(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.
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