|(a) Screening and assessment. When a screening determines
an assessment is necessary, an integrated assessment must be conducted
to consider relevant past and current medical, psychiatric, and substance
use information, including:
(1) information from the individual (and LAR on the
individual's behalf) regarding the individual's strengths, needs,
natural supports, responsiveness to previous treatment, as well as
preferences for and objections to specific treatments;
(2) the needs and desire of the individual for family
member involvement in treatment and services if the individual is
an adult without an LAR; and
(3) recommendations and conclusions regarding treatment
needs and eligibility for services for individuals.
(b) Treatment plan development.
(1) The individual (and LAR on the individual's behalf,
if applicable) must be involved in all aspects of planning the individual's
treatment. If the individual has requested the involvement of a family
member, then the provider must attempt to involve the family member
in all aspects of planning the individual's treatment.
(2) The treatment plan must identify services to be
provided and must include measurable outcomes that address COPSD.
(3) The treatment plan must identify the LAR's or family
members' need for education and support services related to the individual's
mental illness and substance abuse and a method to facilitate the
LAR's or family members' receipt of the needed education and support
(4) The individual, LAR, and, if requested, family
member, must be given a copy of the treatment plan.
(c) Treatment plan review. Each individual's treatment
plan must be reviewed in accordance with DSHS-defined timeframes and
the review must be documented.
(d) Progress notes. The medical record notes must contain
a description of the individual's progress towards goals identified
in the treatment plan, as well as other clinically significant activities
(e) Episode of care summary. Upon discharge or transfer
of an individual from one entity to another, the individual's medical
record must identify the services provided according to this subchapter
and the items referenced in §412.322 (relating to Provider Responsibilities
for Treatment Planning and Service Authorization) of Chapter 412,
Subchapter G of this title, governing Mental Health Community Services
|Source Note: The provisions of this §306.19 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467