Tenn. Comp. R. & Regs. 0940-05-15-.05 - INDIVIDUAL PLAN OF CARE (POC) 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 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 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.

(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 as appropriate and anticipated post discharge needs including documentation of resources needed in the community.

(j) 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 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.

Notes

Tenn. Comp. R. & Regs. 0940-05-15-.05

Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003.

Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302.