New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter A - Medical Facilities-minimum Standards
Article 1 - General
Part 404 - INTEGRATED OUTPATIENT SERVICES
Section 404.7 - Treatment Planning

Universal Citation: 10 NY Comp Codes Rules and Regs ยง 404.7

Current through Register Vol. 46, No. 39, September 25, 2024

(a) Behavioral health treatment planning is an ongoing process of assessing the behavioral health status and needs of the patient, establishing his or her treatment and rehabilitative goals, and determining what services may be provided by the program to assist the patient in accomplishing these goals. An integrated services provider offering behavioral health services shall provide patient-centered treatment planning for each patient. The treatment planning process is a means of reviewing and adjusting the services necessary to assist the patient in reaching the point where he or she can pursue life goals, without impediment resulting from his or her illness. The treatment planning process includes, where appropriate, a means for determining when the patient's goals have been met to the extent possible in the context of the programs offered by the integrated services provider, and planning for the appropriate discharge of the patient from the program.

(b) Patient participation in treatment planning shall be documented by the signature of the patient or the signature of the person who has legal authority to consent to care on behalf of the patient or, in the case of a child, the signature of a parent, guardian, or other person who has legal authority to consent to health care on behalf of the child, as well as the child, where appropriate, provided, however, that the lack of such signature shall not constitute noncompliance with this requirement if the reasons for non-participation by the patient are documented in the treatment plan. The patient's family and/or collaterals (i.e., significant others) may participate as appropriate in the development of the treatment plan and shall be specifically identified in the treatment plan.

(c) Each patient must have a written patient-centered treatment plan developed by the responsible clinical staff member and patient. Standards for developing a treatment plan include, but are not limited to:

(1) For mental health or substance use disorder behavioral care host models, treatment plans shall be completed no later than 30 days after admission. For primary care host models, treatment plans shall be completed no later than 30 days after the decision to begin any mental health and/or substance use services beyond pre-admission services.

(2) For services provided to a recipient enrolled in a managed care plan which is certified by the commissioner or a commercial insurance plan which is certified or approved by the Superintendent of Financial Services, treatment plans shall be prepared pursuant to the requirements of the managed care plan or commercial insurance plan.

(3) If the patient is a minor, the treatment plan must also be developed in consultation with his/her parent or guardian unless the minor is being treated without parental consent as authorized by MHL section 22.11 or 33.21, as applicable.

(4) For patients moving directly from one program offered by an integrated services provider to another program offered by the same provider, whether or not it is a program approved to provide integrated services, the existing treatment plan may be used if there is documentation that it has been reviewed and, if necessary, updated within 14 days of transfer.

(d) The treatment plan shall include physical health, behavioral health, and social service needs. In addition, specific consideration of the need for health home care coordination should be noted when appropriate.

(e) The treatment plan shall include identification and documentation of the following:

(1) patient-identified problem areas specified in the admission assessment;

(2) treatment goals for these problem areas (unless deferred);

(3) objectives that will be used to measure progress toward attainment of treatment goals and target dates for achieving completion of treatment goals;

(4) methods and treatment approaches that will be utilized to achieve the goals developed by the patient and primary counselor;

(5) schedules of individual and group counseling;

(6) each diagnosis for which the patient is being treated at the program;

(7) descriptions of any additional services (e.g., vocational, educational, employment) or off-site services needed by the patient, as well as a plan for meeting those needs; and

(8) the signature of the qualified health professional, or other licensed individual within his/her scope of practice involved in the treatment.

(f) All treatment plans shall be reviewed and updated as clinically necessary based upon the patient's progress, changes in circumstances, the effectiveness of services, and/or other appropriate considerations. Such reviews shall occur no less frequently than every 90 days or by the next occasion when a service is to be provided to the patient, whichever shall be later. For services provided to a recipient enrolled in a managed care plan which is certified by the commissioner or a commercial insurance plan which is certified or approved by the Superintendent of Financial Services, treatment plans may be reviewed pursuant to such other plan requirements as shall apply.

(g) Treatment plan reviews shall include the input of relevant staff, as well as the recipient, family members and collaterals, as appropriate. The periodic review of the treatment plan shall include the following:

(1) assessment of the progress of the patient in regard to the mutually agreed upon goals in the treatment plan;

(2) adjustment of goals and treatment objectives, time periods for achievement, intervention strategies or initiation of discharge planning, as appropriate;

(3) an evaluation of physical health status; and

(4) the signature of the qualified health professional, or other licensed individual within his/her scope of practice involved in the treatment.

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