(1) Based upon the findings of the assessment(s), each mental health center must establish an individualized treatment plan for each client within 24 hours after admission for crisis stabilization program services and within five contacts, or 21 days from the first contact, whichever is later, for other services. The treatment plan must:
(a) identify treatment team members, from within and outside of the mental health center, who are involved in the client's treatment or care;
(b) specifically state measurable treatment plan objectives that serve the client in the least restrictive and most culturally appropriate therapeutic environment;
(c) describe the service or intervention with sufficient specificity to demonstrate the relationship between the service or intervention and the stated objective;
(d) identify the staff person and program responsible for each treatment service to be provided;
(e) include the client's or parent/legal representative/guardian's signature and date indicating participation in the development of the treatment plan. If the client's or parent/legal representative/guardian's participation is not possible or inappropriate, written documentation must indicate the reason;
(f) include the signature and date of the mental health center's licensed mental health professional and of the person(s) with primary responsibility for implementation of the plan indicating development and ongoing review of the plan. If intensive care management is the only service being received from the mental health center, a program supervisor must sign the treatment plan indicating the supervisor's review and approval for appropriateness; and
(g) state the criteria for discharge, including the client's level of functioning which will indicate when a particular service is no longer required.
(2) The treatment plan must be reviewed at least every 90 days for each client and whenever there is a significant change in the client's condition. A change in level of care or referrals for additional mental health services must be included in the treatment plan.
(3) The treatment plan review must be conducted by at least one licensed mental health professional from the mental health center, and include persons with primary responsibility for implementation of the plan. Other staff members must be involved in the review process as clinically indicated. Outside service providers must be contacted and encouraged to participate in the treatment plan review, as clinically indicated.
(4) If a client is receiving case management and/or medication management services along with one or more other services from the mental health center, the treatment plan review must be conducted by at least one licensed mental health professional from the mental health center and include persons with primary responsibility for implementing the treatment plan. Other staff members must be involved in the review process as clinically indicated. Outside service providers must be contacted and encouraged to participate in the treatment plan review, as clinically indicated.
(5) A treatment team meeting for establishing an individual treatment plan and for treatment plan review must be conducted face-to-face and include:
(a) the client as clinically appropriate;
(b) the client's legal representative/guardian if applicable;
(c) the client's parents or legal representative/guardian if the client is a youth and the involvement by the parent or legal representative/guardian is clinically appropriate;
(d) case manager, if the client has one; and
(e) in the case of an adult client, an adult friend or family member may be invited to participate in the treatment planning or treatment plan review meeting, at the request of and upon written consent of the client, and as deemed clinically appropriate by the client's treatment team, prior to the scheduling of the meeting.
(6) The treatment plan review must be comprehensive with regard to the client's response to treatment and result in either an amended treatment plan or a statement of the continued appropriateness of the existing plan. The results of the treatment plan review must be entered into the client's clinical record. The documentation must include a description of the client's functioning and justification for each client goal.
(7) If the mental health center develops separate treatment plans for each service, the treatment plans must be integrated with one another and a copy of each treatment plan must be kept in the client's record.