Individual Plan Of Care (Poc) Requirements

(1) A Plan must be developed for each recipient. The plan must be based on initial and on-going assessment of the service recipient's needs and strengths must be completed within twenty- four (24) hours of the first day of services rendered. 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 development. (c) Standardized diagnostic formulation(s) including, but not limited to, the current Diagnostic and Statistical Manual (DSM) Axes and/or ICD-9. (d) Needs and strengths of the service recipient which are to be addressed within the particular service/program component. (e) Observable and measurable service recipient goals that are related to specified 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 intervention, and planned frequency of contact. (g) Signature(s) of treatment staff who develop the plan, the primary staff responsible for its implementation, including the physician. (h) Signature of service recipient (and/or parent/guardian, conservator, or legal custodian). Reasons for refusal to sign and/or inability to participate in POC development must be documented. (i) Plan for discharge which includes projected discharge date, and (j) Anticipated post discharge needs including documentation of resources needed in the community. (k) A review of the POC must occur every seven (7) days of service or completion of the stated goal(s) and objective(s) 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 3. A statement by the staff psychiatrist or physician of justification for the level of service(s) needed including an assessment of suitability for treatment in a less restrictive environment. Justification for continued services must be documented. MENTAL HEALTH PARTIAL HOSPITALIZATION PROGRAMS CHAPTER 0940-05-33