Section 472-1-B-III - INDIVIDUALIZED TREATMENT OR SERVICE AND DISCHARGE PLANA. Recipients of inpatient mental health or psychiatric services have the right to treatment according to a written individualized treatment or service and discharge plan which shall be incorporated into the recipient's ISP as a discrete sub-part.B. Treatment or service and discharge plans shall be developed based upon an individualized assessment of the recipient's physical, psychological and social needs, as well as the recipient's expressed desires. Each facility or agency shall fully consider the least restrictive appropriate treatment and related services taking into account factors that are supportive of each recipient's exercise of his or her basic rights, consistent with each individual's needs and treatment requirements pursuant to this section and sections VIII and X of these rules. Such considerations shall include accommodation of particular needs involving communication and physical accessibility to all treatment programs.C. Each recipient 14 or over has the right to be fully and actively involved in the development or revision of his or her treatment or service plan. Involvement of recipients who are younger shall be determined on a case by case basis, after assessment of the recipient's capacity to be involved. The exclusion of a recipient 14 or over, based on incapacity, developmental or mental, requires the approval of the clinical director or, in residential settings, the approval of an independently licensed clinician.. The guardian, custodian or legally responsible parent shall be fully and actively involved in treatment or service planning to the maximum extent possible, given time and location constraints. Each agency, program or facility shall make good faith efforts, including 48 hour notice in inpatient settings and 7 day notice in residential settings, of any meeting, to involve guardians or parents and such efforts shall be documented.D. Treatment or service plans shall be developed in a timely manner. Initial plans shall be developed within 72 hours in inpatient or residential facilities. Comprehensive plans shall be developed within 10 working days in inpatient facilities and 20 working days in residential facilities.E. The comprehensive treatment or service and discharge plan shall be developed by the treatment team, and shall be based upon a comprehensive assessment of the recipient. This plan shall contain, but not be limited to: (1) A statement of the recipient's specific strengths and treatment and/or service needs. a. The treatment or service and discharge plan shall include a description of any physical handicap and any accommodations necessary to provide the same or equal services and benefits as those afforded non-disabled individuals.b. Goals which must be met in order for the recipient to meet discharge criteria shall be clearly noted.(2)A. description of short-term and long-range treatment and/or service goals, with a projection of when such goals will be achieved;(3) A statement of the rationale or reason for utilizing a particular form of treatment and/or services;(4) A specification of treatment and/or service provision responsibility, including both staff, recipient and parent, guardian or custodian's responsibility and involvement to attain treatment and/or service goals;(5) An assessment, at each review, of whether the recipient may be safely discharged; and(6) Documentation of current discharge planning.F. Limitations (1) Such a plan must include any limitation of rights or liberties. Such limitation shall be based upon professional judgment and may include a determination that the recipient is a danger to him or herself or to others absent such limitation. Such limitation shall meet criteria outlined for such limitation in other sections of these rules.(2) When such limitation occurs, the treatment or service plan shall address the specific limitation and such restriction shall be subject to periodic review. When possible, such limitation shall be time specific.(3) Whenever possible specific treatment and/or services shall be developed to address the basis of the limitation.(4) Documentation regarding the limitation shall include documentation as per F(l) through 3 above and shall include specific criteria for removal of the limitation.G. A copy of the treatment or service plan shall be offered to each recipient, to a guardian, custodian or legally responsible parent, if any, and to a recipient's representative Of confidentiality has been waived pursuant to PART A, Section VIII).H. All facilities or agencies shall maintain specific written guidelines describing their practices concerning development of treatment or service and discharge plans. (1) The treatment and discharge plan shall be reviewed and revised as frequently as is clinically indicated. Each facility, agency or program shall establish, by policy, schedule for review of all] recipient's treatment and discharge plans.J. Discharge or termination (1) Each recipient and his or her guardians, custodians or legally responsible parents have the right to be informed of and referred to appropriate resources upon discharge or termination from a facility or program.(2) Each recipient has the right to a comprehensive discharge, or treatment or service plan, and to assisted referral to existing resources in such areas as transportation, housing, residential support service, crisis intervention and resolution services, vocational opportunities and training, family support, medical and dental services, recreational/social/vocational opportunities, financial assistance, and mental health treatment options. Recommendations made in discharge or termination plans shall not require the facility or department to provide recommended goods or service.(3) Upon discharge from an inpatient facility, the facility shall provide each recipient and legally responsible parent, guardian or custodian with a copy of the aftercare plan and a written list of his or her prescribed medication, dosage levels, schedules, side-effects, precautions and contraindications. A copy of the medication list and the aftercare plan shall be sent to the recipient's guardians, custodians or legally responsible parents and to the representative.(4) Notification a. Upon obtaining the permission of the guardians, custodians or legally responsible parents, the recipient's representative will be notified of any treatment or service and discharge planning. Additionally, the guardians, custodians or legally responsible parents and, with consent, the representative may, if available, be involved in any treatment or service and discharge planning. Involvement may include, but need not be limited to, participation in any discharge planning meeting. Invited persons who cannot attend shall be notified that they may submit information in writing for consideration at the meeting.b. The recipient's guardians, custodians or and legally responsible parents shall be given notification of the recipient's discharge from an inpatient or residential facility. Upon the request of an emancipated recipient, his or her representative shall be notified, if possible. At least twenty-four hour notice shall be given in planned discharges, if possible. In the case of other discharges, such notice shall be given as quickly as possible.K. The guardians, custodians or legally responsible parents shall be actively involved in the treatment, service, discharge or termination planning, to the maximum extent possible.L. Exceptions (1) No treatment or service plan is required for recipients who solely received informal social support and recreation in drop-in mental health programs.(2) A recipient may choose not to be involved in developing his or her treatment, service, discharge or termination plan and his or her guardians, custodians or legally responsible parents may refuse treatment discharge or termination planning or services.a. All such cases shall be documented in the recipient's permanent treatment record.(3) An emancipated recipient may choose not to be involved in developing his or her treatment or service and discharge plan and may refuse treatment or service and discharge planning or services.a. All such cases shall be documented in the recipient's permanent treatment or service record.(4) Exclusion from planning by professionals may only occur if the guardians, custodians or legally responsible parents pose a documented danger to the physical or mental well-being of the recipient.14-472 C.M.R. ch. 1, § B-III