Plan Of Care Requirements

(1) A plan must be developed for each service recipient. The plan must be based on initial and on-going assessment of needs and strengths and must be completed within seventy-two (72) hours of admission. Documentation of the plan must be made in the individual's record and must include the following: (a) The service recipient’s name. (b) The date of plan of care development. (c) Standardized diagnostic formulation(s) including, but not limited to, the current Diagnostic and Statistical Manual (DSM) Axes I-V and/or ICD-9. (d) Needs and strengths of the recipient that are to be addressed within the particular service/program component. (e) Observable and measurable individual goals that are related to specific needs identified and which are to be addressed by the particular service/program component. (f) Interventions that address specific goals and objectives, identify staff responsible for interventions, and planned frequency of contact. (g) Signatures(s) of treatment staff who develop the plan and the primary staff responsible for its implementation, including physician when appropriate. (h) Signature of service recipient (and/or conservator legal custodian, or attorney in-fact). Reasons for refusal to sign and/or inability to participate in Plan of Care development must be documented. (i) Discharge planning that includes a projected discharge date and anticipated post discharge needs including documentation of resources needed in the community. (j) A review of the Plan of Care must occur at least every thirty days after development of the Plan of Care and every thirty days thereafter and must include the following documentation: 1. Dated signature(s) of appropriate treatment staff, including physician; and 2. An assessment of progress toward each treatment goal and/or objective with revisions as indicated; and MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES 3. A statement by the staff psychiatrist or physician of justification for the level of services(s) needed; and 4. An assessment of suitability for treatment in a less restrictive environment must be part of the review process.