(1) Case management services for youth with serious emotional disturbance must be supported by narrative documentation of all services provided.

(2) Case management services for youth with serious emotional disturbance must be provided according to a case management plan which must:

(a) identify and define measurable objectives for the client and the client's family;

(b) include an objective to serve the client in the least restrictive and most culturally appropriate therapeutic environment possible for the client which is also directed toward facilitating preservation of the client in the family unit, or preventing out-of-community placement or facilitating the client's return from acute or residential psychiatric care;

(c) specify strategies for achieving defined objectives;

(d) identify the strengths and potentials of the client and the client's family which will be a base upon which coordinated services will be provided;

(e) identify agencies, service providers, and contacts which will assist in achieving the defined objectives and specify how they will assist;

(f) identify natural, family, and community supports to be utilized and developed in achieving the defined objectives;

(g) identify the role and duties of the client, the parent, or the surrogate parent and all participants in the delivery of a comprehensive and coordinated service to the client and the client's family; and

(h) specify monitoring procedures and time frames.

(3) The case plan must include a crisis plan that must minimally:

(a) help the client and family identify what to do when a mental health crisis occurs;

(b) identify specific resources for the client and family prior to a mental health crisis;

(c) inform the client and family of the case manager's sub crisis role in responding to a crisis;

(d) identify treatment team member's roles in responding to a crisis;

(e) include the mental health center's crisis telephone service; and

(f) assist the client and family in developing the necessary skills to manage some of their own crises.

(4) Objectives in a case management plan must have an identified date of review no more than every 90 days after the plan date. Plans must be kept current and revised to reflect changes in client goals and needs, the services provided to the client, and provider changes of responsibility.

(5) Case management services for youth with serious emotional disturbance must be delivered in accordance with the individual recipient's needs.