Rights of Recipients of Mental Health Services;
Part B - III. Individualized Treatment and Discharge Plan

A. Recipients admitted to a State psychiatric facility or community psychiatric facility or unit have the right to treatment according to a written individualized treatment and discharge plan that shall be incorporated into the recipient's ISP as a discrete sub-part.

B. Treatment and discharge plans shall be based upon consideration of the recipient's housing, financial, social, recreational, transportation, vocational, educational, general health, dental, emotional, and psychiatric and/or psychological strengths and needs as well as his or her potential need for crisis intervention and resolution services following discharge. Assessments shall be conducted by hospital personnel with appropriate credentials. These assessments shall be updated as frequently as changed circumstances may require, but no less frequently than the standards of the individual professional discipline dictate in order to assure that the information is current and reliable. The treatment and discharge plan shall include a description of the manner of delivery of each service to be provided. The manner of delivery shall be one that maximizes the recipient's strengths, independence and integration into the community. The names of the service providers and their performance expectations will be included in the plan.

C. The plan shall be developed by an inter-disciplinary team that includes the recipient and hospital staff representing the disciplines of social work, psychiatry, psychology, and nursing, except that in community hospitals and units, psychology will be represented when clinically indicated. Other hospital personnel, and other individuals from the community with whom the recipient has authorized the exchange of information and who are needed to assure that the recipient's needs are adequately assessed and that appropriate recommendations are made, shall be included on the team. One of the hospital staff team members shall be designated as a recipient's team coordinator.

D. The team coordinator or designee shall notify the recipient of all treatment and discharge planning meetings and invite and actively encourage the recipient to attend. If a recipient does not attend the meeting, the team coordinator or designee shall relay the recipient's views on issues to other members of the team. A recipient's guardian, if any, shall also be notified of all treatment and discharge planning meetings and shall be invited to attend. The recipient may invite other persons to his or her treatment and discharge planning meeting, and the team coordinator or designee shall encourage him or her to do so. Notices required by this paragraph shall be given by the team coordinator or designee at least two days in advance of the meeting date, with the following exception: When a meeting is being convened to address an emergency, or is called to formulate a preliminary or initial treatment and discharge plan, notice reasonable for the circumstances shall be required.

E. All recipients shall have a preliminary treatment and discharge plan developed within three working days of admission and a treatment and discharge plan within seven days thereafter. This plan shall be reviewed and revised as frequently as necessary, but in no case less frequently than within 30 days of development, every 60 days thereafter for the first year, and every 90 days thereafter.

F. Complete histories shall be obtained from the recipient, community service providers, and to the extent possible, from other individuals in the community as authorized by the recipient or guardian. Upon learning that a recipient has had a prior psychiatric hospitalization, the team coordinator or designee shall request the recipient's consent to the release of the records of that hospitalization to the inpatient facility where the recipient is currently hospitalized. If consent is given, the team coordinator shall, within two working days, send for copies of the records. These records shall be reviewed upon arrival and, to the extent of their relevance, shall be considered in the review of the recipient's treatment and discharge plan.

G. In addition to the foregoing requirements, the treatment and discharge plan shall be based upon a comprehensive assessment of the recipient, and shall meet the following standards:

  1. Goals that must be met in order for the recipient to meet discharge criteria shall be clearly noted.
  2. At each review, the team shall assess whether the recipient may be safely discharged.
  3. The treatment 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.
  4. A description of short-term and long-range treatment goals, with a projection of when such goals will be obtained;
  5. A statement of the rationale or reason for utilizing a particular form of treatment will be included;
  6. A specification of treatment responsibility, including both staff and recipient responsibility and involvement to attain treatment goals will be noted;
  7. Criteria for discharge or release to a less restrictive treatment setting will be included; and
  8. Documentation of current discharge planning will be included.

H. Limitations

  1. Such a plan must describe any limitation of rights or liberties. Such a 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. Any limitation shall meet criteria outlined Or the limitation ha other sections of these rules.
  2. When any limitation is included, the treatment and discharge plan shall address the specific limitation, and the restriction shall be subject to periodic review. When possible, the limitation shall be time specific.
  3. Whenever possible specific treatment shall be developed to address the basis of the limitation.
  4. Documentation regarding the limitation shall include documentation as per H.1. through 3. above and shall include specific criteria for removal of the limitation.

I. A copy of the treatment and discharge plan shall be offered to each recipient, to a guardian, if any, and to a recipient's representative if confidentiality has been waived pursuant to Section A. IX.

J. All facilities or agencies shall maintain specific written guidelines describing their practices concerning development of treatment and discharge plans.

K. Discharge or termination

  1. Each recipient has the right to be informed of and referred to appropriate resources upon discharge or termination from a facility or program.
  2. Each recipient has the right to a treatment and discharge plan and to assisted referral to existing resources in such areas as transportation, housing, residential support services, crisis intervention and resolution services, vocational opportunities and training, family support, recreational/social/vocational opportunities, financial assistance, and treatment options. Recommendations made in treatment and discharge plans shall not require the facility or department to provide recommended goods or service.
  3. Upon a recipient's discharge from. an inpatient facility, the facility shall provide each recipient with a written list of his or her prescribed medication, dosage levels, schedules, and side-effects. A copy of the medication list and the aftercare plan shall be sera to the recipient's guardian and to the recipient's representative upon the recipient's request.
  4. Notification

           a. The recipient's representative, with the permission of the recipient, and the recipient's
               guardian, shall be notified of and, if the representative, or guardian is available, involved in
               any treatment 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.

           b. The recipient's guardian shall be given prior notification of the recipient's discharge from an
               inpatient facility, if possible. Upon the recipient's request, 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, the notice shall be given as quickly as possible.
               Good faith efforts shall be made to notify guardians or representatives, and such efforts shall
               be documented.

           c. A family member designated by the recipient shall, if possible, receive notification of the
              recipient's discharge from inpatient facilities, pursuant to subsection 4(b) above. The recipient
              shall be informed prior to the notification.

L. Exceptions

  1. A recipient may choose not to be involved in developing his or her treatment and discharge plan and may refuse treatment and discharge planning or services. All such cases shall be documented in the recipient's permanent treatment record.

  2. A guardian shall be actively involved in the treatment and discharge planning, to the maximum extent possible. A public guardian has an affirmative duty to be fully and actively involved in treatment discussions and discharge planning.