Iowa Admin. Code r. 481-71.14 - Treatment plan
(1) A treatment
plan must be developed with each resident. The plan must be based on initial
and ongoing assessment of need, be designed to resolve the acute or crisis
mental health symptoms or the imminent risk of acute or crisis mental health
symptoms, and be completed within six hours of admission, or no later than 12
noon following admission if the resident is admitted between 8 p.m. and 6
a.m.
(2) The treatment plan must be
documented in the resident's record and must include the following:
a. The resident's name.
b. The date the plan is developed.
c. Standardized diagnostic formulations, including but
not limited to the current Diagnostic and Statistical Manual (DSM) or the
current International Statistical Classification of Diseases and Related Health
Problems (ICD).
d. Problems and
strengths of the resident that are to be addressed.
e. Observable and measurable individual objectives
that relate to the specific problems identified.
f. Interventions that address specific objectives,
identification of staff responsible for interventions, and planned frequency of
interventions.
g. Signatures of
mental health professionals responsible for developing the plan, including the
qualified prescriber.
h. Signatures
of the resident and any parent, guardian, conservator, or legal custodian.
Reasons for refusal to sign or inability to participate in treatment plan
development must be documented.
i.
A projected discharge date and anticipated postdischarge needs, including
documentation of resources needed in the community.
j. Review of the treatment plan by the appropriate
treatment staff at least daily and upon completion of the stated goals or
objectives and documentation of the following:
(1) Progress toward each treatment objective, with
revisions as indicated; and
(2)
Status of discharge plans, including availability of resources needed by the
resident in the community, with revisions as
indicated.
Notes
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