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 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.
Needs and strengths of the service recipient that are to be addressed within
the particular service/program component.
(e) Observable and measurable service
recipient 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 and/or service recipient responsibility for
interventions, and planned frequency of contact.
(g) Signature(s) of the staff who develop the
plan and the primary staff responsible for its implementation, including
physician when indicated.
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 as appropriate and anticipated post discharge needs
including documentation of resources needed in the community.
A review of the POC must occur within the
first thirty (30) days of service and at least every six months thereafter or
upon completion of the stated goal(s) and objective(s) and must include the
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.