37 Tex. Admin. Code § 353.308 - Treatment Planning, Implementation, and Review
(a) The provider shall work with the client
to develop and implement an individualized, written treatment plan that
identifies the services and support needed to address the problems and needs
identified in the assessment. The client's parent(s) or guardian(s) shall also
be involved unless such involvement is not possible or appropriate. In such
instances, the client record shall include documentation explaining why the
involvement of the parent(s) or guardian(s) was not possible or appropriate.
(1) When the client needs services not
offered by the treatment program, appropriate referrals shall be made and
documented in the client's record.
(2) The client record shall contain
justification when identified needs are temporarily deferred or not addressed
during treatment.
(b) The
treatment plan shall include goals, objectives, and strategies.
(1) Goals shall be based on the client's
problems/needs, strengths, and preferences.
(2) Objectives shall be individualized,
realistic, measurable, time-specific, appropriate to the level of treatment,
and clearly stated in behavioral terms.
(3) Strategies shall describe the type and
frequency of the specific services and interventions needed to help the client
achieve the identified goals and shall be appropriate to the intensity level of
the treatment program in which the client is receiving treatment.
(c) The treatment plan shall
identify discharge criteria and include initial plans for discharge.
(d) The treatment plan shall include a
projected length of stay in the treatment program.
(e) The treatment plan shall identify the
client's primary provider and must be dated and signed by the client and the
provider. When the treatment plan is prepared by a provider who is not a QCC, a
QCC must review and sign the treatment plan.
(f) The treatment plan shall be completed and
filed in the client record no later than seven calendar days after
admission.
(g) The primary provider
shall meet with the client to review and update the treatment plan at
appropriate intervals, as defined in writing by the treatment program. In
non-residential treatment programs, treatment plans must be reviewed no less
frequently than midway through the projected duration of treatment. In
residential treatment programs, treatment plans must be reviewed no less
frequently than monthly.
(h) The
treatment plan review shall include:
(1) an
evaluation of the client's progress toward each goal and objective;
(2) revision of the goals and objectives, as
necessary; and
(3) justification of
continued length of stay in the treatment program.
(i) Treatment plan reviews must be dated and
signed by the client, the provider, and, if applicable, the supervising
QCC.
(j) When a client's intensity
of service is changed, the client record must contain:
(1) clear documentation of the decision,
signed by a QCC, including the rationale and the effective date;
(2) a revised treatment plan; and
(3) documentation of coordination activities
with the receiving provider, if there is a different provider.
(k) Treatment program personnel
shall document all substance use disorder services in the client record within
72 hours, including the date, nature, and duration of the contact and the
signature or electronic authentication of the provider.
(1) Education, life skills training, and
group counseling notes must also include the topics/issues addressed.
(2) Individual counseling notes must include
the goals addressed, clinical observations, and new issues or needs identified
during the session.
Notes
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