New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 37E - OUTPATIENT SERVICE STANDARDS
Subchapter 2 - PROGRAM OPERATION
Section 10:37E-2.4 - Service planning

1. Service plans shall be based upon the findings and treatment recommendations of a comprehensive mental health assessment. The comprehensive mental health assessment shall identify the client's needs and strengths and shall address, at a minimum, the following information about the client:

2. The professional staff shall fully consider the client's preferences when formulating the service plan and shall ensure that the client participates in the development of his or her treatment plan. Level of participation shall be documented in the client record. Exceptions shall be documented, with specific reasons, as to the client's non-participation. If a client does not participate, the specific reasons for the non-participation shall be documented.

3. Service plans shall be developed by appropriately licensed or credentialed professionals. For clients who are receiving medications, a physician shall participate in the development of the service plan, meet with the client regularly and review and approve the client's service plan.

4. The service plan shall contain goals, timeframes, measurable objectives that relate to the goals and specific criteria for termination or reduction of services. Service plans for clients receiving solely medication monitoring services need only address the reason for medication monitoring. For all clients receiving medication, the service plan shall identify the medication, dosage, and frequency of administration and indicate frequency of clinic appointments.

5. The service plan shall specify the following:

6. The service plan shall document any involvement of the family and significant others, and be in accordance with the legal requirements for client consent to family involvement.

7. The service plan shall be completed by the fifth session or within 60 days of the first face-to-face visit, whichever occurs first, except when documented that clinical circumstances dictate that a different time frame is in the client's best interests.

8. The service plan shall be reviewed at significant decision points in each client's course of treatment and the review shall be documented in either the progress notes or treatment plan revision. Significant decision points shall include, but need not be limited to, the transfer or discharge of a client, changes in medication, and any significant change in the client's condition or situation, including, at a minimum, adverse reactions to medications.

9. The clinician and client shall review the service plan together at least every three months for the first year of treatment and at least every six months thereafter. The clinician's supervisor shall review the plan after each review by the client and clinician. For those clients who require only medication monitoring services, the service plan shall be updated by the physician and client, if appropriate, every six months.