Section 2060.421  Treatment Plans

a)         At a minimum, the initial patient treatment plan shall be based on the patient's presenting concerns as evidenced from the biomedical and emotional/behavioral assessment.  Such treatment plan shall be developed within 24 hours after admission for any patient in Level IV care, seven calendar days after admission for any patient in Level III or II care and 14 calendar days after admission for any patient in Level I care.

b)         The initial treatment plan shall be confirmed by the medical director or physician according to established protocol (i.e., in person, by telephone, facsimile transmission, standing order), in accordance with the time frames established in subsection (a) of this Section.  Such confirmation shall be documented in the patient record by date and signature of the physician making such confirmation.  The treatment plan shall also be signed and dated by the patient, indicating participation in the development of the plan, and by the professional staff member assigned primary responsibility for services to the patient.

c)         The treatment plan shall be written, gender and culturally appropriate and individual to each patient.

d)         The treatment plan shall list problems (e.g., an injury, dysfunction or loss), goals (a statement to guide resolution or reduction of the problem), objectives (observable and measurable signposts on the way to achieving the goals), methods (the treatment services to be provided, the site of those services, the intensity and duration of those services) and a time table for achieving the goals and objectives of treatment that are within the time frame of the patient's expected participation.

e)         The treatment plan shall describe and include the frequency of all activities, referrals and consultations planned for the patient and/or any family members or significant others and shall designate all professional staff members assigned to provide or coordinate referrals for such services. Referrals or consultations for other needed services not directly provided may include, but not be limited to, prenatal care, other medical care, child care services or any other appropriate legal, financial, social or mental health service.