Section 0940-05-37-.05 - INDIVIDUAL PLAN OF CARE REQUIREMENTS(1) An individual Plan of Care must be developed and implemented for each service recipient. The individual Plan of Care (POC) must be based on initial history and on-going assessment of the service recipient's needs and strengths and must be completed within seventy-two (72) hours of admission.(2) Documentation of the POC and of its implementation must be kept in the service recipient record and must include the following:(a) The service recipient's name on the POC;(b) The date of development of the POC;(c) Individual problems specified in the POC which are to be addressed within the particular service/program component, including treatment and educational components;(d) Individual objectives which are related to specified problems identified in the POC and which are to be addressed by the particular service/program component;(e) Interventions and staff responsible for addressing goals and objectives in the POC;(f) Signatures of the staff providing the services;(g) Documentation of participation of service recipient and parent/guardian/legal custodian or conservator where appropriate, in the treatment planning process; if any of the parties refuse to participate, reasons for refusal must be documented.(h) Standardized diagnostic formulation(s), [including, but not limited to, the current Diagnostic and Statistical Manual (DSM) Axes I-V and/or ICD-9] where appropriate, and assessment documentation on file which is updated as recommended by POC team;(i) Planned frequency of treatment contacts;(j) A plan for family involvement in the service recipient's treatment.(3) A review of the POC must occur at least every thirty (30) days or upon completion of the stated goals and objectives and must include the following documentation: (a) Dated signatures of appropriate staff, and(b) An assessment of progress toward each treatment goal and / or objective with revisions as indicated, and(c) A statement of justification for the level of service(s) needed, including suitability for treatment in a less restrictive environment and continued services.Tenn. Comp. R. & Regs. 0940-05-37-.05
Original rule filed June 29, 2004; effective September 12, 2004.Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 32-2-302, and 33-2-404.