471 NAC 20-019. TREATMENT PLANS. A treatment plan must be established for each beneficiary

019. TREATMENT PLANS. A treatment plan must be established for each beneficiary. The treatment plan is a comprehensive plan of care formulated by the clinical staff under the direction of a supervising practitioner and is based on the individual needs of the beneficiary. The treatment plan validates the necessity and appropriateness of services and outlines the service delivery needed to meet the identified needs, reduce problem behaviors, and improve overall functioning. 019.01 TREATMENT PLAN. The treatment plan must be based upon an assessment of the beneficiary’s problems and needs in the areas of emotional, behavioral, and skills development. The treatment plan must be individualized to the beneficiary and must include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional. 019.02 GOALS AND OBJECTIVES. The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner, and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary’s response to the treatment interventions based on the recommendations, goals and objectives. 019.02(A) SUFFICIENT NEED. The beneficiary must have sufficient need for active psychiatric treatment at the time the psychiatric service provider accepts the beneficiary. 019.02(B) BEST CHOICE. The treatment must be the best choice for expecting reasonable improvement in the beneficiary’s psychiatric condition. 019.03 TREATMENT PLAN TIME FRAMES. A treatment plan must be developed for every beneficiary within the time frames specified for each type of service and must be placed in the beneficiary’s clinical record. If a treatment plan is not developed within the specified time frames, services rendered may not be reimbursable by Nebraska Medicaid. 019.04 TREATMENT PLAN REVIEW. The treatment plan must be reviewed and updated by the treatment team according to the beneficiary’s level of functioning. Minimum time frames for treatment plan reviews are dependent on the type of service. Refer to each individual service description for the review requirements. The purpose of this review is to ensure that services and treatment goals continue to be appropriate to the beneficiary’s current needs, and to assess the beneficiary’s progress and continued need for psychiatric services. The supervising practitioner and treatment team members must sign and date the treatment plan at each treatment plan review. 019.05 COORDINATION OF SERVICES. If the beneficiary is receiving services from more than one psychiatric provider, these agencies must coordinate their services and develop one overall treatment plan for the beneficiary or family. This treatment plan is used by all providers working with the beneficiary or family. 019.06 BENEFICIARY AND FAMILY INVOLVEMENT. The provider must work with the beneficiary and family, at the beneficiary’s discretion, to develop the treatment plan. 019.07 DOCUMENTATION. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary’s treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws. 019.08 TREATMENT PLANNING DOCUMENT UPDATE. The treatment plan must be reviewed and updated every 90 days, or more frequently if indicated. The beneficiary’s clinical record must include the supervising practitioner's comments on the beneficiary’s response to treatment and changes in the treatment plan. The supervising practitioner must review and sign off on the updated treatment plan prior to its initiation. Changes in the treatment plan must be noted on the current treatment planning document. In addition, the psychiatric service provider must complete an updated treatment planning document annually, or more frequently, if necessary, to reflect changes in treatment needs. A copy of the current treatment planning document must be maintained in the beneficiary’s medical record. 019.08(A) SIGNATURE. For services provided under the supervision of a supervising practitioner, the signature of the supervising practitioner on the treatment planning document indicates their agreement that the scheduled treatment interventions are appropriate.