N.J. Admin. Code § 10:161B-9.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:161B-9.2 - Client treatment planning

(a) A client treatment plan shall be developed for every client based on the assessment of the client in accordance with N.J.A.C. 10:161B-9.1.

1. The program shall initiate the development of the client's treatment plan upon the client's admission, and shall enter the client's treatment plan in the client record at least after three visits following admission, not to exceed 30 days.

2. The facility shall address each problem, including problems requiring placement at the assessed level of care, and needs and strengths identified in the client assessment, within the client treatment plan through direct provision or referral to appropriate services, and shall include at least the following:

i. Orders for medication, medical treatment and other services, including the type and frequency of contact, if applicable;

ii. Client substance abuse or dependence and a plan to reduce symptoms, severity and improve treatment outcomes;

iii. Integrated treatment of co-occurring mental health disorders, either on-site or through the coordination of treatment services with an appropriate mental health facility;

iv. The provision of vocational and educational services if needed, either onsite or by referral to community resources;

v. Client participation in self-help group meetings during treatment and after discharge from treatment;

vi. Family and social support services;

vii. The staff responsible for implementation of the treatment plan;

viii. Evidence of client participation in development and implementation of the treatment plan, including, but not limited to, dated signatures of the client as well as signatures of participating multidisciplinary team members;

ix. Long and short term goals with timeframes for achievement;

x. The assessment measures for determining the effectiveness of, and client satisfaction with, treatment or services, including assessments of client adherence to and engagement with treatment and recovery support services;

xi. The time intervals for review of the client's response to treatment or services; and

xii. Discharge/transfer plans.

(b) Practitioners in each of the services providing care to a client shall participate in the development of the client treatment plan.

(c) The client, and his or her family, if indicated and clinically appropriate, shall participate in the development of the client's treatment plan, including the discharge/transfer plan; such participation shall be documented in the client's clinical record.

1. If a physician or other licensed clinician documents in the client's clinical record that the client's participation in the development of the treatment plan is medically contraindicated, a member of the multidisciplinary team providing services to the client shall review the client's treatment plan with the client prior to implementation, and shall document these activities in the client's clinical record.

2. If the family of a client does not agree to participate in treatment planning, the program shall document the attempt to engage the family as well as their refusal.

(d) The multidisciplinary team shall review the treatment plan and the client's progress at least every 90 days, with such review, and revisions, if any, documented in the client's clinical record in the first year with subsequent treatment plan reviews consistent with program policy.

(e) Results of random drug and alcohol screening shall be incorporated into therapeutic interventions and the treatment planning process.

N.J. Admin. Code § 10:161B-9.2