18 years of age, a minimum of 25% of the staff based on the number of FTE positions shall have CFRP certification within either 2 years of initial licensing or within 2 years of the date the PRS agency received approval of its service description that identifies that it will be serving individuals 14 years of age or older but under 18 years of age, whichever is later.

(i.2) CPRP AND CFRP CERTIFICATION STAFFING RATIO. WHEN A PRS AGENCY SERVES BOTH INDIVIDUALS 18 YEARS OF AGE OR OLDER AND INDIVIDUALS 14 YEARS OF AGE OR OLDER BUT UNDER 18 YEARS OF AGE, THE PRS AGENCY SHALL MEET THE CERTIFICATION STAFFING RATIOS AS PROVIDED UNDER SUBSECTIONS (I) AND (I.1).

(j) Trained staff shall be available, or other accommodations made, to address the language needs of an individual, including American Sign Language and Braille.

§ 5230.53. Individual services.

A PRS agency shall provide individual services in a PRS facility [or], in the community ~~or in~~ ~~the home~~ with a one staff to one individual (1:1) ratio.

§ 5230.54. Group services.

(a) A PRS agency shall provide group services in a PRS facility [or], in the community ~~or in~~ ~~the home~~.

(1) When a group service is provided in a PRS facility, group size may vary as long as the requirement under § 5230.52(c) (relating to general staffing requirements) is met.

(2) When a group service is delivered in the community, one staff shall serve a group of no more than five individuals. Group size in the community may not exceed five individuals. ~~(3) When an individual receives a group service in a home, all other individuals receiving the~~ ~~group service must be in another location.~~

(b) Group services delivered in the community shall be limited to individuals who have IRP goals that specify the need for services in the community.

* * * * *

(f) A PRS agency shall design group services [delivered in the community] to protect confidentiality [in a public location].

(f.1) Only STAFF OF THE PRS AGENCY, INDIVIDUALS WHO ARE INTERNING AT THE PRS AGENCY, AND individuals who receive PRS from the PRS agency may be included in group services delivered in the community.

(g) A PRS agency shall arrange for group discussion of the experience before and after service is conducted in the community. The group discussion shall occur in a setting that assures confidentiality.

§ 5230.55. Supervision.

* * * * *

(c) A PRS director or psychiatric rehabilitation specialist designated as a supervisor shall meet with staff individually [, face-to-face,] no less than two times per calendar month FOR AT LEAST THIRTY MINUTES. AUDIO-ONLY SUPERVISION IS NOT PERMITTED.

* * * * *

§ 5230.56. Staff training requirements.

A PRS agency shall implement a staff training plan that ensures initial and ongoing training in PRS practices as specified under § 5230.4 (relating to psychiatric rehabilitation processes and practices).

(1) Staff providing services in a PRS agency shall complete a Department-approved 12-hour psychiatric rehabilitation orientation course no later than 1 year after hire. This course shall be credited to the annual training requirement listed under paragraph (2) for the calendar year in which it is completed.

(2) Staff providing services in a PRS agency shall complete 18 hours of training per calendar year [with 12 hours specifically focused on psychiatric rehabilitation or recovery practices or both.] as follows:

~~(i) If the PRS agency serves individuals 18 years of age or older, 12 hours of the~~ ~~required training shall be specifically focused on psychiatric rehabilitation or recovery~~ p~~ractices, or both.~~ A MINIMUM OF TWELVE HOURS OF THE REQUIRED ANNUAL TRAINING SHALL BE FOCUSED ON PSYCHIATRIC

REHABILITATION, RECOVERY PRACTICES, OR RESILIENCY, OR A COMBINATION OF THE THREE.

(ii) ~~If the PRS agency serves individuals 14 years of age or older but under 18 years of~~ ~~age, 12 hours of the required training shall be specifically focused on psychiatric~~ ~~rehabilitation or resiliency, or both., with a minimum of 6 hours specifically focused on~~ ~~youth services~~. IF THE PRS AGENCY SERVES INDIVIDUALS 14 YEARS OF AGE OR OLDER BUT UNDER 18 YEARS OF AGE, 6 HOURS OF THE REQUIRED ANNUAL TRAINING SHALL BE FOCUSED ON YOUTH SERVICES.

(2.1) If the PRS agency serves individuals 14 years of age or older but under 18 years of age, training in the child abuse mandated reporter requirements of 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services) shall be completed.

(3) A PRS agency shall assure competency of new staff by providing an additional PRS service-specific orientation that includes the following:

(i) Six hours of training in the specific PRS model or approach outlined in the agency service description prior to new staff working independently. This training is required within the first year of employment.

(ii) Six hours of [face-to-face] mentoring for new staff prior to new staff delivering services independently. Mentoring shall be provided by a PRS director or psychiatric rehabilitation specialist designated as a supervisor and [is required] must be completed in person within the first year of employment.

(4) A PRS agency shall assure that training has learning objectives.

(5) A PRS agency shall maintain documentation of training hours in the PRS agency records under § 5230.13(6)(v) (relating to agency records).

§ 5230.57. Criminal history [background check] checks and child abuse certification. (a) A PRS agency that serves individuals 18 years of age or older shall complete a criminal history background check for staff that will have direct contact with [an individual] individuals receiving PRS.

(b) A PRS agency that serves ~~only~~ individuals 18 years of age or older shall develop and consistently implement written policies and procedures regarding personnel decisions based on the RESULTS OF criminal history background ~~check~~ CHECKS.

(c) A PRS agency that serves individuals 14 years of age or older but under 18 years of age shall complete criminal history background checks and child abuse certifications for staff as required under 23 Pa.C.S. §§ 6301—6388 (relating to Child Protective Services Law) and Chapter 3490 (relating to protective services).

(d) A PRS agency that serves individuals 14 years of age or older but under 18 years of age shall develop and consistently implement written policies and procedures regarding personnel decisions BASED ON THE RESULTS OF CRIMINAL HISTORY BACKGROUND CHECKS AND CHILD ABUSE CERTIFICATIONS in accordance with 23 Pa.C.S. §§ 6301—6388 and Chapter 3490.

SERVICE PLANNING AND DELIVERY

§ 5230.61. Assessment.

(a) A PRS agency shall complete an assessment of an individual prior to developing the IRP. (b) The assessment shall be completed in collaboration with the individual and as directed by the individual, with formal and natural supports, including family members, and must: (1) Identify the functioning of the individual in the living, learning, working [and], socializing and wellness domains.

(2) Identify the strengths and needs of the individual.

(3) Identify existing and needed natural and formal supports, including other ~~[health care~~ ~~facilities and social service agencies]~~ ~~human services programs or facilities~~ HEALTH CARE FACILITIES AND HUMAN SERVICES PROGRAMS.

(4) Identify the specific skills, supports and resources the individual needs and prefers to accomplish stated goals.

(5) Identify the cultural needs and preferences of the individual.

(6) Be signed by the individual and staff ~~or include documentation that the assessment was~~ ~~reviewed with the individual and the date of review~~.

(7) Be updated annually and when one of the following occurs:

(i) The individual requests an update.

(i.1) The individual’s ~~diagnosis and~~ identified needs change.

(ii) The individual completes a goal.

(iii) The individual is not progressing on stated goals.

§ 5230.62. Individual rehabilitation plan.

(a) A PRS staff and an individual shall jointly develop an IRP that is consistent with the assessment and includes the following:

* * * * *

(7) Dated signatures of the individual, the staff working with the individual and the PRS director ~~or documentation of consent to the IRP by the individual and the date consent was~~ p~~rovided and the dated signatures of the staff working with the individual and the PRS director~~.

* * * * *

(d) An IRP update must include a comprehensive summary of the individual’s progress that includes the following:

* * * * *

(5) The dated signature of the individual ~~or documentation of consent by the individual and~~ ~~date consent was provided~~.

(6) [Documentation of the reason if the individual does not sign.~~] (Reserved).~~

(7) The dated signature of the PRS staff working with the individual and the dated signature of the PRS director.

§ 5230.63. ~~Daily entry~~. DOCUMENTATION.

~~A PRS agency shall include an entry for the day service was provided in the record of an~~ ~~individual as follows:~~

~~(1) Indicates the date, time, duration, location and type of interaction.~~ ~~(2) Documents service provided in the context of the goal.~~

~~(3) Documents the individual response to service.~~

~~(4) [Includes the signature of the individual, or if the individual does not sign, documents the~~ ~~reason] (Reserved).~~

~~(5) Is signed and dated by staff providing the service.~~

(A) A PRS AGENCY SHALL COMPLETE A PROGRESS NOTE ON A WEEKLY BASIS FOR EACH SERVICE PROVIDED TO AN INDIVIDUAL THAT SUMMARIZES THE FOLLOWING:

(1) THE SERVICE PROVIDED IN THE CONTEXT OF THE GOAL.

(2) THE INDIVIDUAL’S RESPONSE TO THE SERVICE.

(3) THE INDIVIDUAL’S LEVEL OF SERVICE ENGAGEMENT DURING THE WEEK. (B) STAFF PROVIDING THE SERVICE SHALL SIGN AND DATE THE WEEKLY PROGRESS NOTE.

(C) A PRS AGENCY SHALL KEEP DAILY ATTENDANCE RECORDS OF INDIVIDUALS SERVED, INCLUDING EACH INDIVIDUAL’S ACTUAL ATTENDANCE TIME, WHICH INCLUDES A START TIME, END TIME AND ACTIVITY OR SESSION ATTENDED.

(1) THE ATTENDANCE RECORD IS NOT REQUIRED TO BE MAINTAINED IN THE INDIVIDUAL’S RECORD.

(2) THE DAILY ATTENDANCE RECORDS MUST BE AVAILABLE TO DEPARTMENT.

QUALITY IMPROVEMENT

§ 5230.81. Quality improvement requirements.

(a) A PRS agency shall establish and implement a written QI plan that meets the following requirements:

(1) Provides for an annual review of the quality, timeliness and appropriateness of services, including the following:

(i) Outcomes for PRS.

(ii) Individual record reviews.

(iii) Individual satisfaction.

(iv) [Use of exceptions to admission and continued stay requirements] Number of individuals admitted to PRS that did not have a diagnosis listed in § 5230.31(a)(2) (relating to admission requirements).

(iv.1) Average length of ~~stay in PRS~~ DURATION OF PRS for individuals who did not have a diagnosis listed in § 5230.31(a)(2).

(v) Evaluation of compliance with the approved agency service description. * * * * *

Regulatory Analysis Form (Completed by Promulgating Agency (All Comments submitted on this regulation will appear on IRRC’s website)		*INDEPENDENT REGULATORY REVIEW COMMISSION* IRRC Number:
(1) Agency Department of Human Services
(2) Agency Number: 14- Identification Number: 548
(3) PA Code Cite: 55 Pa. Code Chapter 5230
(4) Short Title: Psychiatric Rehabilitation Services
(5) Agency Contacts (List Telephone Number and Email Address): Primary Contact: Jen Shemas (717) 214-8198 jshemas@pa.gov Secondary Contact: Barry Decker (717) 772-7640 bdecker@pa.gov
(6)Type of Rulemaking (check applicable box): Proposed Regulation Final Regulation Final Omitted Regulation	Emergency Certification Regulation Certification by the Governor Certification by the Attorney General
(7) Briefly explain the regulation in clear and nontechnical language. (100 words or less) The purpose of this final-form rulemaking is to amend Chapter 5230 to allow psychiatric rehabilitation services (PRS) to be provided to individuals who are diagnosed with posttraumatic stress disorder, bipolar disorder, major depressive disorder or anxiety disorders without going through the exception process and to allow individuals who are 14 years of age or older but under 18 years of age who meet the admission requirements to access PRS. In addition, the final-form rulemaking clarifies the documentation that will be reviewed through the exception process to determine if an individual is eligible for PRS and also revises outdated language.
(8) State the statutory authority for the regulation. Include specific statutory citation. The Department of Human Services (Department) has the authority under sections 911 and 1021 of the Human Services Code (62 P.S. §§ 911 and 1021).

(9) Is the regulation mandated by any federal or state law or court order, or federal regulation? Are there any relevant state or federal court decisions? If yes, cite the specific law, case or regulation as well as, any deadlines for action. No Federal or State law, court order, Federal regulation or relevant Federal or State court decisions mandate the final-form rulemaking.

(10) State why the regulation is needed. Explain the compelling public interest that justifies the regulation. Describe who will benefit from the regulation. Quantify the benefits as completely as possible and approximate the number of people who will benefit. The final-form rulemaking is needed to allow the 111 community-based licensed PRS agencies and their 33 satellite locations to provide PRS to individuals 14 years of age or older but under 18 years of age. The final-form rulemaking is also needed to enable individuals who are diagnosed with posttraumatic stress disorder, bipolar disorder, major depressive disorder or anxiety disorders to obtain PRS without having to go through the exception process. PRS is an evidence-based service that uses an integrated approach to assist individuals who have a moderate to severe functional impairment as a result of a diagnosed mental, behavioral or emotional disorder to develop the skills needed to live, learn, socialize and work in the community and improve or maintain their physical or mental health. It is a cost-effective alternative to residential and inpatient treatment. PRS helps individuals reach age-appropriate functioning that has been either lost or never achieved because development was interrupted by mental illness or emotional disturbance. PRS focuses on helping individuals develop skills and improve functioning needed to increase their capacity to be successful in the living, learning, working and social environments of their choice and to develop skills to improve or maintain their physical or mental health. Traditional mental health treatment programs do not focus on these skills; instead, they focus on symptom management. As youth transition to adulthood, the skills that they can obtain from PRS will help them maintain independence in the community. If youth are able to access services that address the development of skills needed to be successful in the community, they will be less likely to discontinue services during the transition to adulthood. The final-form rulemaking ensures that staff who provide PRS to individuals 14 years of age or older but under 18 years of age are qualified and trained to provide PRS and that the PRS agency has completed criminal history checks for staff. The final-form rulemaking will also allow individuals diagnosed with posttraumatic stress disorder, major depressive disorder, bipolar disorder and anxiety disorders to receive PRS without going through the exception process for PRS. PRS will help these individuals develop the necessary skills needed to live, learn, socialize and work in the community and improve or maintain their physical or mental health. Making PRS easier for these individuals to access will also allow them to participate in a service that is likely to decrease the need for or shorten the length of an individual’s inpatient stay, partial hospitalization or outpatient treatment. The 111 licensed PRS agencies and their 33 satellite locations will benefit from the final-form rulemaking because they will be able to provide services to more individuals. Current providers of children’s services may also benefit because they could expand their service array to include PRS. In addition, individuals 14 years of age or older but under 18 years of age receiving services from agencies

that provide PRS will benefit because they will be able to transition to PRS within the same provider agency, which will result in less disruption and decrease the likelihood that they will disengage from needed services.

(11) Are there any provisions that are more stringent than federal standards? If yes, identify the specific provisions and the compelling Pennsylvania interest that demands stronger regulations. There are no provisions that are more stringent than Federal standards.

(12) How does this regulation compare with those of the other states? How will this affect Pennsylvania’s ability to compete with other states? The Department evaluated PRS regulations and provider manuals from other states, including Ohio, Virginia, Michigan, Mississippi and Missouri, and found daily attendance records and weekly progress notes to be a standard included in their state regulations and manuals. The Department also reviewed PRS regulations from Maryland, Idaho, Oklahoma and Louisiana because those states regulate PRS provided to youth. The final-form rulemaking is congruent with the other state’s requirements for this service when provided to individuals 14 years of age or older but under 18 years of age. Links to these regulations are available under Response #28 below. The Commonwealth does not compete with other states for the provision of PRS. In addition, the final form rulemaking positively affects the Commonwealth’s ability to serve individuals who are diagnosed with posttraumatic stress disorder, major depressive disorder, bipolar disorder, or anxiety disorders and individuals who are 14 years of age or older but under 18 years of age.

(13) Will the regulation affect any other regulations of the promulgating agency or other state agencies? If yes, explain and provide specific citations. The final-form rulemaking will not affect existing or proposed regulations of the Department or another State agency.

(14) Describe the communications with and solicitation of input from the public, any advisory council/group, small businesses, and groups representing small businesses in the development and drafting of the regulation. List the specific persons and/or groups who were involved. (“Small business” is defined in Section 3 of the Regulatory Review Act, Act 76 of 2012.) The Department convened a workgroup that included stakeholders to review and provide input on the proposed rulemaking. The workgroup held face-to-face meetings on November 4, 2015, December 8, 2015, and January 28, 2016, to review the current regulation and provide recommendations for the proposed changes. The workgroup included family members and representatives from the following: Pennsylvania Healthy Transitions Partnership; Pennsylvania Council of Children, Youth and Family Services; Drexel University/Behavioral Healthcare Education; Dickinson Center, Inc.; Holcomb

Behavioral Health Systems Berks County; Community Services Group; Commerce Park Clubhouse; Philadelphia Department of Behavioral Health; Threshold Rehabilitation Services, Inc.; Family Services of Western Pennsylvania; Child and Family Focus, Inc.; Allied Services; Aurora Social Rehabilitation Services; Office of Vocational Rehabilitation; Transition Age Advisory Group; Rehabilitation and Community Providers Association; Pennsylvania Association of Psychiatric Rehabilitation Services; Mental Health Association in Pennsylvania; and the mental health service system in Beaver, Berks, Allegheny, Montgomery and Bucks Counties. The Transition Age Advisory Group is an advisory group. Rehabilitation and Community Providers Association and Pennsylvania Council of Children, Youth and Family Services are organizations that represent providers and may represent PRS agencies. There are PRS agencies that are considered small businesses.

(15) Identify the types and number of persons, businesses, small businesses (as defined in Section 3 of the Regulatory Review Act, Act 76 of 2012) and organizations which will be affected by the regulation. How are they affected? The final-form rulemaking will affect all licensed PRS agencies. There are currently 111 licensed PRS agencies with 33 satellite locations. Of the 111 licensed PRS agencies, 8 are for-profit businesses and receive Medical Assistance reimbursement from the Department for services rendered. Section 3 of the Regulatory Review Act (71 P.S. § 745.3) includes the following definition of “small business:” “As defined in accordance with the size standards described by the United States Small Business Administration’s Small Business Size Regulations under 13 CFR Ch. 1 Part 121 (relating to Small Business Size Regulations) or its successor regulation.” Based upon a review of the Department’s paid claims data for the state fiscal year 2022-2023, 6 for profit PRS agencies received less than $16.5 million in Department funds, which would meet the definition of “small business” found in 13 CFR § 121.201. The Federal regulations reference the North American Industry Classification System (NAICS) standards. The NAICS small business size standard for outpatient mental health centers is $16.5 million in annual receipts reported on the small business’s Internal Revenue Service tax return form. The Department does not have access to information on the total revenue generated by each for-profit PRS agency that is reported on its Internal Revenue Service tax return form. Therefore, based only upon the Department’s paid claims data, the Department estimates that 6 for-profit PRS agencies may be considered small businesses under Federal regulation. The final-form rulemaking will benefit PRS agencies by creating an opportunity for additional revenue because it will allow PRS agencies to serve additional individuals who are 14 years of age or older but under 18 years of age. The final-form rulemaking will affect all licensed PRS agencies, including small businesses, equally. The final-form rulemaking will affect individuals who are 14 years of age or older but under 18 years of age because they will be able to access PRS. In addition, the final-form rulemaking will affect individuals who previously could not receive PRS without going through the exception process because they will be eligible to receive PRS under the expanded list of diagnoses that do not require the use of the exception process. The final-form rulemaking also addresses the health and safety of the youth population receiving PRS, supports the engagement of youth and families in the recovery process to

promote better outcomes for individuals receiving services and helps to bridge the gap between the child and adult serving mental health systems. The final-form rulemaking will benefit PRS agencies because it removes the requirement that individuals sign their record every time services are provided. The Department has determined that it is not necessary for the individual to sign the individual’s record every time services are provided because the individual must be allowed access to the individual’s record and can provide written comments on the individual’s record. The final-form regulation will also benefit PRS agencies because it removes the requirements for a daily entry for the day services were provided in the individual’s record and replaces it with a requirement for a weekly progress note and a daily attendance record. Given that some models of PRS require attendance multiple times a week, daily progress notes create an unnecessary staff burden. It is important to verify the attendance of participants, but requiring staff to draft daily progress notes is cumbersome, time consuming and of limited value.

(16) List the persons, groups or entities, including small businesses that will be required to comply with the regulation. Approximate the number that will be required to comply. The final-form rulemaking will affect all licensed PRS agencies, including small businesses. There are 111 licensed PRS agencies in the Commonwealth with 33 satellite locations. All PRS agencies must comply with the final-form rulemaking to maintain their license to provide PRS in the Commonwealth. Although individuals who receive PRS will benefit from the provisions under the final-form rulemaking, they are not regulated entities under the rulemaking. ____________________________________________________________________________________ (17) Identify the financial, economic and social impact of the regulation on individuals, small businesses, businesses and labor communities and other public and private organizations. Evaluate the benefits expected as a result of the regulation. As provided in further detail below, there may be an increase in costs for PRS agencies because the director, psychiatric rehabilitation specialist and 25% of the full-time equivalent staff complement will need to obtain Child and Family Resiliency Practitioner (CFRP) certification and the PRS agency will need to obtain criminal history checks from the Federal Bureau of Investigation (FBI) and child abuse certifications if the PRS agency chooses to serve individuals 14 years of age or older but under 18 years of age. However, the Department anticipates these costs to be offset by the additional revenue the PRS agency will receive by serving individuals who are 14 years of age or older but under 18 years of age. Providers of other children’s services may also benefit because they will be able to expand their service array to include PRS. Youth receiving PRS may also benefit because they may have the opportunity to begin receiving PRS from an agency where they are already receiving services, which will decrease the likelihood of their dropping out of needed services. Individuals seeking to receive PRS will benefit from the final-form rulemaking. Under the final-form rulemaking, individuals who are 14 years of age or older but under 18 years of age, and individuals with additional qualifying diagnoses will be able to access PRS without going through the exception process. The final-form rulemaking also ensures the health and safety of youth receiving PRS, supports

engagement of youth and families in the recovery process to promote better outcomes for individuals receiving services and helps to bridge the gap between the child and adult serving mental health systems. There is no social impact of the final-form rulemaking on small businesses, businesses labor communities and other public and private organizations.

(18) Explain how the benefits of the regulation outweigh any cost and adverse effects. Although some PRS agencies might have increased costs, these costs are anticipated to be offset by an increased revenue source as explained in the answer to Question 17. Further, the benefits of the final form rulemaking outweigh any increased costs. The final-form rulemaking allows individuals 14 years of age or older but under 18 years of age to receive PRS. Youth drop out of services at a high rate as they transition out of children’s services into adult services, in part due to the lack of services that effectively engage them and specifically address their developmental stage. Expanding evidence based PRS to youth will help ensure the availability of targeted, appropriate and high-quality services for this population as they transition into adulthood and avoid the need for more costly and longer-term services. This final-form rulemaking will also benefit individuals 14 years of age or older but under 18 years of age and individuals with additional qualifying diagnoses by allowing them to receive PRS without going through the exception process, which will assist them with developing the skills needed to live, learn and work in the community and improve or maintain their physical or mental health. PRS promotes resiliency and recovery, full community integration and improved quality of life for individuals who have a moderate to severe functional impairment as a result of a diagnosed mental, behavioral or emotional disorder. Additionally, because PRS is an evidence-based intervention, individuals who receive PRS are likely to have a positive outcome. All 111 PRS agencies and 33 satellite locations will benefit from the final-form rulemaking because they will be able to provide services to additional individuals. Providers of other children’s services may also benefit because they will be able to expand their service array to include PRS. Youth receiving PRS may benefit because they may have the opportunity to begin receiving PRS from an agency where they are already receiving services, which will decrease the likelihood of their disengaging from needed services.

(19) Provide a specific estimate of the costs and/or savings to the regulated community associated with compliance, including any legal, accounting or consulting procedures which may be required. Explain how the dollar estimates were derived. The regulated community consists of approximately 111 licensed PRS agencies and 33 satellite locations. Programs that choose to serve individuals 14 years of age or older but under 18 years of age will have some costs as a result of compliance with the new CFRP certification requirements and child abuse clearances for staff. The current cost for obtaining a child abuse clearance is $13 per person. Child abuse clearances would be required for each director, psychiatric rehabilitation specialist and any person working with children. Each PRS program is staffed differently, and it is not known how many staff at each location would require these clearances. For purposes of this cost estimate, the Department has assumed that each

location has 3 staff that will require the new child abuse clearance. Additionally, the Department estimates that approximately 10%, or around 15 of the 144 locations, would serve youth and be affected by this requirement. The total cost for 15 locations would be $585. The cost to obtain the CFRP certification is approximately $395 (registration and examination fee) per person. Additionally, 45 training hours are required for the initial certification. The approximate cost for the training required for CFRP certification using the lowest cost of $12 per hour for 45 training hours is $540 per staff member. CFRP certification would be required for each director, psychiatric rehabilitation specialist, and 25% of staff based on the number of full-time equivalent positions. Each PRS program is staffed differently, and it is not known how many staff at each location would require CFRP certification. For purposes of this cost estimate, the Department has assumed that each location has 3 staff that require CFRP certification. Additionally, the Department estimates that 10%, or around 15 of the 144 locations, would serve youth and be affected by this requirement. The total cost for 15 locations would be $42,075 for the first year. The cost for CFRP recertification is $145 per person every 3 years. Additionally, recertification requires a maximum of 45 training hours for each staff person every 3 years. Trainings typically cost between $12 to $25 per training hour, although some trainings are free. The approximate cost for the continuing training required for CFRP certification using an approximate lowest cost of $12 for 45 training hours is $540 for 3 years, or $180 per year. Training and CFRP recertification would be required for each director, psychiatric rehabilitation specialist, and 25% of staff based on the number of full-time equivalent positions. Each PRS program is staffed differently, and it is not known how many staff at each location would require training for CFRP recertification. For purposes of this cost estimate, the Department has assumed that each location has 3 staff that require training for CFRP recertification. Additionally, the Department estimates that 10%, or around 15 of the 144 locations, would serve youth and be affected by this requirement. The total cost for 15 locations would be $10,260 for each year after the first year. The total cost of the required child abuse clearance, CFRP certification and training required for CFRP certification is $42,660 for the first year. Each year after the initial certification, the total cost of the required child abuse clearance, CFRP recertification and training would be $10,845. As provided previously, this calculation assumes that 10%, or around 15 of the 144 locations, would serve youth and be affected by this requirement. The final-form amendments to the PRS regulation do not require any legal, accounting or consulting procedures.

(20) Provide a specific estimate of the costs and/or savings to the local governments associated with compliance, including any legal, accounting or consulting procedures which may be required. Explain how the dollar estimates were derived. The Department does not anticipate any fiscal impact on local governments. In addition, the final-form rulemaking does not require any new legal, accounting or consulting procedures by local governments.

(21) Provide a specific estimate of the costs and/or savings to the state government associated with the implementation of the regulation, including any legal, accounting, or consulting procedures which may be required. Explain how the dollar estimates were derived. Although more individuals will be eligible for PRS, the Department may potentially realize long-term savings from the implementation of this final-form rulemaking. Allowing individuals 14 years of age or older but under 18 years of age to receive PRS will allow more individuals access to an evidence-based practice. In addition, access to PRS will provide a service option to keep individuals within their community, and not be placed within an inpatient service or another costly service. As such, it is anticipated there will be a potential reduction in the need for future crisis and inpatient services. Many adults and youth who currently receive residential services can be successfully supported by community-based services.

(22) For each of the groups and entities identified in items (19)-(21) above, submit a statement of legal, accounting or consulting procedures and additional reporting, recordkeeping or other paperwork, including copies of forms or reports, which will be required for implementation of the regulation and an explanation of measures which have been taken to minimize these requirements. The changes to service descriptions and the need for additional certifications required by the final-form rulemaking will result in a minimal increase in paperwork. This increase will be offset by a reduction in paperwork because the requirement for a daily progress note is being replaced by a requirement for a weekly progress note. PRS agencies that wish to provide services to individuals 14 years of age or older but under 18 years of age will need to update their service descriptions to include information about the services they will provide and the staff who will provide PRS to this new population. PRS agencies that wish to provide services to individuals 14 years of age or older but under 18 years of age must ensure that staff comply with requirements in the Child Protective Services Law (CPSL) (23 Pa.C.S. §§ 6301— 6386) for criminal history background checks and mandated reporter training. Additional paperwork will need to be completed by agency staff to comply with the requirements for criminal history background checks and mandated reporter training. All PRS agencies will need to update their service descriptions to address new service description requirements, which will result in an increase in paperwork. Likewise, requiring tracking of the number of individuals who were admitted to PRS through the exception process and tracking their average length of stay as part of the agency’s quality improvement plan will result in an increase in paperwork. Additionally, PRS agencies that do not already have a written agreement with a peer support services agency will have to obtain one, which will also result in an increase in paperwork. The rulemaking does not require individuals who receive PRS to complete additional reporting, recordkeeping, or other paperwork. (22a) Are forms required for implementation of the regulation? There are no new forms for the final-form rulemaking. (22b) If forms are required for implementation of the regulation, attach copies of the forms here. If your agency uses electronic forms, provide links to each form or a detailed description of the information required to be reported. Failure to attach forms, provide links, or provide a detailed description of the information to be reported will constitute a faulty delivery of the regulation. N/A

02/01/2024

(23) In the table below, provide an estimate of the fiscal savings and costs associated with implementation and compliance for the regulated community, local government, and state government for the current year and five subsequent years.
	Current FY Year 2023-2024	FY +1 Year 2024- 2025	FY +2 Year 2025-2026	FY +3 Year 2026-2027	FY +4 Year 2027- 2028	FY +5 Year 2028-2029
SAVINGS:	$	$	$	$	$	$
Regulated Community	0	0	0	0	0	0
Local Government	0	0	0	0	0	0
State Government	0	0	0	0	0	0
Total Savings	0	0	0	0	0	0
COSTS:
Regulated Community	$42,660	$10,845	$10,845	$10,845	$10,845	$10,845
Local Government	0	0	0	0	0	0
State Government	0	0	0	0	0	0
Total Costs	$42,660	$10,845	$10,845	$10,845	$10,845	$10,845
REVENUE LOSSES:
Regulated Community	0	0	0	0	0	0
Local Government	0	0	0	0	0	0
State Government	0	0	0	0	0	0
Total Revenue Losses	0	0	0	0	0	0

(23a) Provide the past three-year expenditure history for programs affected by the regulation.

Program	FY -3 2021-2022	FY -2 2021-2022	FY -1 2022-2023	Current FY 2023-2024
Mental Health	$824,697,000	$822,470,000	$866,093,000	$885,567,000
MA Capitation	$3,060,301,000	$4,557,295,000	$3,418,498,000	$4,034,679,000
MA Fee-for Service	$808,350,000	$644,059,000	$589,143,000	$755,834,000

Monica Huber