R03-606 Treatment Planning and Updates

A. A licensee shall ensure an individualized treatment plan is completed:

1. For a client receiving residential services or intensive outpatient services no later than 7 days after the date of admission,

2. For a client receiving outpatient services no later than 45 days after the date of admission, and

3. For clients receiving opioid treatment no later than 30 days after the date of admission.

Review policy and procedure Manual and verify in client files that treatment plans are completed within the required time frames. Date of admission refers to the date the client begins actual treatment services.

 

B. A licensee shall ensure a written individualized treatment plan is developed with the client’s input to include the:

1. Presenting problems or diagnostic impression based on the assessment,

2. Strengths or assets and weaknesses or liabilities of the client,

3. Long term goals,

4. Short term goals,

5. Tasks identified to achieve short term goals,

6. Type and frequency of treatment services to be provided,

7. Community Resources/Referrals,

8. Case management services, if applicable,

9. Name of the primary counselor

10. Name of case manager, if applicable,

11. Date the treatment plan will be reviewed or updated, and

12. Dated signature of the qualified staff and, if applicable;

a. counselor assistant,

b. case manager.

13. Client signature and date.

Review policy and procedure manual. Review client records to verify treatment plans contain the required elements of B 1 through 13.

 

C. A licensee shall ensure treatment plan updates are completed:

1. For clients receiving outpatient treatments, no later than 90 days,

2. For clients receiving opioid treatment – opioid maintenance outpatient treatment, no later than 90 days for the first two years of treatment following admission to the program with a treatment plan to be developed and implemented indicating the clients progress during subsequent and consecutive years of treatment as needed,

3. For clients receiving residential services or intensive outpatient services, no later than 30 days.

Review policy and procedure manual. Review client records to verify that updates are completed in the required time frame.

 

D. A licensee shall ensure treatment plan updates include:

1. Changes in treatment goals and tasks based upon:

a. Documented progress or lack of progress, or

b. Identification of any new problem,

2. Assigned primary counselor, and case manager if applicable,

3. Changes in frequency and type of treatment services, and

4. Signatures of the client and primary counselor, and if applicable, case manager.

Review policy and procedure manual. Review and verify treatment plan updates in client file meet the requirements in R03-606 1-4.