N.Y. Comp. Codes R. & Regs. tit. 14 § 587.16

Current through Register Vol. 46, No. 45, November 2, 2024

Section 587.16 - Treatment planning for clinic treatment programs, continuing day treatment programs, day treatment programs serving children and partial hospitalization programs

(a) Treatment planning shall be an ongoing assessment process carried out by the professional staff in cooperation with the recipient and his or her family and/or other collaterals, as appropriate, which results in a treatment plan. The treatment plan shall be updated or revised as necessary to document changes in the recipient's condition or needs and the services and treatment provided.

(b) Treatment planning shall be based on an assessment of the recipient's psychiatric, physical, social, and/or psychiatric rehabilitation needs which result in the identification of the following:

(1) the recipient's designated mental illness diagnosis;

(2) the recipient's problems and strengths;

(3) the recipient's treatment goals consistent with the purpose and intent of the program; and

(4) the specific objectives and services necessary to accomplish goals.

(c) Recipient participation in treatment planning by an adult and approval of the plan shall be documented by the recipient's signature. Reasons for nonparticipation and/or approval by the recipient shall be documented in the case record.

(d) A treatment plan for a child shall be developed by professional staff of the program with participation of the recipient, as appropriate. A description of such participation shall be documented. The recipient's family and/or collaterals shall participate as appropriate in the development of the treatment plan. Collaterals participating in the development of the treatment plan shall be specifically identified in the plan.

(e) The treatment plan shall include, but need not be limited to, the following:

(1) the signature of the physician involved in the treatment;

(2) the recipient's designated mental illness diagnosis;

(3) the recipient's treatment goals, objectives and related services;

(4) plan for the provision of additional services to support the recipient outside of the program; and

(5) criteria for discharge planning.

(f) Progress notes shall be recorded by the clinical staff member(s) who provided services to the recipient. Such notes shall identify the particular services provided and the changes in goals, objectives and services, as appropriate. Progress notes shall be recorded within the following intervals:

(1) clinic treatment programs-each visit and/or contact;

(2) continuing day treatment programs-at least every two weeks;

(3) partial hospitalization programs-each visit and/or contact; and

(4) day treatment programs-at least every week.

(g) A periodic review of the treatment plan shall include the following:

(1) input of all staff involved in treatment of the recipient;

(2) the recipient, his or her family and/or other collaterals, as appropriate;

(3) assessment of the progress of the recipient in regard to the mutually agreed upon goals in the treatment plan;

(4) adjustment of goals, time periods for achievement, intervention strategies or initiation of discharge planning, as appropriate; and

(5) the signature of the physician involved in the treatment.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 587.16

Amended, New York State Register, Volume XXXVI, Issue 22, effective 6/4/2014