Current through Reg. 49, No. 38; September 20, 2024
(a) Inpatient
mental health treatment. A hospital shall provide inpatient mental health
treatment and medical care to a patient under the direction of a physician, in
accordance with the highest standards accepted in medical practice, and in
accordance with the patient's treatment plan and this subchapter. The treatment
plan shall be appropriate to the needs and interests of the patient and be
directed toward restoring and maintaining optimal levels of physical and
psychological functioning.
(b)
Treatment plan content within 24 hours. A hospital, in collaboration with the
patient and LAR, when applicable, shall develop and implement a written
treatment plan within 24 hours after the patient's admission. If the patient is
unable or unwilling to collaborate with the hospital, the circumstances of such
inability or unwillingness shall be documented in the patient's medical record.
(1) The treatment plan shall be based on the
findings of:
(A) the physical examination
described in § 568.62(e)(1)(A) or (B) of this subchapter (relating to
Medical Services);
(B) the
psychiatric evaluation described in § 568.62(f) of this subchapter;
and
(C) the initial nursing
assessment described in § 568.63(e) of this subchapter (relating to
Nursing Services).
(2)
The treatment plan shall contain:
(A) a list
of all diagnoses for the patient with notation as to which diagnoses will be
treated at the hospital, including:
(i) at
least one mental illness diagnosis;
(ii) any substance-related or addictive
disorder diagnoses;
(iii)
neurodevelopmental disorders; and
(iv) any other non-psychiatric
conditions;
(B) a list
of problems and needs that are to be addressed during the patient's
hospitalization;
(C) a description
of all treatment interventions intended to address the patient's problems and
needs, including the medications prescribed and the symptoms each medication is
intended to address;
(D)
identification of any additional assessments and evaluations to be conducted,
which shall include the social assessment described in § 568.64(d) of this
subchapter (relating to Social Services);
(E) identification of the level of monitoring
assigned to the patient; and
(F)
the rationale for the treatment interventions and any enhanced levels of
monitoring described in subparagraphs (C) and (E) of this paragraph.
(c) Treatment plan
content within 72 hours.
(1) Within 72 hours
of the patient's admission the hospital shall:
(A) establish an interdisciplinary treatment
team (IDT) for a patient;
(B)
conduct the social assessment described in subsection (b)(2)(D) of this
section;
(C) initiate referrals for
any additional assessments and evaluations identified in accordance with
subsection (b)(2)(D) of this section;
(D) review the content of the treatment plan
required by subsection (b)(2) of this section, and revise the plan, if
necessary, based on the findings of the social assessment or as otherwise
clinically indicated; and
(E) add
to the treatment plan:
(i) a description of
the goals of the patient relating to the problems and needs listed in
accordance with subsection (b)(2)(B) of this section;
(ii) the specific treatment modalities for
each treatment intervention by type and frequency;
(iii) the IDT member responsible for
providing or ensuring the provision of each treatment intervention;
(iv) the time frames and measures to evaluate
progress of the treatment plan toward meeting the goals of the
patient;
(v) a description of the
clinical criteria for the patient to be discharged; and
(vi) a description of the recommended
services and supports needed by the patient after discharge as required by
§ 568.81(a)(3)(A) of this chapter (relating to Discharge
Planning).
(2) The treatment plan shall be signed by all
members of the IDT. If the patient is unable or unwilling to sign the treatment
plan, the reason for or circumstances of such inability or unwillingness shall
be documented in the patient's medical record.
(d) Treatment plan review. In addition to the
review required by subsection (c)(1)(D) of this section, the treatment plan
shall be reviewed, and its effectiveness evaluated:
(1) when there is a significant change in the
patient's condition or diagnosis or as otherwise clinically
indicated:
(2) in accordance with
the time frames and measures described in the treatment plan; and
(3) upon request by the patient or the
patient's legally authorized representative.
(e) Treatment plan revision. In addition to a
revision required by subsection (c)(1)(D) of this section, the treatment plan
shall be revised, if necessary, based on the findings of any assessment,
reassessment, evaluation, or re-evaluation, or as otherwise clinically
indicated.
(f) Documentation of
treatment plan review and revisions. A treatment plan review and revision shall
be signed by all members of the IDT. If the patient is unable or unwilling to
sign the review or revision, the reason for or circumstances of such inability
or unwillingness shall be documented in the patient's medical record.
