Current through Reg. 50, No. 187; September 24, 2024
(1) Treatment Plan, Treatment Plan Reviews,
and Progress Notes.
(a) Treatment Plan. Each
individual shall be afforded the opportunity to participate and be actively
engaged in the development and subsequent review of the treatment plan. The
treatment plan shall include goals and related measurable behavioral objectives
to be achieved by the individual, the tasks involved in achieving those
objectives, the type and frequency of services to be provided, and the expected
dates of completion. The treatment plan shall be signed and dated by the person
providing the service and by the individual. If the treatment plan is completed
by other than a qualified professional, the treatment plan shall be reviewed,
countersigned, and dated by a qualified professional within 10 calendar days of
completion. In the case of Inmate Substance Abuse Programs operated by or under
contract with the Department of Corrections, or the Department of Management
Services, the treatment plan shall be reviewed, countersigned, and dated by a
qualified professional within 30 calendar days of completion. A written
treatment plan shall be completed on each individual.
1. For long-term outpatient methadone
detoxification and methadone medication-assisted treatment for opioid
addiction, the treatment plan shall be completed prior to or within 30 calendar
days of placement.
2. For intensive
inpatient treatment, the treatment plan shall be completed within three (3)
calendar days of placement.
3. For
residential treatment level 1, the treatment plan shall be completed prior to,
or within seven (7) calendar days of placement.
4. For residential treatment levels 2, 3, and
4 day or night treatment with community housing, the treatment plan shall be
completed prior to or within 15 calendar days of placement.
5. For day or night treatment, the treatment
plan shall be completed prior to or within 10 calendar days of
placement.
6. For intensive
outpatient treatment and outpatient treatment, the treatment plan shall be
completed prior to or within 30 calendar days of placement.
7. For detoxification and addictions
receiving facilities, an abbreviated treatment plan, as defined in subsection
65D-30.002(1),
F.A.C., shall be completed upon placement. The abbreviated treatment plan shall
contain a medical plan for stabilization and detoxification, provision for
education, therapeutic activities and discharge planning, and in the case of
addictions receiving facilities, a psychosocial assessment.
8. For providers that are licensed for
multiple program components and deliver a continuum of care, any change in
level of care requires a treatment plan review or treatment plan
update.
(b) Treatment
Plan Reviews. Treatment plan reviews shall be completed with each individual
and shall be signed and dated by the individual within 30 calendar days of the
completion of the treatment plan. The treatment plan must be reviewed when
clinical changes occur and as specified in subparagraphs
65D-30.0044(1)(b)
1.-4., F.A.C.
1. For intensive inpatient
treatment, treatment plan reviews shall be completed every seven (7) calendar
days.
2. For residential treatment
levels 1, 2, and 3, day or night treatment with community housing, day or night
treatment, and intensive outpatient treatment, treatment plan reviews shall be
completed every 30 calendar days.
3. For residential treatment level 4,
treatment plan reviews shall be completed every 90 calendar days.
4. For methadone medication-assisted
treatment for opioid addiction and long-term outpatient methadone
detoxification, treatment plan reviews shall be completed every 90 calendar
days for the first year and every 6 months thereafter.
5. For outpatient treatment, treatment plan
reviews shall be completed every 90 calendar days for the first year and every
six (6) months thereafter.
For all components, if the treatment plan reviews are not
completed by a qualified professional, the review shall be countersigned and
dated by a qualified professional within five calendar days of the
review.
For all components, if the treatment plan reviews are not
completed by a qualified professional, the review shall be countersigned and
dated by a qualified professional within five calendar days of the
review.
(c)
Progress Notes. Progress notes shall be entered into the clinical record
documenting an individual's progress or lack of progress toward meeting
treatment plan goals and objectives. When a single service event is documented,
the progress note must be signed and dated by the person providing the service
and shall include the credentials of the person who signed the notes. When more
than one (1) service event is documented, progress notes may be signed by any
clinical staff member assigned to the individual. The following are
requirements for recording progress notes:
1.
For addictions receiving facilities, inpatient detoxification, outpatient
detoxification, short-term residential methadone detoxification, short-term
outpatient methadone detoxification, and intensive inpatient treatment,
progress notes shall be recorded and signed at least daily;
2. For residential treatment, day or night
treatment with community housing, day or night treatment, and long-term
outpatient methadone detoxification, progress notes shall be recorded at least
weekly;
3. For intensive outpatient
treatment and outpatient treatment, progress notes shall be recorded at least
weekly or, if contact occurs less than weekly, notes will be recorded according
to the frequency of sessions; and
4. For methadone medication-assisted
treatment for opioid addiction, progress notes shall be recorded according to
the frequency of sessions and signed.
(2) Ancillary Services. This requirement
applies to addictions receiving facilities, detoxification, intensive inpatient
treatment, residential treatment, day or night treatment with community
housing, day or night treatment, intensive outpatient treatment, outpatient
treatment, aftercare, and medication-assisted treatment for opioid addiction.
Ancillary services shall be provided directly or through referral in instances
where a provider cannot or does not provide certain services needed by an
individual. The provision of ancillary services shall be based on individual
needs as determined by the treatment plan and treatment plan reviews. In cases
where individuals need to be referred for services, the provider shall use a
case management approach by linking individuals to needed services and
following-up on referrals. All such referrals shall be initiated and
coordinated by the individual's primary counselor or other designated clinical
staff who shall serve as the individual's case manager. A record of all such
referrals for ancillary services shall be maintained in the clinical record,
including whether or not a linkage occurred or documentation of efforts to
confirm a linkage when confirmation was not received.
(3) Prevention Plan, Intervention Plan, and
Summary Notes.
(a) Prevention Plan. For
individuals receiving indicated prevention services as described in paragraph
65E-14.021(4)(v),
F.A.C., a prevention plan shall be completed within 45 calendar days.
Prevention plans shall include goals and objectives designed to reduce risk
factors and enhance protective factors. The prevention plan shall be reviewed
and updated every 60 calendar days from the date of completion of the plan. The
prevention plan shall be signed and dated by staff who developed the plan and
signed and dated by the individual.
(b) Intervention Plan. For individuals
involved in intervention on a continuing basis, an intervention plan shall be
completed within 45 calendar days. Intervention plans shall
include goals and objectives designed to reduce the severity and intensity of
factors associated with the onset or progression of substance use. The
intervention plan shall be reviewed and updated at least every 60 days. The
intervention plan shall be signed and dated by staff who developed the plan and
signed and dated by the individual.
(c) Summary Notes. Summary notes shall be
completed in indicated prevention and intervention services where clinical
records are required. Summary notes shall contain information regarding an
individual's progress or lack of progress in meeting the conditions of the
prevention or intervention plan described in paragraphs (a) and (b). Summary
notes shall be entered into the individual's clinical record at least weekly
for those weeks in which services are scheduled. Each summary note shall be
signed and dated by staff delivering the service.
(4) Discharge and Transfer Summaries. This
requirement applies to addictions receiving facilities, detoxification,
intensive inpatient treatment, residential treatment, day or night treatment
with community housing, day or night treatment, intensive outpatient treatment,
outpatient treatment, medication-assisted treatment for opioid addiction,
aftercare, and intervention.
(a) Discharge
Summary. A written discharge summary shall be completed for individuals who
complete services or who leave prior to completion of services. The discharge
summary shall include a summary of the individual's involvement in services,
the reasons for discharge, and the provision of and referral to other services
needed by the individual following discharge, including aftercare. The
discharge summary shall be completed within 15 business days and signed and
dated by a primary counselor.
(b)
Transfer Summary. A transfer summary in accordance with policies and procedures
shall be completed immediately for individuals who transfer from one (1)
component to another within the same provider and shall be completed within 5
calendar days when transferring from one (1) provider to another. In all cases,
an entry shall be made in the individual's clinical record regarding the
circumstances surrounding the transfer and that entry and transfer summary
shall be signed and dated by a primary counselor within 15
days.
Rulemaking Authority
397.321(5) FS.
Law Implemented 397.321,
397.410
FS.
New 8-29-19.
