Section 472-1-C-II - INDIVIDUALIZED TREATMENT OR SERVICE PLANA. Recipients have the right to an individualized treatment or service plan.B. Individualized treatment or service 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 strengths, needs and treatment requirements pursuant to this section. 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 an independently licensed clinician. The guardian or legally responsible parent shall be fully and actively involved in treatment planning to the maximum extent possible, given time and location constraints. Each agency, program or facility shall make good faith efforts, including 24 hour notice of any meeting, to involve legally responsible parents, guardians or custodians and such efforts shall be documented.D. Treatment or service plans shall be developed within 30 days in outpatient agencies and shall thereafter be reviewed and revised no less frequently than every 90 days. Plans may be reviewed more frequently as necessary to address substantial changes in the recipient's life, such as hospitalization.E. A treatment or service plan shall be developed by a team consisting of the recipient, legally responsible parents, guardians or custodians and others among whom there exists the authorization to exchange information and who are needed to ensure the recipient's needs are adequately assessed and that appropriate recommendations are made, based upon a comprehensive assessment of the recipient. The plan shall contain but not be limited to:(1) A statement of the recipients specific strengths and treatment needs.a. The treatment or service plan should 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.(2) A description of short-term and long-range goals with projection of when such goals will be achieved;(3) A statement of the rationale or reason for specifying certain treatment or services to meet identified goals;(4) A specification of treatment or service responsibility, including both staff and recipient responsibility and involvement to attain treatment or service goals;(5) Documentation of current discharge planning.F. A copy of the treatment or service plan shall be offered to each recipient, to the guardians, custodians or legal, responsible parents and to recipient's representative Of confidentiality has been waived pursuant to Part A Section VIII).G. All agencies shall maintain specific written guidelines describing their practices concerning development of treatment or service plans.H. The treatment or service plan shall be reviewed and revised as frequently as is clinically indicated. Each facility, agency or program shall establish, by policy, a schedule for review of all recipient's treatment or service plans.I. Termination (1) Each recipient and his or her guardian, custodian or legally responsible parent has the right to be informed of and referred to appropriate resources upon termination from a program.(2) Each recipient terminated from the outpatient agency, after three visits or ten working days or longer term of treatment has the right to a comprehensive termination plan, and to assisted referral to existing resources in such areas as transportation, housing, financial assistance, crisis intervention and resolution services, family support, medical, dental, social and recreational services and mental health treatment.(3) Upon termination from an outpatient agency, the facility shall provide each recipient and legally responsible parent, custodian or guardian with a copy of his or her aftercare plan and a written list of his or her prescribed medication, dosage levels, schedules side effects, precautions and contraindications.(4) Notification a. The recipient's representative, upon request of the recipient, and the recipient's guardian, custodian or legally responsible parent, shall be notified of and, if the representative, guardian, custodian or parent is available, involved in any termination planning. Involvement may include, but not be limited to, participation in any termination planning meeting.J. 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) At recipient may choose not to be involved in developing his or her treatment or service plan and may refuse such planning. a. All such cases shall be documented in the recipient's permanent treatment record.(3) A recipient may be excluded from treatment or service planning if physically disruptive to the point that A is impossible to conduct a treatment or service planning session. a. All such cases shall be documented in the recipient's permanent treatment or service record.(4) A legally responsible parent or guardian shall be actively involved in the treatment, discharge or termination planning to the maximum extent possible. A public guardian has an affirmative duty to be fully and actively involved in treatment discussions and discharge planning. Exclusion from planning by professionals may occur if the parent or guardian poses a documented danger to the physical or mental well-being of the recipient.14-472 C.M.R. ch. 1, § C-II