Individual Treatment Plan

Licensed or Approved Providers that directly provide services shall complete an individual treatment plan based on the patient's or resident's treatment, medical, psychiatric and social histories, which includes the following elements, as well as applicable elements prescribed for each level or levels of service provided pursuant to 105 CMR 164.100 through 164.400: Part Two. (A) The treatment plan and all subsequent updates shall, at a minimum, include documentation of the following information: A statement of the patient's or resident's strengths, needs, abilities and preferences in relation to his or her substance use disorder treatment, described in behavioral terms; (2) Evidence of the patient's or resident's involvement in formulation of the treatment plan, in the form of the patient's or resident's signature attesting agreement to the plan; (3) Service to be provided; (4) Service goals, described in measurable, behavioral terms, with time lines; (5) Description of discharge plans and aftercare service needs; (6) Aftercare goals; (7) Plan for initiating, coordinating, managing, and referring to: (a) concurrent additional substance use disorder treatment that may require the use of medication, such as medication for addiction treatment when a patient or resident is enrolled in outpatient counseling or residential rehabilitation; (b) treatment of co-occurring disorders; (c) primary medical care; and (d) recovery supports and resources. (B) Such plan shall identify providers of care and responsibilities of each, specifying method(s) for coordination and communication, and method(s) for ensuring that sharing of information is consistent with the requirements of 105 CMR 164.548. With patient consent, treatment plans may be submitted from the discharging provider to the admitting provider during the referral process.