Community Services Programs
Children Mental Health Rights; Rights In Inpatient and Residential Settings - Individualized Treatment or Service and Discharge Plan
A. 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:
- A statement of the recipient's specific strengths
and treatment and/or service needs.
- 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.
- Goals which must be met in order for
the recipient to meet discharge criteria shall
be clearly noted.
- A. description of short-term and long-range
treatment and/or service goals, with a projection
of when such goals will be achieved;
- A statement of the rationale or reason for
utilizing a particular form of treatment and/or
services;
- 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;
- An assessment, at each review, of whether
the recipient may be safely discharged; and
- Documentation of current discharge planning.
F. Limitations
- 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.
- 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.
- Whenever possible specific treatment and/or
services shall be developed to address the basis
of the limitation.
- 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). -47-
H. All facilities or agencies shall maintain specific
written guidelines describing their practices concerning
development of treatment or service and discharge
plans.
I. 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
- 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.
- 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.
- 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.
- Notification
- 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.
- 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
- No treatment or service plan is required for
recipients who solely received informal social support
and recreation in drop-in mental health programs.
- 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.
- All such cases shall be documented in
the recipient's permanent treatment record.
- 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.
- All such cases shall be documented in
the recipient's permanent treatment or service
record.
- 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.
