Section 164.073 - Individual Treatment PlanFor each patient and resident admitted, the Licensed or Approved Provider shall complete an individual treatment plan based on the patient's or resident's treatment, medical, psychiatric and social histories, which includes the following elements, as well as elements prescribed for each service type in 105 CMR 164.000.
(A) The treatment plan, and all subsequent updates, shall include documentation of at a minimum the following information: (1) A statement of the patient's or resident's strengths, needs, abilities and preferences in relation to his or her substance use disorder treatment, described in behavioral terms;(2) Evidence of the patient's or resident's involvement in formulation of the treatment plan, in the form of the patient's or resident's signature attesting agreement to the plan;(3) Service to be provided;(4) Service goals, described in measurable, behavioral terms, with time lines;(5) Clearly defined staff, patient, and resident responsibilities and assignments for implementing the plan;(6) Description of discharge plans and aftercare service needs;(8) The date the plan was developed and revised;(9) Signatures of staff involved in the formulation or review of the plan;(10) Documentation of disability, if any, which requires a modification of policies, practices, or procedures and record of any modifications made; and(11) Plan for initiating, coordinating, managing, and referring to:(a) concurrent additional substance use disorder treatment that may require the use of medication, such as medication for addiction treatment when a patient or resident is enrolled in outpatient counseling or residential rehabilitation;(b) treatment of co-occurring disorders;(c) primary medical care; and(d) recovery supports and resources.(12) Such plan shall identify providers of care and responsibilities of each, specifying method(s) for coordination and communication, and method(s) for ensuring that sharing of information is consistent with the requirements of 105 CMR 164.084. With patient consent, treatment plans may be submitted from the discharging provider to the admitting provider during the referral process.(B) The Licensed or Approved Provider shall ensure that individual treatment plans are reviewed with the patient or resident and amended as necessary. As treatment progresses, further assessment and diagnostic information must be gathered and documented so as to inform longitudinal treatment planning. The patient or resident and staff reviewing the plan shall sign it, and it shall be incorporated into the patient's or resident's record. If there has been no patient or resident contact over a three-month period, the patient or resident shall be discharged from care and the case closed.(C) All treatment plans shall be reviewed and signed by the Senior Clinician.Amended by Mass Register Issue 1305, eff. 1/29/2016.Amended by Mass Register Issue 1314, eff. 1/29/2016.Amended by Mass Register Issue 1482, eff. 11/11/2022.