Sec. 10.21.20.07. Treatment Planning and Documentation

A. Individual Treatment Plan (ITP).

(1) Initial ITP.

(a) Not later than the fifth visit after an individual is enrolled in an OMHC and based on the assessment conducted under Regulation .05B of this chapter, the treatment coordinator and the individual, and if the individual is a minor, the minor's parent, guardian, or primary caretaker if appropriate, shall develop an ITP in collaboration with:

(i) With proper consent, family or others designated by the individual, and others involved in the individual's care; and

(ii) Other OMHC staff, as appropriate.

(b) The ITP shall include, at a minimum:

(i) The individual's diagnosis;

(ii) The individual's presenting needs, strengths, recovery, and treatment expectations and responsibilities;

(iii) A description of needed and desired treatment and interventions to be provided, specifying the modality, frequency, and responsible staff;

(iv) A description of how the needed and desired treatment will help the individual to manage the individual's psychiatric disorder and to support recovery;

(v) Short-term and long-term treatment goals in measurable terms and target dates for each goal; and

(vi) If appropriate, identification of, referral for, and collaboration with other services or child service agencies and providers to support the individual's treatment and recovery, including but not limited to mental health residential services, psychiatric rehabilitation services, self-help organizations, vocational programs, substance abuse services, the local department of social services, the local department of juvenile services, schools, and somatic care.

(c) The content of the ITP shall be communicated to:

(i) Relevant program staff; and

(ii) With proper consent, family or others designated by the individual and, if applicable, community mental health programs providing services to the individual.

(2) ITP Review. As frequently as necessary, as determined by the individual and the individual's treatment coordinator, and at a minimum of every 6 months, the individual and the treatment coordinator shall:

(a) Review the ITP with the individuals identified under §A(1) of this regulation;

(b) Based on the review, record in the individual's medical record:

(i) An assessment of the individual's progress toward the accomplishment of previously identified treatment goals that incorporates the perspective of the individual served;

(ii) Goal changes based on a review of progress;

(iii) Changes in treatment strategies; and

(iv) Changes in diagnosis, if any; and

(c) Communicate the results of the treatment plan review to:

(i) Relevant program staff;

(ii) With proper consent, substance abuse treatment providers and primary care provider, as appropriate;

(iii) With proper consent, family or others designated by the individual and community mental health programs providing services to the individual.

(3) Signature of the ITP and Reviews.

(a) Except as provided in §A(3)(b) of this regulation, the individual shall sign agreement with the plan and reviews.

(b) If the individual is unwilling to sign agreement with the plan and reviews, the individual's treatment coordinator shall:

(i) Verify the individual's verbal agreement with the plan and reviews; and

(ii) Document the rationale for the individual's refusal to sign.

(c) If the individual is a minor, the minor's parent or guardian, or if other than the minor's parent or guardian, the minor's primary caretaker shall sign agreement with the plan and reviews.

(d) With proper consent, family or others designated by the individual, including the individual's caregivers, may sign the plan and reviews.

(e) At least two licensed mental health professionals who collaborate about the individual's treatment, shall sign the plan and reviews.

(f) If the individual is receiving medication prescribed through the OMHC, an OMHC psychiatrist, or Certified Registered Nurse Practitioner in psychiatry, whomever prescribes the medication, shall sign the plan and reviews.

(4) Upon completion of an ITP or ITP review, an individual's treatment coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's acceptance or decline of the offer in the individual's medical record.

(5) Individual Treatment and Rehabilitation Plan (ITRP). Staff may combine the required elements of an ITP and IRP in one document, the ITRP.

B. Continuing Evaluation and Treatment.

(1) Contact Note. Staff shall document each contact with the individual, including, at a minimum:

(a) The date;

(b) The start time and either the duration or the end time;

(c) The individual's chief medical complaint or reason for the visit;

(d) The individual's mental status;

(e) The delivery of services specified by the ITP;

(f) A brief description of the service provided;

(g) The plan for changes in treatment, if any;

(h) The individual's progress toward treatment goals; and

(i) A legible signature, which may include an electronic signature, and printed or typed name of the licensed mental health professional providing care, with the appropriate title.

(2) The treatment coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's treatment.

(3) The treatment coordinator shall ensure that the individual's needs and progress are communicated to:

(a) Staff involved in the implementation of the ITP; and

(b) With proper consent:

(i) Community mental health programs providing services to the individual; and

(ii) Family or others designated by the individual.