(a) Inpatient mental health treatment. A hospital shall
provide inpatient mental health treatment and medical care to a patient
under the direction of a physician, in accordance with the highest
standards accepted in medical practice, and in accordance with the
patient's treatment plan and this subchapter. The treatment plan shall
be appropriate to the needs and interests of the patient and be directed
toward restoring and maintaining optimal levels of physical and psychological
functioning.
(b) Treatment plan content within 24 hours. A hospital,
in collaboration with the patient and LAR, when applicable, shall
develop and implement a written treatment plan within 24 hours after
the patient's admission. If the patient is unable or unwilling to
collaborate with the hospital, the circumstances of such inability
or unwillingness shall be documented in the patient's medical record.
(1) The treatment plan shall be based on the findings
of:
(A) the physical examination described in §568.62(e)(1)(A)
or (B) of this subchapter (relating to Medical Services);
(B) the psychiatric evaluation described in §568.62(f)
of this subchapter; and
(C) the initial nursing assessment described in §568.63(e)
of this subchapter (relating to Nursing Services).
(2) The treatment plan shall contain:
(A) a list of all diagnoses for the patient with notation
as to which diagnoses will be treated at the hospital, including:
(i) at least one mental illness diagnosis;
(ii) any substance-related or addictive disorder diagnoses;
(iii) neurodevelopmental disorders; and
(iv) any other non-psychiatric conditions;
(B) a list of problems and needs that are to be addressed
during the patient's hospitalization;
(C) a description of all treatment interventions intended
to address the patient's problems and needs, including the medications
prescribed and the symptoms each medication is intended to address;
(D) identification of any additional assessments and
evaluations to be conducted, which shall include the social assessment
described in §568.64(d) of this subchapter (relating to Social
Services);
(E) identification of the level of monitoring assigned
to the patient; and
(F) the rationale for the treatment interventions and
any enhanced levels of monitoring described in subparagraphs (C) and
(E) of this paragraph.
(c) Treatment plan content within 72 hours.
(1) Within 72 hours of the patient's admission the
hospital shall:
(A) establish an interdisciplinary treatment team (IDT)
for a patient;
(B) conduct the social assessment described in subsection
(b)(2)(D) of this section;
(C) initiate referrals for any additional assessments
and evaluations identified in accordance with subsection (b)(2)(D)
of this section;
(D) review the content of the treatment plan required
by subsection (b)(2) of this section, and revise the plan, if necessary,
based on the findings of the social assessment or as otherwise clinically
indicated; and
(E) add to the treatment plan:
(i) a description of the goals of the patient relating
to the problems and needs listed in accordance with subsection (b)(2)(B)
of this section;
(ii) the specific treatment modalities for each treatment
intervention by type and frequency;
(iii) the IDT member responsible for providing or ensuring
the provision of each treatment intervention;
(iv) the time frames and measures to evaluate progress
of the treatment plan toward meeting the goals of the patient;
(v) a description of the clinical criteria for the
patient to be discharged; and
(vi) a description of the recommended services and
supports needed by the patient after discharge as required by §568.81(a)(3)(A)
of this chapter (relating to Discharge Planning).
(2) The treatment plan shall be signed by all members
of the IDT. If the patient is unable or unwilling to sign the treatment
plan, the reason for or circumstances of such inability or unwillingness
shall be documented in the patient's medical record.
(d) Treatment plan review. In addition to the review
required by subsection (c)(1)(D) of this section, the treatment plan
shall be reviewed, and its effectiveness evaluated:
(1) when there is a significant change in the patient's
condition or diagnosis or as otherwise clinically indicated:
(2) in accordance with the time frames and measures
described in the treatment plan; and
(3) upon request by the patient or the patient's legally
authorized representative.
(e) Treatment plan revision. In addition to a revision
required by subsection (c)(1)(D) of this section, the treatment plan
shall be revised, if necessary, based on the findings of any assessment,
reassessment, evaluation, or re-evaluation, or as otherwise clinically
indicated.
(f) Documentation of treatment plan review and revisions.
A treatment plan review and revision shall be signed by all members
of the IDT. If the patient is unable or unwilling to sign the review
or revision, the reason for or circumstances of such inability or
unwillingness shall be documented in the patient's medical record.
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