Community Services Programs

Mental Health Agency Licensing Standards; Residential Service Standards - Service Planning

An initial service plan is developed within 72 hours following admission and is based on preliminary assessment findings.

There is documented evidence that the service planning and revision process involves the client, legally responsible party, and other
representatives and professionals whom the client identifies.

Interpretive Guideline for RS.5
The client and legally designated guardian shall be fully and actively involved in the development or revision of the service plan, if possible. All individuals designated by the client, including the representative, family members or significant others (so designated by the client) shall be included in the development and revision of the service plan, unless contraindicated. When these individuals do not attend, their absence is noted. Each agency shall document good faith efforts, including 24 hour notice of any service planning meetings, to involve guardians, representatives or legally responsible parents.

A comprehensive service plan is developed for each client, with the client's consent, and within 20 working days of admission.

The comprehensive service plan minimally contains the following:

problem statements;

short- and long-range goals based upon client needs with a projection of when such goals will be attained;

objectives stated in terms which allow objective measurement of progress;

multi-disciplinary input and specification of treatment responsibilities;

client input and signature;

signatures of all people participating;

the methods and frequency of treatment, rehabilitation, support;

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; and

criteria for discharge or release to a less restrictive setting.

Justification for not addressing problems identified in the assessments is documented in the client record.

Interpretive Guideline for RS.6.B
The intent of this standard is to assure that the clinical staff considers all of the client's identified problems in formulating the service plan. Problems that are not reflected on the service plan should have accompanying documentation identifying the rationale for not addressing the problems at this time. This documentation can take many forms including progress notes, service plan narratives, etc.

The service plan is designed so that the client's progress towards service plan goals can be monitored and evaluated.

Interpretive Guideline for RS.7
Service plans should have measurable goals and some means for reflecting when, or to what degree, a goal has been attained. The organization should also have mechanisms that document monitoring and evaluation of client goals (e.g., QA monitoring, treatment plan review documents).

The service plan is reviewed at major decision points in each client's treatment course, upon client request, and no less frequently than every 90 days.

Interpretive Guideline for RS.8
Major decision points may include, but are not necessarily limited to the following: when there is a change in the client's condition, when a service appears not to benefit the client, when the client is under- or over-utilizing services.

Unmet service needs are documented in the service plan.

Interpretive Guideline for RS.9
If at the time of the service planning meeting, team members know on the basis of reliable information that the needed services are unavailable, they shall note them as "unmet service needs" on the service plan and develop an interim plan based upon available services that meet, as nearly as possible, the actual needs of the client. The organization should also document notification of the organization's leadership and the Commissioner regarding the unavailability of service that is causing the unmet service need.

The agency has a policy and procedure for providing clients with a copy of their service plan within one week following its formulation, review or revision and notification of client recourse should they disagree with any aspect of the plan.

The agency will not fail to provide a copy of the client's service plan and/or notify them of recourse should they disagree.