Current through Reg. 50, No. 187; September 24, 2024
(1) Patients shall
have the opportunity to participate in the preparation of their own treatment
and discharge plans at receiving and treatment facilities and by service
providers. In instances when the person refuses or is unable to participate in
such planning, such refusal or inability shall be documented in the person's
clinical record.
(2) Comprehensive
service assessment and treatment planning, including discharge planning, shall
begin the day of admission and shall also include the person's case manager if
any, the person's friends, family, significant others, or guardian, as desired
by the person. If the person has a court appointed guardian, the guardian shall
be included in the service assessment and treatment planning. Obtaining legal
consent for treatment, assessment and planning protocols shall also include the
following:
(a) How any advance directives
will be obtained and their provisions addressed and how consent for treatment
will be expeditiously obtained for any person unable to provide
consent;
(b) Completion of
necessary diagnostic testing and the integration of the results and
interpretations from those tests. The results and interpretation of the results
shall be reviewed with the person;
(c) The development of treatment goals
specifying the factors and symptomatology precipitating admission and
addressing their resolution or mitigation;
(d) The development of a goal within an
individualized treatment plan, including the individual's strengths and
weaknesses, that addresses each of the following: living arrangements, social
supports, financial supports, and health, including mental health. Goals shall
be inclusive of the person's choices and preferences and utilize available
natural social supports such as family, friends, and peer support group
meetings and social activities;
(e)
Objectives for implementing each goal shall list the actions needed to obtain
the goal, and shall be stated in terms of outcomes that are observable,
measurable, and time-limited;
(f)
Progress notes shall be dated and shall address each objective in relation to
the goal, describing the corresponding progress, or lack of progress being
made. Progress note entries and the name and title of writer must be clearly
legible;
(g) Periodic reviews shall
be comprehensive, include the person, and shall be the basis for major
adjustments to goals and objectives. Frequency of periodic reviews shall be
determined considering the degree to which the care provided is acute care and
the projected length of stay of the person;
(h) Progress note observations, participation
by the person, rehabilitative and social services, and medication changes shall
reflect an integrated approach to treatment;
(i) Facilities shall update the treatment
plan, including the physician summary, at least every 30 days during the time a
person is in a receiving or treatment facility except that persons retained for
longer than 24 months shall have updates at least every 60 days;
(j) The clinical record shall comprehensively
document the person's care and treatment, including injuries sustained and all
uses of emergency treatment orders; and,
(k) Persons who will have a continued
involuntary outpatient placement hearing pursuant to Section
394.4655(7),
F.S., or continued involuntary inpatient placement hearing pursuant to Section
394.467(7),
F.S., shall be provided with comprehensive re-assessments, the results of which
shall be available at the hearing.
(3) The physical examination required to be
provided to each person who remains at a receiving or treatment facility for
more than 12 hours must include:
(a) A
determination of whether the person is medically stable; and,
(b) A determination that abnormalities of
thought, mood, or behavior due to non-psychiatric causes have been ruled
out.
Rulemaking Authority
394.457(5),
394.46715 FS. Law Implemented
394.459(2),
394.4655(7),
394.467(7)
FS.
New 11-29-98, Amended
4-4-05.
