0940-05-37-.05
Individual Plan Of Care Requirements
Cite as Tenn. Comp. R. & Regs. 0940-05-37-.05
(1)
An individual Plan of Care must be developed and implemented for each service recipient.
The individual Plan of Care (POC) must be based on initial history and on-going assessment
of the service recipient’s needs and strengths and must be completed within seventy-two (72)
hours of admission.
(2)
Documentation of the POC and of its implementation must be kept in the service recipient
record and must include the following:
(a)
The service recipient’s name on the POC;
(b)
The date of development of the POC;
(c)
Individual problems specified in the POC which are to be addressed within the
particular
service/program
component,
including
treatment
and
educational
components;
(d)
Individual objectives which are related to specified problems identified in the POC and
which are to be addressed by the particular service/program component;
(e)
Interventions and staff responsible for addressing goals and objectives in the POC;
(f)
Signatures of the staff providing the services;
(g)
Documentation of participation of service recipient and parent/guardian/legal custodian
or conservator where appropriate, in the treatment planning process; if any of the
parties refuse to participate, reasons for refusal must be documented.
MENTAL HEALTH RESIDENTIAL TREATMENT FACILITY
CHAPTER 0940-05-37
FOR CHILDREN AND YOUTH
(h)
Standardized diagnostic formulation(s), [including, but not limited to, the current
Diagnostic and Statistical Manual (DSM) Axes I-V and/or ICD-9] where appropriate,
and assessment documentation on file which is updated as recommended by POC
team;
(i)
Planned frequency of treatment contacts;
(j)
A plan for family involvement in the service recipient’s treatment.
(3)
A review of the POC must occur at least every thirty (30) days or upon completion of the
stated goals and objectives and must include the following documentation:
(a)
Dated signatures of appropriate staff, and
(b)
An assessment of progress toward each treatment goal and / or objective with
revisions as indicated, and
(c)
A statement of justification for the level of service(s) needed, including suitability for
treatment in a less restrictive environment and continued services.