Current through Supplement No. 394, October, 2024
1. A treatment
coordinator shall develop a written, individualized treatment plan for each
resident. Upon admission, the facility shall conduct an initial assessment of
the resident's treatment and service needs and develop a treatment plan. An
initial abbreviated treatment plan should be developed immediately for each
resident while the formal treatment plan is developed by utilizing the needs
assessments and other collateral information within fourteen days. The
resident's treatment plan must:
a. Indicate
review of the level of care assessment completed by the qualified individual,
as well as other supporting documentation to assist in the development of a
written treatment plan;
b. Be based
on a thorough assessment of the situation and circumstances of the resident and
the resident's parent of guardian strengths and needs;
c. Support timely achievement of permanency,
including reunification, guardianship, or adoption, if in foster
care;
d. Specify details, including
the resident's:
(1) Strengths and
needs;
(2) Parent of guardian's
strengths and needs;
(3) Behavioral
functioning;
(4) Psychological or
emotional adjustment;
(5) Personal
and social development;
(6) Medical
needs;
(7) Medication
management;
(8) Educational and
vocational needs;
(9) Independent
living and transition skills; and
(10) Recreational interests and normalcy
activities;
e. Be
time-limited, goal-oriented, and individualized to meet the specific needs of
the resident as identified from the assessment, including:
(1) Implementation date;
(2) Goals and objectives that specify
behaviors to be modified;
(3)
Projected achievement dates, with measurable indicators or criteria for
monitoring progress and assessing achievement of treatment goals; and
(4) The name of the employee or community
provider responsible for providing treatment required to the resident and the
resident's parent or guardian;
f. Include and document the involvement from
the resident, parent or guardian, public custodial agency, courts, schools,
informal social network, residential treatment team members, peer support, or
any other individuals important to the resident;
g. Document the conditions for discharge and
estimated discharge date; and
h. Be
reviewed at least every thirty days by the treatment coordinator employee or
designated facility clinician. Changes and modifications must be made and
documented in writing to ensure appropriateness of the treatment
goals.
2. Family
treatment. The facility shall plan for how the parent or guardian is integrated
into the treatment process, including postdischarge aftercare services, and how
sibling connections are maintained throughout placement. This section of the
resident's treatment plan must include:
a.
Contact information and outreach services with family members, including
siblings. The plan must detail how the resident may maintain contact for any
known family and appropriate social supports of the resident;
b. Family-based support during
placement;
c. Family-based support
for at least six months postdischarge;
d. Document and provide evidence of the
resident's and family's involvement during ongoing planning efforts;
e. Document ongoing outreach to and
engagement with family members during resident's treatment. The facility shall
maintain contact with the resident's custodian and parent or guardian at least
weekly. Type of contact may be detailed and includes face-to-face, phone calls,
and written communication;
f. Date
and signature of the resident, employee, custodian, parent or guardian, and
others, as applicable; and
g.
Evidence of facility providing the treatment plan to the resident's custodian
and parent or guardian.
3. Visitation plan. The facility shall detail
in the resident's treatment plan the agreed upon visitation schedule for the
resident from the custodian and parent or guardian. The plan shall identify
approved visitors and opportunities for the resident to engage in home visits.
A resident who engages in home visits shall have an active safety plan provided
to the responsible party supervising the resident on a home visit.
4. Resident acknowledgment. The written
treatment plan must include an indication of who must provide treatment
coordination, and the residents' signature or the signed statement of the
treatment coordinator employee that the treatment plan was explained to the
resident and the resident refused to sign the treatment plan.
5. Electronic filing. If a facility engages
in electronic data entry and case filing, the facility shall develop a policy
to manage this process. The policy must include the electronic medical records
process, procedures for internal network security, employee access, and
management of facility data, backup systems, and how the facility shall engage
in electronic file sharing with the resident's custodian and parent or
guardian.
