Treatment plan

1. A treatment coordinator shall develop a written, individualized treatment plan for each resident. Upon admission, the facility shall conduct an initial assessment of the resident's treatment and service needs and develop a treatment plan. An initial abbreviated treatment plan should be developed immediately for each resident while the formal treatment plan is developed by utilizing the needs assessments and other collateral information within fourteen days. The resident's treatment plan must: a. Indicate review of the level of care assessment completed by the qualified individual, as well as other supporting documentation to assist in the development of a written treatment plan; b. Be based on a thorough assessment of the situation and circumstances of the resident and the resident's parent or guardian strengths and needs; c. Support timely achievement of permanency, including reunification, guardianship, or adoption, if in foster care; d. Specify details, including the resident's: (1) Strengths and needs; (2) Parent or guardian's strengths and needs; (3) Behavioral functioning; (4) Psychological or emotional adjustment; (5) Personal and social development; (6) Medical needs; (7) Medication management; (8) Educational and vocational needs; (9) Independent living and transition skills; and (10) Recreational interests and normalcy activities; e. Be time-limited, goal-oriented, and individualized to meet the specific needs of the resident as identified from the assessment, including: (1) Implementation date; (2) Goals and objectives that specify behaviors to be modified; (3) Projected achievement dates, with measurable indicators or criteria for monitoring progress and assessing achievement of treatment goals; and (4) The name of the employee or community provider responsible for providing treatment required to the resident and the resident's parent or guardian; f. Include and document the involvement from the resident, parent or guardian, public custodial agency, courts, schools, informal social network, residential treatment team members, peer support, or any other individuals important to the resident; g. Document the conditions for discharge and estimated discharge date; and h. Be reviewed at least every thirty days by the treatment coordinator employee or designated facility clinician. Changes and modifications must be made and documented in writing to ensure appropriateness of the treatment goals. 2. Family treatment. The facility shall plan for how the parent or guardian is integrated into the treatment process, including postdischarge aftercare services, and how sibling connections are maintained throughout placement. This section of the resident's treatment plan must include: a. Contact information and outreach services with family members, including siblings. The plan must detail how the resident may maintain contact for any known family and appropriate social supports of the resident; b. Family-based support during placement; c. Family-based support for at least six months postdischarge; d. Document and provide evidence of the resident's and family's involvement during ongoing planning efforts; e. Document ongoing outreach to and engagement with family members during resident's treatment. The facility shall maintain contact with the resident's custodian and parent or guardian at least weekly. Type of contact may be detailed and includes face-to-face, phone calls, and written communication; f. Date and signature of the resident, employee, custodian, parent or guardian, and others, as applicable; and g. Evidence of facility providing the treatment plan to the resident's custodian and parent or guardian. 3. Visitation plan. The facility shall detail in the resident's treatment plan the agreed upon visitation schedule for the resident from the custodian and parent or guardian. The plan shall identify approved visitors and opportunities for the resident to engage in home visits. A resident who engages in home visits shall have an active safety plan provided to the responsible party supervising the resident on a home visit. 4. Resident acknowledgment. The written treatment plan must include an indication of who must provide treatment coordination, and the residents' signature or the signed statement of the treatment coordinator employee that the treatment plan was explained to the resident and the resident refused to sign the treatment plan. 5. Electronic filing. If a facility engages in electronic data entry and case filing, the facility shall develop a policy to manage this process. The policy must include the electronic medical records process, procedures for internal network security, employee access, and management of facility data, backup systems, and how the facility shall engage in electronic file sharing with the resident's custodian and parent or guardian.