C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.10

Current through 2024-51, December 18, 2024

Subsection 144-101-II-46.10 - PLAN OF CARE REQUIREMENTS

A written plan of care must be established for each member receiving psychiatric hospital services and must include at minimum items described under 46.10-1, General Contents. Plans of care for Inpatient Services and Partial Hospitalization/ Outpatient services are described in Sections 46.10-2 and 46.10-3, respectively. Plans of Care must be available to the Department and its Authorized Agent.

An interdisciplinary team of professionals must develop a plan of care for each such member within fourteen (14) days after the member's admission and must review the plan at least every thirty (30) days thereafter.

46.10-1General Contents of Plans of Care

Plans of care shall at a minimum include the following:

A. Diagnosis, symptoms, complaints, and complications indicating the need for inpatient, partial hospitalization or outpatient services;

B. A description of the functional level of the member, including strengths and weaknesses;

C. Measurable short and long term goals;

D. Any orders for:

1. Medications,

2. Treatments,

3. Restorative and rehabilitative services,

4. Activities,

5. Therapies,

6. Social services,

7. Diet, or

8. Special procedures recommended for the health and safety of the member.

E. Plans for continuing care, including review and modification to the plan of care; and

F. Plans for discharge (see 46.12).

46.10-2Inpatient Services - Plans of Care

A.Plans of Care For Members Age Sixty-five (65) Or Older

The plan of care must also include at minimum:

1. Periodic review of the member's medical, psychiatric, and social needs, and

2. A determination made sixty (60) days and one hundred and twenty (120) days after the initial certification, and every thirty (30) days after a one hundred and twenty (120) day period of continuous inpatient service, of the member's need for continued institutional care and for alternative care arrangements.

B.Plans of Care For Members Under Age Twenty one (21)

1.Plan Specifications for Members Under twenty one (21)

The plan of care for a member under twenty-one (21) must :

a. Be based on a diagnostic evaluation that includes examinations of the medical, psychological, social, behavioral, and developmental aspects of the member's situation and reflects the need for inpatient psychiatric care;

b. Be developed by a team of professionals, as specified below in consultation with the member, and his/her parents, legal guardian, or others into whose care he/she will be released after discharge;

c. State treatment objectives;

d. Prescribe an integrated program of therapies, activities, and experiences designed to meet treatment objectives; and

e. Include post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the member's family, school, and community upon discharge; and

f. Be signed and credentialed, if applicable, by each member of the team providing services.

2.Review of Plan of Care

The plan must be reviewed at least every thirty (30) days by the team specified at (3), below, to:

a. Determine that services being provided are or were required on an inpatient basis, and

b. Recommend changes in the plan as indicated by the member's overall progress towards treatment goals.

3.Team Developing Individual Plan of Care For Members Under Age Twenty one (21)

The plan of care must be developed by an interdisciplinary team of physicians and other personnel who are employed by the hospital or who provide services to members in the hospital. Qualification for participation on the team is based on education and experience, including competence in child psychiatry.

a.Team Skills

The team must be capable of:

i. Assessing the member's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities;

ii. Assessing the potential resources of the member's family;

iii. Setting treatment objectives; and

iv. Prescribing therapeutic modalities to achieve the plan's objectives.

b.Team Composition

The team must include either:

i. A Board-eligible or Board-certified psychiatrist; or

ii. A clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; or

iii. A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases paired with a clinical psychologist who is licensed by the state or province in which services are provided.

The team must also include at least one of the following:

iv. A psychiatric social worker.

v. A registered nurse with specialized training or one year's experience in treating mentally ill members.

vi. An occupational therapist who is licensed by the state or province in which services are provided and who has specialized training or at least one year of experience in treating mentally ill members.

vii. A clinical psychologist who is licensed by the state or province in which services are provided.

viii. A Licensed Alcohol and Drug Counselor (LADC) by the State or province in which services are provided.

46.10-3Partial Hospitalization and Outpatient Services

A.Diagnosis and Treatment Plan

1.Initial Assessment/Clinical Evaluation

An initial assessment, which must include a direct encounter with the member, shall be performed by the interdisciplinary team and included in the member's clinical record. The assessment should include the member's medical and social history and the member's diagnosis.

2.Individual Treatment/Service Plan

Based on the initial assessment, a comprehensive plan of care shall be developed. This plan shall be in writing and shall identify all specific services to be provided, the frequency and duration of each service, the personnel who will provide the services and the goals and/or expected outcomes of each service.

For Partial Hospitalization Services, an initial written plan of care must be completed within three (3) treatment days.

A written comprehensive plan of care must be completed within ten (10) days of the initial plan of care. The comprehensive plan of care is to be updated within sixty (60) days and at least every ninety (90) days thereafter.

For Outpatient Services, a written plan of care must be completed by the third visit and be updated thereafter at least every ten (10) visits or every three (3) months, whichever comes first.

B.Treatment Documentation

1. Written treatment or progress notes shall be maintained in chronological order. Notes shall identify who provided the service, on what date the service was provided, its duration, and the progress the member is making toward attaining the goals or outcomes identified in the treatment plan. All entries shall be

2. signed, credentialed, if applicable, and dated by the individual who performed the service.

C.Discharge/Closing Summary

A closing summary shall be signed, credentialed, if applicable, and dated and included in the clinical record of discharge treatment and outcome in relation to the Treatment Plan.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.10