N.J. Admin. Code § 8:111-9.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:111-9.2 - Client treatment planning

(a) The facility shall establish a client treatment plan that is specific, measurable, and outcomes-focused for every client, which shall be developed based on the assessments made of the client in accordance with N.J.A.C. 8:111-9.1.

1. The facility shall initiate development of a measurable client treatment plan upon the client's admission, and shall enter the client's treatment plan into the client record within 72 hours following the client's admission.

i. The client treatment plan, shall be revised and/or updated as assessments are completed and/or new client information is obtained or on an as-needed basis.

ii. Clients shall be continually assessed, using the ASAM PPC, to assess level of care and needs.

2. Problems, strengths and needs identified in the placement, assessment and treatment planning process shall be addressed directly by the facility or by way of referral to appropriate services. Such service provision shall include, but not limited to:

i. Orders for medication, medical treatment and other services, including the type and frequency of contact, if applicable;

ii. Client substance abuse or dependence and a plan to reduce symptoms, severity and improve treatment outcomes;

iii. Integrated treatment of co-occurring disorders, either on-site or through the coordination of treatment services with an appropriate mental health facility;

iv. The provision of vocational and educational services if needed, either on-site or by referral to community resources;

v. Client participation in self-help group meetings during treatment and after discharge from treatment;

vi. Family, recovery supports, spiritual, housing and social support services;

vii. The staff responsible for implementation of the treatment plan;

viii. Evidence of client participation in the development and implementation of the treatment plan, including, but not limited to, dated signatures of the client, as well as signatures of participating multidisciplinary team members;

ix. Long- and short-term goals with timeframes for achievement;

x. The assessment measures for determining the effectiveness of, and client satisfaction with, treatment or services, including assessments of client adherence to and engagement with treatment and recovery support services;

xi. The time intervals for review of the client's response to treatment or services; and

xii. Discharge/transfer plans.

(b) Practitioners in each of the services providing care to a client shall participate in the development of the client treatment plan relative to the services the practitioner shall provide.

(c) The client and the client's family, if indicated and where considered appropriate, shall participate in the development of the client treatment plan, including the continuum of care plan, which shall be documented in the client's clinical record.

1. If a physician or other licensed clinician documents in the client's clinical record that the client's participation in the development of the client treatment plan is medically contraindicated, a member of the multidisciplinary team providing services to the client shall review the client's treatment plan with the client prior to implementation. The client's family or legal guardian shall be informed of the treatment plan, and such information shall be documented in the client's clinical record.

2. If the family or legal guardian of a client does not agree to participate in the treatment planning, the facility shall document the attempt to engage the family or legal guardian in the treatment planning process, as well as their refusal to participate.

(d) The multidisciplinary team shall review the client treatment plan and client treatment progress at least every 30 days, with such review and revisions, if any, documented in the client's clinical record.

1. The multidisciplinary team shall revise the client treatment plan based upon the client's response to the care provided, the client's abilities and disabilities and each team member's continuing reassessment of services rendered.

(e) Results of random drug and alcohol screening shall be incorporated into therapeutic interventions and the treatment planning process.

(f) Self-help group meetings shall be held on-site or transportation provided to off-site meetings throughout the treatment stay in order to facilitate client involvement in such groups upon discharge from the facility.

N.J. Admin. Code § 8:111-9.2

Amended and recodified from 10:161A-9.2 53 N.J.R. 2208(a), effective 12/20/2021