Individualized Treatment Plan for Residents with Serious Mental Illness Residing in Facilities Subject to Subpart S

Section 300 Section 300.4030  Individualized Treatment Plan for Residents with Serious Mental Illness Residing in Facilities Subject to Subpart S a)         On admission, information received from the admission source (e.g., resident, family, preadmission screening (PAS) agent) shall be used to develop an interim treatment plan.  In developing an individual's interim treatment plan (IITP), the facility shall review the PAS/MH assessments and "Notice of Determination" and consider the use of this information in developing the interim treatment plan. The IITP shall focus on those behaviors and needs requiring attention prior to development of the individualized treatment plan (ITP).  Each IITP shall be based on physician's orders and shall include diagnosis, allergies and other pertinent medical information.  The following information shall also be considered, as appropriate, to allow for the identification and provision of appropriate services until a final plan is developed: 1)         Known risk factors (e.g., wandering, safety issues, aggressive behavior, suicide, self-mutilation, possible victimization by others); 2)         Observable resident medical/psychiatric conditions that may require additional immediate assessment or consultation; 3)         Therapeutic involvement that might be of interest to the resident, be recommended based on referral information, aid in orientation or provide meaningful data for further professional assessment; and 4)         Other known factors having an impact on the resident's condition (e.g., family involvement, social interaction patterns, cooperation with treatment planning). b)         An ITP shall be developed within seven days after completion of the comprehensive assessment. c)         The plan for each resident shall state specific goals that are developed by the IDT. The resident's major needs shall be prioritized, and approaches or programs shall be developed with specific goals, to address the higher prioritized needs. If a lower priority need is not being addressed through a specific goal or program, a statement shall be made as to why it is not being addressed or how the need will be otherwise addressed. d)         The ITP shall contain objectives to reach each of the individual's goals in the plan. Each objective shall: 1)         Be developed by the IDT; 2)         Be based on the results obtained from the assessment process; 3)         Be stated in measurable terms and identify specific performance measures to assess; and 4)         Be developed with a projected completion or review date (month, day, year). e)         Services designed to implement the objectives in the resident's ITP shall specify: 1)         Specific approaches or steps to meet the objective; 2)         Planned skills training, skill generalization technique, incentive/behavior therapy, or other interventions to accomplish the objectives, including the frequency (number of times per week, per day, etc.), quantity (in number of minutes, hours, etc.) and duration (period of time, i.e., over the next 6 months) and the support necessary for the resident to participate; 3)         The evaluation criteria and time periods to be used in monitoring the expected results of the intervention; and 4)         Identification of the staff responsible for implementing each specific intervention. f)         Whenever possible, residents shall be offered some choice among rehabilitation interventions that will address specific ITP objectives using techniques suited to individual needs. g)         ITP Documentation: 1)         Significant events that are related to the resident's ITP, and assessments that contribute to an overall understanding of his/her ongoing level and quality of functioning, shall be documented. 2)         The resident's response to the ITP and progress toward goals shall be documented in progress notes. h)         The ITP shall be reviewed by the IDT quarterly and in response to significant changes in the resident's symptoms, behavior or functioning; sustained lack of progress; the resident's refusal to participate or cooperate with the treatment plan; the resident's potential readiness for discharge and actual planned discharge; or the resident's achievement of the goals in the treatment plan. i)          The resident's individual treatment plan shall be signed by all members of the IDT participating in its development, including the resident or the resident's legal guardian. j)          If the resident refuses to attend the IDT meeting or refuses to sign the treatment plan, the PRSC shall meet with the resident to review and discuss the treatment plan as soon as possible, not to exceed 96 hours after the treatment plan review. Evidence of this meeting shall be documented in the resident's record. k)         The resident's treating psychiatrist shall review and approve the resident's treatment plan as developed by the IDT.  The date of this review and approval shall be entered on the resident's treatment plan and be signed by the attending psychiatrist. l)          The ITP shall be based upon each resident's assessed functioning level, appropriate to age, and shall include structured group or individual psychiatric rehabilitation services interventions or skills training activities, as appropriate, in the following areas: 1)         Self-maintenance; 2)         Social skills; 3)         Community living skills; 4)         Occupational skills; 5)         Symptom management skills; and 6)         Substance abuse management. m)        Activity interventions for individual residents shall be part of, but not used to replace, psychiatric rehabilitation programming and should provide for using skills in new situations. Activity programs shall comply with Section 300.1410  of this Part. n)         Residents' attendance in therapeutic programs shall be recorded. o)         The PRSC shall assess the reason for the failure to attend whenever a resident fails to attend at least 50 percent of any programs included in his or her ITP over a 30 day period. Within 14 days after noting this failure, the PRSC shall document why the resident's attendance was less than 50 percent and that the resident's attendance is, at the time of the documentation, more than 50 percent, or the PRSC shall conduct an IDT meeting. This IDT meeting shall result in a change in components of the resident's treatment plan or shall indicate why a change is not needed. p)         The PRSC is responsible for coordinating staff in the delivery of psychiatric rehabilitation services programs, oversight of data collection, and the review of the resident's performance. 1)         At least quarterly, and prior to the treatment plan reviews, the PRSC shall meet with the resident to review and discuss the resident's current treatment plan, progress toward achieving the objectives, and obstacles inhibiting progress. Based upon this review, the PRSC, in consultation with the appropriate IDT members, shall revise the resident's ITP as needed.  The revised treatment plan shall be submitted to the appropriate IDT members for review, approval and signature. 2)         At least quarterly, the PRSC shall record the resident's response to treatment in the clinical record. q)         The psychiatric rehabilitation services aides shall record the resident's response to those areas overseen by the aide.