Individualized Treatment or Diagnostic Plan

30.3.1 - Individualized Treatment or Diagnostic Plan (Rev. 253, Issued: 12- 14-18, Effective: 01-16-19, Implementation: 01- 16-19) In accordance with 42 CFR 412.27(c)(3) and 42 CFR 482.61(c), each patient must have an individual comprehensive treatment plan that must be based on an inventory of the patient’s strengths and disabilities. The written plan must include— (1) A substantiated diagnosis; (2) Short-term and long-range goals; (3) The specific treatment modalities utilized; (4) The responsibilities of each member of the treatment team; and (5) Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. The treatment furnished to the patient should be documented in the medical record in such a manner and with such frequency as to assure that all active therapeutic efforts are included. The documentation should provide a full picture of the therapy administered and an assessment of the patient's reaction to it.