Current through Register Vol. 54, No. 44, November 2, 2024
(a) For
each individual receiving services, a mental health professional or mental
health worker under the supervision of a mental health professional shall
complete an assessment of the behavioral health, medical, psychological,
social, vocational, educational and other factors important to the individual
prior to the development of the initial comprehensive treatment plan.
(b) An initial comprehensive treatment plan
shall be developed, reviewed and approved within 30 days of the intake and
assessment with every individual who continues to participate in the treatment
process in accordance with the following:
(1)
The mental health professional or the mental health worker under the
supervision of the mental health professional and the individual receiving
services shall develop, sign and date the initial treatment plan.
(2) If the individual is receiving
psychotherapy and other clinical services, the psychiatrist or advanced
practice professional shall review, approve, sign and date the initial
treatment plan.
(3) If the
individual is receiving medication management services only, the psychiatrist,
physician, certified registered nurse practitioner or physician assistant
responsible for prescribing and monitoring the use of the medication shall
review, approve, sign and date the initial treatment plan.
(4) For individuals under an involuntary
outpatient commitment, the mental health professional or advanced practice
professional providing services and the individual shall develop, review, sign
and date the initial treatment plan. The treatment plan shall be reviewed and
signed by the psychiatrist as part of the oversight of the treatment services
provided.
(c) The
treatment plan must be based upon the assessment and shall:
(1) Specify the goals and objectives of the
plan, prescribe an integrated program of therapeutic activities and
experiences, specify the modalities to be utilized and the expected duration of
services and the person or persons responsible for carrying out the
plan.
(2) Be directed at specific
outcomes and connect these outcomes with the treatment modalities and
activities proposed.
(3) Be
developed with the active involvement of the individual receiving services and
shall include strengths and needs. The treatment plan may also address
individual preferences, resilience and functioning.
(4) For children and adolescents under 14
years of age, be developed and implemented with the consent of parents or
guardians and include their participation in treatment as required by statute
or regulation.
(5) Specify an
individualized treatment program for each individual, which shall include
clinically appropriate services such as psychiatric evaluation and diagnosis,
psychological evaluation, individual, group and family psychotherapy, behavior
therapy, crisis intervention services, medication evaluation and management,
and similar services.
(d)
The treatment plan shall be reviewed and updated throughout the duration of
treatment as follows:
(1) For individuals
under an involuntary outpatient commitment, the treatment plan shall be
reviewed and updated every 30 days by the mental health professional or
advanced practice professional providing treatment services and the individual
receiving services. The treatment plan update shall be reviewed and signed by
the psychiatrist as part of the oversight of treatment services
provided.
(2) For individuals
voluntarily receiving treatment, the treatment plan shall be reviewed and
updated at a minimum of every 180 days by the mental health professional,
mental health worker under the supervision of a mental health professional,
certified registered nurse practitioner or physician assistant providing
treatment services and the individual receiving services.
(3) The treatment plan update shall be signed
and dated by the mental health professional, mental health worker under the
supervision of a mental health professional, certified registered nurse
practitioner or physician assistant providing treatment services.
(4) The mental health professional or mental
health worker shall request the individual to sign and date the treatment plan
update. In the event the individual does not sign the treatment plan update,
the mental health professional or mental health worker shall document the
request in the record.
(e) All treatment services shall be provided
in accordance with the identified goals in the treatment plan and
updates.
(f) The treatment plan and
updates shall be kept in the individual record.
(g) The treatment plan shall be reviewed on
an annual basis by the psychiatrist or advanced practice professional
throughout the course of treatment from the psychiatric outpatient clinic and
documented in the individual record.
The provisions of this §5200.31 amended under section 1021
of the Human Services Code (62 P.S. §
1021); sections 105 and 112 of the Mental
Health Procedures Act (50 P.S. §§
7105 and
7112); and section 201(2) of
the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §
4201(2)).
This section cited in 55 Pa. Code §
5200.52 (relating to treatment
planning).
