Sec. 10.21.26.07. Treatment Planning and Evaluation

A. Individual Treatment Plan (ITP).

(1) Treatment Team. At a minimum the following shall participate as members of an individual's RCS program treatment team:

(a) The designated treatment coordinator;

(b) Relevant RCS staff providing services to the individual; and

(c) When available, relevant staff from other agencies currently providing services to the individual.

(2) Individual Treatment Plan. Within 24 hours of placement in an RCS program, based on the screening evaluation under Regulation .05C of this chapter, the initial evaluation under Regulation .06A of this chapter, the assessment under Regulation .06B of this chapter, and the psychiatric diagnosis under Regulation .06C of this chapter, the treatment team shall prepare an ITP:

(a) In collaboration with:

(i) The individual;

(ii) For a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; and

(iii) When appropriate and with proper consent, the individual's family and others involved in the individual's care;

(b) That includes, at a minimum:

(i) The psychiatric diagnosis as provided in Regulation .06C of this chapter;

(ii) A description of the individual's current behavior, symptoms, and level of functioning that includes the individual's presenting strengths, needs, and treatment expectations and responsibilities;

(iii) When relevant to the individual, a description of the family's or significant others' needs and strengths;

(iv) Mental health treatment goals, including the plan for transition and discharge, to be accomplished during an individual's residence in an RCS program, which are outcome oriented and stated in behavioral, measurable terms; and

(v) The anticipated length of stay in the RCS program; and

(c) That specifies treatment strategies, including:

(i) Recommended modality and frequency of interventions, including, if appropriate, case management services;

(ii) Target dates for goal achievement;

(iii) The designation of RCS staff responsible for implementing the elements of the plan;

(iv) Scheduled daytime activities, if any, such as a partial hospitalization program (PHP), psychiatric rehabilitation program (PRP) on-site or off-site services, and school services; and

(v) When appropriate, identification of, recommendations for referral to, and collaboration with, other services to support the individual's treatment.

(3) Signature of the ITP.

(a) The individual or, for a child, the parent or guardian shall sign or tape record agreement or disagreement with the ITP and reviews.

(b) A child's primary caretaker, if other than the parent or guardian, shall sign or tape record acknowledgment of the ITP and reviews.

(c) In addition, the following shall sign the ITP and reviews:

(i) The individual's treatment coordinator;

(ii) When there is an RCS psychiatrist, the RCS psychiatrist; and

(iii) When there is a mental health professional, the mental health professional.

(4) Discharge Before the ITP. When an individual is discharged within 24 hours of admission to RCS, if the treatment team has not developed an ITP, the treatment coordinator shall document, in the individual's medical record, a brief description of the goals established and interventions employed.

B. Continued Evaluation.

(1) Contact Notes. In order to assure that services to an individual are timely and appropriate, staff shall document in the individual's medical record contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the individual, including the dates, locations, and types of contacts.

(2) Progress Summary Notes. The individual's treatment coordinator shall document or assure that staff document in the individual's medical record a daily progress summary note that includes:

(a) A description of progress toward goals;

(b) Changes in goals and interventions based on the review of progress; and

(c) The rationale for the changes.