Ga. Comp. R. & Regs. 111-8-19-.14

Current through Rules and Regulations filed through November 22, 2024

Rule 111-8-19-.14 - Individual Treatment Planning

A program must develop and implement a complete individualized treatment plan for each client. Such treatment plans shall be modified and updated as necessary, depending upon the clients' needs.

(a) Preliminary Treatment Plan. An initial treatment plan will be formulated at the time of admission after assessment (within a minimum of ten working days) and will include the initial treatment recommendation for the client. The initial treatment plan may be documented in the program notes.

(b) Complete Treatment Plan. The complete treatment plan must be comprehensive, formulated by a multi-disciplinary team with the input of the client, approved by the clinical director, completed within thirty days from admission, and shall contain sufficient information about the client's expected treatment including:

1. Descriptions of the client's problems and needs;

2. Measurable goals and desired outcomes that are to be attained by the client, which include both long term goals and short term objectives leading to these goals;

3. The interventions and services that the program will provide to help the client achieve the individual goals and desired outcomes;

4. The expected course of treatment; and

5. Identification of the staff person who will provide treatment or coordinate the treatment.

(c) Progress Notes. A program shall document the services received by the client and document chronologically observations of the client's clinical course of treatment which includes the client's response to treatment and progress towards achieving individual goals and desired outcomes. Progress notes shall be documented by the staff members assigned primary responsibility for the client's care, and shall be legible and recorded in the client's plan. Progress notes shall be recorded as applicable;

1. At the end of each shift in the client's medical record for residential detoxification programs;

2. Following any contact with a client undergoing ambulatory detoxification or narcotic treatment;

3. At least weekly for substance abuse treatment residences;

4. Daily for day treatment programs;

5. Whenever there are face-to-face contacts with the client for outpatient drug treatment programs;

6. Whenever the client is observed to engage in a behavior which may effect a change in the treatment plan; and

7. Immediately following the use of any emergency safety intervention with the client.

(d) Random urine drug screens are required for each client, the frequency of which is determined by the program in order to determine its effectiveness. Clinical directors electing to rely upon presumptive urinalysis results for client management must demonstrate adequate access to definitive qualitative laboratory analysis for use when necessary.

(e) Plan Reviews. Plans shall be reviewed and updated, as needed, by the staff member who has primary responsibility for coordinating or providing for the care of the client. Reviews shall be done whenever necessary as indicated by the client's needs or at least every thirty (30) days for residential and sixty (60) days for outpatient.

Ga. Comp. R. & Regs. R. 111-8-19-.14

O.C.G.A. §§ 26-5-5, 26-5-6.

Original Rule entitled "Individual Treatment Planning" adopted. F. Sep. 9, 2013; eff. Sept. 29, 2013.